Social network theories are used extensively to analyze the international migration of Chinese to overseas regions in the era of Market Economy Reform since 1978. Attention is paid especially on the role of social networks among overseas Chinese on disaster relief in China. Focusing on the ongoing COVID-19 pandemic, this paper investigates how social networks work as a crucial mechanism through which Chinese immigrants in Germany initiated and delivered monetary and material donations to China in early 2020 and then organized self-help in their everyday lives in Germany in late 2020. Different from previous studies, this paper scrutinizes social networks for disaster relief on the macro, meso, and micro levels. Multi-site ethnographic fieldwork in China and Germany combined with online and offline data collected from focus group sessions, interviews with individuals, participant observations, surveys, analysis of news reports on the pandemic, and analysis on relevant policies are utilized comprehensively to collect data on the three levels. This research discovers that internet tools – represented by WeChat – have integrated tightly into the traditional social networks of Chinese immigrants and consolidated the cultural cohesion from overseas Chinese to their connections in China. This paper aims at contributing to present studies on Chinese new immigrants, social network, and disaster management theories with an updated ethnographic case on the COVID-19 pandemic from Germany. The on-going COVID-19 pandemic has affected people’s everyday lives all over the globe in the past three years. The outbreak of COVID-19 in 2019 placed China in a vulnerable situation earlier than any other regions. After the first outbreak in Wuhan in Hubei province near the end of 2019, the pandemic soon spread nationwide and resulted in a public health crisis in the first half of 2020. Soon after that, the global spread of COVID-19 profoundly impacted many other countries and populations in the second half phase of 2020. Social networks are an important social capital for disaster relief. Chinese new immigrants have strong cultural, economic, and emotional connections with China and they have supported China in various disaster events in the past three decades. Taking Chinese new immigrants in Germany as a case, this research examines the roles of social networks among Chinese new immigrants when they combated COVID-19 pandemic and reveals their capacities on disaster relief.th Party Congress, the message was that of finding its own road to modernity. That road is centered on two pillars. Within the country, national sovereignty can be made safe only through social order and continued development, something only a united and well-organized party-state can guarantee. Outside, security is the goal. The situation here is more complex, and its leaders know that there are many factors in the interdependent world that are beyond China’s control.”“China is not offering its own version of universalism; instead, in the 18The research on Chinese overseas since 1978 yields many findings. Studies prove that immigration is changing China  is thus used as a term referring particularly to the Chinese migrating from China’s Mainland to other countries after the 1978 economic reform  and ethnic Chinese (huaren) in Europe is about 2.5 million, there are more than 800 overseas Chinese organizations, and there are more than 43,000 Chinese restaurants” defines a disaster as “a serious disruption of the functioning of a community or a society involving widespread human, material, or environmental losses and impacts which exceeds the ability of the affected community to cope using only its own resources” UNISDR . Coping Disasters occur in specific international and social-cultural contexts , and groups.The research team also conducted participant observations. For instance, we distributed health kits to Chinese students in Germany. We also participated in an event which face masks donated from China were sent to the hospital at the University of Cologne. The authors of this paper experienced the pandemic in both Germany and China because they travelled several times between China and Germany from January 2020 to 2022. They have lived in both two countries during the pandemic and they are familiar with people’s everyday lives in both of these pandemic-affected countries.In China, three structured interviews were completed with the government officials in Wenzhou of Zhejiang province and Jiangsu province. These two places were selected because the governments were active engaging Chinese new immigrants during the pandemic. Wenzhou is one of the key hometowns of new immigrants in China. According to the survey of the city in 2014, there are about 700,000 Wenzhouese living abroad and in Macau and Hong Kong Zhang . The majThe number of Chinese new immigrants in Germany has been significantly increasing in the past four decades. According to Zhuang , the numThere are 42,676 Chinese students in the 2018/2019 semester, ranking as the biggest group of foreign students in Germany  of Chinese immigrants. In Germany, most of the associations have been established since the late 20 century. All German Federation of overseas Chinese was registered in a German court on July 16th, 1998. It was the first national Association of Chinese in Germany after China and Germany officially established diplomatic relations in 1972. Because of the official background of the embassy, the Association has become the head of the associations of Chinese new immigrants, and has led other local associations and two Chinese schools and two Chinese media. These include about fifty region-based Chinese new immigrants associations and trade-based associations. Due to the increase in the number of scholars and students, many university-based associations for Chinese scholars and students have been set up, as well as associations and clubs based on shared interests and hobbies.According to our survey, the most active associations are region-based associations, in particular, the previous mentioned German Federation of Zhejiang Associations and its twenty sub-associations, including Wenzhou association and Qingtain association. The German Federation of Fujian Associations has a voice in immigrants due to its population and its strong ethnic businesses. There are other types of associations as well, such as the Association of Chinese Gastronomy in Germany, German Chinese Chamber of Commerce, All German Chinese Women’s Federation and the German-Chinese Cultural Exchange Association in Bonn. Catering businesses are the major ethnic economies of Chinese entrepreneurs in Germany. According to the president of the Association of Chinese Gastronomy in Germany: “There are more than 10,345 Chinese restaurants in Germany, and they are employing more than 50,000 full-time employees and 75,000 part-time employees. The total annual turnover of the Chinese restaurant industry exceeds 3.6 billion euro” . Light and Gold :3 defineOn January 26 2020 – the third day of shutdown in Wuhan, the All-China Federation of Returned Overseas Chinese (ACFROC) published a proposal calling on overseas Chinese to donate to Wuhan. The article was titled as “Proposal of the China Federation of Returned Overseas Chinese on Calling on Overseas Chinese at Home and Abroad to Donate Money and Materials for the Prevention and Control of New Coronavirus Infected Pneumonia”. This initiative was soon posted and forwarded in many WeChat groups worldwide by leaders of associations among Chinese new immigrants. WeChat is the most commonly used communication tool among the leaders of Chinese new immigrant associations in Germany and the offices in China. A normal working procedure is that the leaders read the donation initiative through WeChat, then they confirm the detailed demand for the medical materials needed from the officials of several Chinese governments, most representative the United Front Work Department (UFWD), Federation of Returned Overseas Chinese (FROC), or the Overseas Chinese Affairs Office (OCAO), and then they hold meetings with their fellow members to launch their initiatives to raise money and purchase medical materials. Soon, many organizations of returned overseas Chinese at provincial and municipal levels launched their donation initiatives, aimed at Chinese new immigrants. Wenzhou was one of the cities that issued a global donation initiative on the same day, on January 26 2020.WeChat plays an important role in the daily life of Chinese new immigrants even though they live outside China. They use WeChat to contact their family members, friends, or colleagues in China. They read news published by the Official Accounts of WeChat. More importantly, they prefer using WeChat even though they have other choices which are more popular in Germany, such as WhatsApp or Facebook. WeChat is an icon through which Chinese new immigrants identify their Chinese fellows in foreign countries. For instance, when two Chinese meet each other in an event for the first time in Germany, normally the first thing they do is to add each other as WeChat friends, rather than getting in contact on WhatsApp or exchanging their German cell phone numbers. Why is this? Castells analyzes the emergence of networked society. “Dominant functions are organized in networks pertaining to a space of flows that links them up around the world, while fragmenting subordinate functions, and people, in the multiple space of places, made of locales increasingly segregated and disconnected from each other” Castells : 476. HoWhile keeping close contact with China and trying to make a living in foreign countries, Chinese new immigrants confront with difficulties in adopting to local culture, and thus face some challenges regarding their sense of identity. Taking the Chinese new immigrants in Germany as an example, on the one hand, they are a minority group in terms of population numbers comparing to other German immigrants  and 21,944 euros in five days . Through contacting with Wuhan officials, the Federation purchased the urgent demanded masks and donated to Huoshen mountain Epidemic Prevention Hospital and Wuhan Central Hospital and the Police Work Support Department of Wuhan Public Security Bureau. On February 14 2020, the German Chinese Chamber of Commerce donated 331 boxes of protective clothing, medical masks and gloves to six hospitals of Hubei Charity Federation and Hankou hospital  in Germany successfully donated medical materials to Wenzhou by March 2020. Meanwhile, various Wenzhou associations in Italy and Spain contributed significantly to support Wenzhou as well. The calling for donation to Wenzhouese living abroad was issued on January 26 2020. At the end of April, a total of 472 associations/enterprises from forty-five countries had donated to Wenzhou. Donations to Wenzhou included monetary donations of more than 50 million  yuan, more than 14 million  masks, 34.6 thousand  items of protective clothing, 34.8 thousand  pairs of goggles, 9 thousand  thermometers, and more than 3.5 million  items of other supplies .“At that time, we were quite touched by a doctor living in Germany. […] He donated a lot of money to the Red Cross. When the Red Cross wanted his name to issue him a donation certificate, he signed it ‘anonymous’. […] After adding me as his WeChat friend, he read my posts in my Moment (pengyouquan) about the changing situation of Wenzhou in the pandemic every day. For every Moment about Wenzhou, he put a “Like” and commented. He does not know how to write Chinese characters anymore since he has lived in Germany for many years. But he still loves Wenzhou and China so much.”In addition to donations from associations, individual donations were also very impressive. Many Chinese new immigrants showed their strong emotional attachment to China through their donations. Nineteen retired new immigrants collected 47,000 yuan and donated to Huben Charity Federation in March 2020 . The interview with the secretary of Qingtain association shows that it is the entrepreneurs who contribute the most. 160 members out of about 300 members in the WeChat group of Qingtian association donated money (April 23 2020).“From January 24 to February 24, 2020, the national customs inspected and accepted a total of 2.02 billion pieces of epidemic prevention and control materials, worth 6.05 billion yuan. They are 1.63 billion masks, 3.56 million pairs of goggles, 18.62 million pieces of protective clothing, 13.55 million pieces of sterilized items, 4.39 million pieces of medical equipment, and 21.23 million pieces of other epidemic prevention and control materials. Significantly, 16.7% of them are donated medical materials which are valued at 1.09 billion yuan, including 184 million masks, 5.09 million pieces of protective clothing and 1.3 million pairs of goggles”  published an article on February 10 2020 to report the process of global buying by Chinese new immigrants.“In the act of supporting Wuhan City launched in January, Chinese in Germany actively donated money to support the city. They purchased and transport high-level medical protection materials with a total of more than 1.12 million, effectively supporting the first-line doctors in Hubei Province.”A leader of a group of new immigrants stated the situation in Germany with the author during an interview in June 2020:The authors witnessed the process in person. When they wanted to interview the leaders of associations of Chinese new immigrants in March 2020, many leaders were fully occupied searching for medical materials needed by the hospitals in China, including N95 face masks, protective goggles and disinfectant lotions.“Global buying” cannot not be accomplished without the success of global transportation because transportation to China was particularly challenging in early 2020, when many flights to China were suspended. Under these circumstances, donors made use of all the methods they could. And Chinese new immigrant businessmen showed their capabilities in logistics to support China in its disaster. Many of them have been doing business in Europe, thus they have established global.logistics chains for their goods before the pandemic. They voluntarily contributed these resources. After purchasing medical materials at very high prices, they stored these materials in their warehouses and transported the materials in their own wagons. Some businessmen persuaded their business partners and put medical materials on the flights of their partners. Some businessmen even persuaded the Chinese government to open a special flight to carry the medical supplies they donated to China. The author witnessed how the leaders of Chinese new immigrant associations in Germany utilized their social networks and business resources to search for medical materials, stored them in their own warehouses and restaurants, and transported them to China. Some association leaders in Germany even drove the goods to the Netherlands to take airplanes in order to send media materials to China as quickly as possible.Individuals were less powerful in terms of managing resources, but they were just as passionate about delivering medical materials which they had collected to China – e.g., by taking flights, ships, or trains. One of the authors witnessed Chinese in the west and south Germany voluntarily transporting the medical materials they donated to catch a flight from Berlin to Beijing. The officials in Wenzhou were deeply touched by the numerous donations, love, and support from Chinese new immigrants worldwide. They put a red heart on the region where donations were from on a world map; the map was soon full of red hearts. This map was collected by the National Museum of China as a milestone of the anti-epidemic campaign. This map clearly shows the social networks formed by its international new immigrants of Wenzhou city. Crucially, the social networks significantly improving the resilience of the city to control the spread of the virus.“In Wuhan City and Hubei Province the people have carried on with fortitude and resilience, while people from all sectors of society and our fellow compatriots in Hong Kong, Macao and Taiwan, and overseas have made generous donations, both monetary and in-kind.” Li The substantive donations of Chinese new immigrants alleviated the shortage of medical materials in China and enhanced the capabilities of the Chinese government in various levels to deal with the pandemic. The news reports in China about the overseas donations enhanced the confidence of Chinese people to fight against the epidemic. Therefore, the Prime Minister Keqiang Li confirmed the contribution of xinyimin on May 22 2020:The phenomena of global buying and global donation prove the powerful role of social networks of Chinese new immigrants to support China in coping with the crisis. There are three outstanding driven reasons for this global buying and global donation by Chinese new immigrants. First, there are strong cultural connections of Chinese new immigrants with their motherland and hometowns. As mentioned previously, many Chinese new immigrants are the first or second migrant generations who have daily contact with their families or relatives residing in China. In addition, many Chinese new immigrants still own properties in China, such as houses, apartments, and companies. These properties are often taken care of by their parents, relatives and friends in China. Many Chinese new immigrants go back to China to celebrate Chinese Lunar New Year, and to worship their ancestors in Qingming Festival. They hold strong cultural identity as Chinese. Second, Chinese new immigrants hold close economic connections with China in various ways. Many Chinese new immigrants are merchants running family-based enterprises in Germany, such as selling made-in-China products. They import and export between Germany and China. Many Chinese restaurants in Germany hire Chinese chefs and their fellow villagers and relatives which have shaped the ethnic economy. Travel agencies arranging travel to and from China in Germany work for Chinese tourists. Meanwhile, many of them directly invest in China. Third, there are political connections between Chinese new immigrants and China. In particular, the leaders of organizations work closely with officials in China at the state level  and the provincial level . Taking Wenzhou’s case as an example, the leaders of new immigrant associations in Germany have stable contacts with the officials of the UFWD, FROC and OCAO in their hometown governments. The above mentioned three aspects form a strong tie between Chinese new immigrants and China, in particular, their hometowns.Chinese governments at different levels also construct the contact with Chinese new immigrants actively. WeChat is a frequently used tool again. The UFWD in China and the officials of Chinese embassies and consulates built many WeChat groups for the leaders of the new Chinese associations. For instance, the UFWD of Jiangsu province established and maintained friendly relations with more than three hundred Chinese new immigrant associations and more than two thousand key figures in more than one hundred countries and regions FJROC . Instituth Anniversary on the National Day in Beijing in 2019. Some leaders of Chinese new immigrant associations obtained honor rewards in Zhejiang province and in Wenzhou for their contributions to their hometowns during the COVID-19 pandemic. One association leader was rewarded as a hero in the pandemic war by Zhejiang government in May 2020. The higher a reward is, the higher the capital attained by the awardee. When leaders of Chinese new immigrant associations are awarded by Chinese governments, they take photos and post them in their WeChat Moments and in many WeChat Groups, to show their capacity and share the honor. Their achievements are also reported in detail by Chinese newspapers and social media in Germany. Names of bigger contributors will be written in the local chronicles in their hometown. This also improves the social status of these leaders and associations in Chinese communities in Germany and in their hometowns in China. These kinds of symbolic rewards encourage other leaders to learn from the awardees in future. This is beneficial for obtaining more support from Chinese new immigrants and thus enhancing the capabilities of disaster management, risk reduction and economic development in China. This responds to what Massey  in Beijing, in their home provinces, cities, or towns, and in the embassy or consulates of China in Germany. For instance, there were about ten Zhejiang people in Germany (six of them from Wenzhou) who were invited to attend the 70t Massey ’s argumeRegarding the reasons for the phenomenon discussed above, this research reveals that Chinese new immigrants hold close cultural, economic, and social ties to China through their social networks at various levels. On the one hand, Chinese new immigrants  keep close daily contact with people and organizations in China conveniently using internet tools. On the other hand, the Chinese government at different levels also reaches out to Chinese new immigrants actively through different associations . More than ninety percent (90.71%) of respondents selected 5 and above. Almost ninety-eight percent (97.97%) of respondents reported that there were people infected by the virus in the cities in which they lived. Some reported that their friends, classmates, colleagues or family were infected. Regarding the risk of being infected by the virus, about half of the respondents believed the risk was medium or higher. They believed they were not far away from the pandemic and that their health was in danger. They were therefore worried that they would not receive sufficient medical care once they were infected. In this situation, it is not difficult to understand that many Chinese new immigrants wanted to go back to China.The situation was particularly dire for Chinese new immigrants and students in foreign countries because of the different cultural understandings about the pandemic between China and other countries. The Chinese government and Chinese people regarded COVID-19 as a serious pandemic. Wearing face masks was compulsory from the very beginning of the outbreak. It was not difficult to persuade the Chinese to wear masks because many Chinese still remember the SARS pandemic that happened in South China and Beijing in 2003. Under these circumstances, Chinese people in general had a stronger awareness of the need to wear masks and prevent infection. Chinese hospitals received all infected patients, and the goal was to cure all infected people. China was regarded as much safer than the foreign countries because individuals in China could wear masks to protect themselves, and once they were infected, they would receive good medical care in hospitals.In contrast, wearing masks was prohibited or at least not encouraged in many foreign countries particularly at the beginning of the pandemic. Many Chinese new immigrants reported in our survey that they experienced discrimination in foreign countries because they wore masks. Moreover, infected cases received medical care in hospital only when the patients were very sick or old. This is why Chinese new immigrants felt their health and even lives were in danger. The fear was particularly strong when Chinese new immigrants and Chinese students compared their lives and situations to those of people living in China. They believed China’s strategies were better and that it was safer staying in China, but they had to stay outside China where government strategies were ineffective.In order to reduce the uncertainty and improve their capacity to deal with the disaster to protect xinyimin and students, the leaders of various associations decided to expand their social networks to the whole Chinese communities. The best way to achieve their goal was to build a new national association. On March 11 2020, the All-German Epidemic Prevention Working Committee was established, and five leaders of Zhejiang associations and one leader of Fujiang Association were elected to constitute the leadership of the Committee. There were about thirty associations participated in the committee. The committee expanded its connections to its member associations and built strong connections with Chinese consulates and organizations in China. One of the authors worked in the secretary group and saw the committee obtained one million RMB and huge medical material from Zhejiang province and then distributed the money to poor students and immigrants along with various medical materials. The committee successfully expands its networks to region-based associations and other types of associations national wide. For instance, there were 37 temporary offices aimed at dealing with the distribution of health kits as well as any emergency of infection cases around the Bonn City in August 2020. The committee also donated many face masks to German governments, organizations (e.g. police states and old people’s homes) or individuals. This reflects the dynamic of social networks of Chinese new immigrants by institutionalizing their social networks and built offline connections. The establishment of a new organization broadens their social networks by including more associations, even some small marginal associations and many individuals, including scholars, lawyers, doctors, journalists, students and young teenagers of second generation. Actually, the Committee expands its social networks to many weak ties of new immigrants who were not part of any associations, for instance, some female new immigrants who got marry to German. By so doing, the capacity and resilience of the Chinese communities were substantially improved. The achievement of All-German Epidemic Prevention Working Committee was admired by the Chinese communities, Chinese government and German partners.“As of June 2 2020, the city has donated 1.1007 million pieces of materials, including 1.0579 million masks and 42800 packages of traditional Chinese medicine, with a total value of 2.645 million yuan, to 17 countries (regions) including Italy, Spain, the United States, France, Germany, Kenya, Brazil and Belgium. In addition, as of June 2, 4.532186 million pieces of medical materials were provided by municipal and county governments, and 1.99 million pieces were donated by non-governmental constituted by local youth” .Chinese governments began to help Chinese new immigrants and students in overseas countries in March 2020. The support was carried out both online and offline. Regarding offline support, health kits were distributed among Chinese new immigrants. The health kits included face masks, N95 masks, disinfectant wipes, Chinese herbal medicine, gloves, and one epidemic prevention manual with positive words encouraging people. In Germany for example, four rounds of health kit distributions were completed near the end of October 2020. Chinese new immigrants and students obtained health kits from Chinese embassies, Chinese consulates or from the Chinese new immigrant organizations. The close connection between Wenzhou and Chinese new immigrants in other countries benefited Chinese new immigrants. As an official in Wenzhou reported to the author:Support was carried out online at the same time. Chinese consulates in foreign countries, such as in Germany and France, invited medical experts in China several times – e.g., the famous Chinese doctor Hongwen Zhang – to online meetings particularly for Chinese new immigrants and Chinese students in Germany  of the respondents took the advice and gave up their plans to travel to China.Many departments were coordinated in this work. In particular, the UFWD, FROC, and OCAO formulated a series of working principles and procedures for the donation to overseas Chinese with the purpose of providing support on time and improve the resilience of Chinese new immigrants. These departments collaborated and collected medical materials from Chinese governments and non-governmental associations. This research reveals that the UFWD is a key department in this process. Firstly, it represents the state’s policies and intention towards Chinese new immigrants. Secondly, this department effectively investigates the needs of Chinese new immigrants globally by organizing webinars and online meetings for leaders of new immigrant associations. There were connections between government departments in China and the association leaders in overseas countries both before and after the COVID-19 pandemic. WeChat groups were the most frequently used tool. During the pandemic crisis more and more Chinese new immigrant individuals and leaders volunteering to join the WeChat groups built by the department. The officials in Wenzhou mentioned that they had extended their relationship with more leaders of new immigrants during the pandemic. Thirdly, this department coordinates most domestic donations, including docking with airlines to transport anti-epidemic materials, conveying the government’s policies to Chinese new immigrants, and publicizing the government’s anti-epidemic measures. This department also negotiated with the leaders of associations when the leaders donated medical materials to their host countries, such as to Germany.One of the authors participated in an event when the leaders of two associations donated face masks to the hospital of University of Cologne in Germany. The author could bridge the association leaders and the person in charge in the German hospital because the author knew a Chinese doctor who worked in the hospital. When the author learned the shortage of medical material of the hospital from the doctor, she informed the leaders of Zhejiang association and Jiangsu association. The Zhejiang association first donated 4500 face masks to the hospital which were donated by its members. A month later, another 30,000 face masks were donated to the same hospital with the support of a returnee from Germany. He is a Standing Committee Member of Zhejiang Chinese People’s Political Consultative Conference Committee as well as the Vice Chairman of the FROC in Zhejiang Province. In this donation, the author and the doctor played an important role in connecting the Chinese association and German hospital. However, without the strong ties between Zhejiang associations and the Standing Committee Member in Zhejiang, the donation could not be happened because of the difficulties of cross border logistics and customs clearance in March–May 2020. According to the observation, there were many associations donated masks to the government, universities and supermarkets in several German cities through different networks.The volunteer donation to the hardest hit county in Germany — the county of Heinsberg was really remarkable. The first infected case of corona-virus in Germany was confirmed in Heinsberg on February 24 2020. In March 2022, according to the county magistrate, Heinsberg neither could obtain enough epidemic prevention resources from the federal government and the state government of Germany, nor could it purchase any materials from the market. In order to control of the COVID-19 spread, German Hangzhou Federation of overseas Chinese, German Qingtian Association and other associations handed over a batch of medical masks, protective clothing and other epidemic prevention supplies to the head of Heinsberg county and the county health bureau to support the county’s epidemic prevention work. This donation was facilitated by the Chinese Consulate General in Düsseldorf. We interviewed the secretary of German Qingtian association who attended the donation on April 23 2022, he said, “We originally had more than 7,000 N95, with a total price of 40,000 euros. After the outbreak of epidemic, the Qingtian association in Germany called on contributions from its fellow members in the name of supporting the fight against the epidemic in hometown. Later, epidemic was under controlled in China, and the FROC in Qingtian informed the association leaders to keep the donation items for overseas Chinese (instead of sending to China). Because the items were medical masks , they were eventually donated to Heinsberg county.” Donations to German institution also reveal the dynamic of social networks of the associations of Chinese new immigrant. The associations work with Chinese consulate in order to have a formal connection with Heinsberg and can donate the medical material in a proper way (reducing risks). During the donations to German society, the goals to reduce stigma and potential discrimination in the host society at that time were achieved. Through civil donation, the trust between China and Germany has been rebuilt.Many Chinese new immigrants and students who received the health kits took pictures and shared them in WeChat groups or Moments to express their appreciation. The officials of UFWD, FROC, and OCAO also asked the leaders of new immigrant associations in Germany about the details of their work, e.g., when they distributed the health kits to Chinese new immigrants. These kinds of records proof that the associations were working to protect Chinese new immigrants and Chinese students in Germany.As discussed in this section, the experience of Chinese new immigrants during the COVID-19 pandemic proves that a disaster is a social, cultural, and medical specific issue. The identification of the COVID-19 pandemic is embedded in the social-cultural structure of the Chinese community in Germany. The cultural element also impacts which methods to be chosen to deal with the public health crisis. Actually, how infected people should be treated are questions that are addressed differently in China and in other countries such as the US and those in Europe. Therefore, coping with the pandemic is particularly challenging for Chinese new immigrants because they are caught in between (mainly) two understandings of the pandemic. Some of them wanted to go to China when they were in a panic and their health was in danger. This brought new challenges for China regarding its coping strategies for dealing with the pandemic. Under these circumstances, Chinese governments at different levels made use of internet tools to reinforce established or to construct new online communication channels to support Chinese new immigrants. Medical materials are sent from China to Chinese new immigrants as well. Mobile apps represented by WeChat play crucial roles in this process. This research argues that while understandings of disasters are culturally specific, the solutions to cope with them are culturally specific as well.Contributing to existing theories on the social networks of Chinese new immigrants, this paper reveals that social networks of Chinese new immigrants have its strength for combating COVID-19 pandemic for individuals, associations, and for the overall disaster relief in China.At the micro level, the contribution of follow members supports the donation initiatives of the associations. It shows the strong ties of social connections among members of overseas associations. Meanwhile, members can obtain resources and support from their associations, such as health kits and online courses. At the meso level, the associations can set up new connections to institutionalize weak relationships between associations. The ties between various Chinese associations were rather weak and many even have conflicts with each other before the pandemic. However, during the pandemic, the establishment of All-German Epidemic Prevention Working Committee reflected the resilience of the Chinese new immigrants by reconstructing their social networks and obtaining better social capital by establishing this institution. Furthermore, the associations are key players of social networks of Chinese immigrants based on its well-organized structure and leadership. Associations have a stronger and bigger social network than individuals, and they can cooperate with the home state and host country by joining diverse institutions as a member association or by linking diverse platforms and agencies. As a broker between China and the host country, the Chinese associations prove their capacity and resilience in coping with the COVID-19 crisis. It also shows that the Chinese associations in Europe “need two worlds” Li . At the As shown in this study, the experience of Chinese new immigrants shows that the understandings of a disaster and the role of social networks for coping with the disaster are very culturally specific. This research argues that studies on disasters and disaster management should pay more attention to the culture in the host countries where Chinese new immigrants live and Chinese culture, particularly when the fast flow of population and goods worldwide nowadays has connected different regions together tightly. The case study on social networks of Chinese new immigrants in combating the COVID-19 pandemic shows that the processes of reciprocity between Chinese new immigrants and China are beneficial to both sides. The circulation of social capital through social networks builds trust and offers support from and for both sides.A salient finding of this research is that the wide use of WeChat has become a crucial infrastructure to build the relationship between Chinese new immigrants and their hometowns in China. This is evidenced in several ways. On the one hand, internet tools – represented here by WeChat – serve as an effective means for the communication between Chinese new immigrants and China. This is crucial for both sides to build their resilience and capabilities for dealing with a disaster. On the other hand, internet tools serve to build faith and confidence between two sides by clarifying misunderstandings, transmitting policies from authoritative institutions, reducing rumors, and so on. The cultural, economic, and social ties of Chinese new immigrants to China are all reinforced during the pandemic facilitated by WeChat. The usage of WeChat captures the core cultural characteristics of Chinese internet users within China and beyond in the cyberspace during the global implementation of social distancing and lockdown measures.


Public health nurses (PHNs) are among the few municipal civil servants who lead community infection control and prevention initiatives in Japanese public health centers (PHCs). This study aims to investigate the distress faced by PHNs and clarify their difficulties and working environment relative to infection prevention control activities during the COVID-19 pandemic. We adopted a qualitative description methodology in this study of 12 PHNs who were involved in COVID-19 prevention and control in PHCs in Prefecture A. The distress during the early phase of the pandemic was due to the uncertainty of the SARS-CoV-2 related disease, which caused panic in medical institutions and among residents. PHNs were overwhelmed, distressed and exhausted by their inability to control the ‘pandemic’, lack of patient cooperation for prevention control and the unsustainable organizational environment. They were also distressed because they were one of the specialized personnel responsible for saving residents' lives with limited medical resources and while having identity crises due to an inability to carry out the PHN's role of controlling infection in the community. For future crises, rapid, drastic innovation defying conventional organizational systems is critical to reform sustainable organizations so that they play an effective role in the community. Innovation in crisis communication and strengthening the medical system will help achieve a resilient community in a health crisis. The eighth wave is threatening people's lives and their social life, and, as of February 2023, >33 million confirmed cases, including 72,320 deaths, have been reported The PHC is a municipal organization that has an essential role in promoting public health in Japan. Besides daily health activities, including mental health services, food hygiene and services for patients with intractable diseases, PHCs are expected to be the local health risk management base for coping with health crises, including food poisoning, infectious diseases, natural disasters and terrorism Japanese PHNs are nationally licensed nursing professionals, and those working in PHCs play the main role in quarantine services as the professional infection control workforce in the community. In Japan, medical examinations and diagnoses are held in local clinics and hospitals. While, PHCs carry out establishment and arrangement of the local medical system, consultation services, active epidemiological investigation of all confirmed cases, transporting patients and medical distribution, including tests and hospitalization Although some studies have focused on medical care workers in hospitals during the pandemic As no studies have reported Japanese PHNs' experience during an infection outbreak before the COVID-19 pandemic, their distress and difficulties during a pandemic are unknown. A few studies revealed that the PHNs who consulted at call centers during the first wave of the COVID-19 pandemic had difficulties such as “being a complaints counter instead of a health consultations provider” and “difficulty in triage test-applicable cases and arrangement of facilities for tests” This study aimed to capture the voices of Japanese PHNs specializing in quarantine services on the frontlines in communities during the long-term COVID-19 pandemic. We also focused on the difficulties and distress they experienced and clarified the background to these issues.2.2.1.A qualitative description methodology explained by Sandelowski Our study was conducted in Prefecture A, which is located in the Kanto area of Japan. Prefecture A is a peri-urban municipality which contains both urban and rural areas, and the number of COVID-19 confirmed cases tended to increase following after the Tokyo Metropolitan area. PHNs involved in COVID-19 prevention and control in PHCs at any point after January 2020 were recruited through leaflet distribution for all PHNs working in PHCs in Prefecture A. Those who belonged to organizations other than PHCs were excluded. We selected a variety of participants, considering their characteristics such as age, experience and their role in PHCs, until the data reached saturation.2.2.A qualitative descriptive study using semi-structured interviews was conducted to gain clear insight about the experiences of PHNs during the pandemic. One-on-one interviews were held either online or face-to-face from October to December 2021. An interviewer (AM) interviewed each participant once. The interviews were conducted in a closed room in PHC or in a meeting room in the university to protect privacy.We asked questions to reveal the distress that PHNs experienced in their overall activities following the interview guide. The interview guide contained the open-ended questions: “Through all of your experience in response to the COVID-19 pandemic, what situation have you found most difficult or challenging?”, “What situation have you found difficult or challenging to deal with [community residents/ patients/ close contacts/ medical institutions/ central government office/ colleagues]?”, “Have you ever evoked the intention to resign? And, what were the triggering events or stressful situation?” For each experience and difficulty, their emotions, feelings, thoughts and mental and physical effects were explored in detail with ancillary questions. Additionally, to ensure clear and profound interpretation, follow-up questions were asked.The dictated recording data were analyzed using inductive content analysis. A content analysis is defined as “a research technique for making replicable and valid inferences from texts to the contexts of their use” by Krippendorff 2.3.In order to establish confidence in the results of this research, we ensured rigor by using the model of trustworthiness of qualitative research by Lincoln and Guba To ensure credibility, member checking was conducted in the interview and in the process of data analysis to ensure accurate understanding and interpretation of the verbal data. During the analysis process, the data were discussed by a research group familiar with the topic. To ensure dependability, we avoided leading questions by using an interview guide with open-ended questions during the interviews. During the analysis process, three researchers confirmed the audit trail in the archives. As a result, we decided to ask the participants for an additional interview or to answer follow-up questions, if necessary. To ensure confirmability, two researchers checked the interpretation of raw data and extracted categories and their relationship to each other. We also referred to previous studies focusing on PHNs and PHCs to strengthen confirmability. To facilitate transferability of the results to the other researchers, we provided a detailed description of the phenomena and context of the PHNs' experience. To ensure authenticity, the interviews and analysis were conducted by researchers who were trained on qualitative interviewing techniques and analysis. Throughout the data analysis process, researchers conducted interpretation of the context of raw data and analysis with continuous reflection and self-criticism.2.4.This study was approved by the medical ethics review board of the University of Tsukuba . Participants were informed about the purpose, anonymity of collected data and right to withdraw participation. Participants were informed that the collected data would not be shared, but would be used exclusively for research purposes. Written consent was obtained from all participants.3.3.1.Twelve PHNs from six PHCs participated in the study . They we3.2.3.2.1.Distress among PHNs, particularly in the early phase, was due to the uncertainty of the SARS-CoV-2 related disease. PHNs, who were the only contact points in the community, became one-sided outlets of complaints and outbursts from people who panicked with fear and anxiety about the new threat of the unknown virus. In addition, these complaints were greatly influenced by their misinterpretation of media reports that did not faithfully reflect the current situation of PHCs and the healthcare system. Under such circumstances, PHNs were at the mercy of the residents' verbal abuse and faced difficulty ensuring that residents understood appropriate information.At that time, gaining cooperation from local medical institutions to triage and detect infected individuals became an urgent issue for PHCs. However, as healthcare workers in medical institutions were also panicked, many physicians and medical institutions refused to take risks and responsibility, and few cooperated with PHCs. PHNs faced difficulty in finding medical resources and responding to triage judgments left by local physicians. Moreover, they struggled with having to respond to local physicians complaining that PHCs were recommending that residents with symptoms of the common colds visit them for consultation.In Phase I, inquiries from residents flooded the PHCs, since it had been the only local consultation service officially designated by the Ministry of Health, Labor and Welfare. Although little knowledge of the virus was available in the early phase, PHNs were asked for more detailed information. With few medical resources to provide tests for suspected patients, PHNs had no choice but to refuse test requests from residents. Moreover, these situations created a large gap between people's expectations and what PHCs could offer, making residents and medical institutions angry and overwhelming the PHNs.3.2.2.PHCs are responsible for the active epidemiological investigation, giving health guidance for prevention, medical coordination and follow-up during home treatment for all patients. They have a responsibility to prevent the spread of infection and for fair distribution of medical care in the community. These responsibilities are stipulated in the Japanese Infectious Disease Control Law. The active epidemiological investigation is generally conducted immediately upon a ‘notification of the occurrence of a positive case’ from medical institutions to triage and coordinate medical facilities promptly.PHNs were exhausted and disappointed by the continuous uncertainty that they had been facing for hours, months or years, wondering when the number of confirmed cases would peak, how many confirmed cases would be reported that day, the time to leave work after completing investigations and medical coordination, and the duration of such situations. Because the virus was invisible and constantly mutating, guessing the trend of confirmed cases was not easy. In addition, due to the PHC's function, there was no limit to the number of ‘notifications’ from local medical institutions, unlike hospitals with a concept of “full beds”.However, there was anguish not only when the number of confirmed cases increased, but also when the wave was on a downward trend. Some PHNs expecting the next wave felt a sense of aversion, saying, “I do not want to imagine the next wave anymore”, considering the past traumatic and distressing experience of dealing with many positive cases. Regardless of such feelings, they could not release tension to prepare for the next wave, such as holding infection control training sessions for nursing care professionals in welfare facilities and developing organizational systems. We clarified the peculiarity of the pandemic, including the repeated peaks, uncontrollability and the uncertainty of the wave's timing, that directly affected their work and exhausted them.3.2.3.PHNs cannot prevent infection in the community and protect patients' lives without the understanding and cooperation of the community, including medical institutions and community residents. Specifically, PHNs have been requesting patients to refrain from working or going out, close contacts to have tests and stay home and the general population to take general infection prevention measures such as keeping their distance and wearing masks. They have been working to protect the residents and the community.However, PHNs' intentions and thoughts were not appropriately understood in the community due to the residents' excessive personal emotions, such as aversion to restrictions on behavior, and cultural differences. Furthermore, PHNs were distressed by becoming the outlet for unreasonable demands, verbal abuse, complaints, one-sided feelings due to excessive emotions, a sense of entitlement from paying taxes and dissatisfaction with services provided by PHCs. At the same time, there was a sense of impatience; complaints from residents slowed down other duties, including medical coordination for patients needing medical care and first contact for the huge volume of diagnosed patients.Until the end of the fifth wave, i.e., in December 2021, PHNs had requested those who had close contact with a COVID-19 case to stay home for 14 days, which was longer than the 10 days for positive cases, following the national policy. However, it was without any legal basis. In Japan, unlike patients whose lives during quarantine were guaranteed by law, there were no such restrictions and guaranty for close contacts. Considering the position of those who had close contact with a positive case, PHNs had conflicts in fulfilling their role of requesting cooperation to prevent infection spread, even though they understood the complaints of long restrictions without any support.3.2.4.They were frustrated with their inability to effectively play their roles as professionals working at the frontline in the community, with delays in organizational arrangements, insufficient instructions and a lack of time for staff members to reach a consensus and resolve their concerns.In the recent pandemic, even though it was the unprecedented emergency at the level of disaster, a clear division of roles throughout the PHC was not instituted. This promoted staff from other divisions to “assist” PHNs rather than act independently. Another issue was the delay and inconsistency in system development, including data management, readiness to receive support staff and building a unified flow appropriate for practice setting within the organization. Clear directions by leaders, such as designating a stopping point for their duty in each day, were also required. These delays and ambiguous development of organizational systems made it impossible to adequately perform the responsibilities and functions as PHNs and PHCs. Because the organization would not change, despite its capacity, frustrations ensued. Even when the situation seemed to be improved, new issues emerged. For example, when the sharing roles were promoted by dispatching staff from outside PHCs, PHNs struggled with instructing and communicating information to newly dispatched personnel each day and unifying the responses of support staff.There were also difficulties related to the consistency of recognition within the organization and problem-solving process that could not be changed with the development of the organizational structure. As the number of confirmed cases increased, all staff members were occupied with their duties of communicating with residents over the phone, making it difficult to interact with each other. As a result, PHNs found it difficult to resolve their concerns and to express frank dissatisfaction and opinions with the organizational structure, which are frequently considered as less urgent and low priority. This delayed further organizational structure development and improvements in operational efficiency and hindered uncertainty elimination in responses.3.2.5.In Japan, examination, testing, diagnosis and prescription of suspected or confirmed cases are conducted at local hospitals and clinics. In most cases, PHCs do not diagnose or prescribe, but conduct quarantine and medical coordination activities after they receive notifications from local physicians. PHCs have played an essential role in the allocation of medical resources, particularly in regard to testing in the early phase of the pandemic and medical facilities for inpatients and home care patients as the number of confirmed cases increased. However, the critical role of saving residents' lives cannot be fulfilled without the cooperation of local medical institutions. The number of cooperative medical institutions admitting and receiving suspected/positive patients was quite limited because of their staff levels, capabilities and facilities.Therefore, as the number of confirmed cases and patients needing medical care increased, PHNs felt huge anxiety about their inability to allocate medical resources and save patients' lives. PHNs were frustrated with being caught between patients and medical institutions. It was an important role of PHNs to advocate for patients in need of medical care. However, they felt distressed when they received further requests of patients to be hospitalized during a crisis in which patients who already needed to be hospitalized were instead being treated at home.They also felt pressure to make decisions quickly, based on information they received through phone communication, amid the demand for fair medical allocation. Some PHNs were pointed out triage errors by physicians when they had directed non-urgent patients to medical institutions.PHNs in some PHCs were exhausted because of extra duties, such as taking emergency cell phones home to respond to sudden changes in home care patients at night, requesting further cooperation from medical institutions in response to a lack of medical resources and operating testing centers on behalf of medical institutions.3.2.6.With increased numbers of confirmed cases, the need to collaborate with local healthcare professionals and share personal medical information increased. Thus, PHNs were forced to ask other professionals to provide the first contact with the target population, such as active epidemiological investigation and guidance on infection prevention to those in-home care and close contacts, which had been the main responsibility of PHNs until then. Some PHNs perceived prevention of the spread of infection throughout the community as paramount in their duties as PHNs. Those with such identities felt conflict about not fulfilling their role while recognizing the importance of coordinating medical resources for individual positive patients in need of medical care.4.This study reveals the distress and emotions of PHNs in having to confront a situation they had never experienced before. It goes without mentioning the need for social and mental support, considering the difficulties they have experienced, their emotions and distress. We examined their distress from four perspectives: crisis communication, resilient organization, heavy liability and identity crisis.4.1.The PHNs were exhausted from dealing with the complaints and verbal abuse from confused residents and medical institutions, especially in the early phase. They were also frustrated by the difficulty of gaining understanding of PHC responses and requests for cooperation from the community.During this pandemic, the whole world was concerned about an unknown and invisible threat, and people were strongly affected by negative emotions such as fear, anxiety and anger Originators of mass media and social media tend to disseminate false or exaggerated information to respond to the needs of people in such crises, and confusion reigned PHCs were the only contact points in the community where people, whose anxiety was heightened by the various false and exaggerated information and rumors, could express their emotions. In past health crises, local government officials, including PHNs, responded to residents' complaints and stress In response to this, it is necessary to re-examine the dissemination of information by the sources, especially mass media, during crises. At the same time, measures are needed to improve the health literacy and media literacy of the recipients Crisis communication is defined as all communication activities when an organization, such as a company or government agency, is in a crisis due to an incident or accident; it is mainly aimed at protecting the organization from secondary damage caused by rumors and overcoming the crisis to achieve sustainable growth In general, the intention and purpose of the PHNs' activities and the PHCs' roles are difficult to be understood by the community 4.2.Japanese PHNs involved in the flood disaster in 2009 reported anxiety about the unpredictable situation According to research by Tomioka et al. 4.3.Japanese PHCs are responsible for coordinating medical institutions for patients who require hospitalization or medical consultation. As the only specialized organizations in the community, they were burdened with a heavy responsibility to make decisions, including those relating to life-threatening matters. Our study revealed that, despite the life-threatening crisis and residents seeking help, PHNs felt a sense of hopelessness, anxiety and conflict because they could not adequately protect people's lives.One of the reasons for their liability was a shortage of distributable medical resources. Since PHCs do not conduct medical examinations as hospitals and clinics, gaining the cooperation of local medical institutions was needed to protect the lives and prevent the spread of infection. However, there was not enough cooperation due to the special circumstances of the pandemic and lack of preparation in advance. Moreover, PHNs also suffered from complaints and intimidating claims from medical staff. Insufficient knowledge of the virus may have caused medical resource shortages. According to Almohammed et al. In addition, they also described the difficulty of collecting accurate information from patients over the phone and properly assessing illness severity. One study revealed that patient triage was one of the physician's stressors during the COVID-19 pandemic 4.4.PHNs who work as civil servants are sometimes described as “men of all work” In the current crisis, PHNs played more roles in protecting individuals' lives instead of preventing infection in the community, and they responded to people's complaints and verbal abuse instead of consultations. These gaps were because of the huge number of confirmed cases, the needs of, and roles expected by, residents, and the limited work that a PHN can practically do. Since they are always aware of individual and community perspectives in their health activities, each PHN's perception of their role may differ. However, some PHNs were found to have a strong sense of mission to protect the community more than individuals, and they strongly perceived this as their own identity. In Japan, PHNs are the only ones who conduct health activities targeting the community as a group, while general nurses in medical institutions can provide care for individuals. This particularity of their job may create their identity as a PHN.Shoji et al. 4.5.In our study, qualitative investigations were conducted with only 12 PHNs in PHCs belonging to one prefecture in Japan. The challenges and distresses faced by PHNs may differ between PHCs in other regions. Therefore, the findings cannot be directly applied to all organizations and PHNs due to different circumstances and situations. In the future, it will be necessary to expand the scope of the study to include other regions and target populations.5.There was remarkable anguish experienced by PHNs in Prefecture A at the frontlines of quarantine in a pandemic that occurred amid a reduction in the number of PHCs in Japan. The PHNs were aware of the fear and anxiety of the general population against the unknown infectious disease, and, even with limited medical resources, they tried to fulfill their role as nurses to advocate for residents in the community. There was also a unique awareness among Japanese PHNs to protect individuals and the entire community by reaching out to residents. However, it became clear that the environment in which PHNs could effectively fulfill their roles and contribute to community infection control had not yet been established at PHCs at regional, prefectural and national levels. Although 3 years of quarantine activities have helped to adapt to this situation, the COVID-19 pandemic is still ongoing. As PHNs continue to fulfill their professional roles in this pandemic, they will continue to experience psychological distress. It is expected that their distress will continue in the long term and during future health crises, such as another pandemic or disaster. Therefore, future roles of PHNs in health crises need to include strengthening local public health systems and interacting with residents and medical institutions as community coordinators.


Handball is a team sport subjected to asymmetric actions that require high physical capacity demands on players. The development of large asymmetries could negatively affect sports performance. However, few studies have analyzed body composition and the force asymmetries in elite female handball players. The aim of this study was to analyze the presence of asymmetries based on limb dominance in body composition parameters and lower limb power in jumping performances in an elite women’s handball team. An entire elite women’s handball team, comprised by of 14 players, was analyzed. Dual X-ray Absorptiometry (DXA) and bioimpedance were used to analyze body composition. Force plates were used to evaluate jump performance. Results show the presence of differences between all the players in the different parameters of the CMJ jump. In addition, an asymmetry between the power of the dominant and non-dominant lower limb was observed between the players. The results show differences in muscle mass between the upper limbs, but not in the lower limbs in terms of both muscle and fat mass. However, there were no crossed asymmetries or significant differences between members based on dominance. The results suggest that the presence of asymmetries does not have to be one of the main parameters to be taken into account by coaches in elite athletes and to highlight the importance of including specific analyzes of body composition and sports performance in an individualized way. It is a contact sport that includes physical efforts such as running, jumping, ball throwing, various movements, turns, and changes in speed and directions2.Handball is characterized as a team sport that involves high-intensity asymmetric actions, requiring significant physical demands on the player3. However, the repeated unilateral loads that occur in handball can lead to crossed asymmetries in athletes, which can increase imbalances between the extremities4.As the first part of the kinetic chain, the contralateral lower extremity plays a critical role in maintaining the dynamics of balance and initiating the forces transferred through the trunk during ball throwing6. Previous studies have indicated the importance of studying parameters such as the concentric and eccentric Rate of Force Development (RFD) and reactive strength index (RSI) for both improving sports performance and preventing sports injuries. This is due to its direct and indirect relationship with the elastic energy of the muscle–tendon system7.Several studies have explored the relationship between asymmetries and sports performance, observing that a high imbalance between the dominant and non-dominant limbs can affect sports performance variables such as speed and strength4. However, an asymmetry value of less than 7% between the dominant and non-dominant limb is considered small and does not demonstrate a significant relationship with sports performance8. It should be noted that depending on the test performed, the asymmetry values between limbs can be different. In addition, the asymmetries do not depend only on the type of sport, but also on the individual demand on each player on the court10.In this sense, the presence of large asymmetries could negatively affect sports performance through vertical and horizontal jump, considering the presence of asymmetries from 6 to 7% in horizontal jump tests and an increase in asymmetries of 10% in unilateral vertical jump tests8. As a consequence, there are a large number of studies that focus on the evaluation of segmental body composition and anthropometric factors in elite sports, considering them essential variables in the context of sports performance and injury prevention11.Nevertheless, limb asymmetries have also been related as an important risk factor in the incidence of sports injuries12, indicate the importance of assessing body composition and anthropometric variations throughout a competition cycle in female handball players. In this way, it is intended to prevent sudden changes during the season that may impair sports performance, or even reinstatement of the players after a period of flack of training due to injuries12. In this sense, it is essential to remember that achieving optimal body composition values can contribute to reducing the risk of asymmetries and injuries and facilitate the rehabilitation process for a return to play13.Kale and Akdoğan15, which shows a high level of reliability with the gold standard in this field, such as dual energy X-ray absorptiometry or DEXA16. Among the variables obtained by the Z, is the phase angle, which is obtained from the relationship between the measurements of resistance (R) and reactance (Xc). This index being equal to the arctangent of the reactance divided by the resistance17. Scientific evidence reflects that a decrease in the phase angle is associated with the presence of impaired integrity and injury to the cell membrane, which leads to a greater risk of acute injury or damage due to tissue over load and decreased the sport performance18.One of the most widely used body composition assessment techniques in sport is bioelectrical impedance19. For this reason, the main objective of this study was to assess whether there are asymmetries bases on the dominance of the limbs between players. A secondary objective was to analyze whether the presence of asymmetries in body composition parameters between lower extremities showed a relationship with the development of asymmetries in muscle power parameters during jumping performance. To achieve this, the study was included segmental analyses, focusing primarily on body composition variables and the countermovement jump (CMJ), enabling to evaluate the presence of asymmetries between dominant and non-dominant limbs.However, few studies have analyzed body composition asymmetries and rate off force development taking into account limb dominance in elite female handball players and the relationship to athletic performanceIn relation to the proposed objectives, it was hypothesized that the presence of slight asymmetries will be visible in most players as it is a sport characterized by asymmetric actions, with the dominant limb being the one that presents the most optimal values of body composition and strength and influencing the jump performance.In this research, a cross-sectional experimental design was carried out, where participants were selected intentionally, non-probabilistically and for convenience. The female handball players participated of your own accord and the data collection presented a duration of eight weeks, within which two previous weeks of familiarization were included.2). The players were recruited from the Málaga Costa del Sol Women’s Handball Club, current European champions .A total of 14 elite female handball players participated . The subjects were informed of the conditions of the study and were aware of the possible risks of the experiment and signed an informed consent ledging their willingness to participate.The technical team of the Costa del Sol Women’s Handball Club (Málaga) team was contacted and they were informed of the entire procedure that would be carried out. The search protocol was carried out in accordance with the ethical guidelines of the Declaration of HelsinkiAll measurements and tests were carried out in the laboratory of effort physiology and sport medicine at the University of Malaga, in the Carranque sports center and in Eshmún Sport Clinic in Malaga Fig. .Figure 1For the analysis of body composition, body weight was previously measured with a scale  and body height using a wall-mounted stadiometer .21.Subsequently, a bone densitometry was consecutively performed on each subject using dual X-ray absorptiometry using the bone densitometer-DXA DXA was calibrated with phantoms according to the manufacturer’s guidelines each day before measurement. It was indicated in each exploration that the participants had to come fasting and not have trained the day before the body composition analysis. In addition, the participants wore light clothing and were asked to remove any materials that might attenuate the X-ray beam. DXA provided reproducible estimates of total and segmental distribution parameters of body composition including body fat percentage, body fat mass, total lean body mass, total body mass, leg fat mass, torso fat percentage and torso fat mass among others.22 using the Inbody® 770 model .Moreover, segmental multifrequency data were obtained that accurately determined total, intracellular and extracellular body water, impedance (Xc and R) and phase angle (Z) in the five body segments  by bioimpedance (BIA)23.As for the criterion device for evaluating jump performance, the force plates Force Decks Dual Plate System  was used24. In addition, Vald Performance makes it possible to know the level of asymmetry between the right and left leg, taking into account the dominant lower limb in the jump test of each player. This allows knowing unilateral values of the dominant and non-dominant lower limb despite using the bilateral CMJ test25.For the evaluation of jumping performance, the Bosco jumping protocol was followed for performing the bilateral CMJ26. In addition, a standardized verbal stimulus was given to each participant during the test in order to achieve maximum performance in the jump.All subjects underwent a two-week pre-training to familiarize themselves with the protocol that was incorporated during general team training. Each subject, after performing a previous warm-up, performed a total of three repetitions in a row with a 1 min rest between tests and the mean of the three repetitions was selected in the statistical analysis25. Furthermore, the analysis of the asymmetry values of these parameters between the dominant and non-dominant limb during the different phases of the jump was carried out; concentric and eccentric phase, acceleration and deceleration phase, and takeoff and landing phase.Performance variables such as jump height, RFD, RSI, kinetic parameters such as average, maximum or impulse force and kinematics, highlighting the average flight time, are selectedp < 0.05, and all statistical procedures were performed using SPSS version 25 .The values presented in the descriptive tables show the mean and standard deviation. To determine the normality of the variables, Shapiro–Wilk tests were conducted, and Levene’s test was used to test for variance equality. A one-sample T-test was performed to compare differences in CMJ performance and asymmetry among the players. This analysis shows the results with percentage values and not with p-values. A paired-samples t-test was conducted to analyze bilateral variability in body composition and dominant and non-dominant limbs. Linear regression was used to detect possible relationships between the asymmetries in mass between the dominant and non-dominant limbs and the presence of asymmetries in jump parameters. All regression models were assessed by model checking, including investigating the linearity of effects on outcomes, ensuring normal distribution, and homogeneous variance. Statistical significance was set at Descriptive statistics for physical parameters and total body composition are presented in Table All players presented differences in the different parameters of the CMJ jump between them. Additionally, a percentage of asymmetry was observed between the left and right lower limb power among the players, mainly in the eccentric and in the maximal landing phase Table .Table 2Dp > 0.05) were found between limbs in the values of total body water (TBW), intracellular body water (IBW), extracellular body water (EBW), electrical impedance and phase angle.The results of the bilateral variability analysis are presented in Table vs non-dominant leg  .The participants did not show differences in lean mass between dominant No associations were observed between the difference in lean mass between dominant and non-dominant leg and the asymmetry between legs in the jump Table .Table 4A27. In the study by Lijewski et al.28, it was observed significant differences in muscle mass in the right and left limbs, presenting greater muscle mass in the upper and lower right limbs, and Arboix-Alió et al.29, found significant differences between the higher performing limb (HPL) and the lower performing limb (LPL).The aim of this research was to analyze the total and segmental body composition, and the power parameters during the jumping performance of an elite women's handball team in order to value the differences between extremities taking into account the dominance of the upper and lower limb. In addition, analyze whether the presence of asymmetries in body composition parameters between lower extremities showed a relationship with the development of asymmetries in muscle power parameters. Regarding the results presented, as in previous studies, in this sample it is observed that the muscle mass of the right upper and lower extremities is significantly higher compared to the left side. In the case of total body fat mass, greater significant differences were also found in the right lower limb in relation to the left side Table 2,27. In 30, most team sports are typically associated with the development of functional asymmetries, as one limb is used more frequently than the other, leading to the dominant limb having greater strength capacity and better coordination than the non-dominant limb. Furthermore, Van Melick et al.31, indicate that the dominant lower limb will be the same in tasks of bilateral mobilization and unilateral stabilization, as in this case the unilateral jump in 70% of women. Nevertheless, in this sample it was observed that despite the fact that most players presented the left limb as the dominant lower limb during the jump test, taking dominance into account. The body composition parameters did not show statistically significant differences between the dominant and non-dominant limbs. In addition, no statistically significant differences were found between limbs in the values of TBW, IBW, EBW, electrical impedance and phase angle  showed a different porcentage in this parameter, which should be taken into account by physical trainers, with a view to improving injury prevention.Barrera- Domínguez et al.10. This type of test should not be replaced, given its validity, but perhaps complemented with other more specific tests, as recent research has shown40.On the other hand, this supports the theory of other investigations which have shown that the presence of asymmetries will be specific to each test and therefore it is essential to include different tests during training, highlighting different bilateral and unilateral tests, highlighting the latter by showing better results related to imbalances between limbs37.However, it is important to highlight the importance of including more specific exercises in different planes of movement such as unilateral plyometric training and variables aimed at improving the execution of specific handball tasks, noting that they can be more useful to detect the presence of asymmetries between extremities10 showed that the values of the asymmetries of the individual players were very different compared to the results based on the average values of all the metrics. For this reason, the importance of including an analysis of body composition during the different periods of the season is indicated to avoid imbalances in sports performance. In addition, to evaluate more specific parameters such as the rate of force development and reactive force to improve sports performance and reduce the development of asymmetries through specific training programs41.By contrast, Bishop et al.42.However, this study does not show that dominance between limbs and the assessment of asymmetries in a generic test such as the CMJ is a relevant method for current training programs for elite handball teams. For this reason, it highlights the importance of assessing the players individually, including more specific exercises, highlighting the importance of eccentric actions, including the mechanics of changing direction, running, jumping and landing. or even the rapid stretch shortening cycle demands that occur in elite women's handballThe main limitation of our study is the sample used per group, which can be extrapolated to a broader population. However, it should be noted that despite the fact the sample is a complete high-level team, the reduced sample prevents us from assessing relevant differences in the position of the player on the court and this limits the possibility of knowing if the dominance of the lower limb in the jump can depend on the position of each player on the court.In addition, the body composition variable has been taken during the season, and it would have been interesting to assess the changes including the preseason and postseason and the menstrual cycle should have been taken into account at the time data collection. Moreover, the limited availability of the elite team hampered the data collection process.The players presented a relevant percentage of asymmetries in the muscle power parameters during the CMJ test between the dominant and non-dominant lower limbs. In addition, differences were observed between players in jumping performance in this sample. However, despite using the main gold standard instruments in the field (e.g. DXA) and showing differences between limbs in body composition parameters, dominance did not appear to show a relevant role in the development of asymmetries. That is why these differences were associated with the development of functional asymmetries in a sport such as handball.On the other hand, the presence of asymmetries in lean mass between the right and left leg was not shown to be relevant in the development of asymmetries in the power of the lower extremities during the CMJ in the different phases of the jump.For this reason, it is concluded that the presence of asymmetries in handball must be assessed. However, it does not have to be one of the main parameters to be taken into account by coaches of elite athletes.Furthermore, highlight the importance of including specific analyzes of body composition and sports performance on an individualized basis in elite players. To this end, it is recommended to include more specific training programs and focus training on eccentric exercises to reduce the risk of asymmetries between extremities. In addition, shows the importance of work plyometric exercises and unilateral actions in the different planes of movement that resemble the actions of the players on the court. The aim is assessing in more detail the dominance of the extremities during these exercises, in order to improve sports performance and avoid the risk of sports injuries.


This paper describes the development and implementation of a telehealth system in Pakistan to build capacity of healthcare service providers and caregivers of children with developmental disabilities. An asynchronous telehealth system, in the form of a web app, improved therapy-related communication between the therapists and caregivers, thus enabling capacity building through sustained communication among the stakeholders. Participatory Action Research (PAR) identified barriers associated with communication, knowledge transfer, and caregiver learning. Data were collected via observations, interviews, focus groups, and field notes. The experiences of therapists and caregivers were analyzed to design and develop a system that works as a learning mechanism for caregivers in their native languages. The system also addresses socio-economic, geographic, and communication barriers as well as pandemic-imposed obstacles. About 95% of global 52.9 million children less than 5 years of age, suffering from some form of a development disability, reside in Low and Middle Income Countries (LMICs) , with alPakistan lags in establishing a structured medical and healthcare system. There is approximately only one rehabilitation professional for a population of one thousand people . There aWith the spread of the COVID-19 pandemic, telehealth options were rapidly adopted worldwide , and werBecause there is an acute shortage of therapists and healthcare-providers in developing countries, the World Health Organization (WHO) recommends enlisting the help of parents as caregivers in the provision of therapy services at home . HoweverAppropriate telehealth services in conjunction with parental support can be a suitable avenue in Pakistan to provide health care to most of the rural population living far from the few specialized settings in urban areas. To explore this avenue, we posed the following research question:How can a low-cost asynchronous web-based application be developed and used to facilitate communication and caregiver learning, and support capacity building at different levels of a healthcare organization?Consequently, we developed “Sehat Agahi,” an easy to use, web-based communication app for therapists and caregivers of children affected by cerebral palsy. The aim is to support the trend toward developing a digital health care system and health care equity.In this paper we present Sehat Agahi  and discuss its potential for supporting communications and capacity building in a healthcare organization and promoting healthcare equity.This paper has three main sections. The next section on methodology discusses the context, participants, data collection, and analysis methods, as well as a detailed description of the web app, Sehat Agahi. The third section analyzes and discusses the app's impact on service redesign. The paper concludes by making recommendations and discussing the potential future role of the application in Pakistan's health sphere to facilitate the digitization of healthcare.The development of Sehat Agahi was possible due to the confluence of three enabling factors. First, there was widespread availability of inexpensive smart phones across the country  for our study. We employed various qualitative data collection methods. These included semi-structured interviews (both in-person and online) and videorecording of the therapy sessions for patients with cerebral palsy visiting the Center. The interviews lasted 30 minutes or more, depending on the availability of the therapists. Data regarding the needs and expectations of the stakeholders were also collected using focus groups, demos, and workshops. We also kept field notes during participatory observation of the therapy process as well as our own development meetings.The identification details were removed from the field notes, interviews, and focus group data. The collected data were analyzed using thematic analysis. After data familiarization, the corpus was reread to identify preliminary codes. We then grouped codes into relevant sub-themes. The thematic analysis  helped uBased on the above analysis, a prototype app was developed. The app was designed and developed in three phases: constructing HTML pages, developing wireframes of a web app, and implementing a fully functional high fidelity web app prototype. It was important that the end product is usable and accepted by both the groups. PAR has been proven to increase usability of the end products by engaging end-users throughout the study , therefoThe web app supports two interfaces, one for the therapists and one for the caregivers. The therapists' interface provides a separate dashboard for each patient, where the therapist can assign a track, upload documents, view progress, and monitor special events.A track is a list of exercise videos along with instructions. These tracks are composed of milestone-based exercises prescribed according to the child's development. The web app enables therapists to manage their patients' unique care needs by providing the caregivers with various learning materials in the form of the tracks. The therapists can also see their patients' progress and provide relevant feedback.The caregiver's dashboard enables them to see and edit their individual profiles. They can also view or download exercises in their assigned tracks from the therapists. They can record progress of their children, which can then be seen by their therapists. Furthermore, they can notify the therapists of special events, chronic ailments, or other conditions affecting the child. These notifications are accumulated in a system generated log for future data analysis purposes. Since the app contains medical information, to ensure privacy of the content, the lead occupational therapist helped us prepare a ticker to alert the caregivers about data privacy. This text was translated into Urdu and later shared with a legal expert to suggest changes. Following  is the sThe home page is simple and concise, as shown in The therapist can register only his/her patients. The registration page contains data related to the child's age, condition, area of residence, and phone number of the caregiver as shown in Therapists can upload and manage items like documents, images and videos related to the attainment of different milestones and positive behaviors of the child. This repository is updated on a continuous basis. These activities and therapies are stored in a standardized manner by combining the name of the exercise with the name of the related body part and the condition of cerebral palsy, so that different therapists can search for and use the therapies for their own patients as suitable.Therapists can combine different video exercises, activities, documents, or images to create a track of items to be shared with patients as required according to their needs and conditions. A track can be used by multiple therapists from the database and can be assigned to multiple children with similar conditions.Upon clicking the patient icon, the therapist is routed to the patient's individual page. Here, the therapist can assign multiple tracks relevant to a child's needs at the time. These can be accompanied by instructions like exercise duration, alternate resources that can be used in exercises, indications of similar activities in daily life, or special instructions and precautions. These instructions can be both voice and text based, depending on the caregivers' learning needs.The therapist can view exercise dosage on the main page of a child on a weekly basis. The number of activities assigned will be tabulated week-wise to show how many times the caregiver administered the exercises to the child. Due to low education and technological literacy, the weekly tracks seen and practiced are reported automatically to the therapists to supervise and manage progress.Interviews with therapists and caregivers revealed that many times important documents are missing when required. This component of record keeping is also the responsibility of the therapist. A significant amount of knowledge is generated in the form of therapy documents at various phases of the long-term rehabilitation journey of the child daily, as depicted in The therapists can use a special feature through which they can keep up with the child's condition, especially chronic medical conditions. This feature works by accumulating notifications from the caregivers and updating the log. For example, if a child falls sick with fever, the caregiver can enter the child's symptoms. The system then automatically sends a notification and updates the log at the therapist's home page.Capacity building is a dynamic and complex process involving rethinking service design using knowledge from different domains. Our study explored how technology can help in improving communication to develop parental competency. In the following paragraphs, we will discuss how the technology solution features impacted the design of healthcare services.This section describes various features of the app and discusses how they help communication at different levels of the healthcare organization, including individual, team, and systems levels.This app allows for continued communication between caregivers and therapists. The two-way communication allows participation in diagnosis, training, monitoring, and problem-solving. For example, the therapists can share a digital long-term plan for the child with the caregivers, who can implement it, and reflect on the shared care plans. As one of the caregivers, when returning to the therapy centre after a long break reported, “My daughter was born five months back; it was really difficult to bring Amin  to the center during that phase. The technological solution will help support Amin at home, minimizing the needs of frequent travelling, which seem difficult with a young born.”This supports skill-building in caregivers using a training and supervision model. The app taps into the expertise of the therapists and applies the acquired technological and strategic capabilities to improve knowledge and skills of caregivers. This improved communication can help in internal capacity building at individual and team levels, and in the overall capacity of the healthcare organizations.The system supports caregivers in learning the techniques for assisting in therapy. They can supplement their direct learning acquired through in-person meetings with indirect learning acquired through the app. As one of the mothers reported, “As Arshad  enters the center he starts to cry, his challenging behaviors disrupt my learning. It is always easy to go back at night in my free time and catch up the missing lessons.”The app supports caregivers by mitigating the barriers associated with knowledge transfer and learning. These barriers include socioeconomic, geographical, and cultural barriers such as travelling, living in rural settings,  and dealIntegration of a digital app such as Sehat Agahi in a healthcare ecosystem also helps in reducing costs, increasing reach and service delivery as well as improving the quality of service provided. The app allows the therapists see  to not oIn this section we discuss the ways in which this app improves communication and thus enhances capacity building within healthcare organizations.Sehat Agahi enables process and service redesign using technology-based skill development in the therapists as a springboard. For example, the item repository, which contains content uploaded by all the therapists, allows for a quick search for the relevant content to be shared with the patients. Since it is a common repository, it encourages learning in groups. The therapists can learn how other therapists treat their patients, and what therapies and activities work better in different situations. This leads to discussion and knowledge exchange on the team and helps the organizational memory to grow. If knowledge remains with individual therapists and is not shared, organizational learning is hampered.The items and tracks assist in explicit codification of procedures, and standardization of therapeutic processes, leading to formalization at the system level. This also helps in training young therapists . The video-based tracks can help young therapists understand the activities and exercises related to the attainment of physical milestones and positive changes in behavior. The app also provides access to informational readings, and audio and written notes to establish context for the therapy. Such knowledge exchange and codification can also easily lead to improvement and redesign of curricula based on accumulated experience and building on organizational memory.Sehat Agahi helps therapists integrate technology in their daily routines and practices. For example, during the in-person therapy sessions, the therapists can use technology for transforming the inputs  to outputs . By doing so each day as a routine, they develop their digital skills. Also, the record keeping on a day-to-day basis of child-patient reports, history, and significant events, enables the therapist to accomplish educating and supervising, which leads to formalization of protocols and standards. This repeated practice of ordinary capabilities could lead to the evolution of capabilities and sustainable change.Sehat Agahi helps in evolution of low-order capabilities into high-order capabilities. Low-order capabilities include simple functions such as patient record keeping , maintaining libraries of items and tracks , standardization of the digital care plans, training and supervision of caregivers and monitoring alerts and caregivers' shared reflection of child's everyday conditions. While these are everyday routine activities, these capabilities can be transformed or integrated into higher order capabilities . For exaInformation from Sehat Agahi can help in connecting parents of children having similar conditions, to run campaigns. For example, we can raise dental hygiene awareness by conducting workshops for caregivers of children with quadriplegia. As another example, data analytic techniques can be run on the accumulated database by experts to gauge the effectiveness of particular therapies or exercises on children under different conditions.Apart from practice-based experiential learning , the app supports continuous acquisitive learning from external industry, IT experts, and the caregivers. The caregivers' reflection on attaining milestones can lead to understanding how different therapies impact the child's progress. This element of communication for building internal knowledge bases and improvement of skills leads to an increase in overall capacity of the healthcare system.The intervention helps not only at individual level; this solution translates into service advancement strategies and disseminating it into group and organizational levels. The app helps to support communication at meso levels and diffuse team conflicts . By usinSehat Agahi is designed to support appropriate telerehabilitation services that include an asynchronous mode of communication which does not require high speed data as required by video streaming based telerehabilitation services. However, the caregiver requires a smart phone and cellular data packages for this service. We also found that there is usually one smart phone available per family, therefore flexibility of time of access to exercises and download option was provided for ease. The socioeconomic conditions of the caregivers demanded a cheaper solution, as most caregivers do not have large screen laptop or tablets; this might compromise their learning. Currently, we are storing best practices of the therapists in the form of items which contain no identifying metadata of the child-patient, so privacy is preserved to a large extent. However, in some of the videos stored in the database, the face of the child-patient may be partially or fully visible. This is a current limitation. However, we have plans to automatically blur the faces in the future versions of the app.Sehat Agahi is a smart phone-based communication solution to diagnose, teach, supervise, and track the care of developmentally disabled children. This solution facilitates asynchronous communication, thereby mitigating the provider shortage problems in under-served areas of Pakistan to some extent. Sehat Agahi is a technology-based, therapy provision intervention, designed to mitigate various demographic barriers to communication faced by both the caregivers and therapists.The app also serves as a learning mechanism for the caregivers. This enhances the caregivers' capacity to care for their child by mitigating the various communication barriers explored during the study. With continued success of caregiver participation and integration into the healthcare system, it is hoped that the overall capacity will generally increase. The use of this app will eventually enable further digitization of healthcare and enhance its capabilities and equity.