Strengthening of mental health information systems (MHIS) is essential to monitor and evaluate mental health services in low and middle-income countries. While research exists assessing wider health management information systems, there is limited published evidence exploring the design and implementation of MHIS in these settings. This paper aims to identify and assess the key factors affecting the design and implementation of MHIS, as perceived by the key stakeholders in Ghana and South Africa.We report findings from the Mental Health and Poverty Project, a 5-year research programme implemented within four African countries. The MHIS strengthening in South Africa and Ghana included two related components: intervention and research. The intervention component aimed to strengthen MHIS in the two countries, and the research component aimed to document interventions in each country, including the key influences. Data were collected using semi structured interviews with key stakeholders and reviews of key documents and secondary data from the improved MHIS. We analyzed the qualitative data using a framework approach.Key components of the MHIS intervention involved the introduction of a redesigned patient registration form, entry into computers for analysis every 2 months by clinical managerial staff, and utilization of data in hospital management meetings in three psychiatric hospitals in Ghana; and the introduction of a new set of mental health indicators and related forms and tally sheets at primary care clinics and district hospitals in five districts in the KwaZulu-Natal and Northern Cape provinces in South Africa. Overall, the key stakeholders perceived the MHIS strengthening as an effective intervention in both countries with an enhanced set of indicators in South Africa and introduction of a computerized system in Ghana.Influences on the design and implementation of MHIS interventions in Ghana and South Africa relate to resources, working approaches (including degree of consultations during the design stage and communication during implementation stage) and the low priority of mental health. Although the influencing factors represent similar categories, more influences were identified on MHIS implementation, compared with the design stage. Different influences appear to be related within, and across, the MHIS design and implementation and may reinforce or negate each other thus leading to the multiplier or minimization effects. The wider context, similar to other studies, is important in ensuring the success of such interventions.Future MHIS strengthening interventions can consider three policy implications which emerged from our analysis and experience: enhancing consultations during the intervention design, better consideration of implementation challenges during design, and better recognition of relations between different influences. Mental health is an important though still neglected area of public health around the world  are well-recognized sources of information to inform decisions in relation to the health of populations , a 5-year 2005–2010) research programme consortium, which was implemented in Ghana, South Africa, Uganda and Zambia and involved nine institutional partners from Africa and Europe. The project aimed to raise the profile of the field and break the cycle of poverty and mental ill health through the partnerships between research teams and policy-makers from the ministries of health in the participating countries  was done in selected districts in two provinces: Northern Cape and KwaZulu-Natal. In both countries the MHIS strengthening was a joint initiative involving researchers from the MHaPP project and the relevant department within national or regional  Ministries of Health to ensure ownership and to design a system responsive to needs of its main users. As shown in In South Africa, a task team was established, involving researchers and province-level policymakers, which agreed on the key principles for collaboration and identified the specific areas for MHIS strengthening in the two provinces MHaPP, a. The foet al. In Ghana, the aim of the intervention was to strengthen the functions of collection, processing, analysis, dissemination and use of information in the three psychiatric hospitals. Discussions between the research team, doctors, administrators, records officers and Policy, Planning, Monitoring and Evaluation division within the Ghana Health Service identified the need for a computerized MHIS in all the psychiatric hospitals in Ghana  issues related to processes of designing and implementing the intervention and (b) issues related to the effects of the system. The key influences on the design and implementation of the MHIS cut across these two categories of questions.Individual in-depth semi-structured interviews were conducted with key respondents, approximately 1 year after the commencement of the implementation of the MHIS intervention. All interviews were audio-recorded, transcribed verbatim and used for analysis. Informed consent was obtained from all respondents prior to each interview.The review of purposefully-selected documents covered key policies outlining and regulating the design of HMIS and MHIS in each of the two countries, as well as the MHaPP project reports. Minutes from task team meetings and teleconferences were also reviewed and results compared with findings from the interviews.A Framework Approach was used in each country to guide the analysis of results, which included stages of familiarization with the data, indexing and charting, coding of the interviews with the help of NVIVO software , and mapping and interpretation of results  and in a step-wise manner by building a logical chain of evidence with themes emerging from the data after noting the patterns, metaphors and clustering in the text. The initial framework for indexing the data reflected the structure of adapted interview guides . This framework was continuously updated using document reviews as the specific themes emerged from our analysis. The key influences which were emphasized by majority of respondents, and were mostly evident in the documents, were regarded as most important as compared with those raised by only some respondents and which rarely featured in the document. The themes were compared across the different groups of stakeholders and between the interviews and documents, to understand differences and similarities and ensure validity of our results.To ensure validity of results, analysis of data was conducted by at least two researchers. Furthermore, results of analysis of data from the interviews were triangulated between the different respondent groups and with results of document reviews.As part of analysis, factors which affected design and implementation of MHIS intervention in each country were identified and grouped into broad categories. Simplified versions of causal loop diagrams were used to illustrate and visualize the relationships between various factors. Causal relationships were identified by the researchers from the analysis of interview transcripts and documents.Ethics approvals were obtained from the Human Research Ethics Committee, in the Faculty of Health Sciences, University of Cape Town (REC Ref: 314/2005) and the Ghana Health Service Ethical Review committee. All the data were stored securely and as mentioned earlier the interview transcripts were anonymized for analysis.We now briefly outline the overall architecture of MHIS in each country and outline the main perceived effects, as a background for reporting the key perceived influences on the MHIS intervention in the two countries.In each hospital in Ghana, the data collection on mental health was done manually, using a newly redesigned patient registration form . Once completed, the data were then entered into computers for analysis. Statistics from the new system were analyzed every 2 months by clinical managerial staff, and fed into specially set up hospital management meetings. Although with a view of future integration, in parallel, the old system of registration of manual data collection producing monthly reports also continued.•◦Total mental health visits◦New mental health visits◦Number of mental health clients on register◦Number of mental health visits per broad diagnostic group: substance abuse, intellectual disability, anxiety disorder, mood disorder, psychosis◦Number of mental health visits for patients under 18 years of agePrimary health care level :◦Outpatient indicators as per primary care level (above)◦Number of mental health admissions◦Number of mental health discharges◦Average length of stay (days)◦Number of admissions per diagnostic group: parasuicide, substance abuse, anxiety disorder, mood disorder, psychosis◦Adverse events◦Readmissions within 3 months of discharge.• Secondary care level :At the primary care and district hospital levels, data were captured on pen and paper using tally sheets. These were then aggregated and captured electronically on a monthly basis by the District Information Officer. The District Information Officer then generated regular reports from the data in the DHIS system.In South Africa, the following individual indicators were added to the existing mental health indicators at each level:Overall, the MHIS strengthening was perceived to be effective by the key stakeholders, particularly health staff and managers, in both countries MHapp, .et al. In Ghana, the uniform system of recording diagnoses of mental illnesses using the ICD-10 was piloted, which contributed to strengthened capacity of the records department .…However, our analysis of data from document reviews and interview transcripts revealed that the use of mental health information was still limited by district level management committees in South Africa, compared with the use of information from other health programmes. Nevertheless, the respondents reflected that data gathered in the district was informally used by mental health coordinators and fed back to the mental health coordinators at provincial levels.In South Africa, stakeholders interviewed expressed the opinion that availability of additional mental health indicators for programme planning and management has improved capacity of district management teams to collect quality information and ensure its use in decision-making.The MHIS strengthening that was perceived, led to some unintended negative effects. For example, the respondents reflected that the workload of clinical staff, particularly consulting room nurses, increased in each of the three hospitals in Ghana. Although not unexpected, this finding also raises a possible need for further refining the data collection forms and processes, to keep increases in workload to a minimum (or perhaps even to reduce the workload by making the data collection and processing more efficient). According to the respondents, the benefits of the improved systems, however, outweighed the negative effects.Different factors were reported to influence the design and implementation stages of MHIS strengthening in Ghana and South Africa. These are summarized in Our analysis of documents and interview data identified different positive and negative influences of these factors on the MHIS design and implementation. These are illustrated in As illustrated in All respondents reflected that adequate staff expertise and sufficient time spent by different experts in the field helped to ensure the appropriate design of the new system. In South Africa, the main resource-related issue which positively affected the MHIS design, identified in both documents and interview data, was the establishment of task teams involving 5–6 members with different expertise, comprising researchers and information management staff, mental health programme management and monitoring and evaluation staff.I think in terms of what worked well is the involvement of …all the important role-players from the doctors and the programme managers and the coordinators at the district level, as well as the doctors at the tertiary, at the hospital level. .In Ghana, analysis of interviews and documents revealed that consultations with key stakeholders were conducted throughout the design stage, including planning the changes to the existing system, incorporating ICD-10 and enhancing the capacity to implement MHIS. It was evident in the data that consultations hence became a continuing factor enabling communication throughout intervention.Continuous consultations with, and involvement of, key stakeholders during the MHIS design in Ghana and South Africa were perceived to be crucial for ensuring their ownership and commitment to the project, as one respondent reflected:“…based in same offices but… are almost a world apart…”.The stakeholders reported opinions that this relatively low priority of mental health contributed to a challenge of integrating mental health indicators into routine HMIS in Ghana. On reflection, this is perhaps less of an information technology-related challenge and relates more to allocation of resources on the basis of perceived policy priorities. In other words, the general health planners and information managers involved in wider HMIS may not have seen the value in spending their time and resources for adding the MHIS indicators into the overall dataset.One contextual constraint to MHIS design, referred to by the respondents in both countries, was the low priority of mental health as a policy issue when compared, for example, with other diseases such as communicable diseases. The low priority of mental health in both Ghana and South Africa was also evident in the documents reviewed from both countries. According to the respondents, this low priority of mental health also contributed to limited interactions between information management staff and clinical staff, who according to a district information officer in South Africa were:The MHIS implementation was also affected by different influences. As shown in The views about positive and negative influences were common in the two countries, and included availability of resources including staff motivations, degree of communication and low priority of mental health. These influences are set out next.Unlike the design stage where the respondents identified mostly positive influences, the implementation stage was associated by the respondents with different positive and negative influences in Ghana and South Africa. As one would normally expect, availability of resources is likely to catalyze the implementation, whereas their absence is likely to be a constraint. In Ghana, procurement of new computers, recruitment of records staff and deployment of new statisticians in some hospitals helped to implement the new system. However, inconsistent internet connectivity, inadequate storage files and data security concerns (e.g. outdated antivirus software), were examples of specific implementation challenges the stakeholders faced in Ghana. According to the respondents, the shortage of paper for printing the data collection forms, due to delays in supplies from provincial level in South Africa, led to delays in the data collection. However, the data collection still continued where it was feasible, largely due to motivated staff.I think we just sort overlooked the area that you know for those indicators to be …for us to get that data into the system, there must be people who must really put in the data…so I think we sort of neglected that component. .In South Africa, different respondents reflected on the motivating nature of incentives for improving data collection, such as certificates to facilities, which performed well during the training:I think that giving out the certificates was a very big motivation… I think it had a great impact… .In Ghana, continued monitoring of implementation by the research team and other stakeholders helped establishing the system of bi-monthly feedback to the hospital staff containing information on patient data. According to the respondents and the documents, this feedback contributed to increase in staff motivation and led to better appreciation of value of good information for management and planning decisions, as one respondent reflected in Ghana:Now the data we collect is more accurate, because the disorder classification is more and they can be easily fit into the classifications. It is not like in the past, where we had to force the other disorders into the classification of other mental disorders”-Recorder, Psychiatric Hospital, Monitoring visit Ghana.However, the clinical health staff in both South African provinces sometimes felt the data collection under the new MHIS considerably increased their workload.We are still having problems with some of the sisters …they actually say they don't have time to actually fully implement the registers but that their statistics could be fairly accurate. .Similarly, different respondents in Ghana referred to increased staff workload as the most challenging issue during the implementation of the new MHIS: for example, dual filling of the forms on paper and computers led to 3 months of data entry back log and the instances of incomplete data collection during the initial stages of MHIS implementation.The influence of the health workforce on MHIS implementation was found to be significant in both countries. As reflected by one respondent consideration of importance of health workforce represents a somewhat neglected area, compared with the other components of the system.In Ghana, the perceived increase in staff workload was in contrast with their expectations that the intervention would mostly use time of the researchers, and not of their own time. This appears to have led to some resistance, and less trust in research projects, reflected in the documents such as meeting minutes, but may also reflect a lack of established culture of information use in decision making, which was identified by the respondents as a constraint for MHIS implementation.Unlike the design stage, the lack of regular communication was identified by the stakeholders as a constraint to MHIS implementation in both countries. For example, some respondents reflected that hospital managers, clinicians and information managers could have been involved more as the intervention progressed in South Africa. In Ghana, each hospital, perhaps understandably, adopted their own flows of information. However, there was lack of regular communication between different departments, for example, resulting in complaints by pharmacy departments and wards for not receiving the information forms in time.…. but I think in terms of allocating budget, there is less money that is allocated for mental health, which is a crucial thing that needs to be addressed from national to local level .Similar to the design stage, the need for improved prioritizing of mental health as a policy issue was also felt during the implementation of the intervention in both countries. For example, in South Africa the respondents reflected that mental health was being neglected by senior management staff, leading to limited availability of resources and potentially contributing to low staff motivation:Reflecting on the key influences identified by stakeholders across the two stages together, more influences were identified on MHIS implementation, compared with the design stage. However, the factors identified during both stages represented similar three categories . Furthermore, analysis shows that the MHIS design stage had more positive influences as compared with the implementation stage. Key positive influences included consultations and working principles, whereas the key negative influences included poor staff motivation at facility level for data collection, lack of culture of information use in decisions and less synergy between MHIS and other staff tasks.et al. et al. et al.  and the low priority of mental health. Three implications are proposed to inform future MHIS strengthening interventions in these and other similar countries: enhancing consultations during the design stage, improved consideration of implementation challenges during the design stage and better recognition of multiple and complex relations between different influences in the planning and implementation of similar initiatives.


Genetics constitute a crucial risk factor to schizophrenia. In the last decade, molecular genetic research has produced novel findings, infusing optimism about discovering the biological roots of schizophrenia. However, the complexity of the object of inquiry makes it almost impossible for non-specialists in genetics  to get a proper understanding and appreciation of the genetic findings and their limitations. This study aims at facilitating such an understanding by providing a brief overview of some of the central methods and findings in schizophrenia genetics, from its historical origins to its current status, and also by addressing some limitations and challenges that confront this field of research. In short, the genetic architecture of schizophrenia has proven to be highly complex, heterogeneous and polygenic. The disease risk is constituted by numerous common genetic variants of only very small individual effect and by rare, highly penetrant genetic variants of larger effects. In spite of recent advances in molecular genetics, our knowledge of the etiopathogenesis of schizophrenia and the genotype-environment interactions remain limited. Despite a century of research, our knowledge of the etiology and pathogenetic unfolding of schizophrenia remains scarce. A persistent scientific problem may have several overlapping sources: it may be due to the intrinsic difficulty of the object of inquiry, to methodological or technological inadequacies, or to a mistaken formulation of the research problem. As we shall see, some of these sources have played a role in the history of research on schizophrenia genetics.In the last decade, genetic research in schizophrenia has experienced a new dawn infused by a regained optimism due to newly developed, far more advanced molecular, technological and statistical methods. Given the rapid progress and intrinsic complexity of molecular genetic research , it may be difficult for outsiders to the field to grasp and appreciate the results from studies on schizophrenia genetics. Since genes are considered the strongest risk factor for schizophrenia, some grasp of this complex research domain is relevant in many clinical contexts.The purpose of this article is to contribute to facilitate such an understanding by providing an accessible overview of some of the central methods and findings in genetic research in schizophrenia, from its historical origins to current status. In other words, we are not offering a comprehensive review of the entire field but a brief overview that may provide the reader with an initial orientation in the field. For this reason, we generally refrain from discussing the details of the manifold findings in especially molecular genetics. Finally, we seek to articulate certain limitations and challenges that tend to be deemphasized in this field of psychiatric research.It has for a long time been known that madness (and many other human afflictions and characteristics) runs in families. After Mendel’s discovery of the laws of monogenic transmission of phenotypic traits, some of the earliest authors, describing schizophrenia, assumed an inherited basis of schizophrenia risk due to familial aggregation of the disease or its milder variants  has been instrumental in molecular genetic research in schizophrenia. The Human Genome Project was an international research effort to determine the sequence of the human genome’s three billion base pairs and to map all of its genes. At the dawn of molecular genetics in the early 1980s, some researchers, though certainly not all, believed that within a fairly limited period of time the availability of DNA would reveal the biological causes of the disorder , estimates of linkage between the illness and genomic loci were obtained. Linkage analysis is based on the observation that genetic markers, which are located physically close on the same chromosome, tend to be inherited together, i.e., they remain “linked” during meiosis. Numerous linkage studies of schizophrenia have been conducted, but positive findings have generally proved difficult to replicate in subsequent studies  but despite identification of some genes with small effect alleles .The next wave of molecular genetic research in schizophrenia employed the “candidate gene” approach, which, using a case-control study design, explored if potential susceptibility genes correlate with the disorder. In contrast to linkage analysis, the candidate gene approach can detect genes with small effect alleles provided that the sample size is adequate. Candidate genes have usually been selected due to their position  or functionality . Today, more than 1000 candidate genes have been tested (for details see  a priori selected candidate genes) for associations between common genomic variants or loci and the disorder. The identification and mapping of millions of common single nucleotide polymorphisms (SNPs), as facilitated by initiatives such as the International HapMap Project and the 1000 Genomes Project , has been instrumental for the GWAS approach. GWAS are based on linkage disequilibrium, i.e., a non-random association of alleles at two or more loci. Recent technological advances such as microarrays and chips have made it possible to quickly and inexpensively scan a million SNPs genome-wide. The reasoning behind the GWAS approach is that if specific allele variants are found more frequently in patients than in their controls, then the allele variants may be indicative of a genetic association. To minimize the risk of Type I errors , most GWAS operate with a stringent threshold of significance (p < 5 × 10−8). Since 2007, schizophrenia GWAS have been published (for details see http://www.genome.gov/gwastudies). Overall, the studies have failed to support the findings from linkage and candidate gene studies, but the GWAS have instead identified a large number of new susceptibility loci of only very small individual effects—and many of these genomic loci have in fact been replicated in subsequent GWAS and have reached meta-analytic genome-wide significance , which also often employ a case-control study design, interrogate the genome purely empirically , and these alleles were moreover found to affect the expression of C4A and C4B in the brain and to be associated with schizophrenia in proportion to their effect on C4A expression. Finally, it merits attention that several GWAS have found shared genetic risk loci in schizophrenia and bipolar disorder  locus on chromosome 6 (25–34 Mb), implicating the MHC locus as strongest of the >100 loci of genome-wide significance . As we have seen, large-scale GWAS have identified more than 100 risk loci.However, it merits attention that a seminal study  or inherited CNVs, i.e., structural genomic variants that consist primarily of duplication or deletion, confer high risk for schizophrenia. CNVs range in size from one kilobase (kb) to several megabase (Mb) pairs. Several studies have found elevated levels of rare CNVs in patients with schizophrenia compared to controls  and N-methyl-D-aspartate receptor (NMDAR) postsynaptic protein complexes, which previously have been linked to schizophrenia in CNV studies  of the genome (the exome), has enabled scans of genes for mutations at single-base resolution, which previously could not be detected, i.e., SNVs and indels. The rationale behind exome sequencing is that variations in these sequences are likely to entail more severe consequences than variations in the remaining 99% of the genome. Several studies have now used exome sequencing to explore SNVs and indels in schizophrenia. Some studies have reported a slightly increased exome-wide level of rare and/or In sum, pre-molecular and molecular genetics have demonstrated beyond doubt that genetics constitute a strong risk factor for schizophrenia. In contrast to the initial monogenic and oligogenic models of genetic transmission, there is now compelling evidence that the genetic architecture of schizophrenia is very complex, heterogeneous, and polygenic—the disease risk is constituted by numerous common genetic variants of only very small individual effects  and by uncommon, highly penetrant genetic variants of larger effect .As any research question, pre-molecular and molecular genetic studies in schizophrenia are based on certain assumptions and confront various limitations and challenges that must be made explicit if we are to properly appreciate the empirical findings. In the following, we discuss what we believe are six of the most important ones.vide supra), it is, in fact, not unproblematic. In order to take the higher concordance rates in MZ than in DZ twins as evidence for a genetic component, some fairly unlikely assumptions are required, e.g., we must statistically hold the environment constant, i.e., we must assume that the environments experienced by MZ and DZ twins do not differ in any way that may be relevant for the development of schizophrenia; and we must assume that genes and environment are both mutually independent and jointly additive (inclusive) for the development of schizophrenia. The problem with the classical twin design is that many, if not most, behavioral traits seem to act quite similarly, i.e., definitely heritable with some variance ascribable to the non-shared environment and little to the shared environment. Notably, these remarks do not undermine the identified concordance rates for schizophrenia in MZ and DZ twins, but they do put into perspective the problem of making inferences and estimations of the size of the genetic component in schizophrenia on the basis of the classical twin design. Although the classical twin design does not play a major role in genetic studies today, estimates of the genetic contribution to schizophrenia, based on previous twin studies, are often stated as facts in many textbooks and research articles on schizophrenia, and therefore we believe it is still important to voice these concerns.First, the classical twin design remains controversial and its validity has regularly been called into question . While identifying shared genetic vulnerability is crucial in its own right, keying in on what is specific for schizophrenia presents an obvious target for contemporary and future molecular genetic research. One way of keying in on what is specific to schizophrenia is illustrated in a GWAS  can to some extent be seen as a return to and a systematic succession of a Bleulerian approach to psychopathology, i.e., the research focus is once more directed towards certain specific, non-psychotic, trait-like features of schizophrenia. However, where Bleuler’s  fundamenPre-molecular and molecular genetic studies have demonstrated that genetics form a strong risk factor for schizophrenia. Many findings from schizophrenia GWAS have been replicated and several of these findings have reached meta-analytic genome-wide significance. The robust associations between schizophrenia and the >100 susceptibility loci, the identified CNVs and SNVs, respectively, seem promising on a number of scores. Also, the importance of the thousands of common alleles of only a very small effect, which do not individually achieve significance but which collectively form a substantial polygenic component of schizophrenia risk, should not be underestimated. Hopefully, these results will pave the way to truly novel, actionable, therapeutic knowledge. However, we should not fail to also notice: (i) that associations between common (SNPs) or uncommon  genetic variants and schizophrenia, though statistical facts, are not necessarily indexes of causal pathways; and (ii) that many of the discovered associations are, in fact, non-specific to schizophrenia but indicative of a genetic vulnerability to several mental disorders. Overall, the details of the etiopathogenesis of schizophrenia and the genotype-environment interactions remain to large extent unknown, and therefore caution is still warranted when drawing conclusions about the size of the genetic contribution in the etiology of the disorder.MGH, JN and LBJ planned the study collectively. All authors contributed to the design, analyses and discussion. MGH wrote the first draft and all authors participated in critical revisions of the draft. All authors approved the final version and made agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.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.


The 1st POQI Consensus Conference occurred in Durham, NC, on March 4–5, 2016, and was supported by the American Society of Enhanced Recovery (ASER) and Evidence-Based Perioperative Medicine (EBPOM). The conference focused on enhanced recovery for colorectal surgery and discussed four topics—perioperative analgesia, perioperative fluid management, preventing nosocomial infection, and measurement and quality in enhanced recovery pathways. The population of patients undergoing elective surgery is expanding. It is estimated that worldwide, more than 230 million surgical procedures occur each year  for major surgery, which are standardized, evidence-based multidisciplinary care pathways to improve outcomes after major surgery  brings together multidisciplinary groups of experts from different backgrounds, specialties, and nations to review and debate the current evidence. The POQI strategy is to follow the rules of evidence-based medicine by first developing a critical analysis of the published evidence available for the issues relevant to the conference topic. The ultimate goal is to generate consensus statements that describe, classify, and interpret the available data and offer recommendations for patient care. In addition, each POQI group will aim to identify unanswered questions and areas of clinical and laboratory research that require priority attention.Perioperative analgesia—how can we best manage pain within an ERP for colorectal surgeryPerioperative fluid management—how can we best manage fluid within an ERP for colorectal surgeryPreventing nosocomial infection—how can we best prevent nosocomial infection within an ERP for colorectal surgeryMeasurement and quality—how can we measure the of quality of care within an ERP for colorectal surgeryThe 1st POQI Consensus Conference occurred in Durham, NC, on March 4–5, 2016, and was supported by the American Society of Enhanced Recovery (ASER) and Evidence-Based Perioperative Medicine (EBPOM). The conference focused on “enhanced recovery for colorectal surgery”. The four discussion topics chosen were as follows:The investigators in each work group are listed in The POQI conference process is inspired by and developed from the methodology used by the Acute Disease Quality Initiative. This has been described in detail previously (Kellum et al During the pre-conference phase, the POQI board and conference directors select topics that will benefit from the POQI process of detailed discussion and analysis of the evidence. The reasons to choose a topic are multifactorial but are broadly based on an apparent need for a consensus statement from a group of international experts to offer recommendations for patient care. Typically, three to four independent but related topics are discussed at each POQI conference.Work groups are then assembled to tackle each topic. The work group consists of a chair, co-chair, and several delegates. Delegates may or may not be an expert on the assigned topic, but all topics are presented to the group at large, and all delegates are able to contribute to the preparation of each manuscript during the POQI conference.The pre-conference work is key to a successful POQI conference. Each work group thoroughly reviews the literature, generates a bibliography of relevant studies, and identifies a list of key questions to be addressed in the final manuscript.Assesses the current of the state of knowledge and classifies the evidence according to evidence-based medicine principlesIdentifies areas of inadequate knowledge, unanswered questions, and prioritized areas of researchDescribes appropriate methodological strategies by which these issues could be addressed in the futureEach work group:In many cases, a workgroup ends the pre-conference activity with a draft manuscript.The POQI conference itself is an intensive 2-day interactive conference where delegates are encouraged to debate and question the key issues in each topic. The conference agenda is divided into plenary sessions, where the pre-conference and later conference findings and deliberations are presented, debated, and refined, and breakout sessions, where work groups address the issues in their assigned topic area. The Conference Directors’ role is to circulate among the breakout groups to direct discussion where appropriate and to facilitate and moderate the plenary sessions.During each plenary session, a different workgroup member presents the results of discussion during the breakout session to the entire group, revising each key statement until delegates agree on a final version. If agreement cannot be reached, this is documented in the manuscript.Post-conference, each workgroup finalizes a consensus statement on their topic for publication in a peer-reviewed journal. The conference directors, whose names are included as co-authors, must approve the workgroup manuscripts. The final manuscripts are circulated to all delegates for comment and revision before submission for publication. The manuscripts and key figures are made available on the POQI website, poqi.us.We believe the five manuscripts in this series will be a valuable addition to the literature and provide guidance as to the current state of the literature regarding ERPs for colorectal surgery. We have attempted to provide practical consensus statements and recommendations to guide practice where consensus exists and to identify areas of inadequate knowledge and unanswered questions.


Potential for adaptation is illustrated for major crops in West Africa through a selection of studies based on process-based crop models to adjust cropping systems  to future climate. Results of the cited studies are crop and region specific and no clear conclusions can be made regarding the most effective adaptation options. Further efforts are needed to improve modeling of the monsoon system and to better quantify the uncertainty in its changes under a warmer climate, in the response of the crops to such changes and in the potential for adaptation.West Africa is known to be particularly vulnerable to climate change due to high climate variability, high reliance on rain-fed agriculture, and limited economic and institutional capacity to respond to climate variability and change. In this context, better knowledge of how climate will change in West Africa and how such changes will impact crop productivity is crucial to inform policies that may counteract the adverse effects. This review paper provides a comprehensive overview of climate change impacts on agriculture in West Africa based on the recent scientific literature. West Africa is nowadays experiencing a rapid climate change, characterized by a widespread warming, a recovery of the monsoonal precipitation, and an increase in the occurrence of climate extremes. The observed climate tendencies are also projected to continue in the twenty-first century under moderate and high emission scenarios, although large uncertainties still affect simulations of the future West African climate, especially regarding the summer precipitation. However, despite diverging future projections of the monsoonal rainfall, which is essential for rain-fed agriculture, a robust evidence of yield loss in West Africa emerges. This yield loss is mainly driven by increased mean temperature while potential wetter or drier conditions as well as elevated CO Climate has a strong influence on agriculture, considered as the most weather-dependent of all human activities Hansen,  with impClimate change and its impact on food security are additional strains on the agriculture sector in Africa. The last Intergovernmental Panel on Climate Change IPCC,  highlighIn the context described above, better knowledge of how climate will change in West Africa and how such changes will impact crop productivity is crucial to inform policies that may counteract the adverse effects. Furthermore, the ability to identify the most suitable crop varieties and practices with the most robust characteristics for withstanding climate change, is crucial for formulating adaptation strategies in this region where farmers are already able to select adapted varieties  or to adapt their practices  to a changed environment , the review presented here does not claim to be exhaustive and certainly misses many studies. However, an effort has been done to present a selection of the most important results, with a special attention to the recent studies. Moreover, the extensive and coordinated discussion of the crop productivity problem and the related climate dynamics aspects represents the noticeable novelty of this review. Section Climate Change Scenarios of this review paper provides observed evidences of climate change in West Africa and gives some robust features about expected changes in the next decades. Section The Impact on Crop Yield and Potential for Adaptation investigates how such climate changes affect crop production as well as potential for adaptation for the major crops in West Africa. Each section attempts to stress the most robust results in the screened literature but, more importantly, includes a discussion about limitations and uncertainties. The reader is invited to read the cited papers for more details on any specific aspects discussed in this review.The West African climate is deeply tied to the West African monsoon (WAM) system, which develops in May over the Guinean coast (~5–10°N), reaches the maturity in August in the Sahel (~10–15°N), and finally retreats to the coast in October , launched in 2002 and involving a number of research institutions in the international scientific community, was the first large scale coordinated program aiming to improve the understanding of the WAM system and its influence on the physical, chemical and biological environment, regionally, and globally. The AMMA community is still active to provide the underpinning science to assess the impacts of WAM variability on health, water resources, food security and demography in the West African countries, and to define and implement monitoring and prediction strategies  standard experimental protocol for studying the output of coupled atmosphere-ocean GCMs, climate variability in West Africa is extensively studied, with promising but still unsatisfying results. Specifically, state-of-the-art climate models in both CMIP3 and CMIP5 exercises show low skill in simulating the observed WAM variability , and sizable uncertainties affect projections in the twenty-first century, ranging from dry to wet conditions in the Sahel , which is recognized as a key planning horizon in a socioeconomic perspective , a WCRP initiative for the assessment and comparison of RCM skills in diverse regions, CORDEX-Africa provides a set of state-of-the-art simulations and predictions for the West African climate at high resolution  contrast with dry anomalies over western Sahel (west of ~0°E), and these sub-regional trends are more robust than the trend simulated in the extended Sahelian belt  with the driving GCMs exist locally  and the southern Sahel by 50–90% (1–4 days), uniformly during boreal summer. The associated changes in extreme wet rainfall intensity show a regional response, including a 30–70% decrease over northern Niger and northeastern Mali, and a 10–25% increase over Senegal, southern Mali, Burkina Faso, northern Nigeria, and southern Chad  and other production constraints such as N limitations, these models require extensive input data on cultivar, management, and soil conditions as well as calibration and validation data that are often unavailable in Africa , there is a wide spread in current climate model projections of regional rainfall changes over West Africa, especially with respect to summertime rainfall totals Druyan,  which ar2 concentration), in the coupling between climate models and crop productivity functions, and in the adaptation of agricultural systems to progressive climate change  but also that the lack of sufficient data for accurate calibration and validation  while in the Eastern part of West Africa in Burkina Faso, where four of the five GCMs simulate wetter conditions, the results show a slight decrease (−3.9 ± 4.3%). This dipole was also found in the study of Adiku et al. (Using simulations of nine bias-corrected CMIP5 climate models and two crop models (SARRA-H and APSIM), Sultan et al.  found a f Deryng  which usu et al.  which us2 concentrations directly contributes to climate change, it has the potential to increase crop water productivity by enhancing photosynthesis and reducing leaf-level transpiration of plants  which are likely to accumulate more biomass and for C4 crops in arid regions through increased water use efficiency  FAOSTAT, , data. IGroundnut is an important crop for Nigeria, southern Mali, Ivory Coast, Burkina Faso, Ghana, and Senegal. Parkes et al.  investigYam is the second most important crop in Africa in terms of production after cassava. Srivastava et al.  simulateUsing the EcoCrop model to investigate the response of important staple food crops for Africa including maize, millets, sorghum, banana, and beans to climate projections by 2030, Jarvis et al.  found thIn this paper, an extensive review of the recent literature on the West African climate and impacts is used to draw a general picture of the main features of the regional climate, the associated observed variability, the future change as well as expected impacts and potential for adaptation in the agriculture sector.2 direct forcing, inducing a thermodynamic feedback on the monsoon system  to future climate. Results of the cited studies are crop and region specific and no clear conclusions can be made regarding the most effective adaptation options.There are many complex processes that drive the response of crop yield to such climate changes. These processes can act in a competing way as we can expect from the role of increased atmospheric COAlthough substantial progress has been made in the assessment of the effect of climate change on crop yield and potential for adaptation in West Africa, large gaps still exist. Important processes like the effect of heat stress or ozone are missing in crop models (Ewert et al., As suggested by Challinor et al. , an objeAll authors listed have made substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Maternal health status before pregnancy is a decisive factor for pregnancy outcomes and for risk for maternal and infant complications. Still, maternity care does not start until the pregnancy is established and in most low-income settings not until more than half of the pregnancy has passed, which often is too late to impact outcomes. In Western societies preconception care (PCC) is widely recognized as a way to optimize women’s health through biomedical and behavioural changes prior to conception with the aim of improving pregnancy outcomes. But the content of PCC is inconsistent and limited to single interventions or preconception counselling to women with chronic illnesses. It has been suggested that PCC should be extended to preconception health and care (PHC), including interventions prior to pregnancy in order to optimize women’s health in general, and thereby subsequent pregnancy outcomes, the well-being of the family, and the health of the future child. With this definition, almost every activity that can improve the health of girls and women can be included in the concept. In the World Health Report of 2005 a longitudinal approach to women’s wellness and reproductive health was highlighted, and the World Health Organization has proposed a more comprehensive maternal and child health care, also including psychosocial issues and intimate partner violence. The present article gives an overview of the recent literature and discusses contents and delivery of PCC/PHC in Western as well as low-income countries. The article puts special emphasis on why violence against women is an issue for PHC. At the beginning of the new millennium, world leaders gathered at the United Nations to shape a broad vision to fight poverty in its many dimensions, resulting in the eight Millennium Development Goals (MDGs). The stipulated time for realizing the goals expired at the end of 2015. Preliminary results show that the framework has in many ways been successful in focusing on crucial issues for a positive development of global health and welfare. Child mortality for under-five-year-olds was reduced from 90 to 43 deaths for every 100,000 children (MDG 4). Maternal mortality rate has declined by 45% globally. More women have got access to reproductive care, and the use of contraception has increased among married or co-habiting women (MDG 5). However, reproductive health risks are still unacceptably high in many countries, and reproductive health and rights remain one of the most important issues for future development  is widely used for activities intended to address and prevent specific problems related to pregnancy. Preconception health and care (PHC), on the other hand, can be defined as the provision of biomedical and behavioural interventions prior to pregnancy in order to optimize women’s wellness and subsequent pregnancy outcomes with the aim to improve not only foetal, infant, and maternal health, but also the health of the whole family and the future well-being of the offspring. Hence PHC includes medical as well as educational and psychosocial issues. With this broad definition, almost every activity that can improve the health of girls and young women can be included in the concept. The present article gives an overview of the recent literature and important issues in the contents and delivery of health care prior to pregnancy in Western as well as low-income countries. The article puts special emphasis on intimate partner violence (IPV) and why violence against women is an issue for PHC.In Western societies PCC is widely recognized as a way to optimize women’s health and improving pregnancy outcomes. But although there is a growing body of evidence supporting that very early pregnancy is a critical period for both maternal and foetal health, preconception care is inconsistent, and PCC is mostly limited to single interventions or preconception information and counselling to women with chronic illnesses such as diabetes even in countries with comprehensive health care systems . Such prIn order to address the lack of consensus regarding the content and the delivery of PCC in the Netherlands, the health authorities organized an expert meeting. The consensus meeting resulted in the following definition:A set of interventions and/or programmes that aims to identify and enable informed decision-making to modify biomedical, behavioural, and (psycho-) social risks to parental health and the health of their future child, through counselling, prevention and management, emphasizing those factors that must be acted on before conception and in early pregnancy, to have maximal impact and/or choice . This deMake Every Woman and Child Count (from 2005), the longitudinal approach to women’s wellness and reproductive health was highlighted, and the World Health Organization (WHO) has in many of its programme recommendations proposed a continuum of maternal and child health, and called for a reformulation of interventions from vertical programmes to those offering a wider range of services  against women, and sexual violence victimization from non-partners. In total 77 studies from 56 countries representing nearly 350,000 women, 15 years or older, were included in the review . The domIn a prevalence study among the 28 member states in the European Union 22% of European women had been subjected to physical and/or sexual violence by a partner after the age of 15. Eleven per cent had experienced sexual violence, and 5% had been raped after the age of 15. In addition, 6% had experienced attempted rape . CompariSeveral prevalence studies have also considered the possible consequences for health of violence victimization. A number of important health problems have been identified among victims of IPV. The WHO systematic review of reproductive health found that victimized women were 16% more likely to have a low-birth-weight baby, more than twice as likely to have an abortion, and, in some regions, 1.5 times more likely to acquire HIV. Depression was twice as common among victims, as compared to women who had not experienced partner violence . RecentlAnother aspect of IPV is the possible impact on women’s control of their reproduction. In a systematic review concerning interactions between IPV and use of contraception, the authors found several IPV-related factors that influence women’s abilities to protect themselves against unplanned pregnancies. Violence victimization may eliminate the use of contraceptives, earlier experiences of violence associated with a request for contraceptives may discourage any new attempts or simply the fear of violence could hinder women from requesting the use of contraceptives. Relationship imbalances might also impact on the victim’s self-efficacy, resulting in the belief that she is unable to make any autonomous decisions. The reviewed studies reported that a considerable number of women experience reproductive coercion, either in the form of birth control sabotage or pregnancy coercion. Loss of reproductive control should also take forced abortions into consideration, but here research is very limited. The authors suggest that health personnel, especially within family planning, should include questions about IPV and reproductive coercion in their consultations .Unintended pregnancy was recently addressed in a European multi-country cross-sectional study among women in antenatal care. Approximately one-fifth of all women reported their current pregnancy to be unintended. Among women reporting any lifetime abuse, the prevalence of an unintended pregnancy was 25%, and among women reporting recent abuse 39%. Women with a history of any lifetime abuse had significantly higher odds of unintended pregnancy, also after adjusting for confounding factors, with an odds ratio of 1.41 (95% CI 1.23–1.60) for any lifetime abuse and 2.03 (95% CI 1.54–2.68) for recent abuse . The preHealth care has a major role in identifying women subjected to violence. Most women find it acceptable or appropriate to be asked ,16,17. TIn Western societies we often believe that the only way to avoid recurrent partner violence is to end the relationship, which tends to be complicated and sometimes dangerous. In many places in the world this is even more difficult for cultural reasons. Many researchers have suggested that promoting issues of gender equality could be a way of preventing or reducing IPV. There are encouraging examples within programmes for fighting HIV-AIDS ,21.PHC directed towards young people should focus on lifestyle and safe sex issues such as contraception, prevention of sexually transmitted infections (STIs), and gender issues including gender-based violence and human rights. That combining education with provision of contraceptives could be effective in reducing unintended pregnancies among adolescents is supported by a Cochrane review .Raising awareness of the hazards of unprotected sex increases the motivation for preventive measures. A model for education about human papilloma virus (HPV) and its association with cervical cancer has been tried in a randomized controlled trial in Swedish school health care. The intervention was based on the Health Belief Model with 30-minute structured information face-to-face about the risk for disease and means of prevention. At follow-up three months later, awareness of the risks had increased significantly in the intervention group. The intervention also had a favourable effect on the views on prevention of HPV infection, and significantly more young women in the intervention group chose to get vaccinated against HPV .Reproductive Life Plan (RPL) is a tool for information and education about reproductive issues. It has been developed to help women to set realistic goals for their reproduction. RPL provides structured ways of discussing matters such as the impact of age on fertility and how to preserve fertility until pregnancy is wanted . RPL hasInternationally, some examples of premarital counselling have been initiated and sanctioned by national authorities. In China, premarital counselling was mandatory until 2003 and focused especially on genetic counselling and family planning to strengthen the one-child strategy . In IranIn order to create the best possible health status for all women of reproductive age, health care providers must be aware of the significance of the condition they are treating in case the woman becomes pregnant. Chronic diseases often require medication that may have to be changed before or during pregnancy, and the woman must be well informed of this.Fragmentation of health care is a problem for many patient groups, but especially when interventions that need the participation of several professionals or a change in life perspective. In many countries the main part of reproductive health care is performed by physicians without contact with the primary level of care. Different aspects of reproductive health are also given as vertical programmes by different caregivers. For instance, family planning services are often separated from STI services. The goal of contraception counselling should, however, not exclusively be to prevent unwanted pregnancy, but also to guard fertility until pregnancy is desired. Therefore, there are many advantages with integrating the two. Information and education about safe sex can naturally be included in testing for STI, as well as in counselling about contraception. Abortion counselling and services could also be integrated into the family planning services ,31. PlanIn most settings worldwide, facilities already exist for antenatal care and well-baby care and could be extended. It would, however, require some reorientation of staff and that primary health care would assume a central position within the system and the community . Nurse-mOne of the many concerns when considering strategies for the implementation of PHC is the resistance from religious, cultural, traditional, and conservative groups in many societies, where even reproductive health care or health information to young and unmarried persons is seen as threatening moral and family values. This applies especially to information about family planning but can also include issues related to pregnancy in general. There are examples that activities have been renamed in respect for religion and traditions, for instance using the term menstrual regulation instead of termination of pregnancy.Sweden has had a favourable development of antenatal care and reproductive health care for women, resulting in extremely low maternal and perinatal mortality and easily accessible services for family planning and counselling about STIs.Ever since midwifery was recognized as a medical profession and mandatory training was established in the seventeenth century, Swedish midwives have been responsible for normal deliveries. In the 1930s when antenatal care was organized it became a task for the midwives outside the delivery wards. Social aspects were considered important in Swedish antenatal care from the start. The midwives were to make home visits to give advice on hygiene, nutrition, and infant care and to check that the family was prepared for the arrival of the new baby. Later psychosocial support for both parents was emphasized, and classes were held to prepare for parenthood. Screening for cervical dysplasia to prevent cervical cancer was implemented in the 1960s, and the testing procedure was added to the responsibility of the midwives, as well as testing for sexually transmitted infections.When the law regulating abortion was liberalized in 1975, the subsequent demands for easily accessible contraception counselling led to the inclusion of family planning in the training of the midwives. They were allowed to administer intrauterine devices for contraception, IUDs and prescribe oral contraceptives and became skilled and appreciated advisors. Education about health issues, such as the risks of smoking and using alcohol during pregnancy, and advice about suitable nutrition and exercise to avoid overweight and diabetes were eventually included in antenatal care. In addition, information about lifestyle factors became a part of contraceptive counselling. Youth clinics were organized in the 1970s and are run by midwives. To support the midwives in complicated cases concerning contraception counselling, pregnancy surveillance, or STIs a supervising physician was appointed, often a specialist in obstetrics and gynaecology at the regional hospital.The goal of this comprehensive model is to strengthen normality in reproductive processes and to empower patients to make informed choices about their sexual and reproductive health. Midwives as counsellors have become very much appreciated, and the vast majority of women in Sweden choose to go to the midwife for reproductive services. One of the strengths of the Swedish system is the excellent continuity. Patients often meet the same staff for issues of safe sex and family planning, pregnancy, STI, and prevention of cervical cancer. Another strength with the Swedish system is that the services are easily accessible and free of charge.PCC has mainly been thought of as counselling before or in early pregnancy to improve maternal and infant health. It has often been limited to single interventions or preconception information and counselling to women with chronic illnesses such as diabetes, or focused on lifestyle changes such as cessation of smoking and drinking alcohol, or supplementation with folic acid. Recently it has been suggested that the perspective should be widened to the well-being of the whole family and the offspring, using the concept PHC instead.PHC covers all reproductive life. Early preconception counselling should aim to achieve the best possible sexual and reproductive health for both for women and men. It should start early with education about healthy lifestyle habits, safe sex, and pregnancy planning. In the preconception period, when pregnancy is being planned, general as well as specific information adjusted to the prerequisites of the individual couple is needed. During pregnancy health education should be given to both parents-to-be, in combination with support to enhance the transition to parenthood. Between pregnancies, PHC aims to restore the nutritional and health status of the mother and the nutrition of the infant and raise the issue of spacing of pregnancies. PHC should be delivered in a comprehensive model and by staff skilled in sexual and reproductive health. PHC should also be free of charge. It is important that gender equality is addressed in the dialogue with both women and men, and that intimate partner violence is recognized as a possible factor in addition to ill health and non-compliance with health advice. To achieve good continuity, we suggest an organization similar to the Swedish model with nurse-midwives as the primary deliverers of care.


Subjects with Alzheimer's disease (AD) show loss of cognitive functions and change in behavioral and functional state affecting the quality of their daily life and that of their families and caregivers. A neuropsychological assessment plays a crucial role in detecting such changes from normal conditions. However, despite the existence of clinical measures that are used to classify and diagnose AD, a large amount of subjectivity continues to exist. Our aim was to assess the potential of machine learning in quantifying this process and optimizing or even reducing the amount of neuropsychological tests used to classify AD patients, also at an early stage of impairment. We investigated the role of twelve state-of-the-art neuropsychological tests in the automatic classification of subjects with none, mild, or severe impairment as measured by the clinical dementia rating (CDR). Data were obtained from the ADNI database. In the groups of measures used as features, we included measures of both cognitive domains and subdomains. Our findings show that some tests are more frequently best predictors for the automatic classification, namely, LM, ADAS-Cog, AVLT, and FAQ, with a major role of the ADAS-Cog measures of delayed and immediate memory and the FAQ measure of financial competency. Dementia is a clinical syndrome which affected more than 35 million people worldwide in 2010, with new estimates of 48.1 million people for 2020 and numbers expected to almost double every 20 years ).Our work explored the contribution of cognitive, behavioral, and functional measures in the automatic classification of different stages of cognitive impairment using ML. Both total and partial scores as measures of cognitive domains and subdomains from a group of different neuropsychological tests available from the ADNI database were considered as potential predictors of cognitive impairment, even at an early stage.Our results showed that, among 131 measures considered, it is possible to use a subset of measures in which the classification accuracy is higher than 90% for severe (CDR = 1) versus no impairment (CDR = 0) and higher than 85% for mild (CDR = 0.5) versus no impairment (CDR = 0). Our performances for these two comparisons are similar to those obtained by Logie et al. . These f designed to handle high-dimensional data.From a methodological point of view, we used a lower number of features than the smallest number of subjects in each group (55 subjects with CDR = 1). This warrants that no curse-of-dimensionality problems occurred. In addition, the feature reduction strategies adopted in our study reduced the number of features used as inputs for the classifier to (at most) 10 (using the feature reduction guided by the neuropsychologists). This number is much lower than the number of subjects in the smallest group, thus avoiding overfitting problems, especially considering the use of SVMs, which areConcerning the final cognitive profile, when comparing the fully automated classification to the classification guided by the neuropsychologists, a good overlap of results between the two classifications was found. Some tests were found more frequently among best predictors for the automatic classification, namely, LM, ADAS-Cog, AVLT, and FAQ, with a major role of ADAS-Cog measures of delayed and immediate memory and the FAQ measure of financial competency.There are some measures known to be highly implicated in AD that this model fails to identify. There are some tests that are specifically recommended, that is, the Free and Cued Selective Reminding Test (FCSRT), which is considered as a valid clinical marker for AD . This teIn the field of neurodegenerative diseases, several other studies have applied ML for the identification of subsets of “optimal” classification predictors e.g., , 42), re, re42]),Promising results on similar approaches have been also published in the field of psychiatric disorders. An interesting study by Costafreda et al.  showed tOverall, the results of our work show that ML provides an effective technique to quantify the process to classify patients and to diagnose clinical disorders by using neuropsychological measures. Combined with multicenter databases that collect information from a substantial number of patients (as the ADNI database used in our work), ML was proven to be suitable to conduct statistically meaningful machine learning calculations and to assist clinicians in the optimization of the best measures (and submeasures) to be used, reducing at the same time the subjectivity of the process. For example, we have shown how ML can support the selection of important subscores for the classification of subjects. This could be useful in the optimization of current neuropsychological tests or in the design of new tests for next-generation cognitive assessment.Notably, cognitive measures found in our works cannot be considered sufficient to perform a neuropsychological classification of patients and we cannot conclude that they are the best predictors from a cognitive perspective, for many reasons. For computation reasons, we have adopted two different strategies to reduce the number of features as input to classification; both strategies have limited the measures used by the machine learning to select the optimal predictors. Furthermore, other measures not included in the considered studies could be behavioral data providing a thorough description of the disease . These measures could improve the model. In addition, our findings need to be verified in other independent databases and by using other machine learning algorithms, thus proving the generality of our results.In conclusion, ML approaches can be a useful tool for clinical neuropsychologists especially when they need to deal with a huge amount of data and the level of subjectivity of the process must be reduced. Given that a higher level of accuracy in classification still needs to be achieved and that some questions remain unanswered, further validations and verifications are needed in future research. However, we believe that this study represents a step towards achieving the goal of automatic classification of AD patients by means of clinical neuropsychological assessment.


The study findings reveal that both perceived social support and perceived religious endorsement are important antecedents of career commitment of Saudi nurses. However, private-sector nurses are found to exhibit a significantly higher level of career commitment compared to their public-sector counterparts. Nurses with greater educational attainment perceive higher level of social support and express greater career commitment than their less educated peers. These findings suggest that nursing as a profession should be more openly discussed in both secular and religious contexts, to ensure an adequate level of respect and compassion on behalf of the public. In particular, endorsement from the individual nurses’ social networks is vital in maintaining their wellbeing and career commitment. Given the religious influence in all aspects of life in the Saudi society, the current practice of gender-based segregation in Saudi hospitals and clinics seems to be meaningful for sustaining the career commitment of the nurses.The present study investigates the effect of perceived social support (PSS) and perceived religious endorsement (PRE) on career commitment (CC) of Saudi nurses. The investigation also extends to the moderating role of different demographic and organizational factors in the extent of PSS, and career commitment these nurses report. Data required for meeting these study objectives were collected from male and female Saudi nurses through a structured questionnaire. Multiple regressions using Partial Least Squares based Structural Equation Model, Smart-PLS version 3.0, and independent sample  While the shortage of nursing professionals is a worldwide phenomenon owing to the rapidly growing population, it is of particular concern in Saudi Arabia due to the adverse societal attitudes toward this profession. According to the World Health Organization , at 48.7Nursing is a relatively new profession to the Saudi society. Prior to 1960, healthcare in Saudi Arabia primarily relied on traditional forms of treatment and care. There were no nursing, or medical schools and Saudi people had not participated in the nursing profession  providedAl-Omar  examinedAs nursing is not traditionally a popular career choice in Saudi Arabia, the choice and quality of nursing education progressed over time. Initially, a one-year certificate course on nursing was offered, with the graduates employed as assistant nurses. Currently, nursing education takes place under the initiatives of three types of institutes, namely, health institutes, junior colleges, and universities. Health institutes and junior colleges offer three-year Diploma in Nursing, while the universities offer Bachelor of Science in Nursing (BSN) and Masters of Science in Nursing degrees. Nurses who graduate from health institutes and junior colleges and hold diplomas are classified as technical nurses and senior technical nurses, respectively. Nurses that hold a Bachelor of Nursing qualification are classified as specialists, while nurses that have completed a Masters of Nursing Science postgraduate degree are classified as senior specialists . Even thPerceived social support refers to an individual’s cognitive appraisal of support a person receives from his/her social network. The support may emerge in three forms: (a) emotional ; (b) informational ; and (c) instrumental  . AuthorsSince the nursing profession usually demands a high level of personal commitment, due to long working hours, direct contact with patients and their families, the need to deal with challenging cases and delicate people, and night shifts, it is usually viewed as both physically and mentally stressful and emotionally difficult job. In the context of Saudi Arabia, because of the poor image of the profession, along with social and religious stigma associated with nursing, the job is even more stressful than in other countries. Therefore, career commitment as well as the professional excellence of nurses in Saudi Arabia is likely to be largely dependent on the support they receive from their social networks, particularly their family and friends. “Whoever visits a patient or visits his fellow brother, an angel says: you are blessed and your steps are blessed and you have made an abode in paradise.”(Bukhari )    can be found in the Sunnah. Such narrations are mentioned below.The above narrations signify that looking after sick and distressed people is highly encouraged in Islam. Rufaidah bint Sa’ad, a woman from the Bani Aslam tribe in Medina who lived during the time of Prophet, is believed to be the first professional nurse in the history of Islam. Rufaidah learned the skill from her father, who was a physician by profession. In peacetime, she used to treat the patients in her camp just beside the mosque of the prophet. During times of war or conflict, she used to lead a team of volunteers to serve the injured soldiers . The exeCareer commitment can be viewed as one’s attitude toward one’s profession or vocation. It encompasses the dedication to work and career, setting personal career goals, and an identification with and involvement in those goals. In particular, it implies willingness and enthusiasm to work toward the chosen career Blau, 1985 ). Career85 . CareWhat is the effect of PSS and PRE on CC of Saudi nurses?What are the moderating effects of a few selected demographic and organizational factors  on the level of PSS and CC?Perceived social support and perceived religious endorsement as predictors of career commitment among nurses have not been explored in extant research. However, the role of social support in one’s ability to cope with stress has been investigated and was found to alleviate stress associated with emotionally sensitive diseases ,31, deprIn this cross-sectional quantitative study, the data was collected by surveying Saudi nurses working in different government and private hospitals/clinics located in major cities of Saudi Arabia. As 146 of the 300 questionnaires distributed through professional research assistants were returned and thus available for analysis, a response rate of 49% was achieved. While questionnaires for perceived social support and career commitment were adopted from Zimet, Dahlem, Zimet, and Farley  and Sakst-test were used to analyze the survey data using Smart-PLS version 3  and SPSS version 22.0 , respectively. For all three variables , respondents were asked to rate the items on the scale from strongly disagree (1) to strongly agree (5), indicating 3 as the midpoint. Therefore, the higher the score, the higher the level of measured variable assumed. In addition to scale questions, the questionnaire also included queries related to demographic and organization specific information. The questionnaire was initially prepared in English. However, for easy comprehension, each question was translated into Arabic by an expert before being reviewed by two other experts to confirm the accuracy of the translation. Both English and Arabic versions of the questions were presented side-by-side in the final questionnaire. Multiple regression and independent sample In the absence of any committee or review board in the University to consider and approve the ethical aspects of this research, the authors took the initiative to ensure that all ethical considerations were adhered to. To maintain transparency, each questionnaire was accompanied by a cover letter, where it was explicitly mentioned that the participation was voluntary and that all individual responses would remain anonymous and confidential. The authors, therefore, strictly maintained the anonymity of the respondents and confidentiality of the data in all stages of the research.To conduct multiple regressions, we analyzed the data via Partial Least Squares (PLS) path model, using the Smart PLS 3 software. Following the guidelines given by Hair et al. , the resThe results, as shown in With regard to composite reliabilities and Cronbach’s alpha, as all the constructs scored above 0.70 , the mea2 for the endogenous construct is 0.289, which is above the adequate level of 10% recommended by Falk and Miller [2 values that substantially exceed the recommended value of zero  bootstrap confidence intervals for the hypothetical paths, the bootstrapping procedure (performed on 5000 bootstrap samples with no sign changes) was applied and the results are presented in p-values of both path coefficients indicate significant positive relationships between perceived social support and career commitment, as well as between perceived religious endorsement and career commitment. These findings indicate that career commitment of Saudi nurses is significantly affected by both perceived social support and perceived religious endorsement. However, the path coefficients indicate a stronger effect of PSS than PRE on career commitment. To calculate the t-tests were performed in order to compare the mean scores of perceived social support and career commitment in relation to different demographic and organizational variables. As shown in Independent samples The goal of the present investigation was to explore the relationship that perceived social support and perceived religious endorsement have with career commitment of Saudi nurses. The findings revealed a strong positive impact of perceived social support and perceived religious endorsement on career commitment of the study participants. Given that nursing is not seen as a prestigious career in Saudi Arabia, and women are in general discouraged from working outside the home, the findings reported in this work support the widely held view that social support has a strong contribution to one’s ability to cope with job-related stress ,12. HighThe present study findings also revealed no significant differences in perceived social support and career commitment between male and female nurses. This is in line with the results reported by Morrow and Wirth , Lee, CaPrivate-sector nurses are found to have a significantly higher level of career commitment than their public-sector counterparts. While Mrayyan & Al-Faouri  reportedThis pioneering study examined perceived social support and religious endorsement as the antecedents of career commitment in the context of Saudi nursing profession. It has revealed that both social support and religion play a vital role in determining the career commitment among the studied sample. Therefore, in order to enhance professionalism in the nursing sector in Saudi Arabia, greater efforts should be invested in improving public awareness of the importance and value of nursing for the national health and wellbeing. Moreover, religious discussions should emphasize compassionate and altruistic aspects of nursing and should promote greater support from family and broader social networks. Finally, to increase career commitment among Saudi nurses, the government should provide them with a greater level of responsibility and empowerment, along with better financial rewards. This is a cross-sectional study where data were collected from a small non-probabilistic sample. Thus, the results should be studied with caution and cannot be generalized. As it is based on the self-administered survey, the study is susceptible to the limitations related to such a data collection method. To understand the cultural embeddedness of the Saudi nursing profession, more intensive studies are required to explore public attitude toward the profession and its connection to socio-cultural and religious factors. The present practice of gender-based segregation in Saudi hospitals and clinics also should be studied to investigate the view of Saudi nurses and other healthcare staffs as well as the general public and its relationship with the career commitment, job satisfaction, and other work-related variables of healthcare employees.