Evaluating risks associated with multiple occupational exposures is no easy task, especially when chemical and physical nuisances are combined. In most countries, public institutions have created databases, which gather extensive information on occupational exposures or work-related diseases. Unfortunately, these tools rarely integrate medical and exposure information, and, above all, do not take into account the possible adverse effects of co-exposures. Therefore, an attempt to exploit and join different existing databases for the assessment of the health effects of multiple exposures is described herein. This case study examines three French databases describing exposures to noise and/or ototoxic chemicals  and the incidence rate of occupational deafness in different sectors. The goals were (1) to highlight occupational sectors where the workers are the most (co)exposed and (2) to determine whether this approach could confirm the experimental data showing that this co-exposure increases the risk of developing hearing loss. The results present data per occupational sector exposing workers to noise only, ototoxic chemicals only, noise and ototoxic chemicals, and neither of these two nuisances. The ten sectors in which the proportion of exposed workers is the highest are listed. This analysis shows that the rate of hearing loss in these sectors is high but does not show an increased incidence of hearing loss in co-exposed sectors. In most occupational settings, workers are exposed to several nuisances ,2,3,4. IExpert assessments are often conducted by public institutions, such as the French Agency for Food, Environmental and Occupational Health and Safety (ANSES), in response to requests from authorities and stakeholders. These analyses, generally conducted by scientists recruited for their knowledge, review the current data on exposures and burden of disease for specific populations, locations or occupations, and provide recommendations for the improvement of people’s safety and health. When carried out over a long period, these studies can lead to job exposure matrices, such as the Canadian carcinogen exposure surveillance project CAREX Canada .https://www.bls.gov/iif/soii-data.htm, last accessed on 2 December 2021) and the “Caisse Nationale d’Assurance Maladie”  in France (AMELI website: http://www.risquesprofessionnels.ameli.fr/last accessed on 2 December 2021). The open data provided on their websites list all occupational diseases that fall under the right to compensation and the number of cases recognized as such per occupational sector (NACE).This type of expertise always relies on the knowledge provided by the collected data. In France, the cross-sectional periodical survey named SUMER  is organized every 6 or 7 years in order to collect such data at the national level. Surveillance data can also be collected by national agencies. The exposure level per nuisance data are probably the most difficult to collect. Some insights are often found in longitudinal and cross-sectional studies. Most of the time, exposure levels are only estimated and self-reported. Thus, data are often presented as ranges. Databases gathering exposure measurements in the workplace exist in different countries, such as MEGA , IMIS 11, COLCHIThe ultimate goal of all these databases is to improve health and safety at work. One way to do that would be to find causal relationships between working environments and the health problems or diseases of workers. The greatest difficulty in reaching this goal is that diseases and symptoms are rarely specific to an exposure or nuisance. Some notable exceptions include bladder cancer caused by amine exposure  or mesotThe main ototoxic substances used in the workplace are aromatic solvents and metals. Metals can be present in inhaled air as fumes, dust or (nano)particles, or produced in cutting, grinding, polishing or welding operations. Animal data suggest that metals have distinct toxic modes of action, but all involve an oxidative stress mechanism and first target the neuronal cells and peripheral nerve fibers of the cochlea before affecting the sensory hair cells . AromatiIn this case study, three French databases are joined to search for correlations and to attempt to confirm a suspected effect observed in experimental or epidemiological studies.SUMER provides the number and proportion of workers exposed to different nuisances for different jobs and/or occupational sectors.COLCHIC and SCOLA provide the intensity and/or the duration and/or the frequency of exposure to chemical substances.AMELI provides the yearly disease burden: the number and proportion of workers having declared an occupational disease during each calendar year.The two aims of this case study are to portray the occupational sectors in which exposures to noise and/or ototoxic substances are the most prevalent, and to investigate if the effect of ototoxic substances and their interaction with noise can be observed in data.The methodology is described in The availability of data sources can be classified into three types. Open data are free and can be directly downloaded, or access can be easily granted by the data provider. Specific conditions of use may be imposed, such as non-commercial use or the obligation to cite sources. Public national data can often be accessed if the data request comes from an academic research institute or a university. The owner of these data might require a financial contribution or to be part of the steering committee of the study, or to be co-author of the resulting publications. In all cases, partnership conventions have to be signed between stakeholders, and this process can take months. Finally, private data, owned either by university laboratories  or enterprises, are the most difficult to access. When access to these data is granted, the data must be hosted in a secure place in terms of software, hardware and workroom. If the data include personal nominative information, additional security measures have to be deployed, such as the traceability of data treatments or data deletion at the end of the study. Moreover, human research protections might be required, as well as related approval processes.SUMER is a survey conducted every 6 or 7 years by the French Ministry of Labor. Occupational physicians collect a vast amount of data regarding workers from all occupations in France. Access to SUMER data has required a partnership. These data allow (among other things) the identification of workers exposed to noise and ototoxic substances per occupational sector. Data from the last three surveys were pooled, adjusted and used. Around 1500 variables were collected. A total of 50,000 individuals were surveyed in 2003, 48,000 in 2010 and 26,000 in 2017. These data are representative of the whole French workforce.COLCHIC and SCOLA are national databases hosted by the French National Occupational Health and Safety Institute (INRS), containing about 1,500,000 measurements of chemical substances at the workplace. Among these measurements collected by occupational hygienists from French public health insurance and privately held laboratories in charge of regulatory controls, the levels of exposure to eight ototoxic substances per occupational sector were extracted. Lead, styrene, toluene, n-hexane, trichloroethylene, arsenic and cobalt were selected because data were available in COLCHIC, SCOLA and SUMER, and because these substances have ototoxic properties demonstrated or suspected in humans.AMELI is a website edited by French public health insurance in which the number of cases of occupational hearing loss (among other pathologies) per occupational sector is provided as open data.Finally, the French national statistics institute (INSEE) provides the number of workers per occupational sector, also as open data.Four databases were used for the present case study:The “statistical unit” is a variable or a set of variables shared between databases. It is also the primary key, which is a unique identifier of each data line. Therefore, the statistical unit represents the expected level of detail of the analysis. Depending on the research question, the statistical unit can be any variable, but for job exposure matrices, the job and the occupational sector are commonly used. These variables are categorical variables: they do not take ordered numbers as values, but rather as labels, often extracted from a thesaurus.In the present case study, the occupational sector was chosen as the statistical unit. In all four databases, the data were classified using the NACE code. This code can be used at different levels of detail: there are 21 main sectors, divided into 732 occupational sectors at the most detailed level. An example of NACE codes is provided as There are thousands of technical issues related to data handling. In principle, the first step is to select and filter the data to remove all redundant or useless information, which might not bring meaningful knowledge to answer the research question. This step reduces the amount of data and computational time. Data from AMELI and INSEE only required typical handling, with no filtering or data transformation. By contrast, measurement data from COLCHIC and SCOLA required an important filtering process in order to focus on ototoxic substances only, as well as on individual sampling data. In addition, data analysis included the identification of the proportion of measurements above the occupational exposure limit values for each substance in each occupational sector.When considering occupational health data, there might be a benefit of pooling different databases containing identical information. This was performed with SUMER data: the data from the three last surveys  were pooled.SUMER data required the computation of extra variables for the identification of the number and proportion of individuals exposed to (1) noise only, (2) ototoxic substances, (3) noise AND ototoxic substances and (4) NEITHER ototoxic substances NOR noise. These extra variables were computed per occupational sector. Finally, when considering individual-based surveys such as SUMER, the data must be adjusted according to survey weights, which allow statistics to be computed upon the entire population based on the surveyed individuals. In SUMER’s case, the survey weights were provided by the data owner.The presentation of the results has to reflect the three dimensions of the analysis: the population, the exposure and the occupational disease. The indicators are expressed with regard to the chosen statistical unit: occupational sector or job. The population indicators are, at least, the number and the proportion of exposed workers. The exposure indicators reflect the nature of the nuisance or the combination of nuisances and possibly the level, the duration, or the frequency of exposure. Finally, the indicator of occupational disease is generally the incidence rate, i.e., the number of diseases per 100,000 workers of the statistical unit.Sorting data into exposure categories is seductive. For example, “exposed/not exposed” or “high exposure/low exposure”, but the limits between these categories are often difficult to define and may result in arbitrary, unsatisfying cutoffs. Indeed, no number can properly define “exposed” versus “not exposed”. The design of statistical models is also an option for the analysis of data but may lead to complex findings that are difficult to interpret. Nevertheless, regarding the complexity and the multiplicity of data, this is probably the most reasonable way to obtain results. Finally, data visualization is definitely an issue that depends on the results.The results of this case study are illustrated by four tables, each of them displaying the 10 occupational sectors where the largest proportion of workers have declared being exposed to noise only ; ototoxiStatistical linear models (with or without data transformations) were attempted to correlate the proportion of workers exposed to noise and ototoxic substances with the rate of occupational hearing loss. The results are not shown because no model had a satisfying predictive performance. This means the data used in this approach do not allow the observation of the toxicological findings that demonstrate the synergetic effect of noise and ototoxic substances. The major reason for this is probably related to the under-declaration of occupational hearing loss: In 2014, French health insurance estimated that about 12,500 cases of hearing loss caused by occupational noise exposures were not declared each year. This number is strikingly higher than the ~600 occupational hearing loss cases declared as caused by the occupation each year . FurtherFurthermore, there is a lack of information about (1) the intensity of noise exposures and (2) the coding of occupational sectors. First, the only information available regarding noise exposure is a declarative statement made by the worker in the SUMER survey (“Are you exposed to noise >85 dB(A)?”). No reliable database compiling noise levels in different occupational sectors is available in France. Second, the occupational sectors used as the statistical unit may cover very different occupations and tasks and therefore may not be precise enough. The same observation was made by Cheng et al. .Another limitation of the current approach is that most occupational chronic diseases appear after repeated exposure to a nuisance. The delay between the exposure and occupational disease can be counted in years, even dozens of years . This should be taken into account, in particular if practices or policies change the average exposure over time. For this purpose, it is important to document the role of each nuisance separately in order to estimate the probable delay between exposures and diseases. In the case of noise exposure, the delay between exposure and the occurrence of hearing loss is rather hard to define because, depending on the noise level and on the type of noise , deafness can appear in hours or over the course of a working career. That is why this delay was not taken into account in this study.More generally, the methodology is based on the assumption that there is a correlation between exposure and occupational hearing loss, as is the case, for example, in this study, which used several databases for cancer related to some occupational nuisances . TherefoThe definition of “multiple exposures“ is also an issue in this type of study. The most precise approach is undoubtedly the epidemiological study: obtained data provide a direct link between the different exposures of the subjects and the adverse effect or the occupational disease. In observational data studies, such as those presented in this paper, the potential correlations between exposure and disease are presented through the aggregated statistical unit . Therefore, it is impossible to precisely associate individuals with exposures; exposed individuals cannot be discriminated from unexposed ones within an occupational sector. Likewise, it is not possible to link exposures directly to diseases. The choice of the most appropriate statistical unit has a dramatic importance because a compromise between the perspectives of findings and the availability of data has to be found.3, which is more precise.The extent of what is covered by each database must be known precisely and must be adapted (if possible) to answering the research question. In this case study, the SUMER database included individual data from the public service, whereas COLCHIC measurement data did not. In this particular case, these issues did not have an important impact because the results were presented with regard to the NACE code , and the public service has a specific status. This would have had an important impact if the statistical unit had included jobs that can be performed in both public and non-public service . Moreover, depending on the data sources used, the information can be more or less precise, but also possibly contradictory, so the most reliable data source for answering the research question has to be chosen. In this case study, SUMER provided information about the intensity of exposure level to chemical substances as categories (very low—low—high—very high), but COLCHIC was chosen because it provided exposure levels as airborne concentrations in mg/mFinally, the technical aspects related to the data can also be improved. The visualization has to be designed from the data gathered. Based on this case study, many attempts were made to provide simple and informative figures, but none were demonstrative enough. The issue of presenting data gathered from several databases assessing multiple hazards, exposures and occupational diseases still has to be resolved. New methods of storing and processing data, such as data lakes, are promising because these methods and the associated tools allow data to be analyzed without changing them. In particular, the graph database model seems suitable since it allows connections between data from different sources to be represented .Although most of the issues listed above were not taken into account in this initial analysis, current and future work will. To be effective, an analysis requires access to a wide range of data belonging to different stakeholders. Researchers, exposure scientists and occupational physicians from universities, national institutes and private companies can be involved in the gathering of data. The required data included information on exposed workers , companies , hazards , level of exposure  and occupational diseases and injuries. Sharing and collaboration is therefore mandatory to perform this approach. If the data are comprehensive, such analysis of the correlations between occupational nuisances and occupational diseases is undoubtedly a meaningful way to confirm the findings of toxicological literature, and to deploy adapted occupational risk prevention actions in companies.This article presents a case study in which data from different sources are joined and analyzed in order to evaluate correlations between occupational exposure to nuisances and diseases. The study focuses on exposures to noise and substances that can impair the hearing system (ototoxic substances) and their potential influence on the incidence of occupational hearing loss. The attempt to visualize the synergistic effect between noise and ototoxic agents, previously suggested by experimental studies, was not successful with this approach. This underlines the fact that the data sources used to document exposures and health effects were not comprehensive: occupational hearing loss is widely under-declared to public insurance, the delay between exposure and disease was too uncertain to be taken into account, and the average noise exposure level per sector was clearly missing. Meanwhile, the study highlighted the occupational sectors where the workers were the most exposed to the combination of noise and ototoxic substances, information that was not readily accessible. These results can be used to target the occupational sectors that require the closest attention from hygienists and occupational health services.The method presented in this paper opens important perspectives. In particular, a joint project between database owners in France was recently launched for the analysis of multiple exposures and their correlations with occupational diseases. This project will include the development of a probabilistic approach to tackle the issue of the lag between exposure and disease.


Background: Patient safety is a public health problem worldwide. In situ simulation (ISS) arises as a learning strategy that allows health professionals to immerse themselves in a real environment without endangering the patients until they have learned the skills needed, thus increasing the quality of care. This systematic review aimed to verify the efficacy of the use of “in situ simulation” as a method that will allow health professionals to increase patient safety in Intensive Care Units after the situation experienced during the pandemic caused by the COVID-19 virus. Methods: Seven studies were reviewed using the PRISMA methodology for systematic reviews. The CASPe guide was used to assess the quality of the manuscripts. Results: The main topics that emerged from this review in relation to in situ simulation were as follows: looking at aspects such as patient self-perception of safety, adverse events, interprofessional communication and health system organization in relation to in situ simulation. Conclusions: The adequate implementation of in situ simulation after the COVID-19 pandemic in ICU services is shown to be an efficient and effective strategy to promote improvement in the attitudes on a culture of safety and teamwork of professionals. The report of the Committee on Quality of Care published in 2000 by the American Institute of Medicine , entitleThe World Health Assembly discussed global action on patient safety in resolution WHA72.6 .The SYREC  study  providedThe current healthcare reality in Intensive Care Units (ICU) demands well-trained healthcare professionals with an adequate level of competence to provide quality care and an adequate culture of safety. There are multiple classifications of simulation in the literature, but among them, Jeffries and Cloches  classifyIn situ simulation training (ISS) is a team-based training technique that takes place in patient care units, using the equipment and resources available in those units, and involving actual members of the healthcare team . With ISThe objective of this review was to systematically assess the benefits of implementing “in situ” simulation as a strategy to improve patient safety in all care settings in intensive care units.The following search strategy was used to search each database. “patient*” OR “intensive care units” OR “in situ simulation” OR “safety”. This systematic review considered studies that evaluated in situ simulation in intensive care units and emergency departments, and those that explored patient safety. Different professional categories  were included. Studies using other types of simulation than “in situ”, such as laboratory simulation, were excluded, as well as articles on pediatrics, neonates or others and studies from other areas of patient care.In the first phase, after the search in the different databases was carried out independently by two researchers, a screening was performed in which the articles were included based on the review of the title. In a second phase, the articles were screened by two different researchers based on the review of the abstract according to the inclusion and exclusion criteria defined. Afterwards, the included articles were subjected to a critical reading using the PRISMA guidelines .The bibliographic search was carried out using the snowball technique , and theOnce the selection of the studies to be included in the systematic review had been made, the CASPe Template ,26 was uData were extracted from the articles included in the review following the protocol established by the PRISMA group for systematic reviews . The extA total of 750 articles were identified after the search, of which 141 were excluded because they were duplicated in the different databases. Of the remaining 609 articles, 67 were selected after reading the title. Next, the abstract was read and 36 articles were excluded because they did not meet the inclusion criteria previously mentioned. Of the twenty-one potentially analyzable articles, a complete reading of the articles and the application of the established inclusion criteria were carried out to finally include seven articles for the present review .The studies were conducted in France, Canada, Australia, Hong Kong, Switzerland, two of them in Brazil, Denmark and United Kingdom. Regarding the methodological design, ten of them were intervention studies, and one of them was a systematic review. It was decided to include it because of the relevance of the content. 42.8% (3/7) were pre-post-intervention studies, and the remaining 57.1% (4/7) were post-intervention. Two of them (28.5%) employed mixed quantitative and qualitative methodologies, using measurement scales in their results, while 71.4% of the studies were qualitative. A total of 36.36% of the studies were conducted in emergency departments, with the remaining 63.64% conducted in ICU departments. The topics analyzed in the review were adverse events, the perception of patient safety, communication between professionals and the organization of the health system .Adverse events (AE) are often the result of several small errors. These errors are called latent safety threats because they occur prior to these events. LSTs are, by nature, difficult to predict or detect until a critical event occurs, often to the detriment of patient care. In situ simulation can identify these safety threats or precursors to AEs by reproducing clinical situations in a real-world setting, allowing LSTs to be addressed prospectively and proactively without risk to patients.Through a case study, Bapteste  revealedThe prospective study conducted by Couto  allowed Through the Safety Attitude questionnaire, Schram  observedSimilar findings were obtained by Paltved  when invAnother study  found thInadequate communication can contribute to the occurrence of critical incidents (CI) and adverse events (AE). Miscommunication is relatively common and can appear directly as a medical error or be described as a contributing factor to the series of events that lead to a medical error. Therefore, Paltved  set out In turn, these data were supported by other studies  on in siIn line with the above, Checuti  not onlyThe aforementioned case study  concludeThis systematic review confirms the implementation of the in situ simulation methodology as an effective way of addressing the elements that promote good patient safety, thus enabling the application of good practices during clinical care.When discussing patient safety, we must address a set of elements that help us to minimize the risk of suffering an adverse event or mitigate its consequences in the health care process. These elements include achieving safe care processes by detecting latent threats that can prevent the occurrence of adverse events, maintaining professionals with a positive attitude towards the culture of safety in order to avoid failures in care, and managing or developing adequate interprofessional communication, among others. These elements are intertwined with each other to ensure quality and safety in care as stated by Kozlowski  in his rIn a study  conducteRegarding the change in the attitude of the staff towards a culture of patient safety post-intervention with ISS sessions, the analysis of the studies included in the present review suggests a positive effect on the creation of an ISS program, showing a significant improvement in staff attitudes towards safety and teamwork climate. This was evidenced in the studies by Schram , PaltvedBoth Paltved , ChecutiTo optimize the effect of in situ simulation on patient outcomes, there is a need to move beyond the use of simulation merely as an educational intervention and human skills screening, to the integration of simulation as a patient safety tool at the organizational and system level. Similarly, this conclusion was supported by other authors  in a revTruchot , throughThe study has some limitations. First of all, the number of articles found, and it is not known why there is such a small number of bibliographic references on this subject. A large number of articles were found on laboratory simulation, but fewer on simulation carried out in the real work site, such as in situ simulation, which may be due to the recent incorporation of this learning technique. On the other hand, most of the publications found on ISS were in the areas of anesthesia, obstetrics and operating rooms, services that were excluded in this review, as it focused on services that had been affected by the recent pandemic caused by COVID-19 such as the ICU and emergency and urgency services, and therefore, the literature found was scarce.On the other hand, although the included articles were evaluated using the CASPe scale and showing their percentage in the results of the studies, it was observed that only four of them had an acceptable quality to be included in the systematic review, while the rest were of lower quality, as they were case studies in which there was a personal subjectivity that generated measurement and reporting biases. Some of them did not allow for comparisons to be made with another control group that did not participate in situ simulation training, and therefore they did not present solid evidence, although they may contribute to the improvement of quality and patient safety. These studies used a non-randomized sample, which conditions the results, as does the impossibility of using blinding in these investigations.These were short-term studies where the results were analyzed once the simulations had been completed, and no studies were found where the long-term impact of the intervention carried out was evaluated.This systematic review suggests expanding lines of research by conducting longitudinal studies to investigate the impact of training and the evolution of safety attitudes that emerge over time. Research studies are needed on the effectiveness of ISS in ICU services, both in technical and non-technical skills, in order to increase the scientific evidence on this technique and to train health professionals with an adequate safety culture and provide high quality care.The implementation of ISS training programs in the services affected by the COVID-19 pandemic would be an efficient and effective strategy to help solve the current problems found in patient safety. In order to be able to achieve our general objective, the basic elements that shape patient safety were analyzed in the different studies, concluding that ISS is a method that allows for the detection of latent threats. This makes it possible to avoid errors in medication, communication, and the system, but more frequently those related to equipment, thus showing its benefit in their detection and possible correction. On the other hand, it was observed how the implementation of ISS in intensive care and emergency departments improved communication both in the transfer of patients and in interprofessional communication in emergency situations, in addition to improving the attitude towards the culture of safety in the provision of care by these professionals. All of this allows for the evaluation and modification of components of the system by improving the systematic and organizational aspects of the services affected by the present pandemic.


Drawing on data provided by 1,841 lay or ordained members of the Anglican Church residing in England during the first half of 2021, this study explores the connection between self-perceived change in psychological well-being during the pandemic and belief in divine control over the pandemic. Change in psychological well-being was assessed by The Index of Balanced Affect Change (TIBACh) that distinguishes between positive affect and negative affect, and divine control was assessed by the God in Control of the Pandemic Scale (GiCoPS). After controlling for personal factors (age and sex), psychological factors , contextual factors (education level and ordination status), and ecclesial factors (conservative doctrine and charismatic influence), the data demonstrated a positive association between belief in divine control and change in positive affect, but no association between belief in divine control and change in negative affect. Robert Browning’s aphorism ‘God is in his heaven, all’s well with the world’ raises an important question for empirical theology and for the empirical psychology of religion in the context of exploring the impact of religious beliefs and psychological well-being of clergy and lay church members during the pandemic. The extent and impact of the rapidly developing COVID-19 pandemic at the beginning of 2020 reached every aspect of human daily experience, and churches and religious institutions were no exception. In England, the government imposed a lockdown on the nation on 23 March 2020. Shops and industries were shut down. Schools and universities were closed. All but key workers were instructed wherever possible to work from home. Setting an example for the nation, the Church of England locked its churches (except for key services like the operation of foodbanks). Clergy were not allowed to enter their churches to celebrate communion. Lay people were not allowed to enter their churches for personal prayer.Book of Common Prayer reflects this idea in some of the special petitionary prayers, which includes one to be used in ‘The time of any Plague of Sickness’:Amen.O ALMIGHTY God, who in thy wrath didst send a plague upon thine own people in the wilderness, for their obstinate rebellion against Moses and Aaron; and also, in the time of king David, didst slay with the plague of pestilence threescore and ten thousand, and yet remembering thy mercy didst save the rest: Have pity upon us miserable sinners, who now are visited with great sickness and mortality; that like as thou didst then accept of an atonement, and didst command the destroying Angel to cease from punishing, so it may now please thee to withdraw from us this plague and grievous sickness; through Jesus Christ our Lord. With Robert Browning’s aphorism in mind, the aim of this study is to examine the perceived impact of the pandemic on well-being among Anglican clergy and laity in England and the connection between change in well-being and belief in divine control during the pandemic. The Anglican tradition inherited the notion of divine providence, which was widespread in early modern England . CentralThe practice of national fasting in times of plague continued into the 19th century, demonstrating “the wide popular acceptance of belief in providence and an interventionist God” , p. 297.Coronavirus, Church & You Survey conducted during the first national lockdown that provided a firm foundation for research among Anglicans during the pandemic. Step 2 examines the balanced affect model of psychological well-being adopted by the Coronavirus, Church & You Survey and introduces the development of The Index of Balanced Affect Change (TIBACh) that is employed in this study. Step 3 turns attention to the COVID-19 & Church-21 Survey conducted during the third national lockdown and introduces the new set of items included in this survey and on which the paper builds to develop a new measure, the God in Control of the Pandemic Scale (GiCoPS). Step 4 explores why the examination of the relationship between scores recorded on TIBACh and GiCoPS were contextualized within specific control variables.The context for this new enquiry is shaped in four steps. Step 1 locates the present enquiry against the background of the Coronavirus, Church & You Survey was developed in partnership between York St John University and the Church Times, the main Anglican newspaper in England. It was promoted both by the Church Times and by a number of Anglican dioceses in England. This survey, launched during the first national lockdown, was open online between 8 May and 23 July 2020 and attracted responses from over 7,000 participants, of whom 5,347 identified as Anglicans living in England. Data from the Coronavirus, Church & You Survey have been used to examine a range of focused research questions concerning the responses of clergy and lay people to the pandemic during that initial lockdown. For example, one set of studies focused attention on the impact of the pandemic exacerbating the fragility of rural Anglican churches through the eyes of clergy . In the foundation paper for this instrument, The second issue concerned establishing a satisfactory method for assessing change in psychological well-being caused by the pandemic. Scientifically, the most effective way of doing this would have been by recording levels of positive affect and levels of negative affect among the same individuals both before the pandemic and after the pandemic had taken hold. Clearly, this was not a viable option. It is for this reason that the Coronavirus, Church & You Survey contained a pool of 20 items introduced by the following rubric: “How would you rate the effect of the lockdown on you so far?, (Please click one button EACH row to indicate a positive (+) or negative (-) effect. The middle button (0) indicates no effect of the lockdown).” Items were presented on a three-point bipolar scale with radio buttons between them to indicate if that aspect of well-being had declined, increased, or remained unchanged during the lockdown. In the foundation paper for the TIBACh , but this was not a perfect correlation, which suggests that the two types of affect were not operating as a mirror image of each other. This raises the possibility that they may be related to slightly different sets of predictor variables.The e TIBACh , explorar = .46, p < .001) and negatively correlated with negative affect . Crucially for the balanced affect model, there was a significant interaction effect of positive and negative affect on coping with the COVID-19 lockdown. The negative slope of coping against negative affect was steeper among those with below-average levels of positive affect and shallower among those with above-average levels of positive affect. This meant that, while there was little difference in average coping levels among those with low negative affect whatever their level of positive affect, for those with high negative affect, coping was higher among those with higher positive affect.In the foundation paper for the TIBACh, Church Times launched a second survey, the Covid-19 & Church-21 Survey that was open online between 22 January and 23 July 2021. This second survey re-ran some of the measures employed in the earlier survey, including the TIBACh, for comparative purposes. The second survey also wanted to explore issues that had not been raised in the earlier survey, and foremost among these issues was the theological question concerning the prevalence of belief in divine control during the pandemic. In particular, this survey was designed to explore the extent to which belief in divine control during the pandemic impacted psychological well-being as operationalised by the TIBACh.When the third national lockdown took hold during January 2021, the partnership between York St John University and the Covid-19 & Church-21 Survey included a section headed by the following rubric: “Some people wonder about the role of God in the pandemic. What do you think?” This section then presented a set of nine statements, largely culled from the church press since the pandemic began:It is for this reason that the God has always been in control during the pandemic.God sent the pandemic to test our faith.God will save us from the pandemic through science.The pandemic is a solely “natural” event without any relation to God.God could stop the pandemic at any point whatever we do.The pandemic is punishment from God.God’s power to save us from the pandemic depends on human co-operation.Science will save us from the pandemic without God’s help.The pandemic is the result of human sin.Previous research has demonstrated that individual differences both in religiosity and in well-being are related to personal factors, psychological factors, ecclesial factors, and contextual factors. In terms of personal factors, sex differences have long been established in the literature . More reIn terms of psychological factors, attention has been drawn to the importance of personality , drawingIn terms of ecclesial factors, the differences between Anglo-Catholic, Broad Church, and Evangelical wings of the Church of England have long been understood and widely researched . A furthCoronavirus, Church & You Survey, Drawing on data from the Against this background, this study was designed to address two primary issues. The first issue concerned developing a new measure to assess belief in divine control during the pandemic. The second issue concerned exploring the association between individual differences in belief in divine control during the pandemic and positive affect and negative affect as operationalised by the TIBACh. In light of what is already known about predictors of individual differences in positive affect and negative affect change, the second issue needs to be contextualised alongside relevant control variables, including personal factors, psychological factors, ecclesial factors, and contextual factors.Church Times, the main newspaper of the Church of England, as well as directly through Church of England dioceses. The survey, named Covid-19, & Church-21, was delivered through the Qualtrics XM platform and was available from 22 January to 23 July 2021. It was designed to be used by various denominations. Within the total response from 5,853 participants, there were 1,841 clergy and lay people who identified as Anglican, lived in England, and had completed sufficient responses to be included in the following analyses.During the third lockdown in England, an online survey was promoted through the online and paper versions of the The 1,841 participants were comprised of 55% women and 45% men, and the majority (85%) were aged 50 or over . Anglo-CThe survey included a section of Likert-type items examining a range of attitudes toward the pandemic and its likely aftermath. One section of nine items was headed by the following rubric: “Some people wonder about the role of God in the pandemic. What do you think?,” which was followed by statements such as “God has always been in control during the pandemic,” “The pandemic is punishment from God,” and “Science will save us from the pandemic without God’s help.” Each had a 5-point response scale ranging from “strongly agree” to “strongly disagree.” The items were designed to give rise to the construction of a new measure, the GiCoPS.The survey contained the two 5-item scales of TIBACh that measured changes in positive and negative affect during the pandemic . They wePersonal variables were sex  and age .Psychological type and emotional volatility were assessed using the revised version of the Francis Psychological Type and Emotional Temperament Scales (FPTETS) . This 50Two aspects of individual context were assessed: educational attainment  and ordination status .Church tradition for Anglicans was assessed using a 7-point bipolar scale labeled “Anglo-Catholic” at one end and “Evangelical” at the other. It is a good indication of differences in belief and practice in the Church of England  and was All analyses employed procedures in SPSS 28 . BivariaM = 13.6, SD = 3.4) and ranged from 4 to 20, with a high score indicating belief that God had a high level of control over the pandemic. A high score on this scale implied a stronger general belief in divine omnipotency, which was expressed in this context as the notion that God is able to control events such as a pandemic. This tended to be associated with a lower sense that science or humans could control events, suggesting that divine omnipotency was conceived as God acting independently of human agents. These items also demonstrate that more than two-thirds of the participants (69%) believed that God has always been in control during the pandemic, and that more than one-third of the participants (36%) believed that God could stop the pandemic at any point whatever we do. Alongside these beliefs in divine control, 44% of the participants took the view that the pandemic is a solely “natural” event without any relation to God, and 12% of the participants took the view that science will save us from the pandemic without God’s help. Clearly, there was diversity of belief among this group of 1,841 Anglican clergy and lay people living in England.The first step in data analysis concerned the development of a new measure to assess belief in divine control during the pandemic. Factor analysis of the groups of items regarding the role of God in the pandemic  identified four items that loaded on the same factor. These items related to how far God was in control during the pandemic, and how far science, rather than God, would save us from its effects . These iThe second step in data analysis concerned examination of the bivariate correlations among the core variables (GiCoPS and the measures of change in positive affect and negative affect proposed by TIBACh) and the control variables, including personal factors (age and sex), psychological factors , contextual factors (education and ordination), and ecclesial factors (conservative doctrine and charismatic influence). Three features of the correlation matrix presented in First, in terms of belief in divine control during the pandemic scores recorded on the GiCoPS are correlated positively with change in positive affect but independent of change in negative affect. This finding may be of theoretical significance as will be discussed later. However, it is also the case that scores recorded on the GiCoPS are correlated with a number of the control variables. In particular, higher scores on the GiCoPS are associated with influence by the Charismatic Movement, with espousing conservative doctrine, with ordination, and with extraversion, while lower scores on the GiCoPS are associated with age.Second, in terms of change in psychological well-being, the two scale of the TIBACh behave in different ways. Influence by the Charistmatic Movement is associated with positive change in positive affect, but independent of negative affect. Similarly, espousal of conservative doctrine is associated with positive change in positive affect but independent of negative affect. Higher levels of negative affect change were found among clergy, those with higher levels of education, higher emotional volatility, and younger people. Higher levels of positive affect change were found among those with lower emotional volatility, intuitive types, extraverts, and older people.Third, attachment to the Charismatic Movement was associated with younger people, extraverts, intuitive types, feeling types, perceiving types, and clergy. Holding conservative doctrine was associated with charismatic influence, being male, younger people, sensing types, thinking types, judging types, and lower education levels.This complex pattern of interrelationships demonstrates the importance of testing whether the connection between belief in divine control during the pandemic and change in positive affect and negative affect remained significant after taking the control variables into account.The data presented from the multiple regression models in The present survey was designed during the third lockdown in England, responding to the COVID-19 pandemic, and open from 22 January to 23 July 2021. Drawing on data provided to this survey by 1,841 lay or ordained members of the Anglican Church residing in England, the present analyses were designed to explore the connection between self-perceived change in psychological well-being during the pandemic and belief in divine control over the pandemic. To test this association, the analyses were focused by two clear research tasks. The first task was developing a new measure to assess belief in divine control during the pandemic, since no instrument had been previously designed to address this specific area. The second task was examining the association between individual differences in belief in divine control during the pandemic and self-perceived change in well-being as conceptualized and operationalised by TIBACh that distinguishes between change in positive affect and change in negative affect. Four main conclusions can be drawn from these data and analyses.The first conclusion concerns the development of the new instrument: the GiCoPS. This 4-item measure, comprising two positively voiced items and two negatively voiced items, demonstrated satisfactory internal consistency reliability for such a short instrument (α = .67) with satisfactory variability in item discrimination, with endorsement of the positive items ranging from 36% to 69% and with rejection of the negative items ranging from 33% to 65%. These four items also display a high level of face validity. The scale can be commended for further use, possibly in forms tailored to specific crisis events.The second conclusion concerns the co-variants of scores recorded on the GiCoPS. Higher belief in divine control during the pandemic was associated with influence by the Charismatic Movement, espousing conservative doctrine, ordination, extraversion, and being younger. While the two strongest correlations with belief in divine control during the pandemic were conservative doctrine and the Charismatic Movement, the regression model on positive affect demonstrated that the GiCoPS was providing an independent perspective additional to the effects of conservative doctrine and charismatic influence.The third conclusion concerns the validity of the affect balanced model of change in psychological well-being. These data support the validity in two ways. First, the two scales of the TIBACh related to the control variables in different ways. Charismatic influence was associated with positive change in positive affect, but independent of negative affect. Espousal of conservative doctrine was associated with positive change in positive affect, but independent of negative affect. Higher levels of negative affect change were found among clergy, those with higher levels of education, those with higher emotional volatility, and younger people. Higher levels of positive affect change were found among those with lower emotional volatility, intuitive types, extraverts, and older people. Second, the two scales of the TIBACh related to belief in divine control during the pandemic in different ways. While belief in divine control during the pandemic predicted a better outcome in terms of positive affect, belief in control during the pandemic was unrelated to change in negative affect.The fourth conclusion addresses the primary research question posed by this study, namely the connection between self-perceived change in psychological well-being during the pandemic and belief in divine control over the pandemic. Employing the balanced affect model of change in psychological well-being has demonstrated that belief in divine control over the pandemic serves to enhance positive change in positive affect but does nothing to mitigate negative change in negative affect. This finding is worth closer scrutiny alongside two other research findings. First, data from this study has demonstrated that conservative doctrine and charismatic influence function in the same way as belief in divine control. Both conservative doctrine and charismatic influence serve to enhance positive change in positive affect, but do nothing to mitigate negative change in negative affect.Second, these findings are consistent with the way in which conservative Christian beliefs function in relation to the two components of the Francis Burnout Inventory, as presented by Both conservative Christian belief and belief in divine control during the pandemic convey a sense of confidence in the Christian revelation and the assurance of divine omnipotency. The issue of psychological interest is why this style of belief should enhance positive affect but not at the same time mitigate negative affect. The following theory offers an account of this phenomenon as operationalised within the model of psychological well-being proposed by the Francis Burnout Inventory. The negative affect of emotional exhaustion in ministry is an experience over which clergy may have relatively little control. The relentless nature of the emotional demands of their vocation may be less amenable to modification by the narrative of divine omnipotency. The positive affect of satisfaction in ministry, on the other hand, may be more readily nuanced by the narrative of divine omnipotency. Clergy who conceptualise their vocation as collaborators alongside the God who is in control may both pattern and interpret the daily experiences of ministry in a more positive light. It appeared that theological beliefs really do matter in relation to how well clergy survive the emotional stresses of their vocation, an idea that would benefit from further research. The balanced affect model of psychological well-being maintains that positive affect is able to mitigate the debilitating consequence of negative affect see . While bThis study assessed the impact of belief in divine control during the pandemic on changes in psychological well-being, and it did so by self-reported measures of change in positive affect and change in negative affect, relying on cross-sectional rather than longitudinal measures of psychological well-being. This design is not as robust as would have been the case were we to have been able to measure psychological well-being among the same participants before and after the onset of the pandemic. Self-report measures of this nature are useful for modeling effects on cross-sectional data and provide the only viable option within the current pandemic. Future studies in times of crisis in the Church of England would be helped by having ongoing long-term panel studies conducted among both clergy and lay people.This study suggests that the beliefs associated with the theological notion of divine providence may still be important to many Christians today. The pandemic highlighted the importance of such beliefs in a time of national emergency, but there has been little empirical study of how they operate under “normal” conditions. Future research could explore this area of belief by developing empirical measures that define the contours of belief in divine intervention among clergy and churchgoers. Such scales could be used to inform the construction of versions of the GiCoPS suitable for particular crisis events. They would also enable better understanding of how beliefs in providence are distributed in different populations, and how far specific interventionist beliefs are associated with better psychological or spiritual well-being.


In the third week of January 2022, the southern districts of Malawi were hit by Cyclone Ana. The worst affected areas were Chikwawa and Nsanje. Four weeks following Cyclone Ana, a rather smaller cyclone, Dumako, hit the same areas, causing more damage. The Partners in Health or Abwenzi Pa Za Umoyo, an international humanitarian nongovernmental organisation that provides primary health care (PHC), organised teams to join Chikwawa District Council – Health, providing PHC assistance in the most affected district (Chikwawa); these teams were joined by three senior residents in family medicine from Kamuzu University of Health Sciences.From the experiences of the interventions reported here, it was learnt that a multidisciplinary team of PHC providers is the key to the success of the emergency PHC programmes in times of natural disasters. While immediate PHC may be important at the actual time of disaster, it was learnt that PHC is also very important for continuation of care for chronic conditions, antenatal clinics and other clinics that are interrupted by the disaster. The experiences emphasised the importance of involving the PHC physicians and other PHC cadres in planning PHC programmes in natural disaster–prone areas. The districts lie in a valley where the Shire River, which is the outlet of Lake Malawi to the Zambezi River, cuts across these two districts. During the rainy season, there is usually some degree of flooding as any significant rise in the water level in Lake Malawi spills over. Despite these yearly floods, about 900 000 people live in the two districts, and a good number settle near the riverbanks because of the productivity of the land.2Recently, Malawi has been hit by several natural disasters, particularly severe weather-related floods, exacerbated by global climate change.3 Chikwawa district was the hardest hit, with thousands of people living in 92 camps. Some of the health facilities were destroyed, resulting in the unavailability of essential health services.When Cyclone Ana hit, a total of 46 people died, and 206 were injured across the country; 21 of the 46 deaths were in Chikwawa district (CD). An estimated 990 000 people needed urgent medical and humanitarian support, including emergency shelter for approximately 190 000 displaced persons.At the request of CD Council in conjunction with Ministry of Health (MoH), Partners in Health (PIH) Malawi, known locally as Abwenzi Pa Za Umoyo (APZU), in collaboration with the Family Medicine (FM) Department of Kamuzu University of Health Sciences (KUHeS), supported CD with the provision of medical care to people living in camps as an immediate response to the disaster. Partners in Health Malawi is a nongovernmental organisation (NGO) that has worked in another district in Malawi for over 15 years to support the MoH in the provision of primary health care (PHC). Due to the dire need for support, PIH decided to provide urgent support to the population of Chikwawa.The team worked with the Chikwawa District Health Office (DHO) to: (1) strengthen the district’s coordination of partners working in the provision of health services; (2) provide essential health services to people living in camps; (3) support the supply of medication, human resources and other logistics needed for the provision of medical care; and (4) support the collection of health information during the mobile camp visits.The team supported the district to coordinate the weekly health cluster meetings where the DHO and all partners discussed the overall health response to the disaster. Guided by the DHO, the PIH team supported the initial and follow-up health cluster meetings. The overall health cluster response plan was developed.To initiate the camp visits, five mobile teams were identified. The composition of the team members was guided by the package of care that would be provided to the camps. The package of care included:Provision of acute healthcare services. Patients who were acutely ill received care. Partners in Health coordinated care for patients who required secondary level care by providing referral services from the camps to the district hospitals. These referral services included the decision to refer the patients and also provision and facilitation of transportation.Continuation of chronic disease care pathways. The researchers of this study ensured that patients living with human immunodeficiency virus (HIV) and noncommunicable diseases (NCDs) had adequate medication and supplies and they were enrolled in chronic care clinics.Strengthening the provision of care for reproductive and maternal health services. Family planning was offered, as well as antenatal care (ANC), postnatal care, sexually transmitted infection (STI) services and malnutrition screening and treatment to the people living in the camps.Preventive health services. Camp committees were educated to provide education on water and sanitation and communicable diseases such as coronavirus disease 2019 (COVID-19), as well as distributing mosquito nets.Common mental disorders were screened for and provided mental healthcare to the mental health clients, such as people with depression and anxiety disorders and victims of sexual and gender-based violence (SGBV), among others.Screening was included and care for SGBV, as these are common when people are displaced from their homes.A simple formulary of medications needed to cover the priority conditions in the camps were created. Because of shortages of medication, extra medication and supplies were procured and donated to the main district hospital for use in the camps.Each team was composed of one to two medical doctors, clinical officers or technicians, a pharmacist or pharmacy technician, two to three nurses, an environmental health assistant, a laboratory technician, an HIV diagnostic assistant and a social worker. Camps that needed to be visited were identified by the Chikwawa DHO, starting with extremely hard-to-reach camps and aiming to visit each camp at least once a month. Partners in Health provided medical supplies and human resources , with the rest of the staff provided by the MoH. Partners in Health also provided two vehicles and other logistics for the camps.4 The FM residents, together with PIH physicians, clinicians, nurses and other cadres, provided PHC to the victims. The residents were included because: (1) it was an opportunity for them to be involved in disaster management, as part of their training; (2) they were better placed in the provision of PHC than residents from other specialities. There is a good relationship between PIH and FM, as PIH focuses on providing high-quality PHC in Malawi. Additionally, residents also benefitted by learning how to plan and implement an intervention in PHC in times of disaster.At the time, the district had only two doctors available. Care at the primary care level is mainly provided by clinical officers , medical assistants (2-year college training) and nurses. Malawi has a well-structured PHC system, but a poor distribution of resources leaves the rural areas like Chikwawa with an inadequate workforce, even when there is no disaster.Overall, the interventions benefitted the flood victims through the provision of PHC. Under the usual circumstances, less than 50% of Chikwawa’s population lives within the 5 km radius of health facilities recommended by the World Health Organization (WHO). This implies that even in the absence of a disaster, PHC is not accessible to the people living in the hard-to-reach areas.5 The syndromic management approach was used to diagnose and treat STIs without laboratory tests. This requires competent physicians who can work with limited resources.Between January 2022 and April 2022, the Chikwawa DHO conducted 277 mobile clinic visits to 71 camps. Among the mobile clinic visits, 41% were directly supported by PIH. 6Diarrhoea was the most common condition, followed by skin conditions and sepsis . The majWhile sepsis is a medical emergency, most of the cases reported may not have been sepsis. In this setting, where it was not possible to laboratory investigations to support the diagnosis, a good history, physical examination and a high suspicion for bacteria as a possible cause of the symptoms were enough to treat for suspected sepsis or bacteraemia with antibiotics.8 Malawian women have good knowledge about starting ANC in time, but they may prefer to have fewer visits or to start later because of social factors.9Among women of reproductive age group, 54 women registered for their first ANC visit, of whom 36 registered in first trimester see . PreviouSeveral lessons were learnt during the emergency response, including the need to support the coordination of care at the district level, the comprehensiveness of care packages including SGBV, mental health and the need for rapid mobilisation of resources to support care in the camps. Primary health care was provided for 5 weeks; and left when all the health facilities were fully open and functional. The PHC provision to tropical cyclone victims was urgently needed for people living in the camps. The intervention ensured the continuation of care to patients with chronic conditions and also the provision of acute care for patients with various conditions. The access to PHC for many people who would otherwise have no easy access to healthcare was improved. Good examples are the 54 women who attended ANC for the first time and the 14 new HIV clients who were started on treatment.The authors noticed challenges with the provision of mental health services. They did not have a specialised team to provide such care; there were no psychosocial counsellors or mental health clinicians. While PHC physicians can provide primary mental healthcare, ongoing care from mental health clinicians or psychosocial counsellors would be ideal to provide more comprehensive mental care. Additionally, the focus were on the provision of essential care in camps but did not address the infrastructure problems and provision of care at the PHC facilities that were still functioning.This experience is crucial to future planning for interventions in times of natural disasters that have now become more prevalent because of unpredictable global climate changes. The experience also shows the crucial role that PHC providers play. The role of FM residents and physicians in the provision of emergency PHC cannot be over-emphasised.The authors recommend that FM residents and physicians should be involved more in planning for emergency PHC. They recommend having a mental health team involved in providing PHC to internally displaced victims living in camps. They also acknowledge that the need for interventions by NGOs, such as PIH, in collaboration with the MoH, may be recurrent and need to persist for longer as areas take many months to recover from the effects of natural disasters.Partners in Health (PIH) is acknowledged for funding the interventions reported in this report, as well as the publication of this report. The authors also acknowledge the Department of Family Medicine at Kamuzu University of Health Sciences for allowing the family medicine registrars time to be part of this project. There are many names from Chikwawa District Council with whom the authors worked side by side to assist the cyclone victims; their memories of these people strengthened our inspiration and motivation to write this report.


With anxiety a growing issue and barriers to accessing support services, there is a need for innovative solutions to provide early intervention. In-the-moment interventions support individuals to recognize early signs of distress and use coping mechanisms to prevent or manage this distress. There is potential for wearable sensors linked to an individual’s mobile phone to provide in-the-moment support tailored to individual needs and physiological responses.The aim of this scoping review is to examine the role of sensors in detecting the physiological signs of anxiety to initiate and direct interventions for its management.Relevant studies were identified through searches conducted in Embase, MEDLINE, APA PsycINFO, ProQuest, and Scopus. Studies were identified if they were conducted with people with stress or anxiety or at risk of anxiety and included a wearable sensor providing real-time data for in-the-moment management of anxiety.Of the 1087 studies identified, 11 studies were included in the review, including 5 randomized controlled trials and 6 pilot or pretesting studies. The results showed that most studies successfully demonstrated improvements in their target variables. This included overall anxiety and stress levels, and the implementation of in-the-moment stress and anxiety management techniques such as diaphragmatic breathing. There was wide variation in the types of sensors used, physiological measures, and sensor-linked interventions.This review indicates that sensors are potentially a useful tool in detecting anxiety and facilitating the implementation of a known control mechanism to reduce anxiety and improve mood, but further work is needed to understand the acceptability and effectiveness of this type of intervention. Anxiety is a critical issue internationally , with COmissing middle, people with mild to moderate mental health needs that may not fit diagnostic criteria. For example, young people in particular generally only access mental health services when their condition has started to significantly affect their daily life, with many continuing to suffer from extended periods of mild to moderate anxiety-related morbidity alone [Access to treatments for anxiety and other mental health conditions are a significant challenge . The curty alone ,10. The ty alone ,12. Eventy alone . Concernty alone . Furtherty alone . Self-hety alone .Wearable devices, which are worn on the body or clothing, provide an innovative tool for the detection, diagnosis, and management of health conditions through the noninvasive measurement of physiological information in real time . There iDespite the subjective nature of assessing anxiety, the measurement of the physiological changes common in anxiety can be used as indicators of a person’s stress response and experience of anxiety. A number of biomarkers have been found to provide real-time objective measurement of the physiological impacts of anxiety and exposure to stressors ,24, inclThis paper provides the findings of a scoping review on the role of sensors in the management of anxiety with the goal of informing the development of digital interventions to treat mild to moderate anxiety.The aim of this scoping review was to examine the role of sensors in detecting the physiological signs of anxiety to initiate and direct interventions for its management. The review follows the PRISMA-ScR  guidelines for the reporting of scoping reviews  see Mul, and theEligible studies included human participants of any age with anxiety or stress, or at risk of anxiety. Due to the limited number of studies, a decision was made to include studies of participants with stress, not just anxiety. Comorbidity of anxiety with other psychiatric conditions  were also considered since anxiety may often coexist with or be the result of other psychiatric conditions. Eligible studies needed to include a wearable sensor that provided real-time data/information for in-the-moment management of anxiety. As the focus of the review was on the use of sensors for the identification of early signs of anxiety, before the individual is likely to be consciously aware of the anxiety episode, only sensors that collected physiological data in a passive manner (not requiring active engagement from the user) were included; sensors that required manual input of data only were excluded. Sensors had be worn on the body, but no other restrictions on the type were applied . Studies including multifaceted interventions in which sensors were just one component were included in the review.All study designs were included with the exception of protocols and reviews. There was no limit on year of publication because of the recency of the study subject. No restrictions on comparator or outcome measures were included. The review was restricted to full-text articles published in peer-reviewed journals. Studies were excluded if published in languages other than English or were published only in the form of conference abstracts.Searches were conducted from inception through to December 8, 2021, using Embase, MEDLINE, APA PsycINFO, ProQuest, and Scopus. Searches were limited to papers published in the English language. The initial search strategy conducted included words associated with anxiety, such as “stress,” to form search strings. However, these produced results that were too broad, and the term was excluded. An example of the revised search strategy can be seen in exp wearable devices/ or wearable*.mp.sensor.mp.1 or 2exp anxiety/ or anxiety.mp..mp.4 or 53 and 6limit 7 to English languageAssessment of study eligibility was performed on the Rayyan platform. The first assessment was screened independently by LLL, identifying duplicates and filtering based on the title and abstract. The second screening of full-text papers was then undertaken by three authors LLL, RW, and RD, and disagreements between reviewers were resolved by discussion.Data were extracted using structured forms including study design , population characteristics, intervention type, sensor characteristics , and outcomes/findings. A narrative synthesis methodology was used to synthesize the data extracted.The total number of studies identified was 1139 from database searches, in which 51 were duplicates. A further 4 studies were identified through reference lists. This resulted in 1092 studies screened by title and abstract, with 911 being considered ineligible. The full texts of the remaining 181 full-text papers were reviewed according to the inclusion criteria. At the end of the screening process, 11 articles were included in the scoping systematic review. Of the studies included in this scoping review, 5 were randomized controlled trials (RCTs), and 6 were pilot studies or pretesting studies. Sample sizes ranged from 14 to 328 participants. The duration of the studies varied, with the shortest being one session  and the Studies were conducted in the United Kingdom ,32, the All sensors had some form of capacity to display their sensor data back to the participant. HRV or HR was visually displayed back to participants in 6 studies -30,32-34In 3 studies ,31,35, sMost studies  included sensors that were linked to some form of breathing techniques such as diaphragmatic breathing to help manage stress or anxiety. Eight studies used guided diaphragmatic breathing -32,34,36Some of the studies had interventions that included additional information or therapy to supplement stress or anxiety management. Three studies included CBT-based techniques as part of their intervention ,30,36, aOf the 5 RCT studies included in this review, 4 found significant improvements to measures of stress or anxiety. One study assessed the effectiveness of an anxiety meter to improve awareness of anxiety symptoms and, therefore, engage in relaxation techniques in children with ASD . ResearcInterestingly, 1 study found contrasting findings . ResearcThree pilot or pretesting studies also found promising improvements to either stress or anxiety. One study assessed the effectiveness of an HRV biofeedback wearable device and stress management coach to reduce symptoms of anxiety . ResearcThis review explored the use of wearable sensors to detect, manage, and treat anxiety. The results showed that most studies successfully demonstrated improvements in their target variables. This included overall anxiety and stress levels, and the implementation of in-the-moment stress and anxiety management techniques such as diaphragmatic breathing. Where applicable, most studies also noted a reduction in secondary symptoms such as depression, anger, and negative emotions. The results therefore indicate that sensors are potentially a useful tool in detecting stress and anxiety and facilitating the implementation of a known control mechanism to reduce anxiety and improve mood.The utility of sensors was shown to extend beyond sensing physiological signs of anxiety and stress. Sensors have the potential not only to alert the user to their change in emotional state but also to connect with other systems and prompt interventions that can treat the detected changes and deliver those interventions through the sensor itself. For example, the results of this review showed that when a user is alerted to their change in anxiety, the screen on some sensors could be used to guide the user through the subsequent recommended breathing exercise. Exploration of other in-the-moment control mechanism or therapeutic techniques could be explored to diversify and maximize the treatment options available through sensors.This review also identified that sensors can be used by a wide variety of people in a range of contexts. Studies ranged in age and clinical severity, from mild to moderate levels of stress, depression, or anxiety to diagnosed clinical disorders including anxiety, posttraumatic stress disorder, and ASD. Studies also varied in length and nature, from wearing sensors and learning coping mechanisms in brief laboratory sessions to wearing the sensors for multiple weeks of everyday life. The variety of populations and contexts included in the literature thus far supports the idea that wearable sensors are a broadly applicable tool with flexible utility that may offer benefit to most populations.This is an initial scoping review to determine the body of existing knowledge on this topic. The limitations of this review are that there are only a small number of RCTs; several studies were only performed in laboratory conditions; we did not limit the review to just anxiety (the inclusion of stress); and the sensors and conditions of use  varied considerably. This indicates that there is not yet sufficient evidence to show that these interventions are feasible in real-world situations, although there appears to be sufficient potential for further investigation. With the growing use of consumer-wearable devices it may be possible in the future to use population-based, real-world data in this field, but there is much to be worked out before this can proceed in relation to ethics, privacy, and ownership of data.train an individual to be more aware of their own symptoms earlier.There is also substantial further research required on the digital interventions that may be acceptable and effective in the moment for different cohorts, for example, the question of whether the sensor data should be made visible to the individual at the time or just the intervention. There is a risk that the availability of such continuous data could heighten anxiety in some people or could become the focus of their anxiety. It is also not clear whether an intervention based around identifying the physiological signs of anxiety would need to be long-term or could potentially The acceptability and usability of the sensors is going to play a key role in their success, as was highlighted by Millings et al . Technic


In the COVID-19 pandemic, the healthcare system faced unprecedented challenges with increased number of patients and limited resources. Managing nursing resource was a major challenge for hospital administration. They had to be on the frontline, but their safety was of paramount importance.This study aims to analyze the measures taken for the management and effective engagement of nursing personnel for deployment in the COVID area of the hospital and the exemption trend based on their health status.A retrospective cross-sectional descriptive study was carried out to analyze the requests of nursing staff received for exemption of duty in COVID patient care areas. These requests were categorized and examined by the medical board constituted for this purpose. Microsoft Excel was used to interpret the results.The study evaluated the health reasons of nursing officers on the basis of which exemption was given for deployment of nursing officers in COVID areas. They were mostly medical reasons (91.1%) and few personal reasons (8.77%). The majority suffered from diseases affecting two or more than two specialties. Out of 376 applications, 223 were exempted, 81 were not exempted, 13 were given short-term exemption, and 26 were shifted to administrative assignments. Thirty-three staff members were referred to an appropriate forum. The COVID-19 pandemic took over the world like an unrelenting storm testing the resilience of healthcare systems everywhere. Healthcare systems were faced with unexpected influx of patients requiring treatment within limited resources. Healthcare providers at the front line faced numerous challenges. Different guidelines were laid down to equip COVID facilities with staff, essential equipment, and medicines. The nursing staff and other healthcare providers were under extraordinary pressure and played a pivotal role in providing patient care services 24 × 7 during the pandemic. At the same time, management of the nursing manpower emerged as one of the major challenges the world over. Various International and national guidelines were laid down to address the huge demand of nursing staff trained in managing communicable diseases and infection prevention.The situation was no different in our 2,210 bedded tertiary care institute and research center. Although there was an unprecedented demand for nursing staff and every possible resource had to be utilized, it was equally important that the health and wellbeing of committed care providers were adequately safe guarded. “No country, hospital, or clinic can keep its patients safe unless it keeps its health workers safe” was a statement issued by the WHO in a news release. In our institute, this was done by providing PPE, provision of testing for COVID-19, training for infection prevention and control, and psychological care by counseling to mention a few. A lot more measures were suggested to protect the old and vulnerable members in our communities, but apparently, similar emphasis was not given in the case of healthcare workers including nurses. There is not much literature available on protocols in place for vulnerable healthcare workers and their deployment in COVID patient care areas. In the absence of any clarity, hospitals and organizations devised their own protocols to safeguard vulnerable staff . This waThis study aims to analyze the measures taken for the management and effective engagement of nursing personnel for deployment in the COVID area of the hospital and the exemption trend based on their health status.A retrospective cross-sectional descriptive study was carried out to analyze the requests received for exemption of duty. The guidelines issued by the Ministry of Health and Family Welfare were circulated to concerned officials for dissemination. Applications/requests received from the nursing staff for exemption of duty in COVID areas were examined. A medical board was constituted to examine the requests seeking exemption on medical grounds based on the issued guidelines. The requests were categorized. The proceedings of the medical board and all related office orders were studied. Requests that did not fall under the purview of the board were referred to an appropriate forum. Microsoft Excel was used to interpret the results.The institute ethical committee  approved the study with protocol in their meeting held on 22 March.2022, with reference no: IEC-INT/2022/study-29.The institute caters to more than 100,000 IPD patients, and as expected of a tertiary center, patient care services to both COVID and non-COVID cases (new and follow up) have to be provided. During the pandemic, the allocation of nursing staff in COVID patient care areas was done according to nursing norms, area requirements, government guidelines, and in consultation with nursing manpower management committee. The number of duty shifts of nursing staff was increased from 3 to 4 because of difficulties associated with wearing of PPE. The number of off-duties was increased to enable staff to handle stress and burn out along with rotational deployment in COVID care areas. The physical OPD was scaled down drastically during pandemic peak and elective surgeries were stopped to enable the diversion of staff for COVID care.A total of 376 requests were received from the nursing cadre staff for exemption from COVID area duties in a period of 6 months, i.e., 1 August 2020 to 31 January 2021. The reasons for these requests were examined by the medical board which consisted of specialists from Department of Medicine, Endocrinology, Orthopedics, Urology, Psychiatry and Hospital Administration along with the provision of co-opting any other expert as and when required. Out of the 376 nursing officers, 323 were women and 53 were men.N = 88), followed by diseases involving pulmonary function (N = 49), internal medicine (N = 31), orthopedics, etc. Antenatal (21) and lactating (29) staff members were also included under medical conditions  in this age group as compared to the more experienced staff above 34 years of age, and the same is mentioned in other studies , 9. In oarranged , 11. MosIt was difficult to relate these findings to other institutions/hospitals as the literature on this topic is scarce.In these unprecedented times, frontline workers are the army deployed the world over to tackle the enemy, but their protection and safety are paramount while treating patients. Numerous mechanisms were developed to ensure the protection of staff members both in terms of physical and mental health. Equally important is ensuring the safety of immunocompromised staff and their engagement in non-COVID areas to ensure optimal and rational staff deployment in both COVID and non-COVID patient care settings. The overall health of healthcare providers is a vital chain link for effective and efficient management of pandemics, and there have to be clear guidelines for vulnerable nursing staff regarding their deployment in direct patient care.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.SS, ND, AK, and SB contributed to conceptualization and design of the study. SKS contributed in data analysis. SS wrote the first draft of the study. ND, AK, NP, and SB revised and approved the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The present research investigates the possible causes of resistance to vaccination against the COVID-19 virus. A significant percentage of different countries' populations is refractory to being vaccinated . A 92-item questionnaire was filled in by a sample of 613 subjects, of which 50.4% said they were against COVID-19 vaccines . Guided by the hypothesis that emotionality constitutes a basis of pre-reflective judgment, items relating to fear, anger and anguish were introduced in the survey. The subjects compiled the Difficulties in Emotional Regulation Scale. The differences between the means of the two samples evaluated with the Student test show that it is, above all, the underlying anguish that constitutes the primary discriminant between the two samples. No Vax mainly considers external the sources of anguish, while Yes Vax sources of anguish appear more internal. From this result an interpretation is advanced: it seems more difficult for No Vax to trust authority recommendations/obligations to get vaccinated because anguish is located just outside the one's body, where Authority dominates.The online version contains supplementary material available at 10.1007/s44202-022-00038-2. The 2020 pandemic locked down led to months of social distance with several different reactions in the population , 23. AltMore recently, some researchers have tried to identify the psychological factors that could explain the anti-vaccine attitude of a part of the No Vax population , 32, 34.The present study aims to reach a description and interpretation of the attitude toward vaccinating or not concerning the epidemic caused by the COVID-19 virus. The central hypothesis that we intend to test is the following: the bodily experience, that is, the "affective evaluation" that the subjects make of the COVID-19 vaccines, represents the most relevant dimension in the refusal to undergo vaccination. Edelman  and DamaMental processes that Kahneman  called "According to the psychological meaning of Anzieu , who focIn English, it must be clear that "anguish" is perfectly synonymized with the word "anxiety". Nevertheless, for the theoretical frame of this study, what is intended here with anguish is not a general state of nervousness. Authors formulated a questionnaire that asked about the essential, profound state of "suffering", not referable to anxiogenic events. This could be a reason why in academic social psychology, one can find many articles on the topic of anxiety  can be integrated into our genome and can over time exacerbate latent pathologies or create new ones, hence the need for monitoring overtime of this large vaccine experiment.'".As reported in every social psychology textbook, attitudes are a fundamental construct for interpreting how people react to social events. They can be considered a relatively stable organization of beliefs, feelings, and behavioral tendencies towards objects, groups, events, or socially significant symbols . The psyIn one sentence, the central hypothesis of this research is that the No Vax population could be distinguished based on particular anguish, especially the anguish to be invaded into his/her body (following Anzieu–1987–theory of psyche).A total of 613 subjects from Italy (56.4%) and other European countries  undertook this study. 542 participants responded to the entire survey, while 71 did not respond to the sections on anger and anguish. Table Data were collected online in September 2021. A survey composed of an ad hoc 92 items (presented in a random order to avoid possible anchoring phenomena) and two additional self-report measures were administered to participants.Data were collected using an original questionnaire, a validated scale on emotional difficulties, and a projective test.Ad hoc questionnaire. An original questionnaire was prepared based on the results of an online (via Telegram) focus group with No Vax declared activists. On a six-value scale, the questionnaire proposed statements concerning which the subject had to choose his/her point of agreement . The questionnaire aimed to collect the subject's opinion on his/her social positioning about vaccination , in the sample against vaccines M = 4.40, SD = 0.88, compared to the sample favourable to vaccines with M = 3.90, SD = 0.94 .The between-group differences on DERS subscale and total scores did not reach significance. None of the factors calculated by the DERS were statistically significant on the t-test. This result suggests that the levels of emotional dysregulation of those who were favorable towards the vaccinations were similar to those who were against it. In other words, the two samples, Yes Vax and No Vax do not differ from each other regarding the difficulties in managing emotions.If a confident tool such as the DERS was unable to say anything about the affective component of the two samples, another tool, perhaps less authoritative, due to an ongoing validation, was able to point out differences between the sample Yes Vax and No Vax. This tool is the Body Image and Schema test (BIST). Table As detailed in Table The two significant factors that resulted in significantly different t-test are the "Bonds factor" and, above all, the "Psychomotor ego factor", "reinforced" by the item "Getting up/‘Agentivity’". BIST strip examples are presented in Supplementary file.The research highlights how emotions such as anger and fear discriminate between the two samples for the judgments implicit in these emotions towards situations created by the COVID-19 pandemic. According to the data collected by this research, the Yes and No Vax samples are not different in the management of emotions in general, as shown by the absence of significant differences on the DERS scale. Even the indices and items relating to fear and anger, in general, do not show particularly significant differences. Only on the attribution of the causes of anger, there are differences between the two groups: a tendency towards introversion of anger by the Yes Vax, while in the No Vax, there is a more significant presence of reactions of anger caused by the impositions to do and not do something (see Table 7 in Supplementary file).These findings would indicate that the two samples, No and Yes Vax are not distinguishable in managing emotions in general. Something more "profound" in affective life has to call onto the psychological scene. This is anguish, which is not a common concept in social psychology, particularly in Anglo-Saxon culture, also because the word "anguish" has a limited use only in philosophy (see ). HoweveIn fact, in the No Vax sample, we mainly find anguish resulting from feeling invaded. The higher average recorded by the No Vax sample is significant due to the relative anguish of being invaded, very pertinent to the research hypothesis that predicts an unconscious fear in the No Vax population dependent precisely on the intrusion into the personal ego skin. The No Vax group's anguish comes from sources external to the individual, while for the Yes Vax group, the anguish comes from sources internal to the individual. This difference could explain the distinct attitudes of the two groups towards the pressure to get vaccinated; as for the No Vax, everything that comes from "outside oneself" constitutes a potential threat, while for the Yes Vax, just what is proposed by a collective subject external to oneself constitutes the possibility of saving oneself from anguish whose source is internal to the individual. The anguishes of the Yes Vax sample could be grouped into two categories: a category that includes the loss of references, such as falling apart, feeling the earth opening up, feeling that time has stopped; and a category that collects anguishes with social references, such as not receiving esteem, feeling alone and no longer counting for anyone.The Yes Vax group has only one item whose average is statistically higher on the t-test, the item that signals anguish and agitation. Also, from this, we can understand the profound difference between the active imagery in the two samples: the Yes Vax is restricted in the narrow space dominated by anxious agitation; the No Vax, on the other hand, is enhanced by an imaginary so flourishing as to invest the same reality.Strips "Item Skin as protection" and "Item Symbol of the Female Genitals/Imago female sex" refer to the theory of the skin ego developed by Anzieu , in partAn interpretation of the highest average of the No Vax sample of the BIST Factor "Bonding" could concern the sense of community that has been created in individuals who have chosen to resist the social pressures that push toward COVID-19 vaccination. It should also be emphasized that a particular share of the subjects was "recruited" by this survey on social media such as Telegram, where they gather in debates and organization of public positions precisely of the homogeneous groups of No Vax.Being part of a cohesive group, practically impermeable to external influences, highly reactive, allows the anguish of being invaded, the only item in which the No Vax record an average higher than the Yes Vax, to take on the appearance of a treatable experience . The extThis anguish seems to find a possibility of meaning through an ideological construction, that set of ideas that can be verbally articulated to give shape to it. Social shared in group ideology reinforce by opposing the specular out-group ideology.The construction of ideological representations and narratives is the work with which the ego gives shape to anguish itself. Ergo, in the schemes of the collective narrative of the Yes Vax and No Vax groups, we will find the ways and means that allow the individual's expulsion-reclamation of the anguish itself.The Yes Vax narrative is formed by resorting to authors who use the language of scientific rationality, decidedly well-rooted in evidence obtainable from reality data but poor, however, in symbolic evocativeness. The narrative of No Vax is formed by gathering a multiplicity of voices, which find their most favorable breeding ground in social networks. The jumble of voices that rise from this humus creates an iridescent system of phantasmatic symbols powerfully evocative of the bodily self. The multitude of pseudo-scientific and anecdotal details, news from an "alternative" world, receives its clot from the opposition to the voice of the Authority . The kaleidoscope of the discursive universe of the different and multiple fringes of the No Vax groups enhances the symbolic fantasy with which the individual bodily self tries to control its own fundamental anguish. On the other hand, the discursive universe of subjects in favor of vaccination rests on the only register of scientific and economic rationality. Science in general and medicine, in particular, restrict de facto symbols of the body and its health because their statute is anti-symbolic  , 17.The data collected from the survey allow us to elaborate further research hypotheses made public in future articles. The female No Vax sample is closest in the averages to the Indices to the Yes Vax sample. For example, there is a significant difference in the averages between males and females in the No Vax sample on the anguish items, thus indicating that the female No Vax population experiences these times of pandemic with greater apprehension.According to this preliminary result, female subjects who declared themselves No Vax could constitute a communication bridge with the health authorities. When the No Vax sample is broken down into males and females, the "awareness" factor of the DERS shows that No Vax females have less difficulty than males in being aware of their emotions.Supplementary file 1 (DOCX 636 KB)Supplementary file 2 (DOCX 44 KB)Below is the link to the electronic supplementary material.