Agricultural workers are susceptible to several health problems as a result of occupational exposure to toxic substances, especially pesticides. The aim of this review was to describe the health issues associated with occupational exposure to pesticides in agricultural workers. A descriptive study, in the form of an integrative literature review, was conducted based on articles retrieved from the LILACS, SciELO and PubMed databases, published between January 2015 and October 2018. The searches were conducted using the keywords “pesticides,” “workers’ health,” “occupational exposure” and “agricultural workers.” The study was guided by the following research question: what health problems do agricultural workers experience as a result of occupational exposure to pesticides? The screening process led to the selection of 35 studies performed in several countries and continents, all of which shed light on the vulnerability of agricultural workers, especially due to the misuse of personal protective equipment and lack of knowledge about the correct use of these devices. The studies investigated a variety of health issues, and most reported a positive association between these conditions, which include cancer, and the use of pesticides. Educational and preventive measures must be implemented to promote the health of rural workers. Furthermore, it is crucial that governments play an active role in these initiatives and provide alternatives to pesticides for pest control. Occupational health surveillance is an important tool for addressing workers’ health issues, since it provides an understanding of the occupational environment and the risk factors to which workers are exposed in their professional activities, all of which can be harmful to their health. These observations underscore the need for interventions to improve workplace health and safety. As such, workers’ health surveillance contributes to the promotion of interdisciplinary strategies to improve quality of life at work.2Most health-related initiatives in Brazil are linked to the Unified Health System (SUS), which oversees and regulates these practices through ordinances and public policies. Issues associated with occupational health are guided by the National Workers’ Healthy Policy, established by Ordinance No. 1.823, issued August 23, 2012.3 Yet agricultural workers are also exposed to several health hazards as a result of their professional activities, including ultraviolet radiation; exhaust toxicity; inhalation of organic dust from spores and minerals when handling feed; exposure to microorganisms such as viruses, bacteria and infectious parasites, and their toxic products; as well as pesticides, which are among the greatest potential hazards to the health of agricultural workers.4Agriculture plays an important role in the economy of most countries and in the lives of local populations, since it provides stable jobs and a steady income to many families.6 Given the widespread use of these substances to increase productivity, reduce the need for labor and manage plant diseases, all agricultural workers are likely to have at least some exposure to pesticides during their occupational activities. Pesticide contamination can have acute and chronic effects on exposed individuals, ranging from mild toxicity to neurotoxicity and even death.7 Pesticides have been associated with neurological, endocrine, psychological, immunological, respiratory, hematological, skin, kidney and liver issues, as well as fetal malformation.8 In tropical countries, pesticides can remain in the soil and water for a period of 1 to 2 months depending on temperature, sunlight and the presence of microorganisms, increasing the risk of contamination for workers and all other individuals who live in areas where these products are used.11Pesticides comprise over one thousand chemical compounds used in agriculture to prevent, eliminate or control insects, weeds and fungal diseases.13 Currently, the country is experiencing significant changes in this sector due to the approval of Bill No. 6.299/2002 by the Chamber of Deputies. The bill modifies the criteria for approval, risk analysis and nomenclature of pesticides, allowing the indiscriminate use of pesticides, to the detriment of population health and in sharp contrast with the experience of developed countries in the European Union as well as the United States.14 The State has the duty to provide the population with comprehensive, universal and equitable health care. As such, it is also responsible for the oversight of initiatives implemented by employers in order to protect workplaces and residences. The environment can have a significant effect on workers’ physical, mental and social well-being. A major issue that affects the environment, in addition to health and work, is pesticide use and its repercussions on worker health.15Brazil is one of the largest consumers of pesticides in the world, accounting for 86% of the pesticides used in Latin America.Given the importance of this issue and the need to understand the health impact of pesticides, we performed a search of the national and international literature to identify studies that discuss the health effects of occupational exposure to pesticides in agricultural workers.An integrative literature review was conducted based on articles in journals indexed in the LILACS, SciELO and PubMed databases, published between January 1, 2015 and October 31, 2018. The searches were carried out using the following keywords: pesticides, workers’ health, occupational exposure and agricultural workers. This study was guided by the following research question: what health problems do agricultural workers experience as a result of occupational exposure to pesticides? Data were collected in October 2018. The inclusion criteria were scientific articles with full-text available online and open access publication in Spanish, English and Portuguese. Duplicate articles and those that did not address the research question were excluded from the review. The study selection process involved screening the titles of the studies retrieved by the literature search, followed by abstract screening and, if necessary, full-text reading to exclude any studies that did not cover the topic of the present review. The articles selected were then read in full and analyzed descriptively.The database search retrieved 155 articles with the selected keywords. The study selection flow diagram is shown in The data were extracted and entered into 41 Studies show that agricultural workers tend to consume less alcohol and tobacco than workers in other occupations; their work activities also include regular moderate-intensity physical activity, which contributes to lower morbidity and mortality rates than observed in the general population. Yet pesticide handling exposes these workers to a number of other illnesses, as demonstrated by studies performed in several countries where pesticides are used in agriculture.30Agricultural workers are exposed to a series of physical, chemical and biological health hazards during their professional activities. Pesticides are widely used to increase crop yield in these settings, but the absence of prior assessment, an effective cost-benefit analysis, and evaluations of the amount and time of application result in a significant risk to the health of workers. The lack of assessment of agricultural workers, combined with the negligent attitude of some governments, aggravate the risks of chemical exposure for agricultural workers, who are often unaware of these issues, much like the health care workers they eventually seek, often when their healthy is already severely compromised.30 found that the pesticides most commonly used in vineyards were associated with health problems in farmers. Several disorders were identified in the sample, with acute poisoning being the most significant and prevalent. The most commonly reported symptoms were headaches, nausea, vomiting, shortness of breath, bradycardia, dermatitis, burns and eye irritation. Gesesew et al.40 studied agricultural workers in Ethiopia, and found that acute toxicity was also the main health problem in that population. In the study, agricultural workers expressed awareness of inhalation and ingestion as routes of exposure to pesticides, but were unaware of the possibility of contamination through the skin, which poses a major challenge for preventive measures. Additionally, agricultural workers who experienced symptoms of pesticide toxicity tended to resort to home remedies such as drinking milk and applying creams to the affected area, seeking health care services only in severe cases.All of the articles included in this review evaluated the chemical risks to which agricultural workers are exposed, as they examined the consequences of exposure to pesticides during occupational activities. A study performed in Chile39 A systematic review30 found that exposure to organophosphates may affect cognitive and motor functions, as well as concentration, agility, memory and coordination. A study performed in Pakistan revealed that the symptoms most frequently cited by cotton farmers after pesticide exposure were irritation of the skin and eyes, headache and dizziness, followed by shortness of breath, vomiting and fever.22The inadequate use of pesticides can also have neurobehavioral effects. A case-control study conducted in China revealed that chronic occupational exposure to pesticides can lead to symptoms of depression, lack of motivation and anxiety.41China is considered a major global supplier of pesticides, in addition to making extensive use of these products in agricultural production. As such, the country has conducted a number of studies to investigate the short- and long-term effects of these substances on the population. A cohort study in which the hematological and neurological parameters of 246 agricultural workers from three Chinese provinces were evaluated over a 30-year period demonstrated that a longer duration of pesticide exposure can trigger alterations in nervous system functioning. Laboratory analyses also provided evidence of muscle damage. Short-term effects in the form of altered liver and kidney function were also observed within three days of pesticide exposure. Another relevant finding was that only 14% of those interviewed used personal protective equipment (PPE). The study concluded that both short- and long-term exposure were associated with hematological, hepatic and peripheral nervous system alterations.16 In Greece, a case-control study of agricultural workers being treated for myelodysplastic syndrome found that occupational exposure to pesticides increased the risk of developing this condition.17Alterations in hematological parameters due to pesticide use were also reported in Thai orchid farmers, especially those who did not use PPE. Toxicological analyses conducted after pesticide application revealed alterations in immunological factors - B lymphocyte numbers and biochemical marker levels - which were not clinically significant, but suggested caution and emphasized the need for PPE in these settings.36A study of rice farmers in Sierra Leone revealed that health issues such as dermatitis, nausea, seizures and respiratory illnesses were significantly more frequent among farmers who used pesticides than those who did not. The authors noted that pesticides are cheap and easily accessible in Sierra Leone, as they are smuggled into the country. The indiscriminate use of these substances has a significant impact on health and the environment, leading to soil and groundwater contamination, and reducing biodiversity. The study also found that the procedures used in the storage, application, handling and preparation of these products were detrimental to human health. Lastly, the health care workers interviewed in the investigation emphasized the lack of national programs to address health and environmental issues, as well as the absence of education and prevention initiatives in the country.40 The studies also showed that many rural workers do not routinely use PPE, which could protect them from exposure to health and safety risks during their occupational activities. Barriers to the use of this important preventive measure include low education levels, insufficient understanding of the importance of PPE and a lack of training, in addition to the high costs of specialized equipment.10 A study performed in Ethiopia found that 42% of agricultural workers had never used PPE.40 Ghafari et al.3 reported that 68% of rural workers in Iran did not use any form of PPE during pesticide application, while Zhang et al.38, in China, reported that only 13.4% of farmers used PPE when handling pesticides. The attention to correct PPE use, which includes removing clothing immediately after use and washing the hands and face after handling pesticides, are as important as the equipment itself.40 Acute toxicity can also be caused by inadequate storage and the reuse of empty pesticide containers to store water and food, as reported by Muñoz-Quesada et al.30, Gesesew et al.40 and Silva et al.6.The main determinants of pesticide exposure include lack of knowledge about correct pesticide use, the inability to comprehend product labels, inadequate storage conditions and the underestimation of the health risks of these products.32A study performed in Tanzania found that an estimated 220 thousand people die every year from pesticide exposure in low- and middle-income countries. The authors attribute this to lack of knowledge and low education, in addition to the absence of legislation to protect the health of agricultural workers in these locations. These factors contribute to poor handling practices that increase exposure to dangerous products, leading to toxicity and long-term effects on workers’ health. The study highlights the importance of continuing education regarding the effects of these products and their adequate use.25 and Korea.23 According to the researchers, the exposure to high levels of organophosphate pesticides over several years, with or without episodes of toxicity, inhibits acetylcholinesterase, leading to the accumulation of acetylcholine in cholinergic receptors and decreasing impulse control, contributing to aggressive behavior, depression and suicidal ideation.The handling of pesticides also exposes workers to an increased risk of depression and other mental and behavioral disorders, in addition to higher levels of aggressiveness/impulsivity and suicide attempts, as shown in studies performed in China18 the inhibition of acetylcholinesterase induces respiratory depression, increasing the risk of this condition. Sleep apnea, in turn, contributes to increased morbidity and mortality in individuals exposed to pesticides, interfering with workers’ sleep and quality of life. The results of the study showed that in male agricultural workers, exposure to carbofuran was positively associated with sleep apnea.The frequency of sleep apnea was also higher in workers exposed to pesticides in an agricultural community in the United States. According to Baumert et al.,33 and França et al.8, respectively. In a study of Latino workers exposed to pesticides in the United States, Quandt et al.33 found that pesticides can significantly affect olfactory function even when inhaled at low doses. The study also found that olfactory impairment occurs earlier than other symptoms of neurodegenerative diseases such as Parkinson’s. Since the study had a short follow-up period, it was not possible to determine whether the duration of exposure was associated with progressive olfactory loss, and it is therefore possible that factors other than pesticide exposure also contribute to the occurrence of this symptom. A separate study of tobacco farmers in Brazil8 also found that organophosphates can affect auditory function by inhibiting acetylcholinesterase and interfering with the transmission of action potentials from efferent fibers, thereby affecting peripheral, central and vestibular components of the auditory system. The issue is aggravated by the exposure to multiple risk factors for hearing loss, such as pesticides and noise, both of which are present in agricultural settings.Olfactory and hearing loss were studied by Quandt et al.10 in a study conducted in Washington, D.C, in the United States. Clinical and laboratory examinations performed before and after the period of exposure revealed little to no association between pesticide use and the development of the disease. However, these findings may have been influenced by the small sample size of the study. Additionally, factors such as living far from the place of work and correct PPE use may have had protective effects and prevented continuous exposure to the contaminant. A study of French agricultural workers, however, did identify an association between the intensity of pesticide exposure and tremors associated with Parkinson’s disease. Herbicides were the most common type of pesticide used by participants, followed by insecticides and fungicides.28The association between pesticide use and Parkinson’s disease was investigated by Nielsen et al.20Some experimental studies suggest that the neurotoxicity caused by exposure to pesticides can induce endocrine alterations, especially in agricultural workers, who, in most cases, come into direct contact with these products. The study was performed in a city in southern Brazil, and its results showed that pesticide toxicity may be associated with mental disorders, since these are more frequent in individuals who use pesticides containing dinitroanilines, pyrethroids, sulfonylurea and aliphatic alcohol. The data obtained in this study also pointed to an association between early pesticide exposure and mental illness.26 In Venezuela, a study of sperm quality in agricultural workers exposed to pesticides confirmed the risk of infertility in male farmworkers exposed to these products.27A study of agricultural workers in North Carolina, in the United States, focused on the assessment of rheumatoid arthritis. Though few studies have examined the association between these variables, the study in question found that occupational exposure to some types of pesticide was linked to an increase in the prevalence of rheumatoid arthritis, regardless of age, smoking history and educational level. The incidence of rheumatoid arthritis was associated with the frequent use of the organophosphate insecticide fonofos, the carbamate insecticide carbaryl and the sulfonylurea herbicide chlorimuron-ethyl.37 A study of agricultural workers in vineyards in southern Brazil revealed that both currently used and banned pesticides affect the thyroid gland, leading to symptoms similar to hypothyroidism, especially in men, who tend to be exposed to higher concentrations of pesticides than women.13A non-systematic review of the relationship between pesticide particles and cardiovascular disease in agricultural workers also found a close association between these variables. However, the authors noted that further studies are needed to investigate the health hazards associated with pesticide exposure, and that governments and agricultural producers must implement measures to reduce cardiovascular mortality in this population.31 Another study evaluated the association between pesticide exposure and wheeze in male participants of the Agricultural Health Study (AHS), a prospective investigation of farm workers in North Carolina and Iowa, in the United States. The results showed that 19 pesticides were significantly associated with allergic wheeze; 21 with non-allergic wheeze; and 11 were associated with both, suggesting that commonly used pesticides in agricultural and residential settings can have adverse respiratory effects.42A study conducted in Ethiopia also identified an increased risk of respiratory illness in agricultural workers. The authors described their finding as ‘alarming,’ since the workers demonstrated significant reductions in pulmonary function - as evidenced by chronic cough and shortness of breath - despite the relatively short duration of pesticide exposure (4 years on average), alerting to the need for urgent intervention.19 Though a study of pesticide exposure and bladder cancer did not support a conclusive association between these variables, it did reveal a significantly higher incidence of cancer in vegetable farmers, women and non-smokers.19 A study of agricultural workers in France examined the association between cancer and exposure to some types of pesticides, but could not determine a causal association between these variables due to the high frequency with which workers moved between crops and their handling of multiple types of product. The study also identified an interesting association between pesticide use and an increase in the incidence of central nervous system tumors, especially gliomas and meningiomas.5 A case-control study of pesticide exposure which compared agricultural and non-agricultural workers in Italy over a lengthy chronological period (1965-2009) revealed a higher likelihood of cancer in the former group than in the latter. The association between pesticide use and non-melanoma skin cancer, colorectal and breast cancer also reached statistical significance.35With regards to cancer, some authors note that rural workers are less likely to develop cancer than the general population, probably due to a lower intake of alcohol and drugs and the level of physical activity in their professional practice. However, some types of cancer are common in this population, either due to exposure to ultraviolet rays, as in the case of lip cancer and myeloma, or pesticide exposure, which is associated with a higher frequency of prostate and hematological cancer, as well as non-Hodgkin’s lymphoma and even brain tumors.21 The prevalence of breast cancer among the wives of agricultural workers who used pesticides on their farms was also studied, but no differences were observed between women who handled the pesticides and those who did not, nothing a similar breast cancer risk in both participant groups. The highest risk of breast cancer was observed in premenopausal women and those who used organophosphate pesticides.43 In a meta-analysis performed by Spanish researchers, the analysis of pooled data did not support an association between organochlorine pesticides and the risk of prostate cancer, suggesting the need for further studies in this area.24 In China, a study of genetically modified crop production found it to be associated with decreased pesticide use, as well as blood chemistry markers and peripheral nerve conduction. The results demonstrated that this type of crop requires less pesticide and allows for the use of products that are less hazardous to health, which could be greatly beneficial to agricultural workers.24In female agricultural workers, studies showed an increase in the incidence of ovarian and pancreatic cancer, acute myeloid leukemia and breast cancer.The present review identified several studies that demonstrated the hazardous effects of occupational pesticide exposure on the health of agricultural workers around the world. There also appears to be some concern about the need to conduct further research on this issue. The articles included in this review identified several ways in which excessive pesticide exposure during occupational activities can harm the health of agricultural workers. The conditions associated with pesticide exposure include hematological alterations, respiratory issues, endocrine dysfunction, neurotoxicity, infertility and, most concerningly, an increased risk of some types of cancer.The use of pesticides and their impact on the health of agricultural workers is a global concern. Governments should acknowledge their role as protectors of public health and create laws and public policies whose aim is not only to increase land productivity, but also promote the protection of workers against possible occupational risks. Studies that investigate the use of less hazardous chemical alternatives are also required. The encouragement of non-pesticide alternatives for pest and weed control would also have a major impact on the health of both producers and consumers of agricultural products, bringing balance and health to the environment and to agricultural workers.Awareness campaigns, subsidies for the acquisition of PPE and specialized training are crucial for improving occupational safety and working conditions. Adequately trained workers are more likely to use PPE, implement protective measures and use safe handling practices. The labels on pesticides and other agricultural products must also be made more understandable, and workers must be encouraged to pursue formal education and seek basic health services; these steps will allow agricultural workers to access the knowledge and resources necessary to take preventive and effective measures to protect their health and that of their families. Of equal importance is the need to continue conducting short- and long-term studies of pesticides and the harm and illnesses they cause when they come into contact with the human body.


Despite many efforts, maternal mortality remains a major burden in most developing countries. Mobile health  has the potential to improve access to obstetric care through apps that help patients and providers.This study aimed to use mHealth to provide antenatal care (ANC) to 1446 pregnant women in a rural area in Madagascar and evaluate the quality of ANC provided by an mHealth system designed to change the behaviors of providers and patients.We included 1446 women who attended ANC visits in rural Madagascar from 2015 to 2019 using an mHealth system called Pregnancy and Newborn Diagnostic Assessment (PANDA). This cross-sectional study used data from different participants, with information collected over several years, to analyze the outputs related to the quality of ANC over time. Specifically, we examined the timing of the first ANC visit, the relationship between the visit duration and the risk factors among pregnant women, and the number of ANC visits per woman.P<.001). In 2019, fewer women attended their first ANC visit in the third trimester  than in 2015 . There were statistically significant associations between the ANC visit durations and the risk factors, including age , educational level , experience of domestic violence during pregnancy, gravidity, parity, infectious diseases , and level of anemia. Statistically significant associations were observed for all quality indicator variables. We observed a statistically significant increase in the number of ANC visits per woman over time from 2015 to 2017; the number of ANC visits per woman then became stable after the third year of implementing the PANDA mHealth system.Following the implementation of the mHealth system in 2015, we observed that women started to come earlier for their first ANC visit; more women attended their first ANC visit in the second trimester of pregnancy in 2019 than in the previous years (This study shows the potential of an mHealth system to improve the quality of ANC, change provider behavior by standardizing ANC visits, and change patient behavior by increasing the willingness to return for subsequent visits and encouraging ANC attendance early in pregnancy. As this is an exploratory study, further studies are necessary to better understand how mHealth can change behavior and identify the conditions required for behavioral changes to persist over time. Mobile health  tools are an innovative technology that can allow patients and their health care providers to effectively access medical data before, during, and after medical appointments. mHealth has the potential to improve the quality of health care through apps that can facilitate communication between patients and health care providers . In the Maternal mortality has decreased dramatically in low- and middle-income countries (LMICs), declining by 45% from 2008 to 2013 ,7. AntenExpanded use of mHealth could help improve health care quality in the context of LMICs . mHealthWe conducted a study in Madagascar using an mHealth system to record and access women’s data during their ANC visits. The main goal of this study was to evaluate the quality of ANC provided with mHealth by measuring the adherence to ANC visits, the timing of the first ANC visit, and the duration of the visits.This cross-sectional, observational study was conducted from January 2015 to September 2019 in the Ambanja district in northwestern Madagascar. Data related to ANC visits were collected using an mHealth system called Pregnancy and Newborn Diagnostic Assessment (PANDA). The local health authorities in Ambanja, Madagascar, and the Human Research Ethical Cantonal Board of Geneva, Switzerland  approved the study.We implemented an mHealth system to support providers in conducting ANC visits in Madagascar. Maternal mortality in Madagascar has decreased by over 50% in the last 20 years—from 776 to 353 deaths per 100,000 live births—but maternal mortality remains high and the Millennium Development Goal 5 has not been reached . In the The Ambanja district is a rural area with a population of 240,000 inhabitants . FarmingA collaboration between the University Hospitals of Geneva and the Centre Médico Chirurgical was established in 2010 for a cervical cancer program and was continued in 2015 with the implementation of the PANDA system. The PANDA team collaborates with the Ministry of Health of Madagascar.The PANDA mHealth system was first implemented in 2015 in a pilot study to assess the system’s feasibility and usability in Madagascar . The proPANDA point of care is a kit containing all the instruments needed to take measurements such as height, weight, body temperature, and blood pressure and to screen for syphilis, HIV, malaria, anemia, gestational diabetes, urinary tract infections, and malnutrition. Second, the PANDA app is an Android smartphone app made up of 5 sections: sociodemographic information, medical and obstetric history, clinical screening test results, health education and birth plan, and postpartum care. It is an app mostly based on icons and illustrations with very little text. A quarter of each visit is dedicated to educating the patient regarding warning signs during pregnancy, labor, and postpartum as well as birth preparedness. The education section of the visits also focuses on breastfeeding recommendations and overall well-being of women. Alert functions are integrated into the PANDA app to notify the provider of abnormal clinical results, technical problems, or missing patient information, thereby assuring a complete assessment [PANDA medical unit is a web-based database that captures the data and results collected during the ANC and postpartum visits and enables the hospital team to open a computerized medical record for each woman to make a diagnosis and define the frequency of follow-up. In addition, after all the data were collected for this study, the PANDA medical unit allowed the team to stratify pregnancies by area, time, and risk conditions. The on-site medical team has access to the PANDA database via username and password; all data are encrypted to ensure privacy. Patients were informed, and they agreed to their data being transmitted to and saved in the medical unit to create their medical records. Patients were asked to provide both paper and electronic consent.The system comprises the following 3 elements. First, sessment . The proData were collected during the women’s first and subsequent ANC visits. The 3 following types of information were collected: (1) sociodemographic characteristics; (2) medical, surgical, and obstetric history; and (3) results from screening to detect obesity or malnutrition, hypertension or preeclampsia, anemia, HIV, syphilis, malaria, diabetes, infections, and other conditions. The PANDA system collected data on at least 75 items per woman on their past and current medical and obstetric history as well as clinical screening data.Since 2015, we have trained 13 providers to use the PANDA system. In the PANDA medical unit, it is possible to track the content of the visits, including each provider’s activities, such as the number of visits conducted and eventual errors in completing the visits, thus allowing the team to build a learning curve for each provider.A total of 1446 pregnant women fulfilled the inclusion criteria and were enrolled in the study. All pregnant women, regardless of age or stage of pregnancy, were eligible to participate in the study. The only exclusion criterion was the inability to understand or act as described in a previous publication explaining the acceptability and feasibility of the PANDA mHealth device . As ANC We used a convenience sample of 1446 women. We planned to recruit patients from 2015 until the end of September 2020, which resulted in a total of 1446 women.P=.04. We reported the estimated marginal mean duration and 95% CI for each independent variable from the multivariable model and the associated P values for each category of the variables. Stata Statistical Software, release 16 (StataCorp), was used to describe the study population and to analyze the indicators of the ANC quality.The data collected with PANDA were digitized as electronic medical records, which were used to analyze maternal morbidity and evaluate the quality of the ANC. Continuous variables are presented as mean (SD) or median, and categorical variables are presented as frequencies and relative percentages. The proportions of patients who tested positive for syphilis, HIV, or malaria are provided with their 95% CIs. Comparisons of categorical variables by year were performed using the chi-square test, and the mean durations of ANC visits were compared by the different categorical variables using the nonparametric Kruskal-Wallis test. We assessed the associations of different patient characteristics, place of residence, year, and visit order (independent variables) with visit duration (dependent variable)—first at the univariate level, using mixed linear regression models with the patient as a random factor to take into account repeated measurements within patients. We then constructed a parsimonious multivariable mixed linear regression model including all the variables that were significantly associated with the visit duration at Most of the 1446 women in the study were recruited in the city of Ambanja. The first table in P<.001).P=.001) or secondary school . The visit duration also differed significantly by age, with significantly longer visits for women aged at least 35 years  than for those aged between 16 and 20 years . Patients who reported domestic violence during the visit had longer visit durations than those who did not report domestic violence (P<.001), and those who had running water at home had longer visit durations than those without running water at home. There were also significant differences in the visit duration by patient gravidity (longer duration with higher gravidity), parity (longer duration with higher parity), and trimester of pregnancy . The providers noted that the visit duration increased with parity and gravidity as they had to go through more detailed information about each past pregnancy and delivery. Active smokers had longer visit durations than did nonsmokers, and women with severe or moderate anemia had longer visit durations than women with no anemia or mild anemia. Finally, there were significant differences in the visit duration by HIV status (longer duration among patients with positive HIV status compared with those with negative or unknown status), syphilis status (longer duration among patients with unknown status compared with those with positive or negative status), and malaria status (longer duration among patients with positive status compared with those with negative or unknown status). In the multivariable model, the mean visit duration remained independently associated with the year, visit order, level of education, age category, domestic violence, availability of running water at home, and HIV and syphilis status  to cover all the main topics that should routinely be part of a high-quality ANC visit. The duration of the first ANC visit, a quality indicator defined by the WHO, remained stable over the study period, indicating that the use of the mHealth device did not significantly lengthen the visit duration. We also found that the visit duration was positively associated with several patient risk factors. Low education, being over 35 years of age, experiencing domestic violence during pregnancy, having anemia, and having an HIV positive status were all associated with a longer ANC visit duration.In terms of the completeness of the ANC visits, most pregnant women in our sample were tested for HIV during these visits (92.7%), compared with only 10% of pregnant women in an analysis of national-level data from 2018, which also reported that only 3% were receiving antiretroviral therapy to prevent vertical transmission . FurtherIn this study, we found that the number of ANC visits per pregnant woman tended to increase over the study period. In the study by Atnafu et al,  the numbThis study analyzed data from a large population over a 5-year period following the implementation of the PANDA mHealth system to support good quality ANC in a resource-constrained setting (Madagascar). The indicators in our study, such as the timing of the first ANC visit, the visit duration, and the number of visits, strongly suggest that this mHealth system encourages the performance of a standardized ANC visit and thereby facilitates the provision of high-quality ANC services. This study has shown the benefits of the PANDA mHealth system for both providers and patients. The providers received guidance on how to conduct standardized ANC of good quality, and they also received a record of all important patient data that can be used in follow-up visits. The women and their families received ongoing education and encouragement to seek appropriate care throughout the ANC and postpartum visits conducted with the PANDA system. The system improved communication between the health care workers and patients, facilitated continuous education, and encouraged the patients to play a more active role in the decision-making processes related to their health.Our study has several limitations. The most significant limitation is the lack of a control group to compare with participants using the PANDA mHealth system. Instead, we used national-level surveys as a standard reference—the 2009 Madagascar Demographic and Health Survey and the 2018 Multiple Indicator Cluster Survey. Although our results differed significantly from the findings of these two national-level surveys, the lack of a comparison group and a randomized design limits the conclusiveness of our findings. D-tree International’s study on safer deliveries in Tanzania, which also lacked a control group, demonstrated that the examined mHealth program was a success as it reached over 13,000 pregnant women in Zanzibar. The implementation of this mHealth system was described as a success as it was linked to unprecedented rates of both service delivery and postpartum attendance, even though this mHealth system did not provide support for either ANC or postpartum visit content or quality . A seconSeveral questions about the use and diffusion of the PANDA mHealth system remain open. These questions relate to, for example, dealing with the low quality of service delivery and the scalable and sustainable integration of the PANDA system in the local health system.This study shows that the PANDA mHealth system has the potential to improve the quality of ANC in a resource-limited setting, modify the behavior of providers by providing standardized ANC visits, and increase patient compliance. Mobile technology should not be considered a stand-alone health intervention for ANC; rather, it is a strategic tool for improving the delivery and quality of maternal health care. Further studies are necessary to better understand the conditions under which behavioral changes occur and persist over time with the use of mHealth systems such as PANDA as well as whether undesired behavioral changes may also arise with the use of mHealth in ANC settings.


Demographic data suggest a rapid aging trend in the active workforce. The concept of aging at work comes from the urgent requirement to help the aging workforce of the contemporary industries to maintain productivity while achieving a work and private life balance. While there is plenty of research focusing on the aging population, current research activities on policies covering the concept of aging at work are limited and conceptually different. This paper aims to review publications on aging at work, which could lead to the creation of a framework that targets governmental decision-makers, the non-governmental sector, the private sector, and all of those who are responsible for the formulation of policies on aging at work. In August 2019 we searched for peer-reviewed articles in English that were indexed in PubMed, IEEE Xplore, and Springer and published between 2008 and 2019. The keywords included the following phrases: “successful aging at work”, “active aging at work”, “healthy aging at work”, “productive aging at work”, and “older adults at work”. A total of 47,330 publications were found through database searching, and 25,187 publications were screened. Afterwards, 7756 screened publications were excluded from the further analysis, and a total of 17,431 article abstracts were evaluated for inclusion. Finally, further qualitative analysis included 1375 articles, of which about 24 are discussed in this article. The most prominent works suggest policies that encourage life-long learning, and a workforce that comprises both younger and older workers, as well as gradual retirement. The older population is growing rapidly. In 2019, approximately 700 million people were aged 65 years or more in the world population. It is anticipated that this number will be doubled to 1.5 billion in 2050 [The growth of the older population is an effect of a reduced fertility rate and an increased life span . VariousSocieties need to take a smart and multidimensional view of aging since these individuals may provide vast economic and social opportunities . Rather Not employing older people in certain work positions does not have to be a symptom of age-based discrimination, which is the most common form of discrimination, with one in five workers having witnessed it or personally experienced it . It comeSustainable growth at work means reaching the living and working conditions that support older people in their involvement in and continuance of work for a longer duration in their lifetime . To achiFurthermore, an employment deficit calls for an effective response that should balance economic and regulatory needs with an influence on the jobs, working conditions, skills demands, and social protection . DespiteIn response to the aforementioned issues, the aging labour force has been studied over the last decade to contribute to the understanding of different motivations and solutions in the given context. However, there is a lack of systematic review of these motivations and solutions to support the aging labour force. Therefore, the aim of this paper is twofold. The first goal is to recognize and summarize the articles related to the aging labour force in terms of recent trends and future directions. The second objective is to capture the main motivation issues and solutions to support the concept of aging at work, i.e., the aging labour force.What are the motivations that drive the research on the aging labour force?What are the most common solutions for addressing the issues related to aging at work?The following research questions were posed:In order to answer the research questions, we examined studies on the aging labour force that were published between January 2008 and August 2019, to recognize the trends in the literature written in English with respect to motivation issues and potential solutions. We focused on the trends starting from the recession in 2008, when, although the economic growth slowed, the employment rate of older people remained strong, thus basically changing the position of older workers . An addiWe adopted the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) methodology  to revieThe collected papers on aging at work policies exceeded the capacity that would allow articles to be searched manually. Thus, we used natural language processing (NLP) algorithms to perform an efficient search of the identified literature. The NLP toolkit  was desiThe NLP search strategy was applied in order to automatically screen irrelevant articles that have a low correlation with the topics of interest in the study. Additionally, it helped in consolidating the collected articles by automatically merging results from multiple digital libraries as well as removing duplicate entries. Moreover, it allowed us to iteratively fine-tune and modify the search phrases in the hope of identifying more relevant articles. Finally, the NLP toolkit automatically generated charts such as  that higBy using yearly graphs, we were able to analyze and report the potential trends in data by investigating articles in each property group  separately.The NLP toolkit input parameters are a collection of phrases. Keywords, together with their synonyms, are applied as search terms for the digital libraries used in the literature search. The input can be further expanded by NLP toolkit properties. Properties are phrases that are being searched within the title, abstract, or keywords section of the articles identified from the previous keywords search. Property groups are sets of properties that can be used for a more comprehensive presentation of search results.The input parameters used in this study are shown in The titles and abstracts retrieved by the NLP-based search strategy were evaluated by two independent researchers. They compared their opinions in order to select articles that satisfied the inclusion and exclusion criteria.(a)Articles that discuss any of three motivation factors, i.e., discrimination, growth, and deficit;(b)Articles that support any of three solution pillars, i.e., assistance, policies, and legislation.Articles that consider the concept of aging at work, i.e., the aging labour force.Articles that use research methodology with any results.The inclusion criteria were as follows:Articles that are about aging and older people in general that do not consider the concept of aging at work;Articles that cover any of three motivation factors, i.e., discrimination, growth, and deficit, in a context other than the aging labour force;Articles that cover any of three solution pillars, i.e., assistance, policies, and legislation, in the context other than the aging labour force;Articles that do not provide sufficient information for classification.The exclusion criteria were as follows:When researchers differed in their opinions about an article’s suitability, the article was selected for further consideration. This resulted in an initial selection of 70 articles. Furthermore, the full texts of the chosen articles were reviewed in order to determine their suitability for further discussion. After the data abstraction of the final selected articles, two additional researchers separately reviewed 20% of randomly chosen articles. In the case of any disagreement on the suitability of articles, a third researcher was consulted for recommendation and assessment of the given article. This researcher was a specialist who drew a final conclusion regarding the article selection process.For the selection of the final 24 articles, two of three authors needed to be in agreement, considering the completeness of the methods, relevance to the study goal, details about the population, and impact of the study.Articles that focused on motivation factors ;Articles that focused on solution pillars .We used the inductive approach for the article review and analysis. The selected articles were systematically organized into two groups:We generated a detailed summary of each article and extracted the following items: objective, methods, main findings, limitations, and keywords. The extracted items provided the input data for discussion and conclusions.After searching PubMed, IEEE Xplore, and Springer, we identified 47,330 potentially articles. After performing the PRISMA steps shown in The selected keywords aimed to show different aspects on the literature corpus on aging at work. Findings related to property groups show that the number of papers related to “motivation” of the adult workforce is relatively constant, with a small decline in the last two years, while the papers focused on the “solutions” property group seems to be slightly more predominant in the last few years .A more granular analysis was carried out on the property groups data at the properties level, and the chart reveals that “growth” is the primary topic within the motivation group of papers, followed by “discrimination”. The papers related to the topic of “deficit” appeared only in recent years .The focus of papers within the “solutions” property group  seems toA total of 12 articles out of 24 were selected for the further analysis of motivations that drive the research on the aging labour force. The selected articles were organized into three focus groups according to the considered terms related to motivation, i.e., “discrimination”, “growth”, and “deficit”. A more detailed analysis of these articles is presented in Table 2.The remaining 12 articles out of 24 were used for a more detailed analysis of solutions for the aging labour force. The selected articles were organized into three focus groups according to the considered solutions, i.e., assistance, policy, and legislation. Table 3 shows results of the analysis.The ageing labour force could represent a risk both for society and economy unless it is well managed. Therefore, the attention that researchers, governments and other stakeholders have devoted to this issue has grown over the time. According to analysis of motivations  and soluExtend the length of work ability. Different organizations implement changes by creating common policies and strategies, but they are not oriented toward the older workforce. Intentionally interrupting the existing age-graded logic and its replacement with age-neutral logic are proposed in . The autAvoid the age-based discrimination. The labour market will have to adapt working positions and eliminate the attitude of age-based discrimination, since it will have to fight for a working force older than 65 because it is lacking. When facing age-based discrimination at work, the organizational help and friends and family support were found to be significant in achieving better health and adaptability . On the Improve the well-being of older workers. Difficulties that older people experience at work indicates a need for healthcare strategies to adjust the work conditions so that they are suitable for older workforce with decreased physical ability. The authors in  identifiPromote the lifelong learning. The growth of the aging labour force and emerging technologies change the work environment, generating a need to train older workers to improve their skills. Older workers gain benefits when well-designed training approaches are used. Therefore, the authors in  studied Encourage the late retirement. In order to achieve more successful inclusion of older people into labour market, there is a need for more comprehensive policies and harmonized all-age legislation. This is indicated by the fact that the overall decrease in the share of individuals in pension and disability programs is caused by changes in regulations . In thisEncourage incentives to extend the working ability in old age;Eliminate age-based discrimination at work along with promotion of gender equality;Invest in education, lifelong learning, health and well-being while increasing the productivity;Improve the working conditions to increase the safety at work and health of workers;Support late retirement along with the increase of life expectancy;Reduce the use of early retirement if workers’ health and work ability are satisfactory.The abovementioned policy implications may be useful from policy making perspective. They could lead to the creation of framework that targets government, the non-governmental sector, private sectors and other stakeholders. However, the creation of such policy framework should take into account many other contributing factors  that canThis study provides a systematic review of articles related to the aging labour force in terms of recent trends and future directions. Additionally, it identifies and evaluates the motivations that drive research on the aging labour force and potential solutions that address the issues related to the aging at work. Sustainable growth and age-based discrimination are recognized as the main motivations to perform the research activities in the given context. On the other hand, policies that stimulate life-long learning are identified as a potential solution for the aging labour force. The additional value of this study lies in its identification of policy implications and recommendations for governments and other stakeholders.Furthermore, along with this paper, we also provide a Despite the valuable insights in this study, it suffers from several limitations as well. First, this study took into consideration only three digital libraries, so some relevant articles could be unintentionally omitted from the study because of the specificity of the search strings and the fact that we have not taken into account the non-indexed publishers. However, the size of the searched digital libraries is sufficient, so the obtained results are suitable for the purpose of the study. Additionally, the articles obtained for this study are the results of a search query sent to different search engines with different retrieving and formatting rules from those that are used in the considered libraries. However, we are convinced that the specificities of the publishers’ search engines had no influence on the findings of this study, taking into the account the number of analyzed articles.Finally, the articles are categorized to provide the quantitative results that show the recent trends and future directions of aging at work, whereas the qualitative results are manually covered to a limited extent to describe the motivation issues and solutions for the aging labour force.The aging of the population raises many issues and provides many opportunities. It intensifies the requirement for long-term care, healthcare, and a better-skilled workforce, and increases the demand for age-friendly environments. On the other hand, it enables the contributions of older people to their family, local community, or broader society.In order to review articles related to the ageing at work in terms of recent trends and future directions, we performed a scoping literature review using an NLP-based framework to automate some of the steps in the PRISMA methodology and quickly identify potentially relevant articles. As a result, starting from over 70 thousand potentially relevant articles, we analyzed in detail about 70 of the most relevant approaches and discussed 24 of them.We identified that the most prominent works suggest policies and practices that support life-long learning, a workforce that comprises both younger and older workers, and gradual retirement. Approaches like these could be the best response to the globalization issues, reduction of workforce, maintenance of financial independence of the aging workforce, and other social benefits.Future work could be focused on standardizing approaches to this problem across different countries, supported by different policymakers. The goal should not be to end up with the same approaches in different environments, as this would hardly encompass all cultural, sociological, and economic factors. Instead, we believe that systematically documented and well-thought-out approaches will facilitate the measurement of the results and analysis of causality when investigating benefits and drawbacks.


Horses are used for a wide range of different purposes and may be vulnerable to a large number of different welfare issues, some of which are unique to equines, such as responses to being ridden or trained. Compared to farmed livestock, their welfare has received less attention, but concern for their welfare is increasing. Welfare issues can arise from the environments in which animals are kept, how they are treated by their human caregivers and their health. To determine which of the issues are most important and may need the greatest attention in terms of research effort or owner education, we used a process of eliciting expert opinion. Through a series of surveys and ranking of issues, we determined that, in the opinion of equine experts, the most important issues for horses were poor disease prevention, issues arising when old or sick horses are not promptly euthanized, lack of owner knowledge of welfare needs of horses, fear and stress involved in horse use, inability of owners to recognize pain behaviour, obesity and inadequate feeding practices. Prioritizing different welfare issues can help to focus attention on the most pressing or severe issues causing the greatest amount of suffering. n = 37) were included in subsequent rounds. Finally, a subset of experts attended a two-day workshop to determine the final priority list of welfare issues. The welfare issues perceived to be most prevalent were lack of biosecurity, delayed euthanasia, lack of owner knowledge of equine welfare needs, fear and stress from use, and obesity. The issues considered to cause greatest suffering for individual horses were delayed euthanasia, lack of recognition by owners of pain behaviour, large worm burdens, obesity and being fed unsuitable diets for equine feeding behaviour. These outcomes can help to focus research and education interventions on the most pressing welfare issues for horses. Equine welfare issues are receiving increasing attention in the UK, but welfare problems can arise from a wide range of causes. In order to identify the most important welfare concerns for horses, we used a Delphi method with 19 equine welfare experts. An initial list of 84 equine welfare issues was generated using an online discussion board and NVivo thematic analysis. Subsequently, experts ranked these welfare issues for perceived prevalence, severity and duration of suffering associated with each issue on a 6-point Likert scale. All issues with a mean score of 3 or above ( Survey studies and estimates suggest that there are around 7 million horses in the EU , with apUntil relatively recently, horse welfare studies had focused primarily on stereotypic behaviour, horse transport and health-related issues. However, there has been a recent increase in the number of papers addressing varied horse welfare issues, considering the management of horses , and then to determine a prioritization following from the premise that, where the animals’ capacities to suffer can be assumed, the most pressing issues are determined by the severity and duration of suffering and the number of animals affected . FinallyAll research generated from this study was approved by the University of Edinburgh’s Human Ethics Review Committee (HERC). The study formed part of a larger study to identify and prioritise welfare issues for a range of different species. Detailed methods were as previously described  and are The aim was to recruit between 12 and 20 horse welfare experts to the study and to recruit a broad range of stakeholders, including practising veterinarians, academics, trainers, charity sector employees and equine industry representatives. Experts were defined as having worked in their field for at least 3 years and being based in the UK. Experts were recruited using a snowball sampling technique and were sent a consent form to sign in accordance with HERC guidelines before commencing the study. A list of horse welfare issues was developed through the use of a Delphi Conference procedure using an online discussion board. An initial list of horse welfare issues (derived from a list generated by the British Veterinary Association) was provided and experts were then able to add to and comment on issues anonymously for two weeks. All comments and discussion from the online platform were collated, and a detailed thematic analysis was conducted using NVivo 11 Pro. Using an emergent coding process, each comment from the board was categorized into themes, reaching saturation at 12 themes, which were later combined into 9 categories. Duplicate welfare issues were deleted, and the final list was checked by two independent assessors to remove redundancies or to add omissions. Two rounds of anonymous surveys were conducted using the Online Survey tool . In both rounds, demographic data were collected from the experts including age, gender, expertise  and highest level of educational attainment. For the first survey, participants were asked to score each of the potential welfare issues derived from the thematic analysis for severity (the intensity of suffering likely to be a consequence of the welfare issue in their opinion), duration  and perceived prevalence (the likely proportion of the UK horse population they considered to be affected by the welfare issue). Each issue was scored on a 6-point Likert scale for each factor, where 1 = never/none, and 6 = always/high. An even-numbered scale was chosen as this forced the experts to make a choice (prioritised or not). The results of the first survey were reviewed and mean scores for each welfare issue and each factor calculated. Those issues that scored at least 3.0 or above  were included in the second survey as a ranked list. In the second round, experts were asked whether they agreed or not with the ranking position, and whether, in their opinion, the issue should be ranked higher or lower. Agreement between experts was assessed by calculating Fleiss’ kappa statistics and by assessing the proportion of experts that agreed with each rank position. The final stage of the process was an expert workshop conducted in Edinburgh over 2 days. This involved two horse welfare experts drawn from the experts who completed the earlier rounds, as well as 19 other experts from the wider study who had broad animal welfare expertise in other species, including farm and companion animals . Over the two days, experts participated in small-group (species-specific) and larger-group exercises to achieve a final rank order, working from the ranked prioritized lists of horse welfare issues that had been generated in the earlier rounds. In a few places, experts also combined areas which they felt to be too similar to separate. Consensus at the workshop was considered to be unanimous where a final list was produced with the agreement of all participants.Nineteen experts were recruited to the horse study. Experts had a mean age of 45 (SD = 7.89) and were predominantly female . Experts were associated with NGOs or equine charities (28%) or were academic researchers (26%), trainers (18%), industry representatives (13%), veterinarians (8%), associated with equine policy (5%) or had other expertise (2%). Experts were nearly all educated to at least university graduate level (94%), with 53% holding postgraduate qualifications . The response rate was 68% (first round) and 74% (second round). Horse welfare experts generated a comprehensive list of 84 welfare concerns from the analysis of the discussion board. These were finally classified into 9 themes in preparation for the first online survey .The outcome of the first ranking process conducted by experts is shown in Horse experts had an overall low level of agreement with the rank order generated in the first round survey , and generally less than 75% of experts agreed on the top 10 highest-ranking welfare issue for perceived prevalence, severity or duration, although there was better agreement (70%–85%) on the five lowest ranking positions for all welfare issues. Experts considered that lack of understanding of horse welfare needs by owners, over-rugging, inappropriate training and handling, and delayed euthanasia were more prevalent than as scored in the first round. In addition, hunger and obesity were considered less severe, but lack of recognition of pain behaviour, delayed euthanasia and inability to perform normal social behaviours were more severe (see The workshop was more successful than the anonymous online surveys in achieving a consensus (unanimity was achieved), and over two days of discussion, a final welfare ranking on which the experts agreed was achieved .Although the horse experts in the initial rounds of the Delphi did not achieve very high levels of agreement, a better consensus was achieved during the face-to-face discussions in the workshop, and many of the areas considered to be important in the survey were also ranked highly in the workshop. Overall concerns reflected all aspects of horse management and use, from health , owner knowledge (lack of recognition of pain behavior and lack of understanding of equine welfare needs), management  and use of horses . The initial rounds of the Delphi were anonymous and had the advantage that individual respondents were not influenced by the decisions of others. However, a disadvantage of the Delhpi method is that it prevents live discussion where individual ideas and perceptions can be broken down, discussed and reassessed. In our study, we found that considered discussion, in a structured way in the workshop, allowed a better consensus to be achieved, building on the preliminary analyses derived in the anonymous process. Other qualitative studies that have considered horse welfare have used varying techniques, and not all studies yielded outcomes that could be directly compared to our prioritization. However, a UK study using interviewing and focus groups of industry professionals  found thDespite use of different qualitative methods, different selection of experts or industry professionals, and different ways of prioritization, there are a number of similar issues that have arisen in UK and Canada that may reflect general areas of concern for the welfare of horses. In our study, we specifically asked experts to address welfare by focusing on the amount of suffering caused by the welfare issue. The study of McGreevy et al.  used theOf the issues that arose in all studies, owners’ lack of knowledge, particularly in relation to horse behaviour, was clearly highlighted. In our study, this was identified as a specific theme in the initial development of the list of welfare concerns for horses and was also included as one of the most important issues in the final rankings for recognition of pain behaviour and lack of knowledge of horse welfare needs. Lack of owner knowledge may also contribute to other welfare issues, such as inappropriate feeding and training methods and use of restrictive or poorly-fitting tack. In their review of recreational horse management, Hemsworth et al.  suggest A number of studies have suggested that the vast majority of owners believe horses to be sentient and capable of specific emotions such as pain, fear or joy ,27. HoweThe impact of owner knowledge or management responses has also been shown to be an issue with health practices as well as behaviour. Although lack of knowledge or understanding was not specifically assessed, Thompson et al.  found thwww.bluecross.org.uk and www.bhs.org.uk) or emergency conditions where euthanasia would be recommended. The consequences of delaying euthanasia decisions, and so increasing the risk of animals suffering uncontrollable pain or disease, was considered by experts in this study to be one of the most prevalent horse welfare issues and to cause the greatest suffering to individual horses. Delayed euthanasia was also identified as important in two other studies that have attempted to prioritize horse welfare issues ,18, suggHorses are unusual amongst other domesticated species in the degree of use and training that they usually receive, often by owners who themselves have had no specific education in learning theory or training practices. This lack of owner knowledge of equine learning or training methods was a significant concern in our study and in others ,18,22. TConcerns about feeding practices in our study were either about the quantity of feed given  or that the method of feeding management, such as restricted forage access, might cause adverse behavioural consequences for horses. Studies in the UK, Sweden, Italy, Germany and the USA suggest that between 25% and 45% of horses and ponies are overweight or obese ,35,36,37Actions to manage the weight of horses can induce hunger and/or frustration in horses, as described above. However, these emotional states may also occur when horses are fed in ways that are very different from their evolved feeding responses. In our study, feeding animals unsuitable diets for equine feeding behaviour was considered by experts to be both an important cause of horses suffering and to be prevalent. Feral horses spend 12–18 hours a day grazing , and theIn our study, issues with social behaviours were considered both to be prevalent  and to cause significant suffering to individual horses . Prolonged stabling and management in inappropriate environments were identified as welfare issues in the study of Horseman et al. . In our Various studies suggest that 83%–92% of horses are continuously managed at pasture in groups or have pasture access ,46,50 buBy comparing the outcomes from our data with those of other studies that have attempted similar types of assessments, we have found that there are common welfare concerns that are raised frequently with different groups, which lends greater weight to arguments that these are important issues for horse welfare. In particular, lack of owner knowledge, or application of knowledge to the management of horses, is an important welfare concern, which has also been seen in other species ,51. In aOne of the limitations of a Delphi procedure, and for other techniques that rely on expert opinion, is that the outcomes reflect only the knowledge and understanding of the experts . However


Thailand lacks occupational injury and illness (OII) surveillance for its agricultural sector, a sector that comprises 34% of the total Thai workforce but is not covered by the workers compensation system. This study used data from Thailand’s Universal Health Care System to estimate the medical costs of OIIs from agricultural work in Thailand. In 2017, OII medical costs totaled $47 million (USD), about ~ 0.2% of the gross domestic product produced by the Thai agricultural sector. We recommend that some of the national funds currently used for medical treatment of OIIs be used instead to develop and implement prevention programs in agriculture. This would improve not only worker health and safety, but also productivity. Availability of data on working conditions, injuries and illnesses, and especially lost time, lost income and productivity, and OII-related costs for the workers and their dependents might enable better public health policy formulation. In recent years, the importance of Thailand’s agricultural sector to the national GDP has declined from 10.5% in 2014 to 8.6% in 2018 .Thailand’s Labor Protection Act covers workers in the private sector but does not apply to informal sector agricultural workers . AgriculThailand’s Universal Health Coverage Scheme (UHCS) is a tax-financed scheme that provides free healthcare at the point of service introduced in 2002 . The UHCFormal sector workers in the SSA are also covered by the Workers Compensation Fund Act of 1994 that compensates employees who experience work-related injuries or diseases, disabilities, or die. The Workers Compensation program is the principal collector of data on occupational injuries and illnesses in Thailand. Workers Compensation does not, however, cover informal sector workers, and lacks a mechanism to subsidize informal sector worker enrollment in the SSA or Workers Compensation. These gaps and the general lack of government regulation of occupational safety and health in the informal sector have shifted medical treatment expenditures for OIIs to the UHCS . In. In23]. The estimated average cost per farmer of all OIIs was $3.88USD Table . If thisThis is the first report on the number and medical treatment costs of occupational injuries and illnesses in the Thai agricultural sector. Other reports on OIIs have used data from the Workers Compensation System, which are only available for formal sector employees. This study is unique in using UCHS data to identify 1,704,655 occupational injuries among agricultural workers for 2017  had the largest number of visits and medical costs for occupational injuries  have previously been reported as a common problem in Thai agriculture . This, hHearing loss has also been identified as a hazard in Thai agriculture, with a prevalence of up to 88% in some farming populations . ExposurAlthough others have reported the problem of pesticide poisoning among those who mix or apply pesticides in Thai agriculture , 26, it The UHCS rely on the primary care staff  to identify occupational illnesses. The difficulty in diagnosing occupational illnesses without more extensive training may be reflected in the low number of occupational illness visits (3%) relative to injuries (97%) in our data. In addition, it is difficult to link occupational exposures to illness with a latency period between exposure and illness . In the Establishing the cost associated with OIIs is essential for strategic planning by governments to enable them to allocate scare resources and put in place adequate prevention measures. The cost estimates for OIIs available for this paper are based solely on medical treatment costs.In the economies of high resource countries in the West, the most important cost element for OIIs is not the medical treatment cost, but the immediate lost work time and productivity, plus the “lost return on investment in human capital” when a fatality or disability results in the inability to continue the job . Such inThai farmers are currently covered under the Ministry of Labor’s Department of Labor Protection and Welfare “Guidance on Occupational Safety, Health and Environment for Informal Workers, 2013” . Under tCurrently, the UHCS budget mainly covers medical treatment costs rather than prevention programs for OIIs. We recommend a re-allocation of a portion of the OII treatment costs enumerated here to providing agricultural workers with the critical components of prevention programs: hazard identification and remediation, training, and personal protective equipment. The Ministry of Public Health and the Ministry of Labor might develop safety programs that provide incentives for subsidizing the use of safely guarded machinery for farmers; training in sustainable and organic alternatives; subsidized personal protective equipment and additional training requirements before licensure for pesticide purchase. Outreach agricultural occupational safety and health training programs need to be set up around the country, in every district and sub-district, to reach agricultural workers in the remote rural areas. Prevention programs and subsidized using medical treatment funds could reduce OIIs and improve productivity.Our study used Health Data Center data from 2017 resulting in an underestimate of current OII costs, as Universal Health Care System (UHCS) costs have increased over time. Due to the lack of adequate training and limited interest from the UHCS, many OIIs may not have been put into the proper Diagnostic Related Group. The determination that an illness was work related was not verified by the Bureau of Occupational and Environmental Disease and might be an over or under estimate. With regard to OII medical costs, our study assumed that the costs of medical treatment for most occupational illnesses were the same as the most frequent DRG category claim . Due to lack of data, these OII cost estimates represent only direct medical expenses. Because the number of days away from work or the number of days of job transfer or restriction is not available for informal workers, we do not include the other costs to workers and the economy due to daily lost productivity or income.The U.S. Bureau of Labor Statistics conducts an annual Survey of Occupational Injuries and Illnesses that generates estimates of nonfatal workplace injury and illness rates. U.S. law requires agricultural businesses with more than 10 employees to participate in the surveys. This type of OII data collection process does not exist in Thailand and even in the U.S., information on OIIs in the informal sector is difficult to obtain. Therefore, in 1990, the U.S National Institute for Occupational Safety and Health developed the National Agricultural Workers Survey, a periodic surveillance program of nonfatal injuries to hired workers on U.S. crop farms, regardless of worker immigration status .Thailand needs data collection tools and a database that can measure OII, lost income and workdays, and lost productivity for informal sector workers. It should be developed by the National Statistical Office of Thailand in collaboration with Ministry of Public Health and the Ministry of Labor. If collected through UCHS it will require sufficient training for healthcare personnel to classify an injury or illness as work related. It is important that family members who are injured on a family-owned farm, especially children, should be classified as having an OII. In addition, a method is needed to indicate that a family member was living on a family-owned farm, but not working at the time of exposure to a farm hazard that caused an injury or illness  .Alternatively, the Ministry of Agriculture or Ministry of Labor might develop a nationwide surveillance system to collect demographic, employment, and health and safety data in face-to-face interviews. Ideally, this would involve direct collection of data on working conditions, injuries and illnesses, and especially lost time, lost income and productivity, and related costs for the workers and their dependents. The timing of data collection should reflect the seasonality of agricultural production and employment. Better data on OIIs and the true costs, beyond medical treatment, including lost worktime and productivity, will provide incentives for changes in government policies to reduce UCHS expenditures and improve national agricultural productivity. Detailed information about the sources and nature of OIIs  will aid efforts to target occupational health and safety training and interventions.


To the editor,The COVID-19 pandemic has emerged as the greatest challenge to the healthcare system worldwide. The pathogenesis involves the infection and replication of the virus in the epithelial cells of the respiratory system leading to severe acute respiratory syndrome and death. As on 25th April 2020 more than 187,000 deaths have been reported worldwide and the number of people infected stands at 2,724,809 (World Health Organization, The enforcement of lockdowns, uncertainties about income, news regarding the pandemic and prolonged isolation measures will increase the psychological stress on patients which may, in turn, lead to an increase in the smoking habit (Patwardhan, This scenario calls for an urgent increase in the anti-tobacco campaign. We as healthcare professionals must counsel smokers and prevent the emergence of new smokers. A clear message should be sent to patients that although these are stressful times, smoking is not a solution. Proper guidance to patients who smoke regarding the delirious effects of smoking especially concerning the COVID-19 pandemic should be imparted. They should be educated in terms of prevention of both active and passive smoking and given counseling on the availability of de-addiction services, coping with mechanisms for withdrawal symptoms which include balanced diet, regular physical activity, adequate sleep and nicotine replacements such as nicotine gums. Patients can be directed to a host of education material and motivational videos available on the internet. In addition, telemedicine services can be used by patients to communicate with their treating physicians and virtual group support sessions organized for psychological support and motivation. Opportunistic advice to patients on relapse prevention and to watch for increased smoking tendencies can be given. Training sessions can be organized for healthcare professionals in terms of the WHO 5A's model for tobacco cessation incorporating components such as ask, advice, assess, assist and arrange.In summary, smoking is possibly a modifying factor for the aggravation of COVID-19. There is increased psychological stress which may lead to an increase in smoking during the pandemic. It is vital that healthcare providers recognize this disturbing trend and take active measures to prevent the rise in the number of smokers.


It was thought that tool use in animals is an adaptive specialization. Recent studies, however, have shown that some non-tool-users, such as rooks and jays, can use and manufacture tools in laboratory settings. Despite the abundant evidence of tool use in corvids, little is known about the neural mechanisms underlying tool use in this family of birds. This review summarizes the current knowledge on the neural processes underlying tool use in humans, macaques and corvids. We suggest a possible neural network for tool use in macaques and hope this might inspire research to discover a similar brain network in corvids. We hope to establish a framework to elucidate the neural mechanisms that supported the convergent evolution of tool use in birds and mammals. The classic definition of tool use in animals is “the use of an external object as a functional extension of mouth or beak, hand or claw, in the attainment of an immediate goal” , p.195, Corvus moneduloides) using twigs as hooks to retrieve food from small holes (Corvus brachyrhynchos) dropping nuts in roads to get them crashed by the passing of automobiles over them . They explored the brain areas that are active during tool use by using PET scans during a task in which the subjects were previously trained to use tools to collect an unreachable food pellet. They used a control task in which the subjects experienced almost the same sensorimotor circumstances as in the experimental task, but without any learning involved . In their 2001 study, the subjects had to reach the pellet with one rack. In their 2002 study, they had to poke a pellet with a rack out of a transparent tube and reach it with a second rack. In their 2004 and 2007 studies, the subjects had to obtain an unreachable pellet by manipulating a joystick or a pair of dials, respectively, which controlled the position of a shovel that moved in a two-dimensional space. They found the following active brain areas during tool use in macaques . This region is involved in object recognition and memory. Its extensive connections with IPS suggests that it might help this other area in maintaining and manipulating the body-image .There are two areas of interest within this region: F5 and dorsal premotor cortex (PMD). F5, the area containing mirror neurons in macaques, is involved in the execution of goal-directed manual actions . The PMDThis area, which receives input from the premotor cortex , was suggested to be involved in the maintenance and updating of the body-image, which would be helpful for the execution of tool-based/use actions and sequential movements , 2004.It was suggested that the basal ganglia, as well as the IPS bimodal neurons, is involved in the creation and maintenance of the spatiotemporal representation of the hand during tool use .The cerebellum was suggested to be involved in the learning processes required for tool use and “reconstruction of the acquired body-image,” and “may modulate higher cognitive functions of the executive process as a cerebro-cerebellar loop from an anatomical perspective” .These brain areas are important for tool use but that is not their only role. They can also be involved in less functional or less goal-directed forms of object manipulation, such as object exploration or object play, often claimed to be associated in the development, evolution and daily expression of tool use .Based on the information collected in the aforementioned studies and the available data on macaque brain connections , we suggThe study of the neural processes of tool use in birds is of great interest, given that some species of birds have shown cognitive abilities and tool-use capability similar to those seen in primates . By studCorvus hawaiiensis), which were considered extinct in the early 2000s and currently live in captivity, are capable of tool use and tool manufacture  were able to spontaneously create hook tools from pieces of straight wire and use them to collect food that would otherwise have been out of beak reach (Garrulus glandarius) (Cyanocitta cristata) also made and used tools to obtain food out of reach (Corvus corax) demonstrated problem-solving skills by string-pulling to collect food  . Northerof reach . Furtherect food , and areect food . Many ofIt is for all these reasons that corvids make an excellent model for the study of the neural mechanisms of tool use . FurtherSubsequent studies showed that the neuronal density of the brain of several bird species significantly exceeds the neural densities of many mammals, including primates, of similar brain mass . This fiIn mammals, the prefrontal cortex plays a crucial role in problem solving . Given tNew Caledonian crows, which are known for their exceptional ability to build and use tools, have an enlarged mesopallium, pallidostriatal complex, septum and tegmentum, compared to three other passeriformes  . MehlhorAnother region that seems to be important for tool use is the cerebellum. The cerebellum seems to be active during tool use in macaques and humans, as described previously. In birds, it was found that, although the total size of the cerebellum was not significantly different between tool-user and non-tool-user species, the number of folds in the cerebellar cortex was significantly larger in the former . It is pCactospiza pallida) found that these birds probably learn to use tools by trial and error during their development (Cacatua goffiniana) found social transmission of tool use and tool manufacture in the males of this species (The current literature differs in whether tool-using birds learn to use tools from conspecifics or not. A study on woodpecker finches (elopment . However species , and a s species . Thus, aThe study of the neural processes underlying tool use in humans and non-human primates has received increased attention over the last decade. Early studies in patients suffering from apraxia showed that complex actions that require motor skills and conceptual knowledge, such as tool use, are represented in dissociable neural systems within the left cerebral hemisphere. Two interconnected regions are particularly important, the anterior supramarginal gyrus and the putative human homolog of the anterior intraparietal cortex. However, it is clear that these two regions do not work alone, and a complex neural network is required to use tools. Similarly, in macaques there are also two areas of particular interest: area F5 and the dorsal premotor cortex, both located within the premotor cortex. However, although these two regions seem to be of utmost importance during tool use in macaques, it is evident that, as in humans, tool use requires the activation of a complex network of brain activation, as we have suggested here. We hope that a similar brain network can be elucidated for tool-using corvids in the future, given the abundant evidence of tool use and manufacture in this family of birds. We know that New Caledonian crows and Hawaiian crows can use and manufacture tools, and New Caledonian crows can infer their physical properties . FurtherMC-Á wrote the manuscript, with critical reviews and important discussions and additions by NC. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.