When individuals interact, their phenotypes may be affected not only by their own genes but also by genes in their social partners. This phenomenon is known as Indirect Genetic Effects (IGEs). In aquaculture species and some plants, however, competition not only affects trait levels of individuals, but also inflates variability of trait values among individuals. In the field of quantitative genetics, the variability of trait values has been studied as a quantitative trait in itself, and is often referred to as inherited variability. Such studies, however, consider only the genetic effect of the focal individual on trait variability and do not make a connection to competition. Although the observed phenotypic relationship between competition and variability suggests an underlying genetic relationship, the current quantitative genetic models of IGE and inherited variability do not allow for such a relationship. The lack of quantitative genetic models that connect IGEs to inherited variability limits our understanding of the potential of variability to respond to selection, both in nature and agriculture. Models of trait levels, for example, show that IGEs may considerably change heritable variation in trait values. Currently, we lack the tools to investigate whether this result extends to variability of trait values. Here we present a model that integrates IGEs and inherited variability. In this model, the target phenotype, say growth rate, is a function of the genetic and environmental effects of the focal individual and of the difference in trait value between the social partner and the focal individual, multiplied by a regression coefficient. The regression coefficient is a genetic trait, which is a measure of cooperation; a negative value indicates competition, a positive value cooperation, and an increasing value due to selection indicates the evolution of cooperation. In contrast to the existing quantitative genetic models, our model allows for co-evolution of IGEs and variability, as the regression coefficient can respond to selection. Our simulations show that the model results in increased variability of body weight with increasing competition. When competition decreases, i.e., cooperation evolves, variability becomes significantly smaller. Hence, our model facilitates quantitative genetic studies on the relationship between IGEs and inherited variability. Moreover, our findings suggest that we may have been overlooking an entire level of genetic variation in variability, the one due to IGEs. Social interactions are common in nature, and other individuals are usually the most important part of the environment experienced by an individual Wolf . The envIn the traditional quantitative genetic model, the phenotype of an individual is the sum of the direct effect of its own genes (DGE) and an environmental effect. However, because the environmental effect includes a component due to the social environment, the phenotype of an individual is also a function of the genes of its social partners. The heritable effect of a social partner on the trait value of the focal individual is known as an Indirect Genetic Effect (IGE) Griffing . IGEs haIn the field of animal breeding, interest in social interactions has increased in recent decades, as both theoretical and empirical studies show that not only fitness but also trait values of individuals can be affected by genes of other individuals Muir , b. IGEsIn addition to the effects of social interactions on trait values, it has been observed in aquaculture populations that competition for feed and formation of social hierarchies also inflates trait variability Jobling . BecauseIndications of a close relationship between competition and variability are also coming from the field of plant breeding, where breeders have successfully improved productivity of crops by selecting, partly unintentionally, less competitive phenotypes, which also resulted in more uniform crops Donald . MoreoveThe variability of trait values of a genotype, measured either repeatedly on the same individual, or on multiple individuals belonging to the same family, has been studied as a quantitative trait in its own right. This trait is often referred to as “inherited variability” or “heritable variation in environmental variance”  chase and attack smaller conspecifics, but avoid larger individuals  breeding value for growth rate of individual i, Ep,GR,i and Et,GR,i are permanent and temporary non-heritable  effects of individual i, and bij is a regression coefficient.Therefore, we developed a basic quantitative genetic model involving interactions of two individuals. In this model, our target trait is growth rate between time point bij in our model measures the effect of a difference in body weight between the social partner and the focal individual on the growth rate of the focal individual. Hence, the absolute value of bij reflects the strength of the social interaction. When bij is negative, growth rate of individual i is reduced when j has higher body weight than i, indicating competition. Conversely, when bij is positive, growth rate of i is increased when j has higher body weight than i, indicating cooperation, i.e., “helping the one who lags behind” . The model described by Eq. The ind” Box . Thus, bψ is constant within a population , representing resistance to competition, and an indirect genetic effect of its social partner, representing cooperative effect . While b is a property of both the focal individual and its social partner, it affects the phenotype of the focal individual only; we will therefore refer to this b as “the b value of the focal individual”. Thus, for focal individual i with social partner j, the regression coefficient bij, i.e., the b value of the focal individual, is given byAD,i and ED,i are the direct genetic and environmental effect of individual i on bij, while AI,j and EI,j are the indirect genetic and environmental effect of individual j on bij. Appendix Trait-based IGE models usually assume that the “regression coefficient” tion Eq. . Howeverentclass1pt{minimab. In other words, our model shows that heritable effects on competition result in inherited variability. In the “Discussion” section, we further investigate how breeding values for b correlate with direct and indirect breeding values for inherited variability .Note that our model does not include an explicit breeding value for inherited variability. Instead, as shown in the section “Simulation” below, genetic variation in variability is an emerging property of the model, resulting from genetic effects of competition, i.e., the direct and indirect breeding values for We use the term “competition” to describe the situations where the larger individual continues to increase in size, while the smaller individual lags behind, leading to divergence of their body weights through time Fig. . This isime Fig. . This ocAD) and cooperativeness (AI), as these may be different properties of an individual. For example, consider the pair i and j in a population showing competition  and also resistant to competition , while j is very cooperative  but very sensitive to competition . Then the effect of j on i will be small, while the effect of i on j will be large , assuming Mendelian inheritance, while their environmental values were sampled from independent normal distributions. All individuals were randomly assigned to groups of 2 members. Phenotypes were constructed for 10 time points using Eqs. For each scenario, there were 100 replicates. Table The relationship between competition and variability generated by our model was assessed at two levels. First, we considered the average within-group variance of body weight at the last time point. Second, we considered the overall phenotypic variance in the entire population. Results are presented in Fig. 2  to 20.9 g2 , which is an 18-fold difference in variability of body weight between scenarios 1 and 5. The phenotypic variance ranged from 457.3 g2  to 95.1 g2 , showing a 5-fold difference in variability between scenarios 1 and 5. These results show that our model results in a relationship between competition  and V, demonstrate that the phenotypic variance within a group is directly related to the sum of b values within the group. The expressions show that the expected difference is zero if there is no initial difference at T = 0, while the variance depends directly on the sum of bij and bji. More details can be found in Appendix Expressions Appendix ppendix AAD) for b, as these individuals should be more resistant to competition. This links our model to the definition of inherited variability, where parents with low breeding values for variability have offspring with lower phenotypic variance. Figure AD of sires for b and variability of body weight of their offspring is negative, ranging from −0.55  to −0.20  across scenarios. This suggests that individuals that are genetically more resistant to competition are less variable. Moreover, offspring of sires with positive indirect breeding values (AI) for b should be less competitive. The group mates of these “social” individuals should therefore show less variability compared to group mates of individuals with negative indirect breeding values for b. In other words, AI of a sire affects the variability of phenotypes of the group mates of his offspring. As expected, Fig. AI of sires and variability of the group mates of their offspring. Figure AI of a sire and variability of his offspring, and between AD of a sire and variability of the group mates of its offspring. This result suggests a second-order effect; for the direct effect, for example, the AD of a sire first affects the trait values of its own offspring, which subsequently affects the variability of their groups mates in the next time period. For standard errors of the correlations see Supplementary file If a connection between competition and variability exists not only on the phenotypic level but also on genetic level, we should see less variation in body size among the offspring of sires that have positive direct breeding values  and indirect genetic effects (AI) for b with existing selection methods, we performed three types of selection: individual selection for body weight, group selection for body weight, and group selection for lower variance of body weight. In all three cases, selection was done using observations from time point 10. With individual selection, the 11 % of the heaviest individuals were selected as parents of the next generation. With group selection for body weight, the individuals from the 11 % of groups with the highest average body weight were selected. With group selection for lower variance, the individuals from the 11 % of groups with the lowest variance in body weight were selected. We illustrate the effect of selection by using base population with AD and AI, AD and AGR, and AI and AGR, were all set to 0. See Appendix To see how variability responds to selection, and whether we can capture direct .Our b for all groups, using the modelFirst, to estimate the overall average level of competition, one could fit single fixed b  additive genetic effects on growth rate. The b, where aD is a vector of random direct genetic effects on b, and Pt−1,j−Pt−1,i in the row and column for focal individual i. The b, where aI is a vector of random indirect genetic effects on b, and Pt−1,j−Pt−1,i in the row for the focal individual i and column for its group mate j. Hence, direct and indirect effects on b are so-called random regressions. Note that the above expression merely serves as starting point, and will have to be extended with non-genetic random effects, such random group effects and permanent individual effects variances of growth and the direct and indirect effects on entclass1pt{minimab of the sire. Figure b of the sire. Therefore, it may be possible to capture direct and indirect effects on b by fitting linear mixed models to the within-family variance, and to the variance of the group mates of a family, with sire as random effect. This analysis requires an appropriate family and group structure, but not time series data. More research is needed to see how breeding values for inherited variability correlate with direct and indirect effects on b, and how those effects can be fully captured.When time series data are not available, which may often be the case, another approach could offer a solution. Quantitative genetic models for inherited variability can be used to estimate genetic variance in variability from records on within-family variance. Figure b available in the literature. However, some indications for variation in b may come from estimates of ψ (psi) in so-called trait-based models of IGE  strain was paired with three individuals from a different, unrelated strain i.e. social strain. In that way, each focal genotype was tested against different social environments. The results of the study show that the level of Phenotypic uniformity is an important trait in animal breeding. In the pig industry, for example, it is desirable to deliver animals within a preferred range to the slaughter house, while deliveries outside that range result in penalties for the farmer Hennessy . In aquab.There is substantial evidence of a genetic basis of variability, which has been obtained through selection experiments and by quantifying genetic variation in variability  has a genetic component and is under stabilizing selection. In that study, phenotypic variability was considered either a trait of the individual, or a trait of its parents, and it was discussed how this view would change the interpretation of the genetic parameters. Here we focused at connecting differences in phenotypic variability between individuals to the level of competition, which may be useful for future studies on variability in natural populations.Mulder et al.  showed tKin-selection theory predicts that individuals should interact differentially with kin vs. non-kin, because this increases their inclusive fitness Hamilton . Togetheb from our model can respond to selection, and changes in b resulted in changes in variability, indicating the co-evolution of social interactions and inherited variability. Selection results showed that the effect of IGEs on b is ignored in classical mass selection, but can be partly captured by group selection on the mean or the variance. The latter also resulted in a decrease of variability. These findings suggest that we may have been overlooking an entire level of genetic variation in variability, the one due to IGEs. Genetic improvement of social effects, therefore, may be a promising route to reduce variability.We presented a quantitative genetic model in which direct and indirect genetic effects lead to inherited variability of trait values on the phenotypic level. The The data are available from the Dryad Digital Repository: 10.5061/dryad.c3k48j0bBox 1: Direct and indirect breeding values for AD) is the additive genetic effect of the focal individual on its own b and is referred to as a “resistance to competition”. Negative AD would mean that the individual is sensitive to competition, while the individual with positive AD is resistant to competition.Direct breeding value (AI) refers to additive genetic effect of a social partner on b of a focal individual. It is also referred to as “cooperativeness”. The social partner with negative AI is competitive, while the one with positive AI is cooperative.Indirect breeding value  = 2bij, and similarly ΔPt,j = bji = −2bij  is 0.02 g, while ΔPt,j = −0.02 g. However, if both individuals are competitive and sensitive to competition, AD,i = AD,j = AI,j = AI,i = −0.03, then ΔPt,i = −0.22 g, while ΔPt,j = 0.22 g. Hence, in a competitive environment, when both b are negative, the larger individual grows fast, while the growth of smaller one is slowed down. Positive breeding values in a competitive environment lead to small increase in growth for the smaller individual, and a small decrease for the larger one.In the competitive environment, where, for example, For explanation on chosen values see “Simulation and Appendix Cooperative environmentPt,i = 0.22 g, while ΔPt,j = −0.22 g. If both individuals have all negative breeding values of −0.03, then ΔPt,i = −0.02 g, while ΔPt,j = 0.02 g. Therefore, when both b are positive, the growth of the larger individual slows down, allowing the smaller individual to catch up. Negative breeding values in a cooperative environment lead to small increase in growth for the larger individual, and a small decrease in growth for the smaller individual.In the cooperative environment, where b, see Supplementary File For more scenarios and effects of combining positive and negative breeding values for Supplementary file 1(DOCX 17 kb)Supplementary file 2(XLSX 29 kb)Supplementary file 3(DOCX 1155 kb)Supplementary file 4(DOCX 16 kb)Supplementary file 5(DOCX 13 kb)Supplementary file 6(DOCX 20 kb)


In the last decade, the family system has changed significantly. Although in the past, older people used to live with their children, nowadays, they cannot always depend on assistance of their relatives. Many older people wish to remain as independent as possible while remaining in their homes, even when living alone. To do so, there are many tasks that they must perform to maintain their independence in everyday life, and above all, their well-being. Information and communications technology (ICT), particularly robotics and domotics, could play a pivotal role in aging, especially in contemporary society, where relatives are not always able to accurately and constantly assist the older person.The aim of this study was to understand the needs, preferences, and views on ICT of some prefrail older people who live alone. In particular, we wanted to explore their attitude toward a hypothetical caregiver robot and the functions they would ask for.We designed a qualitative study based on an interpretative phenomenological approach. A total of 50 potential participants were purposively recruited in a big town in Northern Italy and were administered the Fried scale (to assess the participants’ frailty) and the Mini-Mental State Examination . In total, 25 prefrail older people who lived alone participated in an individual semistructured interview, lasting approximately 45 min each. Overall, 3 researchers independently analyzed the interviews transcripts, identifying meaning units, which were later grouped in clustering of themes, and finally in emergent themes. Constant triangulation among researchers and their reflective attitude assured trustiness.From this study, it emerged that a number of interviewees who were currently using ICT  did not own a computer in the past, or did not receive higher education, or were not all young older people (aged 65-74 years). Furthermore, we found that among the older people who described their relationship with ICT as negative, many used it in everyday life. Referring to robotics, the interviewees appeared quite open-minded. In particular, robots were considered suitable for housekeeping, for monitoring older people’s health and accidental falls, and for entertainment.Older people’s use and attitudes toward ICT does not always seem to be related to previous experiences with technological devices, higher education, or lower age. Furthermore, many participants in this study were able to use ICT, even if they did not always acknowledge it. Moreover, many interviewees appeared to be open-minded toward technological devices, even toward robots. Therefore, proposing new advanced technology to a group of prefrail people, who are self-sufficient and can live alone at home, seems to be feasible. Aging is associated with physiological decay, higher risk of multiple acute and chronic diseases, and ultimately, loss of independence and disability . The conFrom the individual perspective, many older people want to remain as independent as possible and to remain in their own home; aging in place rather than in nursing home, even when they live alone, is an essential part of this wish ,4-6. AgiThere is a growing interest in exploring the potential of information and communications technology (ICT) in interventions to assist frail older people and also to promote active and healthy aging ,3,6-11. Studies conducted so far have often showed age as a limiting factor for the use of ICT devices ,15. Othefamilism —which denotes the centrality of family in the life of people and expectations of mutual emotional and instrumental support among family members throughout the life span  Google Earth, that map used for searching Geography. [...] Well yes, [I search] any information, from Geography to historical figures, some historical figures, some art worksInterviewee 9Moreover, the participants declared that they used computers for some applications such as Office , for their personal accountancy , to archive photos (n=1), and to watch Digital Versatile Discs (n=1).Furthermore, from the analysis of the interviews, 3 trends emerged concerning the current use of ICT in relation with the past use of ICT, that is, at a younger age. About one-third of the participants used a computer in the past  and still used either a computer (n=6) or a smartphone (n=6). Most had an internet connection. An exception in this group was represented by 1 interviewee who used a computer in the past, but at the time of the interview, the only ICT he/she owned was an old mobile phone.A second trend was represented by those (about one-third of the participants) who did not use a computer in the past and just used an old mobile phone at the time of the study.Finally, a third group of participants did not use a computer in the past, but declared to currently use 1 or more ICT devices, such as a smartphone (n=7), a computer (n=3), or a tablet (n=1).With regard to the association with the level of education, about half of the participants who had a computer in the past, received a postsecondary level of education. Conversely, among the 13 smartphone owners, only one-third went through higher education. Surprisingly, we did not find any obvious association between the participants’ age and their use of technology.Almost one-third of the interviewees (n=11) did not have an opinion about their relationship with technological devices. One-third (n=9) claimed to have a negative relationship with ICT, that is, endorsing a feeling of denial, inadequacy, or a lack of expertise:[...] The only thing...because I’m not good at these technological thingsInterviewee 2My relationship with technologies is very bad, very bad, very bad. [...] I think I refuse [to learn] it, because I do not think I’m so stupid not to be able toInterviewee 6For goodness sake, It’s already so much that I’ve used this [the phone]! Absolutely! I’m not able to use them [technological devices].Interviewee 7This type of feeling was not necessarily associated with a refusal to use ICT. In fact, 8 of those who considered their relationship with technologies as negative (n=11) used several devices in their daily life .A total of 8 participants declared that they needed, and someway sought for, some help to be able to use ICT:Yes, but, for the most tremendous things, my brother in law used to come, he was the king of technology.Interviewee 6Then, if a payment via home banking has to be completed, well...it’s made by my son or my daughter.Interviewee 9In addition, 5 of those who could not define their relationship with ICT actually used several devices.A small group of participants affirmed that they were in favor of new technologies (n=1), or stated that they wanted to improve their relationship with ICT or they wanted to adapt themselves to “advancing technology” (Interviewee 8), for example, by learning how to use their smartphone better (n=2), or by attending an informatics course (n=1). One participant said he/she wanted “to live in the technological era” (Interviewee 11).Finally, 3 participants clearly stated that ICT was not a fundamental part of their lives, as “you can work the same without having a computer” (Interviewee 7) or was not “essential” (Interviewee 16). One interviewee declared he/she still used a paper telephone book “only because I often lose my cell phone” (Interviewee 15). However, 2 of these participants actually used a computer (Interviewee 15) or a smartphone (Interviewee 16).Most of the participants (n=18) wished to own a robot that helped them with cleaning the house. According to an interviewee, a robot could be a valid substitute of the housekeeper:[A small robot should] first of all, do the cleaning and then I don’t know, nothing else, because I’m only interested in having the house cleaned and tidied up.Interviewee 1Among these 18 interviewees, only 7 did not have any help with housekeeping activities.Cooking was another desired task (n=5). One participant imagined that the robot could even be used as an oven.multitasking robot, 1 participant imagined that this mechanical device could be able to drive a car. Another participant imagined the robot to go shopping with him. Others (n=2) wanted this hypothetical robot to go shopping for them or to buy their medicines, if they were unable to go by themselves (n=2). One participant asked for help with getting washed and dressed. Finally, 1 participant asked for support with physiotherapy.Some participants (4) asked for a multitasking robot, able to act as a formal caregiver or babysitter or maid. According to 1 participant, it might be a machine with “its own intelligence” (Interviewee 7), able to perform the tasks that a human does not want to do or cannot do. Following this request of a Other participants (n=3) believed that a robot should be able to monitor the old person and ask for help in case of emergency:If I fall, I fall. I can’t get up and knock at my neighbour’s door. And if...if I had the robot instead...very good [...] If the robot is present, it doesn’t sleep, it hears that something doesn’t work, or it rather has a sensor which tells it directly and it...does what it has to...nips, calls 113, I don’t know, 118 [emergency telephone numbers], it does anything [...] well [I would like] it to monitor me...and that it should intervene in case I couldn’t make it.Interviewee 2weak or fair social life.On the other hand, about one-third of the participants would ask for a robot with more entertaining functions. The imaginary robot could itself be a companion (n=3) to listen to music (n=1), sing together (n=1), play cards (n=1), or share hobbies with (n=1). It was otherwise seen as a provider of general leisure activities (n=1), or to keep abreast of news (n=1), or as a tool to learn writing and reading (n=1). Most of the interviewees in this second group had a Finally, a small group of participants (n=3) claimed that a robot could not only be useless but also a deterrent for those people who can perform some tasks autonomously .After watching the video about Giraff, a robot carer which offers company and some monitoring functions , the parThe most requested function from a robot was still related to cleaning the house, but this request was expressed by 9 participants instead of 19.The second most frequent request, after watching the video, became the robot’s ability to ask for help in case of emergency (n=9), falls (n=1), and danger, in general (n=1). In particular, according to 5 participants, the robot could be useful in case of gas leaks, open windows, or an attempted break-in (n=5).Moreover, only after watching the video, the participants could endorse the usefulness of the robot in monitoring vital signs (n=4). One person even spoke about “being monitored 365 days per year” (Interviewee 6). Giraff was not only perceived by some participants (n=3) as a useful instrument to remind the older person to perform some health-related tasks , but also as a reminder for buying groceries. The function of preparing meals was still considered important by 2 participants.The robot was also acknowledged, but only minimally, as a communication instrument (n=2); indeed, it was considered by 1 participant as a valid alternative to a computer or a tablet. Moreover, an informant speculated an amplification function for people who suffer from hearing problems.However, the idea that a robot could be a companion for an older person increased after watching the video (mentioned by 7 participants). One participant sustained that Giraff could be useful to go for walks together, and another imagined it could drive a car and take a person out. The fact that the robot could not “speak, offend, or get angry like a human being” was mentioned as an advantage of this special companion by 1 participant (Interviewee 9).Some participants considered Giraff as a useful caregiver for those who are in old age (n=4) or have cognitive problems. However, although some informants still endorsed that the robot could perform important assistance functions in the case of people with lower levels of autonomy, overall, after watching the video, the participants tended to scale down the robot’s functions compared with the multitasking robot they had imagined before.Interestingly, Giraff was seen as inadequate if an old person was self-sufficient in performing certain tasks (n=4) or even as a deterrent to keep oneself active and self-sufficient (n=2):I don’t know, these things...all those possibilities, it’s true, they exist and in my opinion they are very good for those who, unfortunately, can’t move and then I can understand, but, as long as a person is self-sufficient and can move freely, I think they are wasted potentialities.Interviewee 4Yes, well it does anything so, then...I don’t close the window anymore, I don’t switch off the light, it turns the light on, it does anything! I stay there completely still...so, O.K. when I am 102 years old...I agree...But if it does these things now using technology...when it gets dark all the lights go on, there are lots of things around...well, human beings don’t do anything anymore! [Technologies] can do all these things, if the door or the window are open, they close them...so I sit on my chair or in an armchair with that thing opposite me and I don’t move anymore.Interviewee 8One participant highlighted that Giraff cannot be useful in increasing social relationships, particularly for self-sufficient people. Another participant did not consider this robot as a valid alternative or as an addition to other devices such as computer and telephone. One participant stressed the fact that Giraff could be annoying for those who live in a small house.We noticed that the participants’ capacity to change their mind (about the possible functions of the robot), after watching the Giraff video, were mainly related to their baseline relationship with ICT, that is, the more positive it was, the more easily they changed their mind and could grasp the potentialities of a robot aimed at assisting an older person who lives alone.youngolder people (aged 64-75 years). Furthermore, we found that a negative view of ICT (thinking negatively) not always corresponds to its actual rejection or underuse in everyday life.Our study partially challenges the previously reported positive association between older people’s past and current use of ICT, as well as the positive association between the current use of ICT and higher education and lower age ,12,14,15Referring to robotics, our interviewees appeared quite open-minded. In particular, robots were considered suitable for housekeeping, for monitoring older people’s health and accidental falls, and for entertainment. After watching the Giraff video , many inAlthough ICT is providing a wealth of new devices and possibilities, because of the common belief that older people are not keen to adapt or use new technologies in the same way younger generations would, researchers have been very cautious in developing new platforms, applications, and systems for older people .Indeed, literature reported some correlation between the positive or negative perceptions of ICT and older people’s level of education, age, and previous familiarity with technological devices ,12,14,15technological older people for several aims. The most frequent use is to communicate with their children and relatives, but also to search for the meaning of some words, recipes, and to manage their money (home banking).Concerning the actual use of technological devices, we found that they are used by more In accordance with a recent study , our resIn general, the older people in our study had many negative preconceptions about technology. They often declared that they were not able to use it despite the fact that they actually used several devices in their daily life. This feeling of inadequacy or incompetence in using technologies also emerged from other studies -10, and With regard to the functions that the participants would ask a hypothetical robot for, when assisting them at home, we found that they require, above all, cleaning functions. In some cases, they asked for support in preparing meals and in other cases they requested to have their health state monitored or to receive monitoring and aid on request, as already reported in literature ,7. From Bimby or Thermomix, a kitchen robot which helps to prepare meals.Health status is a common concern of all participants. A vital parameter control function was also considered important by participants, especially for the anxiolytic effect it may have on them. They also requested an option for Web-based shopping  and functions that are similar to tools such as the The need of sociality also emerged clearly. Some older people  would ask a hypothetical robot for entertainment-related functions such as listening to music, singing, playing cards, receiving information or keeping up-to-date, and even sharing hobbies. A robot supporting older people living alone could thus have management and monitoring functions, as well as entertainment and company functions.After watching the Giraff video, many of the above functions advocated by participants were confirmed, some reinforced, and new possibilities on socialization envisaged. The interviewed participants understood more clearly the usefulness of a robot in monitoring and managing emergencies, particularly the Giraff’s function of calling in case of emergency, which was acknowledged by one-third of the participants. One-third of the participants highlighted the perceived usefulness of Giraff in detecting gas leaks or intrusion of strangers into the house. From the socialization point of view, the participants’ acknowledgment of a robot’s ability to communicate and entertain increased after watching the video. This is an interesting aspect as people may not be automatically disposed to recognize a nonhuman interlocutor (the robot) as a converser in communication processes or as a leisure companion. One participant even emphasized that the robot “could not speak, offend, and get angry like a human being”; so, this mechanical device could be sometimes preferred to the company of a person.We found that although only a few participants considered that a robot with the abovementioned functions would be useful to those who lost their autonomy, many realized that such a device would help maintain one’s own autonomy and be able to keep living alone in their home.The way participants changed their mind (before and after watching the video) on the possible functions of a robot assisting them at home, seems to be correlated to the views of the technologies that the informants had previously expressed: the more positive it was, more they easily changed their mind and could grasp the potentialities of a robot aimed at assisting the older person who lives alone. Therefore, when proposing a robot to a prefrail elder living alone, the relationship with technologies and their views should be carefully evaluated. Both the older person and the other significant ones around them must perceive the usefulness of technologies, for example, in the contribution that they can give to their safety.The functions that our participants asked a robot for are perfectly in line with those recommended by others belonging to different cultures, such as house cleaning, help in finding information, detecting falls or domestic accidents, monitoring vital parameters, and even in walking around ,7. In adIn conclusion, the results of our study indicate that a technological device such as Giraff could be well received by prefrail older people who live alone at home, even when they belong to a Latin culture (Mediterranean countries and Latin America), where the elder’s assistance is commonly delegated to family members, usually women. In some cases, the robot was considered useful in communication processes or even as a leisure companion. This means that some participants could consider such a device as a remedy to their loneliness. This does not mean considering a technology such as Giraff as a substitute of a human person, but as a tool to maintain and broaden one’s relationships and interests.socially active older people. Furthermore, our participants lived in a big city. Different perspectives on technologies could be gathered from prefrail older people who live alone in a countryside.The qualitative design of this study entails both strengths and limitations. Though we were able to examine data not easily accessible to quantitative research, these results are not transferable. An additional limitation stems from our recruitment mostly coming from ANTEAS, in which participants volunteered or participated in recreational activities. Therefore, even if purposively sampled, the majority of our participants could be defined as This study provides insights on the perceptions of new technologies in a group of prefrail older people. This is a target of potential users that has received little attention by the literature. Our study suggests that many participants were able to use technologies, even if they did not always recognize it. Moreover, many seemed to be open-minded toward technological devices, even toward robots.familism —a strong commitment to the family as a system of support, learning, socialization, and assistance—can be a core cultural value, could recognize among the functions that a robot should have, some not trivial ones, such as company and entertainment.Moreover, some older people, even from Latin culture where Therefore, proposing new advanced technology to a group of prefrail older people, who are self-sufficient and live alone at home, is both attainable and desirable. However, before proposing robots to this target group, it is highly recommended to conduct a pilot study on the development of such new technology to make it more suitable for the end users, as we began to do in this study.


Sub Saharan African (SSA) prisons have seen a substantial increase in women prisoners in recent years. Despite this increase, women prisoners constitute a minority in male dominated prison environments, and their special health needs are often neglected. Research activity on prison health remains scant in SSA, with gathering of strategic information generally restricted to infectious diseases (human immunodeficiency virus infection HIV/tuberculosis TB), and particularly focused on male prisoners. Health care provisions for women (and pregnant women) in SSA prisons are anecdotally reported to fall far short of the equivalence care standards mandated by human rights and international recommendations, and the recent agreements set out in the Southern African Development Community (SADC) Minimum Standards for HIV in Prisons.A scoping review mapped what is currently known about women prisoners’ health experiences, unique prison health care needs and health care outcomes in SSA. A systematic search collected and reviewed all available and relevant published and grey literature (2000–2017). Following removal of duplicates and application of exclusion measures, 46 records remained, which represented 18 of the 49 SSA countries. These records were subsequently charted and thematically analysed.The Prison Regime’; ‘Navigating inside the Prison Health Infrastructure’ and ‘Accessing the outside Community and Primary Care Health Services’. Women in SSA prisons experience the same substandard nutrition, overcrowding and unhygienic conditions which exacerbate poor health and infectious disease transmission as males. Human rights abuses, substandard prison conditions and poor access to prison based and community clinical care, along with the invisible nature of women and that of their unique health needs are deplorable.Three themes were generated; ‘The review has highlighted the dearth of gender specific strategic information on women prisoners in the region, appalling environmental conditions and prison health care provision, and violation of human rights for those incarcerated. Enhanced donor support, resource allocation, prison health and population health policy reform, health systems surveillance and gender sensitive prison health service provision is warranted. This will help address women prisoners’ conditions and their specific health needs in SSA prisons, and ultimately bridge the gap between prison and population health in the region.The online version of this article (10.1186/s12914-018-0170-6) contains supplementary material, which is available to authorized users. I had an abscess in my mouth… I had to buy antibiotics from another woman [fellow inmate] who was taking antibiotics for her tooth that was removed...” , the officers tell you that you still have to go…” [Equity in prison health care access in Zambia was reported to be affected by prisoners’ hierarchy  . Female  to go…” . Lack of to go…” , 46, 47.“…I have not been to the clinic yet, no antenatal care. I went to the clinic once but was told the nurses were not working...” [We had no regular medical check-ups… And then there was the abuse- They called us names…Some of the nurses shouted at me while in labour at referral hospitals where I had been taken in my prison uniform and handcuffs… You are forced to return to jail within 48 hours after giving birth at public health facilities together with the newly born baby and that is when you get an extra blanket for the baby...”[Provision of specific sexual and reproductive health services for women prisoners in the SSA region were reported as poor, ill-equipped and not meeting recommended international standards , 42, 61.king...” . An ex-iking...”  shared h baby...”.“…For those who are pregnant, they are tested for HIV...Whether you like it or not you are tested to prevent transmission to the baby…” [“…I normally get my medicine once a month and I take it each day. I started ARVs in 2006, but when I was in Kwa Kabuga I did not get them…” [When I told the prison officer I was HIV positive, he said, ‘Fight on, complete the sentence, go home, and get treatment.’ It meant he can’t do anything for me. There were wardens I informed. They said prison has nothing to offer me...” [HIV Prevention, Treatment, Care and Support (PTC&S) and treatment for opportunistic infections such as TB in SSA is not adequately implemented within prison based health services , 62. HIVe baby…” . Medicale baby…” , 42, 66.e baby…” . Other se baby…” . A femalt them…” . Non-avar me...” . In Soutr me...” .Additionally, prevention efforts were observed to be weak with nurses lacking in training of preventative medicine and insufficient clinical staff in prisons in Malawi, Tanzania, Swaziland, South Africa, Mauritius and Zimbabwe . Other s“…There are no resources, when you have to take prisoners to the hospital, …then you are wondering how you are going to help these people? So that makes me dread work … even fuel you have to go and beg from other services …” [Bureaucracy in administrative procedures, requirements to procure resources for transport and fuel for medically referred prisoners, lack of adequate trained health personnel and prison staff for the transfer of sick inmates, inadequate vehicles for transportation and fuel, and security fears were described by prisoners and prison officers as delaying clinical care  outside of prisons located in Namibia, Malawi, Cameroon, Mali, Chad, Mozambique, Ghana and Zambia –57, 66. vices …” . Severalvices …” , 49, 50.“…There are delays in getting to the clinic. It depends on the officials, if they want to take you there or not. Sometimes you can go as long as a month waiting to go to the clinic.... They don’t open the door of the cell at night for anything…” .[. Issues relating to lack of confidentiality and privacy for women when accessing outside clinical care were described, particularly in relation to prison security protocols that required prison officers to sit in with patients during primary care and hospital consultations in Mali, Ghana and Zambia [In some prisons in Zambia, access to outside health care was reported to be controlled by medically unqualified and untrained prison officers . Negativthing…” .. Issues d Zambia , 43, 66.The scoping review represents a unique and first step toward gathering mapping available literature on women prisoners’ health experiences, unique prison health care needs and health care outcomes in SSA. Scoping reviews offer a novel route to synthesising a wide range of literature specific to women’s health and health care provision in SSA prisons. We have provided an extant descriptive overview of the situation for women incarcerated in SSA prisons. The review was thorough in terms of its multi layered strategies to locate information. This occurred via online searches, hand searching of international aid and development organisations, health, medical and human rights related databases, websites of various government and non-governmental bodies in SSA, relevant conference listings, and prison and health news sites in each SSA country. In addition, manual searching of reference lists, and the expert consultation post charting occurred in order to cross check for any missing data sources. Limitations of the review centre on the relative lack of available data sources and published studies on women prisoners, with only 18 countries out of the 49 Sub Saharan African countries represented in the final data set. The gathering of strategic information and investment in academic research in SSA prisons at country level warrants improvement.The healthcare needs and experiences of female prisoners in the SSA region remain de-prioritised and inequitable in prison health policies, prison-based health services, and SOPS, and yet are also poorly understood and rarely studied. This, and the dearth of gender disaggregated and empirical information available on women prisoners’ health, and particularly regarding sexual and reproductive health, and infectious disease prevalence , 67, 68 ‘Fast Track to end AIDS by 2030: For People in Prisons’, UNODC, ‘Women and HIV in Prison Settings’, UNODC/UNAIDS, ‘Women’s Health in Prisons’, WHO/UNODC, and ‘Health Systems and Needs Assessment in Prisons - Practical Guide and Toolkit’, ICRC.The review underscores how SSA prison environments remain contra not only to international mandates, but also regional agreements in the SADC Minimum Standards for HIV in Prisons; the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa; and the SADC Protocol on Gender and Development. Human rights violations, abuses and substandard prison conditions, along with the invisible nature of women and that of their health are deeply concerning , 69. In Despite the proportion of women prisoners in SSA prisons being lower than that of their male counterparts’, they are distinctly and negatively affected by prison environmental factors, which impact severely on their specific female health needs and wellbeing , 38, 53.The issue of HIV/AIDS in SSA prisons is both a human rights and public health issue, which requires a strategic approach with shared public health and human rights goals in policies, to prevent HIV transmission and improve health for all, whilst at the same time ensuring equivalence of care to that provided outside prison, with the respect of human rights and dignity of those infected and requiring treatment . It undeno-one left behind’. Health citizenship of women prisoners must be fostered along with a sense of belonging to a community of people whose citizenship has been devalued at two levels, namely that of gender, and that of incarceration. Such prison health policy reform activities sit within the global aim of leveraging the end of AIDS  agenda of ‘nd AIDS,  , May 2017, adopted the resolution E/CN.15/2017/L.5/Rev.1, Women prisoners are entitled, without discrimination, to health care, both within and accessing community care including preventive measures, of a standard equivalent to that available in the outside community . The revAdditional file 1:Table S2. Summary of Records. The scoping review charting of records (DOCX 74 kb)


The motivation of health workers is a key concern of policy makers, practitioners and researchers. Public Service Motivation (PSM), defined as the altruistic desire to serve the common interest, to serve others and to help patients and their families regardless of financial or external rewards, has been shown to be key to the performance of public servants. Yet, limited attention has been paid to this kind of motivation in health care settings in low- and middle-income countries. Little is known about PSM and its contextual specificity in the Moroccan health system. We set out to qualitatively explore the meaning of PSM and its expression among health workers in four public hospitals.We adopted a multiple embedded case study design to explore PSM in two well-performing and two poor-performing hospitals. We carried out 68 individual interviews, eight focus group discussions and 11 group discussions with different cadres . We carried out thematic analysis using NVivo 10.Our analysis shows that public service motivation is a notion that seems natural to the health workers we interviewed. Daily interactions with patients catalysed health providers’ affective motives (compassion and self- sacrifice), a central element of PSM. It also provided them with job satisfaction aligned with their intrinsic motivation. Managers and administrative personnel express other PSM components: attraction to public policy making and commitment to public values. A striking result is that health workers expressed strong religious beliefs about expected rewards from God when properly serving patients.This study highlights the presence of PSM as a driver of motivation among health workers in four Moroccon hospitals, and the prominence of intrinsic motivation and compassion in the motivation of frontline health workers. Religious beliefs were found to shape the expression of PSM in Morocco. I enjoyed that. This was not for the sake of doing good for others, but it was mainly for my own satisfaction… My objective was to accomplish this managerial task and to prove to myself that I can do this. This is why I was striving to make that effort.” NHMH 10, Doctor.“I participated in several ‘medical caravans’. This was for me just pleasure. I just enjoyed it. It was not about the feeling to do good for others. I gained patient recognition and above all I felt self-efficacious toward patients”. NHMH 31, DoctorPerforming non-clinical tasks such as participating in quality circles and community volunteering aligned with intrinsic motivation. This enhanced their feeling of self-efficacy.“We need that leaders recognise our performance: 6.000 deliveries a year! We need that they congratulate us”. SMBA 06, Midwife.“We are satisfied when our effort is acknowledged by others (patients).” NHMH 13, Doctor“When people came to thank me, because they get well because of me, I feel that I am the happiest man in the world. Because, I hate to walk around in the city and that people bad mouth me: “This obnoxious doctor did not treat me well”. I cannot tolerate this.” SMBA 18, Doctor.Esteem from supervisors was highly valued and led some health workers to feel guilty when they do not meet their supervisors expectations.“I feel ashamed, if I did not do the work my superior ask me to do”. SMBA 05, Nurse / senior manager.More extrinsic motivation-related drivers were reported as well, including the importance of recognition by leaders and patients.“Here in the public sector, there is a certain liberty, work is fluid. This is why I choose the public sector. I avoided the private sector where I could earn twice or thrice my salary, but I dropped the economic reasons, and chose to get the minimum wages offered in the public sector, because I chose to be free, because there is less hierarchy than in the private sector or in the university teaching hospital, where the doctor in chief could sanction me severely and even stop my salary.” NHMH 2, Nurse.“Why am I staying at the public sector? I can earn three times my salary in the private sector. Well, I have a six years old daughter, I need to enjoy her company.” RKMH 3, Doctor.Other sources of extrincic motivation mentioned by our respondents include job security, flexibility of working schedules and work-family life balance.It emerged from our analysis that public service motivation is a notion that seems natural to the health workers we interviewed. When talking about PSM, respondents mentioned several components: affective motives (compassion and self-sacrifice), normative motives  and rational motives (attraction to public service). In addition, they reported religion-based motives they labelled as ‘seeking divine rewards’.“Patients are important for me because I got sick. So, I sense what the patients are feeling. My family members, my daughter and my grandmother got sick. So, I feel the pain patients are suffering from. I can feel their suffering. ” SMBA 35, Nurse.Staff were expressing compassion with the vulnerable and underprivileged members of the population. They were placing themselves in their situation and showing empathy toward these patients and their families. This even led some of them to help patients pay user fees.“One day, a citizen came to pay for laboratory tests for his daughter who had fever and he could not afford to pay the fees. I added the missing amount from my own money. Not every day, but often, I bring small change to help citizens who do not have the full amount. My wallet is always opened.” NHMH 29, Revenue officer.Respondents explained that serving the underprivileged and caring for the poor is one of the reasons that kept them working in the public sector.“Here, I work a lot with vulnerable citizens. It is a reward in itself to serve poor patients. It is my source of motivation”. RKMH 3, DoctorThe notion of self-sacrifice was mentioned but not often. Some respondents expressed the importance of serving the patient compared with the financial rewards. Some health workers may forgo their own health needs in order to serve patients in what we call an “escalation of commitment”.“Sometimes, I think I sacrifice a lot in order to serve others. We cannot justify this. It is not reasonable. It is 16h30 and I just ate! I do not eat. I lost weight, I got tuberculosis, I had cervical pain, arthralgia, backpain, a sciatica. I had thoracic pain because I suffered from a pleural effusion. Is it logical to suffer in order to treat patients?” EJMH 38, Doctor Emergency Unit.“The cardiologist is highly concerned about patients. She is worried about them. Even if her shift ends at 4H30 pm, she keeps coming back to the hospital to check on them, even during weekends. She is continuously in contact with us by phone to check on her patients, their test results, their condition. She is omnipresent. If a patient is in a bad condition, she returns to the hospital. She does not have to, but she keeps coming back even during weekends. She is so consciencious and keeps checking on her patients. This is why she got sick!” EJMH 24 nurse.In terms of affective motives, our respondents talked mainly about compassion and self-sacrifice. To a striking degree, nurses and physicians expressed compassion with patients’ conditions as a major motivational factor. This emotional response was also expressed by administrative personnel with frequent contacts with patients (e.g. cashiers).“A love for our country, love of our territory, love of the land of our ancestors, love of neighbourhoods, we love to leave a suitable environment for our siblings.” EJMH 8, Administrator.“We are Moroccans serving Moroccans. I do not feel proud if I could not serve adequately our citizens. We are an integral part of this institution. The reputation of this institution is our reputation. We are a small cell within a large cell that is the Ministry of Health. We work with devotion”. NHMH 16, Doctor.Some of the health workers who expressed a commitment to public values described how that led to prosocial behaviours, such community volunteering.“We care for the public service. We organized a community action in the former hospital location on a voluntary basis, without any instruction from the hospital administration. We noticed that the hospital garden was deteriorating. So, with other friends and union representatives, we refurbished the garden.” EJMH 23, Nurse.“I worked for non governemental organisations, doing medical caravans with doctors in rural areas in Walidia. I started working for NGOs not affiliated to any political party in 1979-1980. I believe that working for NGOs educates young people. We grew up doing medical caravans, serving the population, we worked with doctors till 8 or 9 pm.” EJMH 41, Nurse.In terms of norm-based motivation, our analysis shows that many respondents emphasised their desire to serve the public interest and their high sense of civic duty. They referred to these motives as feelings of citizenship, the desire to serve the nation, the citizens and the general interest, and the need to be rightful and equitable. This was expressed by all categories of staff .“As the chief of this department, the most important thing for me is when I am involved in decision-making. I do not only report on problems. As a leader, I suggest solutions that get always approved by the hierarchy.” EJMH, 12 Nurse intermediate manager.“This title [Chief Nursing Officer] allows me to commit to my job. As a chief nursing officer, I have an authority on all nurses in the hospital. Sincerely, this title motivates me because I am solicited by staff to provide them with the necessary support. This is true for both doctors and nurses. I am fully satisfied when my opinion is listened to and taken into consideration. This makes me more motivated to fill this position that allows me to serve people.” EJMH1, Senior manager, Nurse.PSM was expressed similary by respondents from both poor- and high-performing hospitals. However, in poor performing hospitals, staff said they were suffering from psychological distress and feelings of guilt because of their inability to perform their job adequately and to ease their patients suffering.“We lose patients stupidly because of a lack of material. There is no material to work with. You see patients die in front of you and you do not have necessary tools to save them. These conditions are beyond our control.” SMBA 43, DoctorThis influenced negatively their well-being.“When you do not have necessary material to work with, you are in trouble! It is not only a constraint, but a source of suffering. Instead of relieving patients’ distress, it is us who get stressed.” SMBA 45, DoctorFinally, we examined in how far respondents mention rational motives for working in the public service. We found that nurses who occupy managerial positions emphasised the importance of participating in decision-making and the social importance of their function. They feel proud when they are consulted and involved in decision-making. For some, this contributes to their motivation, as it allows them to more effectively serve the public.The respondents in both high- and poor-performing hospitals identified a number of factors that contribute to high PSM: family education, military service, volunteering, professionalism and religion.“I do not take bribes. I have an ideal about the role of doctors in society. Their role is not limited to being a care provider at the hospital. They should get out to the community, sensitize the population during health education sessions. I feel satisfied when we organize a round table with practitioners and local representatives, when we organize medical caravans, when we circumcise children for the sake of God. I learned these principles through my parents’ education. When we were young, we were educated to help people, to help others, neighbours, friends, siblings and family members. I cannot explain these things, I do not know if it is genetics, but we learn that we do not live alone but in a society. We depend on each other, we belong to a society, we live with neighbours and people. Everybody is leaning on others, like dominos.” SMBA 40, SurgeonHealth workers with a high level of PSM explained how family education and childhood experiences contributed to their high sense of civic duty and a high orientation to civic participation. Parent modelling and education led them to serve others and to act for the common good from a non-self-interested perspective.“Every health worker, specifically males, should do military service, as I did. At that time, I went to Al Farssia, a remote area in the Moroccan territory in the middle of nowhere. I used to stay there between two to three months and then would go back to town for a short period of time. Every time I went back to that region, I recognized the true meaning of life and the true value of things, when I compared urban life to these remote areas.” NHMH 32, Doctor/Senior Manager.“I was asked to join the military service. … I believe that in my country, we are more effective if we serve the poor, if we work for the interest of the most vulnerable citizens. The experience I had in the medical service in the military affected me a lot. It has shown me that Morocco needs more faithful and serious health workers.” SMBA 18, DoctorSome health workers explained that their commitment to public values is reinforced by their former experience in the mandatory military service. These experiences provided them with high sense of civic duty and citizenship, which subsequently contributed to their feelings of public service motivation.“From 1970 to 1980, I was part of an NGO doing medical caravans with physicians in rural areas. Volunteering educates people. When you grow up volunteering, you will be loving to serve the population. I worked for 8 to 9 hours a day without being paid. I did it for the sake of God without waiting for external rewards. EJMH 41, Nurse.The experience with volunteering in remote areas during medical outreach caravans shaped the feelins of PSM of some respondents. They identified this as a catalyser of self-sacrifice and civic participation.“I love my job. I cannot neglect my job. This is how I was educated and taught in the first place. I cannot let down a patient, even though I know that this  does not depend only on me. I cannot. I try to help patients even if they are from other departments. I call the surgeon to deal with a patient with a suspicion of appendicitis, even if it is the job of the physician at the emergency department.” SMBA 24, Nurse,Their commitment to serve the patients is integrated within their professional identity but also with their religion.damir]. I have to serve them conscientiously. It is important part of my personality. I do not like to fail to properly perform my duty. My money will be then halal [Compliant with what is permitted in Islam]. NHMH 13, Nurse“ ‘Citizens’ means for me ‘professional conscientiousness’  praises God for you, he says nice prayers! “May Allah [God] be pleased with you. May Allah be merciful to you. May you be covered by the grace of God”. At such moments, I feel reassured and relieved during my night shift. Then I go home fully satisfied.” SMBA 35, Nurse.ajre (divine rewards) from God, which is far better than money.” EJMH 18, Administrative staff.“When serving people, you earn ajre [divine rewards]. We do not know what might occur to us in the future. We seek ajre from God. He is the only one who will reward us for our effort”. SMBA 7, Nurse.‘This is between us and God, Glory be to Allah. It is between me and God who created me. We do good deeds when serving patients because we need Our analysis indicates that religious beliefs may underlie public service motivation to the extent that these beliefs contribute to an altruistic and compassionate attitude towards patients as well as to commitment to public values.halal [meaning in compliance with Islamic rules]. This means I have to work, to serve people. We are equal to them. We are all Muslims. They [patients] are our fellow countrymen, our fellow citizens. We are obliged to give them back what we owe to our country.” NHMH 11, Surgeon, Intermediate-level manager.“There is a religious element that plays a role in my motivation. We have to make our money Our data show that these religious beliefs are closely aligned to the professional sense of responsibility and duty, to the attraction to public service and to compassion.“I am pleased when I treat patients decently and they pray God for you. I am pleased when I see that patients are happy and in a good state.” SMBA 35, Nurse“Have mercy on those on earth, the one in Heaven will have mercy on you ... This is our real profession, to love others. I am a human, I can also become sick. We are all patients”. SMBA 17, NurseWe found that for many health workers we interviewed, PSM and religious beliefs and values are intertwined. They express their altruistic and compassionate attitude towards patients as a spiritual personal obligation. When serving patients ethically and altruistically, they expect to receive intangible and divine rewards (in arabic hassanat’ or ajre). They also frame this as a commitment to public values such as equity and patriotism.Halal.” [Halal means compliant with Islamic rules]. “Thank God.” We said this because it is very important! We must make sure that our salary is halal before God and our own conscience. There is nobody watching over us, whether we came at 8 am in the morning or not”. EJMH 9 doctor“In Arabic terms, we do this because we need to make our salary “When discussing PSM, health workers also referred to the ‘Hadith’, the sayings of the Prophet Muhammed, when they justified why they are committed to help patients and the underprivileged.“[In the Prophet Muhammed sayings and teachings], the prophet said “Who served other muslims, is rewarded like someone who stayed a month praying in this mosque.” This explains why I came early at 8h30 am. Sometimes, when I come late to work, I stay late in compensation, hoping that this way, God will help my siblings.” NHMH 11, surgeonHadith’ ]. I feel satisfied and I enjoy that. We have an ideology that dominates our behaviour as muslims. We are not compensated directly but we get rewards later in other circumstances. Sometimes, I might serve and help this old lady we have just seen. By doing so, I might be helped in the future when I will experience the same situation.” NHMH 7, Doctor.“We are muslims. Then, satisfying the need of others is essential [referring to ‘Our analysis shows that quite some interviewees expressed strong religious beliefs about expected rewards from “God” when properly serving patients. They explained their altruistic behaviour by their expectance of divine rewards  on the other. We found, in line with other study findings , 93, 94,Our study showed that managers, and nurses in management positions in particular, similar to previous studies , 99, valAlthough PSM scholars usually do not consider that intrinsic motivation is an essential part of PSM , our stuWe also found that a number of respondents framed their public service motivation in religion-based motives, such as divine rewards  and with roots in family education. This is similar to findings of studies in Morocco , 110–112As mentioned in the introduction, this study on PSM is part of a larger project looking into the relationship between leadership, motivation and performance. Future research needs to examine the link between PSM and individual and hospital performance. We think managers of public hospitals should be aware of the differences in PSM among health workers and adapt their leadership practices accordingly. In the Moroccan context, they may need to emphasise spiritual and public values when communicating about organisational mission and objectives, and reinforce the interaction of their early-carrier health personnel with the underprivileged parts of the population during, for instance, medical outreach and other community-level initiatives. Finally, they also may ensure that adequate resources are provided for frontline healthworkers to allow them to experience valued outcomes such as saving patients’ lifes.This study has a number of limitations. First, we did not measure actual levels of PSM, largely because of the time constraints which precluded validation of existing scales in Morocco. This study was thus necessarily exploratory in nature. Further studies should indeed validate, and adapt if necessary, the scales of for instance Kim et al.  in orderWhile the notion of PSM is not part of the management discourse in Morocco, we found that PSM seems to be a ‘natural’ concept to health workers in Moroccan public hospitals. We found that hospital staff are motivated by different drivers of PSM and that religious-based beliefs infuse the notion of public service. Hospital managers should pay more attention to the nature of staff motivation  and adapt their leadership practices accordingly.Additional file 1: Open ended interview.Additional file 2: Focus Group Discussion Guide (senior managers).Additional file 3: Sociodemographic characteristics, case study 1 (NHMH).Additional file 4: Sociodemographic characteristics, case study 2 (EJMH). Additional file 5: Sociodemographic characteristics, case study 3 (RKMH).Additional file 6: Sociodemographic characteristics, case study 4 (SMBA).


One hundred years have passed since the discovery of bacteriophages (phages) by Frederick Twort and Felix d'Hérelle. Over that century an enormous amount of phage research has been undertaken globally—based on the exquisite ability of phages to both infect and kill bacterial cells—in a chase to better understand life generally and also to use phages as tools to eradicate problematic bacteria. The latter typically is described as phage therapy, bacteriophage therapy, or some approximation of phage-mediated biological control of bacteria .After the discovery of penicillin and subsequent dazzle of antibiotic outcomes on bacterial diseases, phage therapy research had seen a deceleration. This decline, however, was predominantly a Western phenomenon while phage therapy research as well as clinical practice continued to take place especially in the former Soviet Union and, subsequently, in Poland In 2010 an editorial was published in Nature Reviews Microbiology titled, “Raiders of the lost articles” Lack of awareness of what has been published on phage therapy, both past and present, is both unfortunate and potentially enormously wasteful. As noted in In many scientific fields there seems to be an increasing lack of appreciation of the early literature around which the field has grown. As a consequence, junior scientists entering a field, who might be unaware of some of the work of the early pioneers, risk wasting a great deal of time and money asking scientific questions that are baseless or have already been answered. …the next generation of scientists must be encouraged to engage more fully with the older literature. Not only will this provide individuals with a greater appreciation for the history of their given field, but it will also help to inform their current work and the scientific questions that they ask. If we fail at this task, then we face the very real prospect that much hard-won knowledge will be lost.Thus, we face a problem, not limited to but nonetheless highly relevant to phage therapy, one in which, in a sense, a certain degree of ignorance is being institutionalized by limitations in the power of information technology.Another problem which perhaps is more specific to phage therapy is that of terminology. Phage therapy has been around, as noted, for nearly 100 years, but has not existed during that time as a highly coherent field. Indeed, the simplicity of using phages as antibacterial agents allows entry from many different fields, really anybody with a bacterium which they would like to reduce in numbers. As a consequence, not everyone calls phage therapy “phage therapy”. To a degree, this is very legitimate since the term “therapy” should be limited to describing situations which are in fact therapeutic, such as clinical or veterinary use of phages. Other types of phage therapy should be described as forms of biocontrol or, more formally, as phage-mediated biocontrol of bacteria The result is a difficulty in finding phage therapy “wheat”. A “phage therapy” search on PubMed, in quotes, yields 645 references, as this is being written, while a “bacteriophage therapy” search yields 214, “bacteriophage therapy” NOT “phage therapy” yields 141, and “phage therapy” NOT “bacteriophage therapy” yields 572 references. In addition, not all journals are indexed through PubMed, especially papers which lean less towards therapy and more towards biocontrol, and in particular towards applications in aquaculture along with the biological control of foodborne pathogens.The problem with “chaff” stems in part from the noted issue of generality of the use of “biocontrol” as a term. This is seen in searching Google Scholar, even when limiting searches to those that mention “phage” or “bacteriophage”. The following search, without the external quotes, thus yields over twenty thousand hits: “(phage OR phages OR bacteriophage OR bacteriophages) AND ”. A second issue is that “phage therapy” is a “hot” buzzword to use in phage publications, particularly when describing phages with potential but not yet demonstrated phage therapy application, where the latter simply are not phage therapy publications. Thus, a Google Scholar search on “phage therapy” OR “bacteriophage therapy” (with the quotes) yields approximately 9,000 hits, which probably is seven or so thousand in excess in terms of actual phage therapy work, or reviews. Given use of alternative descriptive terms, perhaps there are hundreds of references missing as well. The issue, then, is one of identifying phage therapy or phage-mediated biocontrol “wheat” from faux “phage therapy” and “biocontrol” chaff, which, to the extent we so far can tell, is simply a matter of putting in sufficient time and effort. Here then we describe both the culmination of nearly 20 years of tracking down phage therapy references along with plans to keep the process going, on a year-to-year basis, as an online Phage Therapy Bibliography.We have compiled and have made freely available references to primary research articles, reviews, books, and book chapters covering the subject of phage therapy and, more generally, phage-mediated biocontrol of bacteria. This can be found at publications.phage-therapy.org or phage-therapy.org/literome.  The bibliography focuses on English-language publications and is listed in descending-year and ascending-author order. At the moment the bibliography covers the years 1917 to 2016 with a goal of expanding the collection both yearly, i.e., as initiated prior to the end of the following year, and on a more ad hoc basis as we become aware of otherwise missed publications. To achieve these goals, as well as towards error checking, we kindly ask individuals with an interest in phage therapy to look into the bibliography and help us towards making it as complete as possible.In the bibliography, each reference is complemented with the PubMed link to the article, if available. There the user often can access the article abstract, and in many cases view the entire article as well. References are highlighted (“Open Access!”) for those articles which are of obvious open access availability via PubMed. In addition, we are in the process of providing links, via Google Scholar, which can be helpful especially when PubMed indexing is lacking. At the moment the bibliography comprises approximately 1400 phage therapy-related references, which is remarkable when compared to PubMed which for the same 1917–2016 period, when searching on “phage therapy” (in quotes), provides roughly 600 references. Our aim especially is to provide to phage therapy researchers, including, of course, ourselves, a somewhat complete gateway to a majority of the English-language phage therapy scholarly publications.A fundamental part of doing research, apart from experimentation, is searching and reading the published literature. It is, obviously, truly difficult to overstate the importance of doing this, though at the same time we are personally aware of how difficult a task this actually can be. The older literature especially should not be overlooked simply for reasons of false perceptions of irrelevance or, instead, of inconvenience. Certainly phage therapy researchers with interests in treating specific organisms should not hesitate in reaching as far back as possible in this literature as it pertains, therapeutically using phages, to those specific organisms. For academic and industry researchers therefore it is crucial to be at least aware of and, ideally, also to have access to previous and pioneering research, where often science was done under fewer institutional pressures, less pressing near-term goals, or indeed fewer limitations on clinical research. Such collective awareness is essential towards expanding our knowledge of phages, the dynamics of their interactions with bacterial cells, their interactions with treated environments, and especially their clinical use. Insufficiencies in such awareness can result in a “polluting” of the published literature with what politely may be described as poorly processed information. Researchers, that is, need to be asking the next questions rather than wasting time and money unknowingly repeating or otherwise obscuring what already has been published. Our hope is that this online phage therapy bibliography, in providing better access to the phage therapy literature, will be helpful towards the development and eventual Western re-acceptance of phages as effective antibacterial agents.