The aim of this study was to present challenges of implementing the accreditation model in university and military hospitals in Iran.In this qualitative study, purposive sampling was used to select hospital managers and implementers of the model working in 3 hospitals affiliated to Kerman University of Medical Sciences and in 3 military hospitals in Kerman, Iran. A total of 39 participants were interviewed, and semi-structured questionnaires and thematic analysis were used for data collection and analysis, respectively.In this study, 5 major codes and 17 subcodes were identified: (1) perspectives on accreditation model with 5 subcodes: a difficult and time-consuming model, less attention to the patient, accreditation as a way of money acquisition, not being cost-effective, and accreditation means incorrect documentation; (2) absence of appropriate executive policy, with 3 subcodes: lack of financial funds and personnel, disregarding local conditions in implementation and evaluation, and absence of the principle of unity of command; (3) training problems of the accreditation model, with 2 subcodes: absence of proper training and incoordination of training and evaluation; (4) human resources problems, with 3 subcodes: no profit for nonphysician personnel, heavy workload of the personnel, and physicians’ nonparticipation; (5) evaluation problems, with 4 subcodes: no precise and comprehensive evaluation, inconformity of authorities’ perspectives on evaluation, considerable change in evaluation criteria, and excessive reliance on certificates.This study provided useful data on the challenges of implementing hospitals’ accreditation, which can be used by health policymakers to revise and modify accreditation procedures in Iran and other countries with similar conditions. The accreditation model is comprehensive and has been implemented to improve the quality of services and patients’ safety. The basic philosophy of hospital accreditation did not fully comply with the underlying conditions of the hospitals. The hospital staff considered accreditation as the ultimate goal rather than a means for achieving quality of service. The Ministry of Health and Medical Education performed accreditation hastily for all Iranian hospitals, while the hospitals were not prepared and equipped to implement the accreditation model. Accreditation and continuous quality improvement is an inseparable part of health service activities. Health care accreditation programs started in the 1970s and accreditation organizations have been established and developed since then . Many coDevkaran et al. argued that there is little empirical evidence on the benefits of accreditation , while aIn Iran, the government is responsible for providing health care services to the public , which iThere has been a need to improve the quality of health services in Iranian hospitals. Some hospitals voluntarily used ISO and EFQM industrial models for evaluation. The growing recognition of credible hospital accreditation around the world, especially in EMRO countries such as Lebanon, has encouraged some Iranian hospitals to seek international accreditation programs. Given that the accreditation model has been developed specifically for the health sector, the MOHME decided to develop a national accreditation model for Iranian hospitals . Few couThe Control and Accreditation Office of the MOHME, in line with its main responsibility, which is to control health care services to ensure their quality and safety and to update scientific evidence-based feature, has substituted the evaluation of health care centers with accreditation model since 2007 . For hosThe first edition of the Iranian hospital accreditation standards was developed in 2010 in the form of 37 hospital wards and 8104 metrics, which was announced to hospitals across the country. Standards were more of structural and process type, and there were a limited number of output/outcome standards. Also, the evaluation team comprised 20 to 25 surveyors . In 2014Hospital Joint Measures in the form of enterprise-centric integrated guidance were expressed in the management and leadership unit. A number of similar standards were separated from the various sections and cited as common clinical and nonclinical standards . Then, tImplementation of the accreditation model, like any other model, has some challenges whose identification can help better implement the model, improve policymaking, and execute similar models in Iran as a developing country. Moreover, Iran’s experience in implementing the accreditation model can also be useful to other developing countries.Since only few studies have been conducted on accreditation implementation in university and military hospitals in Iran, this study aimed to present challenges of implementation of the accreditation model in these hospitals to the health system authorities and policymakers. In addition, this study was conducted in Kerman, which is the largest city of the largest province of Iran. In Kerman, hospitals are supervised by Kerman University of Medical Sciences, and there are 2 types of hospitals: academic and military. Academic hospitals are managed by medical sciences universities, and military hospitals provide health care services to military forces. Providing high quality services to military personnel in military hospitals is highly important , 16.In this qualitative case study, which was conducted in 2019, purposive sampling was used to select the participants. Those who had knowledge about hospital accreditation and those responsible for performing accreditation in hospitals were included in the study. There are 4 academic hospitals and 3 military hospitals in Kerman, which were included in this study, and those staff who met the inclusion criteria entered the study.Overall, 23 staff of military hospitals and 16 of academic hospitals, including hospitals’ heads, matrons, accreditation supervisors, all supervisors of clinical wards, and accreditation executive experts, were interviewed. Sampling was continued until data saturation, with 39 interviews. Of the interviewees, 20 were women and the rest were men. Also, 12, 10, and 17 interviewees held PhD/ MD, MSc, and BSc degrees, respectively. Moreover, the researcher did not have any relationship with the participants prior to study commencement.A meeting was held with members of the project team to formulate the research questions. A semi-structured questionnaire with open questions was used for data collection. The interview guide developed for this study is provided as Additional file One member of the research team conducted the interviews (N.O). Also, data were collected through 15–40 min face-to-face interviews, recorded by a tape recorder in hospitals. Only participants and the researcher were present at the time of the interview. During the interview memos were written.Data were analyzed using thematic analysis. First, each interview was typed at the earliest time possible after the interview by one member of the research team (N.O). Next, the typed text was repeatedly studied by 2 members of the research team , and subcodes were identified. Then, the subcodes were studied several times and the main codes were extracted and sorted. MAXQDA software version 10 was used for data analysis and coding. Then, the codes and subcodes were compared by 2 members of the research team  and differences were discussed in a meeting attended by all members of the research team and finalized.The validity and reliability of the data were determined using Lincoln and Guba’s criteria . The creThis study was approved by the Ethics Committee of Kerman University of Medical Sciences. Prior to conducting the interviews, the research team explained the aim and process of the study to the participants and obtained written informed consent from all of them.The results of this study were categorized into 5 major codes and 17 subcodes.This major code showed participants’ perspectives on the accreditation model. Overall, participants had a negative viewpoint about the hospital accreditation model and believed that this model added to workloads of hospital staff. The participants stated that the purpose of the accreditation model was to improve working conditions through process modifications, so that performing tasks according to defined standards would be the easiest way to perform their duties in the hospital; however, this aim was not achieved."Considering the heavy workload and lack of training, this model is unrealistic for our hospitals. We imported this model without receiving sufficient training and consideration, just like other technologies that had been imported." "For example, one of the documents we need to provide in the accreditation model is that doctors must provide full explanation to patients, write down the descriptions they have given to patients in a form, and stamp and sign it. However, in practice, doctors do not give patients complete and accurate explanations, and the forms are completed by the nurses, and the doctors only stamp and sign the form. Did the doctor provide a full explain to the patient? The answer is no. However, the document indicate the doctor provided a complete explanation to the patient." Although the model specifies the actions to be taken by physicians and they should fill out forms, interviewees noted that these tasks were done by other personnel, especially nurses; the forms were filled out by the nurses and eventually signed by physicians.This code addresses issues related to the evaluation process performed by the accreditation model evaluators."At evaluation time, the assessors just see the papers not the patient, so I spend a lot of time to complete these forms. The evaluator just sees documents and does not realize the amount of time and effort we put into all this. Why should I work so hard and honestly? I can just present a document." [cument." According to this subcode, one of the evaluation problems of this model is inattention to all aspects of performance, and this is another cause of incorrect documentation. Interviewees stated that evaluators only reviewed the documentation and did not evaluate the patients’ condition. Processes and actions in hospital accreditation forms that have been documented were not double-checked with patients to ensure their correctness and lack of fabrication. Therefore, hospital staff do not have the incentive to implement the model properly, and given the difficulties involved in implementing the model, they prefer to engage in incorrect documentation. In fact, the tracer methodology which traces the real services that patients receive, such as patient journey surveys, can be helpful in monitoring the effectiveness and efficiency of the model. However, this part has been neglected.“The most important problem related to authorities is evaluators’ disagreement. The members of the evaluation team did not have sufficient and similar information. They did not agree with each other, and there was a great difference in their perspectives.” [ctives.” This subcode refers to the difference of perspectives on evaluation and absence of a clear source for solving ambiguities concerning evaluation. Interviewees indicated that evaluation checklists were not transparent. The lack of transparency in the checklists led to personal preferences and disagreements among the evaluators.“Sudden changes of criteria 2 months before the evaluation was like a nightmare for us. There is no standard form. We should adopt ourselves to interpretations of our managers.” [nagers.” This subcode refers to changes of evaluation criteria during one period and causes a change in the whole process of accreditation implementation in hospitals. Interviewees mentioned that in the old version, standards were announced by the MOHME for 36 hospital wards and 2157 measures. Standards were more of a structural and process type. Then, 1 month before the evaluation, the new version was announced by the MOHME. Standards were announced in 8 scopes, 248 standards, and 903 measures. Common measures of hospital wards were integrated in the format of management and leadership unit. The combination of the measures also had an impact on the evaluation process. Related metrics were reviewed in all previous sections of the accreditation in the previous version and reviewed in the new version in limited wards of the hospital at the discretion of the evaluator. In addition to structural and process standards, a small number of outcome standards were added. Also, making changes in evaluation indices and measures in a short time before the evaluation was unpleasant for interviewees. Changing the process so close to evaluation time, although resulted in fewer standards, discouraged the staff.This subcode refers to the training courses that the staff must pass before starting the accreditation assessment and present the certificate at the time of the assessment. In fact, excessive emphasis of checklists on considering certificates with no attention to learning or actions taken in the field is a challenge in this model. Excessive reliance on certificates means to present certificates only to obtain a score with no change of behavior. Poor learning causes different problems, such as incorrect documentation in the implementation stage, as some of the evaluation checklist indicators include completing training courses by hospital staff.Evaluators only check the course certificate, and in reality no behavioral change occurs in the personnel as the result of the implementation of the model. However, the tracer methodology can be helpful in clarifying what happens in practice, not in theory, in hospitals.The first main identified code was the perspectives of interviewees about accreditation. This major code included the following 5 subcode: (1) a difficult and time-consuming model; (2) less attention to the patient; (3) accreditation as a way for money acquisition; (4) not being a cost-effective accreditation model; and (5) accreditation means incorrect documentation. Thus, it should be noted that the subcodes are based on the opinions of the interviewees, which can be due to the implementation problems of this model in Iran.These subcodes showed the negative perspectives of interviewees about the accreditation model. The subcode “the difficult and time-consuming model” indicates that accreditation has increased personnel’s responsibility and working pressure, while the approach of quality models, including accreditation, is to make things easier by modifying work processes . This fiBased on participants’ opinions, the model increases hospital costs, leads to no adequate outcome, and causes unnecessary documentation and bureaucracy, resulting in a decrease in the quality of services and misunderstanding of the model’s philosophy by the executors in hospitals. These findings are in contrast to those of a study by Jardali et al. in which nurses believed that accreditation is a good tool for improving the quality of hospital care  and alsoThe results showed that accreditation was identified as a way of money acquisition. The related trainings have caused a source of money acquisition for a group of trainers. Inappropriate provision of training by the MOHME causes hospitals to require additional training to perform accreditation. Trainers also demand large sums of money for training, making this model more difficult to implement, given the adverse budget situation in hospitals, especially in military hospitals.The interviewees’ negative attitude and hopelessness toward the quality improvement models may be due to ineffectiveness of previous similar models. Furthermore, Alkhenizan and Shaw systematically reviewed health staff attitudes toward accreditation and mentioned negative attitudes of health care professionals about accreditation . MoreoveThe second major code was absence of appropriate executive policy, with 3 subcodes: (1) lack of sufficient personnel and financial resources, (2) disregarding local conditions in implementation and evaluation, (3) and the absence of unity of command in hospitals.Military hospitals not only suffer from a lack of funds but also suffer from staff shortage. Therefore, the results indicated poor service quality and excessive workload. Numerous studies have indicated that the cost of implementing the accreditation model is high; this is while the validity of the accreditation model, given the costs involved, is in question –25. AlsoSince Iran is a vast country, disregarding the local conditions of each regional hospital is another challenge. The MOHME did not consider regional differences or the facilities, infrastructure, and contextual differences in the formulation of the Hospital Accreditation Plan. Pascale Pomey et al. study mentioned attention to environmental differences in hospitals as one of the success factors of the hospital accreditation model . NewhousThe third identified major code was training problems of the accreditation model, with 2 subcodes: (1) absence of proper training and (2) incoordination of training and evaluation. Adequate and complete training is the administrative requirement of each quality improvement system . Soh et The other identified code was the problem of human resource, with 3 subcodes: 1) no profit for nonphysician personnel, (2) heavy workload of the personnel, and (3) physicians’ nonparticipation. The accreditation model requires an extended documentation, which increases the workload of the hospital staff and may cause poorer performance. Brubak mentioned that increasing the workload of the personnel in implementing the model was a challenge in his study  no profi.The accreditation model requires participation of all hospital staff, particularly physicians; however, physicians do not cooperate with its implementation. Baskind et al. found that the accreditation model increased the quality of services and regarded physicians’ cooperation as a significant factor in this success . AlkheniNo precise evaluation indicates that evaluators only pay attention to documents without paying attention to the reality of work content in the field that leads to incorrect documentation. Bukonda et al. considered incorrect documentation a sign of accreditation model failure in Zambia . Shaw etAccording to the present study, due to absence of a clear common source for evaluation and evaluators’ different interpretations of indices, there were different perspectives on evaluation, which caused confusion. According to Shaw, a clear homogenous evaluation plays a crucial role in the model success . ChangesFailure to interview the patients as the target group of the accreditation model was a limitation of this study. Thus, interviewing patients could have fulfilled the challenges of implementing the accreditation model.This study provided useful data on the challenges of implementing the accreditation model in hospitals. The findings of this study can be used by health policymakers to revise and modify the accreditation procedures in Iran and other countries with similar conditions.The accreditation model is comprehensive and has been implemented with the aim of improving the quality of services and patient safety. The basic philosophy of hospital accreditation did not fully comply with the underlying conditions of the hospitals. The hospital staff considered accreditation as the ultimate goal rather than a means for achieving quality of service. The MOHME performed accreditation hastily for all Iranian hospitals, while the hospitals were not prepared and equipped to implement accreditation. Also, military hospitals need more attention from the MOHME. Thus, the MOHME should consider these contextual conditions before developing quality models for Iranian hospitals.Additional file 1. Interview Guide.


Formaldehyde made spoiled milk taste tolerable. Ground coffee was more than likely ground chicory. The yellow coating of children’s candies often contained arsenic. Ketchup was a soup of “waste products from canners, like coal-tar colors or starch paste.” Thus was the status of the foods the US public ate during the late 1800s. In The Poison Squad, author Deborah Blum tells the story of Harvey Washington Wiley and his dogged pursuit of government regulation for food safety and purity at the turn from the 19th to the 20th century .She first details the food industry before his work, when dangerous chemicals were used without regulation to cut, mimic, or enhance the flavor of foods with little regard for effects on human health. She then describes the initial failed attempts of food safety advocates and their efforts to focus the attention of the general public and then the US Congress on food safety. Passage of the Pure Food and Drug Act of 1906 was only the first part of Wiley’s story. Appropriately, the first section of The Poison Squad ends there.In the second half, Blum deftly walks through the varied and complex difficulties Wiley faced in enforcing the laws mandated by the act. These difficulties included a hesitant and sometimes antagonistic boss, co-workers pitted against him, the various priorities of multiple presidents, and large and powerful food and chemical companies looking to work around the law. However, as Blum so keenly explains, Wiley was not alone in his quest. He had loyal supporters inside his own Bureau of Chemistry at the US Department of Agriculture, of course. But more important, he made allies along the way, such as Alice Lakey of the National Consumers League; colleagues at the American Medical Association; and even H.J. Heinz, founder of the food company that still bears his name. Blum does a wonderful job describing the value of these supporters to Wiley as he struggled for food purity and public health.With intriguing anecdotes, vivid quotations, and expert attention to detail, Blum guides readers through the tedious process of moving an idea into legislation, applied regulation, and finally enforcement, and she does so with a storyteller’s touch. This captivating book relates the importance and practical impacts of Wiley’s endeavors to the life of an ordinary citizen of the time. It is equal parts informative and entertaining.https://www.pbs.org/wgbh/americanexperience/films/poison-squad).Blum’s optimistic book demonstrates that, with hard work and determination, laws can be passed to protect public health, even when opposition is fierce. It also shows that forming and nurturing partnerships with citizen groups, academic institutions, and industry leaders is key to these endeavors. Although the book does an excellent job describing Wiley’s contributions, it only briefly addresses some of the ethical issues regarding his actual “Poison Squad” studies, or the flaws in their study design. This book will educate and inspire readers who have worked in public health for decades and those who are just entering the field. It will also inform persons who work toward other public service endeavors and entertain those who simply like a good story. A Public Broadcasting Service special that closely follows this book is also available (


The dataset was collected using the survey method with an electronic questionnaire. The use of electronic questionnaires is intended to reach many respondents during the physical distancing caused by the COVID-19 global pandemic. The instrument used in data collection was adapted from Alinovi, Mane, and Romano (2008). The instrument was designed anonymously to ensure the privacy and independence of respondents in giving their responses. Data that is captured includes several categories either nominal, ordinal, or interval refers to the information that needs to be captured. Determination of the type of data also refers to the recommendation of previous research. The data was collected using the Google form platform. Questionnaire distribution was conducted on April 12–20, 2020, and 1096 responses were collected. The date is two weeks after the government call of the Republic of Indonesia to carry out Physical Distancing to anticipate the COVID-19 Global Pandemic. The entire data is then screened and filtered so that it only leaves the data with respondents who are domiciled in Medan City. After filtered, there is remained 846 data that is ready for analysis. In order to make more informative data, researchers conducted a descriptive statistical analysis, ANOVA, Kruskal Wallis, and the Spearman's rank correlation. Analysis of the data provides valuable information related to the interrelation of each item and the pattern of economic resilience that the urban city community has as a data of the COVID-19 global pandemic. Researchers can then further analyzed the data with more advanced analytical tools to produce more valuable information in the development of science and in developing strategic policies related to anticipating the economic vulnerability of the household due to the global pandemic disaster. Specifications table•This data is useful for observing patterns of household economic resilience in the face of a global pandemic, which in this case is COVID-19. In the future this pattern will be useful in anticipating pandemics that may occur with certain social engineering so that household economic stability can be maintained.•This data will be useful for policymakers in determining economic risk control strategies that can attack households when implementing physical distancing in the face of any disaster, especially the COVID-19 global pandemic. On the other hand, other researchers can also use this data to develop knowledge and recommendation for more valuable strategies of mitigation.•This data can be further analysed using more sophisticated statistical tools to investigate important variables that determine the economic resilience during Physical Distancing or the differences in responses from various sample groups, such as logistic regression, multinomial regression, and structural equational modelling (SEM). The data was possible for wide range data analysis because it has a vary data characteristics, like nominal, ordinal, and interval, also has a suitable sample size.•The data presented respondents' perceptions regarding their wellbeing. It is indeed respondents' subjective wellbeing, but it represents the definition of their economic resilience, which is in line with the positivism paradigm. Therefore, it will more suitable for developing public-oriented regulation.•Further analysis of this data will be useful in generating social engineering that has the opportunity to control the economic vulnerability of the household.1Data analysis that has been done is descriptive statistics, ANOVA, Kruskal Wallis, and Spearman's Rank correlation ,2. DescrBased on the data presented in p-values <0.05. Analysis of this data was carried out with ANOVA and Kruskal Wallis Furthermore, 2The data is collected from the household of Medan. Medan is the capital city of North Sumatra. The researchers choose Medan because of Medan is the 3rd largest city in Indonesia and have contributed to a 3% COVID-19 case in Indonesia. Despite only give a 3% contribution, Medan still has moderate risk in facing COVID-19 because its geographical position was accessible both nationally and internationally. Therefore, The Mayor of Medan and Governor of North Sumatra decide Medan to do Physical Distancing and closes the school, mosque, public area, and tourism area following the President of Indonesia Instruction. In turn, the decision brought the economic risk among household in Medan. Beside, Medan was appropriate to be an indicator of regulation in facing it a financial threat for the region outside Java island. Java is the island of the capital city which the spreadable of COVID-19 higher than non-java while in facing the physical distancing every region facing similar economic risk. So that, the impact of COVID-19 global pandemic on economic regulation should be different between java cities/districts and non-java cities/districts.This data proposed the household perception regarding their economic resilience in facing the government instructions to carry out Physical Distancing to anticipate COVID-19 Global Pandemic. Data were collected two weeks after the instructions were first announced using a convenience sampling technique. This is intended to get an actual response after the respondent feels the impact of the application of physical distancing regarding their economic resilience. The unit of analysis is the household. So, the data describe economic resilience at the household level. The dataset was collected by a survey method with an electronic questionnaire. The use of electronic questionnaires is intended to reach a broad range of respondents during the physical distancing caused by the global COVID-19 pandemic. The uses of an electronic questionnaire may risk to the bias of responses. However, the behavioral research method has stated the possibility of using electronic questioner in order to face several conditions related to time, space, access, and financial limitation The instrument used in data collection was adapted from Alinovi, Mane, and Romano (2008) None.


However, given the weak routine immunization structures in the African Region, coverage is enhanced with supplemental immunization activities (SIAs), and mop-up immunizations. Unfortunately, anecdotal information show that vaccination teams sometimes omit some catchments areas without immunization. This paper thus describes the use of The study was based on review of call records during polio supplemental immunization campaigns in Bol Districts in Chad from February to May 2018. The immunization coverage resulting from these campaigns was compared with that of February 2018. A compilation of data – details on communities, community leaders, and their phone numbers was performed. On the eve of the campaign, community leaders were alerted on the vaccinators’ visitThe community leaders were called on the eve of the campaign to alert them on the visit of the vaccinators. At the end of each day, activities (visits as well) were reviewed at the coordination centres Vaccinators were asked to return to any community where community leaders did not confirm visits).Telephone calls allowed the verification and confirmation of the vaccinators visits in 92% of cases. Villages where vaccination was planned but which were not reached were revisited. More than 1,011 children were caught up through this approach in 10 villages in the Bol district.In conclusion, call centers played significantly higher role in generating covering more children with immunization during immunization campaign. Cases of poliovirus Response to Polio Virus Disease Outbreaks in the Horn of Africa and Lake Chad Basin type 1 (WPV1), declined by almost fourteen-fold (59 to 4) between 2013 and 20163. The Region was course of chalking two years with no case of wild poliovirus since the last case reported on 24th July 2014 in Nigeria, until four new cases were reported in the same area in Borno state, between July and August 2016.The recent successes in polio eradication globally and in the World Health Organization, African Region, are evident. Cases of wild poliovirus (WPV) types 2 and 3 (WPV2 and WPV3) were last reported in 1999 and 2012 respectively7.This new outbreak, once again, returned the countries in the Lake Chad sub-region, including Chad, in a list of countries at risk for poliovirus transmission. The necessary response saw the declaration of this outbreak to be a regional public health emergency and is implementing a regional outbreak response, coordinated with neighbouring countries. The four key strategies of the Global Polio Eradication Initiative (GPEI) namely, high coverage with routine oral polio vaccine in immunization schedules, surveillance for acute flaccid paralysis, supplemental immunization activities (SIAs), and mop-up immunizations, were activated in responding to the Nigerian outbreak within the lake Chad sub-region, including the Republic of Chad. The sub region, and indeed Chad remained at risk for wild poliovirus (WPV) because of several factors mainly attributable to poor quality and immunization coverageThe Lake District has two major challenges, namely, supplying vaccines to the island sub-districts, and reaching out to the remote villages with power difficult access, characterized by a lack of qualified human resources, during the routine immunizations programmes and even during the Supplementary Immunizations Activities “SIA”. In Lake Chad Basin’s Contingency Plan for Polio Response, planning established specific strategies to improve immunization activities in Island areas. These particularly focused on market places, the nomads, refugees and IDPs, where children 0-10 years were found with low immunity, including a significant number of zerodose or never-vaccinated children and partially or totally uncovered villages during the routine immunization, intensive vaccination activities (IVA) and supplementary immunization activities (SIAs).During our first interventions in the Bol Islands, it was observed that vaccination was only conducted in routine and static approaches. In addition, advanced immunization strategies were almost non-existent. Approximately 90% of children vaccinated in our first intervention had never received any other vaccine including that against Polio. Villages were found where all children aged 0-5 years had never been vaccinated.To tackle this major challenge, the district task force, the WHO support team / Task Team and UNICEF’s Bol district-based team put in place an experimental strategy during the April 2018 Polio SIA. This strategy consisted on informing all island villages leaders, the camp and Canton ferrick’s in Bol district, on a regular and systematic basis, to ensure that they were informed (on the eve) of vaccinators visits and their subsequent confirmation or denial on the actual visits at the end of the day. This activity of tracking the vaccinators movements through the local and traditional leaders was called “Call center”.8. Community members and health facilities report deaths and suspected Ebola cases to local alert numbers operated by prefecture health departments or to a national toll-free call center. The national call center additionally functions as a source of public health information by providing answers to the public on Ebola8.Such passive surveillance strategy has been used for Ebola in Guinea, principally with a telephone alert systemThis innovative strategy, which was piloted in the Banangorea area of responsibility during the April SIA, proved to be effective. For the first time the district executive team was able to achieve a daily assessment of the coverage of the villages, nomadic ferricks and camp of fishers, thanks to the consistent and continuous communication with the leaders of the different local stakeholders involved. Following its success, the strategy was extended to cover all the activities of boosting immunity of the populations of island areas, ferricks, and nomadic camps throughout Bol health district. This paper documents the experiences and lessons learnt in using this strategy to boost immunization in the Island settlements of Chad.We conducted an action-research study involving 12 sub-districts of Bol (Chad): Banangorea, Fitine, Ngarangou, Matafo, Urban Bol, Kinaserom, Melea, Kangallam, Bougourmi, Tchongolet, Merom and Sawa where an innovative approach was tested. The study was conducted in three phases, from February 1 to May 31, 2018, with 3 rounds of vaccination campaign for children aged 0-10 years. The first phase concerned the development of innovative strategies called “call centers for polio efforts” aimed to improve the vaccination coverage for the district of Bol. The second phase consisted of the experimentation of this approach in a sub district. In the third phase, a benchmarking was carried out based on the first experiment, which allowed extending the approach throughout the district of Bol. This period was marked by security instability in the Lake chad islands following operations of the terrorist group Boko Haram. The various attacks of the latter had a negative impact on health activities in the region.children under 10 years old.WHO, UNICEF, management team of the district, the team of the sub-district, vaccinators, the pointers, outreach supervisors, main supervisor.Before vaccination activity, a microplanning update was first carried out. The managers of Sub-district, vaccinators and social mobilisers were briefed on the polio situation, route and dosage of the vaccine, the messages to be conveyed to parents and caregivers, number of teams per area of responsibility and the budget. Finally, the vaccination progress plan for each health area was presented and validated.The actual vaccination took place over three days and one catch-up day. The vaccine was stored in Sub-districts, which each morning provided the required daily doses to each vaccination team. For remote or hard-to-reach areas, vaccination teams received the doses for all vaccination days at once. After vaccination, the vaccinators brought the tally sheets back to Sub-districts. The health centres compiled these tally sheets and sent them to the district level. The results sent to the district were compared with the results of telephone calls from village, ferry and fishing camp chiefs. An evaluation was carried out at the end of each day. This daily evaluation helped to resolve some of the difficulties encountered during the vaccination. Corrective actions were decided during this meeting.After the vaccination campaign, partners and the district management team evaluated the campaign. This evaluation focused on the number of villages reached. Afterwards, partners, the district management team, managers of health facilities and EPI managers held feedback meetings, particularly on activities according to the framework established by the district management team and the call centre activity organised by partners. Finally, they wrote the campaign report.To confirm whether vaccinators had reached all the targets (villages and children under 10 years of age), a telephone verification system was set up and implemented.a)Call centre for polio control effortsThe main tool in the call centre approach to polio control efforts was the telephone.b) Description of the polio call centre approachThe implementation of the call centre approach was carried out in three phases:A first meeting was organised between the Task Team consultant (lead coordinator) and the District Management Team. This meeting made it possible to design the call centre approach and to select the BANANGORE sub-district as the first site for testing the approach during the first campaign in February 2018.A second meeting, named a “community meeting”, was organised by the consultant with various stakeholders in BANANGORE village, including the village chiefs, the representative of district chief, the team of Sub-districts, community workers and members of the health committee. The purpose of this meeting was to raise community awareness of the vaccination campaign, validate the vaccinators’ progress plan and develop the telephone directory to include the village chiefs. A copy of the directory and vaccinators’ progression plan was given to the Task Team consultant and another to the canton chief representative.A first meeting was organised by the District Executive Team with the support of partners . The objective of this meeting was to present the results of the experience of the call centre approach conducted in BANANGORE sub-district.–the responsible sub-districts were informed by the district management team.–the establishment of a directory of village chiefs–the validation of progress plans.Two meetings were organised by the district management team with the support of partners. The aim of the first meeting was to prepare the May 2018 campaign and to extend the call centre approach to the entire BOL district. During the second meeting, several actions were undertaken: (c) Implementation of vaccination in the island parts of 12 sub-districtsBefore the beginning of vaccination campaign, the managers of sub-districts were asked to provide a list of all villages under their responsibility and the telephone contacts of village, ferry and fishing camp chiefs. The same information was requested simultaneously from the heads of cantons. The coordination team triangulated the information obtained. In the event of a discrepancy between the information provided by managers of subdistricts and that obtained from canton chiefs, to findout the accurate information, the village, ferry or fishing camp chiefs concerned were called on the two telephone numbers obtained to confirm or refute the information obtained. Thus, a telephone directory was established. The telephone numbers of all villages, ferries and fishing camps were recorded in it.+” or “V” when the vaccinators had visited the area, “-” when the vaccinators had not visited the area, and “±” when some children were not vaccinated despite the vaccinators’ passage.The main coordinator made the telephone call to the village, ferry and fishing camp chiefs on the eve of the launch of vaccination campaign to inform them of the visit of vaccination teams to their respective areas. Verification phone calls were then made to ensure that vaccinators had visited these areas. The lead coordinator, learned some local expressions to ask the following questions: “Hello, have the vaccinators come to your village? Are all the children vaccinated? If the conversation became too long, UNICEF C4D or the driver would take over. Each evening, the information on villages not reached collected by the canton chief was compared with the information collected by the main coordinator and passed on to the health centre managers. A registration code was assigned to each village: “When these telephone calls indicated that vaccinators had not visited the community or that some target children were not being vaccinated, vaccinators were required to return to the communities during the mop-up exercise for effective vaccination. The next day, at the coordination meeting, the senior coordinator provided the district health officer with a list of fully vaccinated, partially vaccinated and unvaccinated villages. The list was based on the team’s progress plan. The district head instructed the relevant health centre managers to send vaccinators back to villages, ferries and fishing camps that had not been reached the previous day.After the vaccination campaign, partners and the district management team evaluated the campaign. This evaluation focused on the number of villages affected. Afterwards, partners, the district management team, the Head of the sub-districts and EPI managers held feedback meetings, including on activities according to the framework established by the district management team and the call centre activity by partners. Finally, the campaign report was elaborated. The coordination reporter recorded data related to calls made to village, ferry and fishing camp chiefs in the vaccination effectiveness register. After verification and validation by the lead coordinator, these data were entered into the database by a data manager and then verified by a second one.Word and Excel software were used for word processing and the creation of tables and graphs.To determine the rate at which villages, ferries, and fishing camps were reached, data from telephone calls made to their chiefs were analysed. The frequency, percentage, and means were calculated to describe the rate of reaching villages, ferries, and fishing camps. The theoretical target of 56.194 is the result of an enumeration survey organized by the Bol district in April 2018. We used Stata 15 software for data analysis. The t-test was used to analyze the change observed before and after the intervention, and the difference between the two periods was compared based on the principle of linear regression.The results showed that 87.5% of the 536 heads of villages and communities were alerted (phoned) on the planned vaccinators visit. However, 78.5% of the total communities were vaccinated. Nine percent were not vaccinated. The remaining 12.5% could not be reached due to network problems and they were not vaccinated, throughout the entire vaccination first round. See The result showed that the call center had a significantly positive impact on immunization coverage. Compared to the period before the intervention, its increased vaccination coverage by 52% during the first round and 50% during the second round. See Furthermore, comparative analysis between campaigns using call centers and those without them, showed a remarkable increase in the number of children vaccinated while using the call centers. See Several important results were achieved through the implementation of the call center strategy, that deserves a highlight s on the high value added to the otherwise inefficient routine immunization practices in Chad’s health system. There was a strong citizen and community participation, with 98% of the leaders taking part in the call center approach in the first round, compared to 95% in the second round. This allowed us to have 53,389 children vaccinated in the first round and 52,597 children vaccinated in the second round.Visits of unconfirmed vaccinators account for about 8% of responses from village chiefs and township chiefs. The non-confirmation is due to non-compliance with the implementation plan by the head of health centres. This could be due to too much workload or poor planning. These planned and unvaccinated villages on the planned days are still caught up the following days during the activity period. Nevertheless, some villages especially difficult to access have been vaccinated after the denunciation of the village chiefs. Thus, more than 1011 children were caught through this approach in 10 villages in the Bol district. The objective is not to prime on board to increase vaccine coverage but to seek to cover all villages. After the vaccination program was given over the phone some village chiefs had to call to confirm the visit of vaccinators without waiting to be called back.The call center experience during the immunization campaign provided sufficient satisfaction to all involved stakeholders, especially to the partners, the district task force, and especially to the beneficiary community of the intervention. Indeed, Bol District has taken ownership of this successful result and has extended the strategy into routine immunization activities. This brings great value to district’s performance not only in assuring the quality in the implementation of mobile EPI strategies, but also in the authenticity of routine immunization data. In the final analysis, the aim of this report is to share our successful result / outcome with other countries also committed in the polio eradication process.9. On the other hand, delay in detection of cases will speed up the spread of the virus. This is true of the polio eradication. Any unvaccinated child becomes a potential reservoir for the polio virus. This technology provides a fast, simple, and affordable platform for the rapid identification of populations missed during immunization campaign akin to the detection of early- stage disease outbreaks10.It is important to note that the same results have been confirmed from other interventions that used the call centers in the delivery of interventions. For instance, the swift control of Ebola virus disease (EVD) outbreak in West Africa was attributed to the engagement of this strategy for early detection of cases, which was later followed by intensive contact tracing efforts and the subsequent isolation of infected secondary cases9. Similarly, based on the second global e-Health survey, toll-free telephone services reported 88% for emergency alerts in South-East Asia Region; 63% on lower-middle income Countries and 58% on high income countries. The African Region reported the least (31%) activity in this category. Currently only few African countries had disease-specific emergency toll- free telephone services. One of these is Zimbabwe, which launched a telephone line for citizens to report cholera cases. Madagascar established its own service to support victims of domestic violence while Togo used the emergency toll-free telephone service to obtain information from citizens on H1N1 and TB9·10.In Sierra Leone, toll-free line, Walk-Ins, and community suspects were the three main case notification strategies used in EVD surveillance11. Similarly, community members were encouraged to flag any signs of fever and bleeding using the toll-free numbers. The toll-free platform was used in the detection of the first EVD case in Senegal12. This technology is thus becoming increasingly deployed for other public health interventions and should be used for immunization services as well.During the 2012 Ebola outbreak in Uganda, the m-health platform known as mTrac was operationalized. Using a free SMS hotline, communities were engaged in reporting report suspected Ebola casesAmong the possible methods or complementary technologies that could be used in the future for the populations located in the area where the network has problems, we can mention the use of “e-tracking” and the involvement of civil society and local non-governmental organizations.13.“E-tracking/vaccine tracking system (VTS) is a method of tracking the movement of vaccinators using a telephone application, Mobile Tracker. This application makes it possible to locate a mobile phone and to have a history of its GPS positions. To monitor the progress of the vaccination, the phone with the Mobile Tracker application is given to the vaccinator. The vaccinator is called to work (vaccinate) with the phone on throughout the vaccination. At the end of the vaccination campaign, all these phones are recovered. All you must do is connect them to a computer to read all the vaccinators’ movementsThis method has many drawbacks. It’s a method that allows us to identify the villages reached but does not allow us to know if all the children have been vaccinated. In addition, the vaccinator may forget to turn on the phone or lose it during the vaccination, and despite being charged by the solar power bank, the phone may also discharge, hence the impossibility or interruption of the recording of information.14.The involvement of civil society and local nongovernmental organizations appears to be a complimentary method. Members of these associations can supervise the vaccination campaign. Their neutrality makes it possible to have reliable information and, by extension, to increase the rate at which villages are reachedAfter a successful first experience in the Banangorea area of responsibility during the Polio SIAs in April 2018, we extended the strategy throughout Bol district during the first and second rounds of the special SIA in the islands in May 2018. This new approach allowed us to have a telephone directory of the heads of the various entities and to actively involve them in the immunization process. This empowerment of the community doubled the number of children vaccinated. Ownership of this approach by incountry local communities and the different partners by involve in the GPIE Global Polio Eradication Initiative will improve field campaign.The call center strategy that was implemented in place in this remote region of the country does not pretend to be the panacea for the best strategies that can sustainably improve immunization coverage. We must continue to draw and share lessons learned with national and local officials to improve / potentiate the chances of success of such unique and future and initiatives. While this is an inexpensive and easily achievable strategy, it remains limited in several ways, as it requires the continued mobilization of the ongoing commitment of local leaders and community leaders in support of the community health officials for adoption and transferability to other settings in the similar context of the country and elsewhere.


Purpose: The barriers generally facing women wishing to pursue careers in the disciplines of science, technology, engineering, mathematics, and medicine (STEMM) in the United States have been well described. However, additional layers of cultural beliefs and needs may pose further obstructions to women in certain cultural subgroups who wish to enter STEMM. Recognition of the challenges faced by such subgroups is important and culturally sensitive educational and training approaches may be necessary.Methods: We therefore created a science mentoring and education program incorporating the specific requirements of our test group, young Orthodox Jewish women. Our goals were to facilitate their knowledge, skills, and attitudes to embark on a scientific career in biomedicine. Interventions were designed to target physical, intellectual, emotional, and spiritual areas of growth with each intervention crafted to the sensitivity of the women's cultural and religious backgrounds.Results: Over the course of 6 years, we enrolled 59 Orthodox Jewish women, ages 16–20 years. These women spent their summers as part of the larger Summer Internship Program (SIP) at the National Institutes of Health. They participated in cohort sizes ranging from 6 to 26 in dozens of multilevel experiences in the SIP over 6–10 weeks. Participants reported strengthening interest to pursue careers in health care-related fields. Other graduates committed to pursue careers in the general sciences, and other graduate studies.Conclusion: This unique educational platform shows promise for other intersectional groups approaching educational barriers to careers in STEMM. According to a 2015 study, 77% of black women and 63% of white women in STEMM-related careers reported having to provide proof of competency beyond that of men of their same skill level.Within mainstream Orthodox Judaism, women traditionally prioritize domestic roles and large families. However, for many Orthodox women, they also desire to use their personal strengths and talents outside of the home, which creates a perceived conflict of priorities, both for the women themselves and from the community. Particularly in STEMM fields, where there is extensive training, one's career is expected to be a priority in terms of time and commitment. This creates a conflict of interest without a clear standardized resolution. Therefore, despite inclinations and strengths in the sciences, many women may forego a science career in favor of other fields where balancing work and domestic responsibilities is more readily achievable.5–7 (2) cultural conflicts of disparate moral values and an independent career being incompatible with the women's important family role,8 and (3) practical challenges, such as religious requirements, few role models who balance career and children, and a dearth of mentored pathways.9 These factors necessitate finding novel systems to support Jewish religious women in STEMM fields. To that end, a distinctive experience offering support, guidance, and encouragement in biomedical science was considered for Orthodox Jewish women to address all three considerations.There are additional complex reasons for the underrepresentation of Orthodox Jewish women in STEMM careers, including the following: (1) historical barriers where outside society was not welcoming for Jews,10Specifically, a mentored pathway into STEMM was designed utilizing summer internships at the National Institutes of Health  facilitated through the Orthodox Jewish Women's Support Group (OJW). We sought to determine whether a supportive program with the use of integrated journaling would encourage these women to enter careers in STEMM by removing barriers, conceived or practical, unique to their demographics. The OJW was created by Daniel C. Edelman, PhD, National Cancer Institute, to integrate Orthodox Jewish women into the fields of STEMM. The OJW drew its cadre from Orthodox Jewish women's schools and provided mentored support for the selected students to experience first-hand biomedical research and health care. By these means, we sought to provide these women exposure and increased awareness of all facets of STEMM careers, while maintaining their religious identities. Although community groups exist at the NIH for other intersectional and minority groups, no other group offered this type of individualized mentorship, intensive and yet broad training, cultural support, and guidance as did the OJW. We present here the educational and cultural parameters entertained to affect a positive outcome in STEMM of this underrepresented population and “hidden diversity.”via multiple means: essay of purpose, written answers to elucidating questions regarding science background and personal strengths, in-person interviews with additional questions, and discussions among the vetting volunteers, including summer interns from previous years. Women who were experienced enough to enter a laboratory environment directly without need for preparation from the 1st-year experience were permitted to apply directly to the SIP. These women still benefited from support and mentoring provided by the OJW once they had gained internships. Following the vetting process based on the expected competencies, all applicants were then placed into three categories: primary selected interns, alternate (backup) interns, and rejected applicants.The intensive vetting process to be accepted into the OJW NIH Summer Internship Program (SIP) at NIH revealed to the women, most for the first time, a world of professional activities and expectations that included job applications, resumes, and cover letters. Applicants were aware of the opportunity to apply for the OJW SIP primarily through word of mouth. The applicants were vetted Women accepted into the pathway were subsequently required to fill out official NIH paperwork. Federal government personnel paperwork is extensive and so that no time would be lost should a primary intern withdraw, alternate interns were also processed up to the point of submission into the NIH personnel system. The women were encouraged to keep stated deadlines; however, and importantly, when deadlines were not met, the accepted applicants were not then rejected from the internship, but rather, counseled how to meet the job prerequisites. These interventions were all part of the overarching mentoring that began even before the interns arrived at NIH. Online trainings in matters of privacy, Health Insurance Portability and Accountability Act, and laboratory safety introduced the students to professional standards and knowledge necessary to participate in a sensitive health care environment.Interns and their parents were responsible for finding their own housing for the summer and arranging modes of transport to the NIH Bethesda campus. It is forbidden by the NIH policy for employees to assist interns with obtaining these logistical needs. Instead, interns relied upon local networks in the Jewish communities surrounding the NIH Bethesda campus for carpooling and finding boarding opportunities in culturally supportive homes.The primary goal of the 1st-year program was to introduce the interns to the wide range of disciplines in biomedicine through exposure to both clinical and research aspects of the NIH. This in turn would help the interns gauge their budding interest in science careers for further exploration. During the 1st year of the pathway at NIH, the interns shadowed in different laboratories and clinics as volunteers as an introduction to biomedicine. Once on campus, it was clearly expected that the interns would make a personal effort to understand and diligently study medical articles and new scientific material presented through a multitude of rotations and real-world experiences. Each workday was between 7 and 9 hours long and was followed by evenings spent preparing for the next day's rotations, journaling, and conducting literature research.Having never read scientific literature in any critical way, the women were presented with the challenge to craft a literature review from primary sources to be presented at the end of the summer as a poster presentation at the NIH SIP Poster Day. NIH library staff assisted in this endeavor by teaching and coaching the women in both reading scientific literature and utilizing several scientific research modalities such as PubMed and EndNote software. Moreover, OJW leadership and mentors assisted with topic selection and formatting in creating their professional posters. This educational effort allowed the women to choose their own scientific topics and learn about the scientific literature review process, an integral skill in any scientific field.Subsequent to the summer spent as volunteers, the women had the opportunity to become research trainees as part of the general SIP at the NIH, and they were typically monetarily compensated. The OJW aimed to provide the interns deeper insight and experience into a career in biomedicine, specifically through research benchwork and clinical shadowing; here we coupled the mentored pathway with the SIP. Although these subsequent internships maintained active participation with the OJW, the women had day-to-day responsibilities to their respective laboratories gaining additional training in oncological, genetic, and biology research methodologies, and had the opportunity to present their research projects during the SIP Poster Day at the culmination of summer. The NIH laboratory and clinical staff guided each student in specialized benchwork, while also allowing many of the students to experience clinical shadowing, most for the first time. This extensive crossover of clinic and benchwork is unique at the NIH, and this facet of the programming allowed students to further understand the integration of seemingly disparate biomedical fields. It also provided immediate comparison of the different modalities of biomedical research, thus allowing the women to make more rapid and informed decisions as to their career paths; this somewhat obviated the practical challenge of comparing different fields of study to reach a surer career choice.12 the OJW established a journaling modality and adjustment evaluation integrated into the summer experience. Pennebaker established that journaling allows a person to put structure to their stressful circumstances, which relaxes the body and allows for all-around improved functioning.12 The women were given journals to specifically chronicle their NIH experiences, and at the beginning of the summer they were briefed on the expectations of journaling once a day and the benefits of journaling.12 The most recommended prompts came from Jason M. Satterfield in his course from the Great Courses series. They were as follows: (1) What surprised me today? (2) What moved me today? (3) What inspired me today?13 The OJW leadership hoped that through journaling, the women would find more meaning in their everyday NIH experiences and reflect and learn from situations that may have been stressful or culturally shocking. Personal integration through journaling of meaningful activities and challenges was a method to process events of the summer for future review and reflection. Although the women were never required to publicly share their journals, they were encouraged to reflect on what they wrote with their mentors and friends during group discussions.Based on works by James W. Pennebaker,via written surveys given at the beginning of summer and then again at the end: one anonymous survey each for journaling and adjustment. The NIH Office of Human Subjects Research Protections deemed these surveys not human subjects research, and therefore, institutional review board approval or waiver was unnecessary. The surveys were modified from the original College Adjustment Test, a 19-response questionnaire,11 to account for the different cultural and nonacademic venues at NIH.The effects of journaling and SIP activities on the women's well-being, adjustment, and positive affect from their summer were evaluated 14 This mentoring summit held by the Committee of Women in Science, Engineering, and Medicine (CWSEM) included women speakers from a wide range of stages in their careers, including department heads at large research facilities, such as Johns Hopkins and the U.S. Naval Academy, as well as women in college in the beginning stages of pursuing their career goals. Their analysis found >95% of participants agreed that having a mentor was a critical aspect to their success in entering a STEM-related field. In addition, all participants agreed that the CWSEM mentoring for just the day of the summit gave them a better understanding of barriers faced by underrepresented groups in STEM. Importantly, starting mentoring early in the women's education is necessary. A study of 998 school-aged girls (grades K-8) partaking in an online STEM mentoring program found that participants experienced increased educational endeavors as well as additional success in the sciences specifically, and especially in STEM-related activities. The women also displayed a mean growth in certainty about their career trajectories in STEM.15Mentoring of women has been reported in the literature as a necessary component to their future success in the sciences. A survey analysis was conducted following a 1-day mentoring summit for high school women who were interested in STEM-related fields to mitigate the “leaky pipeline” of women post-graduation who intended to pursue STEM careers.We therefore instituted structured mentoring to provide a guided pathway for the Orthodox Jewish women to address their unique cultural and practical challenges that might be associated with deviation from traditional domestic roles expected of Orthodox Jewish women. The pathway leaders, advisors, and mentors were from the same cultural community as the young women. From the Orthodox Jewish community this included religious men leaders, women physicians, and other women professionals, as well as other NIH scientists not from the community who prioritized family values in addition to their professional roles. These mentors and advisors were available for the interns to seek guidance on religious, professional, and personal life questions. NIH mentors and instructors with little exposure to Orthodox Judaism were provided cultural awareness information, which provided insight into some of the women's religious sensitivities and laws; this allowed for optimal comfort and limited surprises for both parties.We believe that one of the most important aspects of the OJW-mentored pathway, both for 1st-year and SIP interns, was providing leadership from a similar cultural and religious background. The senior author is from the same religious faith, Orthodox Judaism, and as an experienced scientist at the NIH had both the knowledge and background to work well in religious and secular worlds. As both the OJW founder and organizer, he guided the application process, led the weekly group discussions, and provided impromptu mentoring. To help surmount cultural barriers, the program aimed to allow the students to feel secure that all religious concerns could be addressed from within the accepted bounds of their Orthodox Jewish community. Also, trust in the OJW leader's experience with handling this unique combination of worlds enabled the group leader to show the women how to make their own religious experiences relevant to the world of science. The shared values between the leadership of the program and the Orthodox Jewish community leadership helped to alleviate any pushback from community members or rabbinical leaders who may have not been comfortable with this type of integration due to perceived risks to religious observance.As an added dimension to the mentoring aspect of the program, the 1st-year women were each placed with NIH postdoctoral and postbaccalaureate trainees. NIH trainee women were specifically sought due to the sensitive nature of gender interactions for Orthodox Jewish women: especially important in their first major experience in the secular science world. By essay and interview, these mentors were vetted for their passion to support the next generation of biomedical women scientists. The matching process was favorable to the mentors and allowed them to choose their mentees as opposed to being assigned one. Mentees were selected based upon similar personal and scientific interests by review of their SIP applications. A presummer meeting between OJW leadership and the mentors was held to set the expectations and to clarify questions relating to the unique mentoring needs for this mentee population. SIPs, however, primarily relied upon the day-to-day mentorship provided by the laboratory's principal investigator or their designate; secondarily, OJW leadership maintained an open-door policy to allow for contact if necessary.One additional level of mentoring was instituted at the peer level. For those interns having previously experienced the 1st-year program, we requested that they be matched up with incoming 1st years for peer-to-peer mentoring (P2P). Having P2P mentoring provided a more equitable interaction for the young women allowing for greater trust overall for the entire mentored pathway and assisted with ways to deal with all barriers faced by Orthodox Jewish women. The P2P mentoring also allowed the women to facilitate relationships beyond the summer internships and extended the reach of the P2P mentoring itself.We propose that a unique element critical to the success of the OJW/NIH experience, both in the 1st-year program and SIP internships, was scheduled weekly group discussions, known as “chats.” At the chats, any issue could be addressed, and feedback garnered relating to the past week's events. This was done in a forum limited to OJW members or their supporters to emphasize the teamwork needed among the women and to learn from each other's successes and difficulties. The group discussion also allowed for assimilation of the past week's activities in a context of each woman's level of religiosity. For example, how to parse the gender separation in their cultural environment with a much more mixed interaction in their professional environment.The sense of safety was further enhanced by creating an event reporting mechanism that was woven into the chats. From the first interview and throughout the summer, interns were encouraged to make leadership and mentors aware if they felt endangered in any way: physically, emotionally, or spiritually. This required a certain level of immediate trust to be built up at the beginning of summer, which we did through small group discussions and sharing of personal and religious ideals.Several formal measures of student outcomes suggest a salutary impact of participation in the mentored pathway. Spanning three summers (2016–2018), the OJW leadership distributed anonymous written surveys to the interns at the beginning of summer and then again at its conclusion. They were asked to rank their emotions and beliefs surrounding the program, such as anxiety, happiness, and depression. Overall changes in these categories were analyzed. To evaluate the impacts of each subprogram, 1st-year interns and SIPs indicated their status as such on the forms. The satisfaction that the women gained from the program can be demonstrated from the increase in general knowledge, improvement of social life and self-confidence, and elevated optimism exhibited by the 1st-year interns of OJW groups . These sn = 23, 38.9%) have returned for at least three or more summers. The 59 interns attended 15 colleges and high schools from 10 different cities and 8 states in the United States; the program design and implementation were equivalent for both groups of students.Fifty-nine interns were enrolled and completed the mentored pathway (1st years and/or SIPs). Of those, 50 (84.7%) have returned or have wished to return to the NIH for a second summer exemplifying their desire to continue in exploring the fields of biomedical science as potential career choices. More than a third of the interns  of the women indicated that they wish to become medical professionals; of those, about 1 in 6 (n = 10) want to earn medical degrees. The remaining 29 interns expressed an interest in pursuing careers as nurses (n = 10), physician's assistants , or other health-related fields (n = 7). About a quarter of the interns (n = 15) have committed to or are pursuing careers in the general sciences, including graduate studies in engineering or bioengineering, psychology, and occupational therapy. Six women (10.2%) chose careers in fields other than science such as law, interior design, and accounting (A large percentage of women (88.9%) who completed internships as part of the OJW reported continued interest in entering a medical- or science-related field . Helpfulcounting . Reasons25 Regardless of their subsequent career paths, all the women contemplating the societal, work, and religious components of their futures were able to begin to make the necessary practical decisions about life priorities and finding one's own unique work/life balance.Life aptitudes we expected interns to acquire in the OJW such as critical thinking, intercultural skills, problem solving, networking skills, innovated thinking, and accountability should prove beneficial in careers other than STEMM.Thus, we believe that the creation of this culturally sensitive mentoring pathway for young Orthodox Jewish women was successful in promoting their interest and success in pursuing STEMM careers. In relation to the typically anecdotal low rate of Orthodox Jewish women in STEMM, and the observations of increased excitement and commitment to these careers by the pathway's participants, we suggest that the program did provide meaningful value in surmounting unique barriers related to careers in science for them.26 In this study, self-reflective journaling was introduced at the beginning of each STEM class, and assisted students in identifying stress levels, while also allowing them to partake in peer-to-peer dialogue through sharing of journal entries. This resulted in increased positive affirmations within the class as well as in students persisting and succeeding in STEM-related coursework.Anonymous surveys administered at the beginning and end of the summers (2016–2018) asked 1st-year intern participants of the OJW to rank qualitative measures regarding their journaling experience. There were insufficient survey returns from the SIP interns to draw any conclusions and it is unclear why this occurred. The leadership of OJW did not mandate participants share their entries to assure the intern's privacy, and as such were not able to conduct a qualitative analysis of journal entries; each one's journal was to be their very own safe space. A related study investigating the use of a self-reflective modality incorporated into STEM classes to benefit students underrepresented in science found that journaling helped the study groups experience positive changes in learning.Similarly, 1st-year interns in the OJW reported, through survey analysis, an 81% increase [data not shown (DNS)] in the value they placed on the journaling aspect of their NIH experience indicating that they overcame preconceived negative notions surrounding journaling. In addition, the likelihood that the interns would share their journal entries with their mentors increased by >90% (DNS). We witnessed that when the women experienced stressful situations, impromptu sharing of their entries in group meetings allowed them to receive feedback and encouragement while also providing their peers an opportunity to glean from the experiences. When asked to estimate the impact of the program's journaling modality, students noted that journaling was mostly a positively experience at the NIH and this included how integral journaling became to them . They also felt that there would be a long-lasting positive impact from the journaling overall . We believe that journaling contributed to the success of the pathway because, in part, it forced the women to be mindful and aware of their daily experiences.As hoped for, by the end of summer, the women felt increasingly more comfortable  sharing their journal entries with friends. This may indicate that the encouragement to disclose their entries during group meetings increased their sense of trust within the group without embarrassment and made them more confident that their peers could gain valuable insight through their journal entries as well. The increased comfort with disclosing entries was also reflected in the growing likelihood that the women would share entries with their mentors . There was, however, no change in the women's disinterest in revealing their entries to their families. This could be due to the bond they formed through sharing personal events with those who experienced similar situations, which the parents and siblings had not. Additional survey studies are necessary to form a more comprehensive view of the effects of journaling and the sharing of journal entries on the OJW experience, as well as the ongoing impacts of the practice on subsequent internships at the NIH.The 1st-year women experienced emotional and social successes as measured by our survey analysis  and 2. IDiscussing relevant struggles allowed the women to learn how to deal with difficult and uncomfortable situations in the workplace. The group discussion also allowed for mutual support and empathy of shared multicultural experiences. Throughout the summer, teamwork and mutual support were stressed to impart upon the women that they were not at NIH just as individuals, rather, that they have responsibilities for each other's welfare and improvement of the OJW. The support structure built into the program gave each intern a sense of community throughout the summer. It also allowed the women to network among themselves in the context of a group with shared backgrounds, values, and interests as reported through e-mail correspondence from women in the program. The chats enabled all participants in the OJW to deal actively with and prepare for the historical, cultural, and practical challenges for Orthodox Jewish women involved in STEMM fields.A significant limitation in this study is the lack of qualitative analysis regarding the influence of our interventions upon the participants. Increased qualitative data analysis would be expected to further showcase the degree to which the OJW pathway impacted the women's career decisions, as well as delineate the key aspects of the program that garnered this success. Future summers should provide the means to gather these important qualitative data.This report describes a cohort study without controls with resulting selection bias. It is unknown what the success rate would have been without our interventions; perhaps the highly motivated students who applied for this program would have pursued STEMM careers even without its support. Although we were careful to collect data on outcomes of interest, this effort was not intended to be a controlled study. However, feedback from participants was overwhelmingly positive in the survey results  and 2.27 exchange and discuss cultural awareness sheets giving basic facts about each religion, and continually apply the principles of the Outward Mindset from the Arbinger Institute28 in our multiple venues of interaction.The enacted principles and interventions can be applied in future summers at the NIH SIP integrating women with similar cultural barriers but of different faiths or other intersectional groups together with those of the Orthodox Jewish faith. We plan to incorporate discussion guidelines from the Center for Research on Learning and Teaching, University of Michigan,via the group chats and the girls' shared passion for science. The Mormon intern expressed “how desire for truth and knowledge [transcends] cultural and religious differences.” She was subsequently accepted to Harvard University for undergraduate studies.We piloted these ideals for the summer of 2019 when a rising high school senior woman of Mormon faith joined four women of the Orthodox Jewish faith for the 1st-year experience. In brief, using our lessons learned along with cultural awareness, creating safe spaces for effective communication as well as mutually agreed upon guidelines we were successful in this integration effort as reported back to us orally and in written form by the five interns . Although this experience only included one intern of dissimilar faith from the others, it was specifically noted by the Mormon intern in her essay to Harvard University that the program was successful because of open and honest communication. This allowed for connection and understanding We report on the success of a culturally sensitive and focused mentoring pathway into science-oriented careers. Here we targeted young women of the Orthodox Jewish faith; a group that is underrepresented in the sciences in the U.S. population. Importantly, our efforts and interventions took a holistic view of the training and educational process, incorporating a strong and active mentor/mentee relationship on multiple levels. By purposefully incorporating, acknowledging, and prioritizing the students' religious backgrounds together with scientific inquiry, we were able to successfully encourage and support their interests in pursuing STEMM careers. This framework may potentially be recreated in other unique, culturally sensitive approaches for other underrepresented groups in STEMM.


The phenomenon of migration is characterized and influenced by a number of different variables; and the different stages of journey are related to different levels and types of psychological distress. Women, in particular, are exposed to further specific risks during migration. To determine the factors that affect the psychological health of migrant women during the different stages of the migration journey. We provide a narrative review of the literature around the experiences of women during migration process, with a geographical focus on women migrating to the Mediterranean area. Little data is currently available on the burden of mental health disorders for female migrants. Most studies about the mental health status of migrants were not gender-disaggregated or focused specifically on migrant women’s experiences of violence. Sexual and Gender-Based Violence (SGBV) was found to be a common risk factor faced by all the women who leave their native country to migrate to other countries. Despite the importance of the issue and the gender-specific variables related to the experience of migrant women, few studies have looked specifically at psychological variables and mental health status in the female migrant population. It is crucial that future studies are conducted around female migration, violence towards women, and women’s mental health, in order to provide an evidence-base for promoting adequate policies and prevention/treatment programs for women. However, due to changes in geo-political factors, recent levels of migration to Europe through the Mediterranean region have become of major interest to policymakers and researchers alike. Migration and experiences related to migration are affected by a number of factors, and gender differences are of paramount importance in understanding the stressors experienced by migrants.2A narrative review of the literature was conducted on the phenomenon of migration in the Mediterranean area, and specifically on the psychological and psychosocial experience of migrant women. We searched english-language publications in Pubmed, Scopus, ScienceDirect and PsycInfo. We used the search terms, “women” “migration” “mental health”, “psychological, distress” “mediterranean”, “Sexual and Gender-Based Violence (SGBV)”,“mutilation”, “Intimate Partner Violence Against Women (IPVAW)”, “Female Genital Mutilation (FGM)”, also checking references and bibliography of selected publications to identify additional relevant material.33.1According to the data from the United Nation High Commission for Refugees (UNHCR) about new arrivals in the European countries, the number of refugees and migrants who arrived by sea to the European coast  after crossing the Mediterranean Sea was 97,546 at the end of October 2018. In previous years, these numbers were considerably greater at 172,301 arrivals in 2017, 362,000 in 2016, and a massive 1,015,078 in 2015. This number is a notable increase from that in 2014, when only 216.054 arrived on the coasts of Europe [Despite the more recent reduction in the number of migrant and refugee arrivals, which could possibly be attributed to changes in the European policies the situation remains challenging from many points of view. People arriving at European coasts are often affected by physical and psychological diseases and illness ; either 3.2In the migration literature, the stages of migration are described to be: 1) pre-migration; 2) migration; and 3) post-migration . The lasIn each of these stages, migrants are exposed to specific conditions, which in turn determine vulnerability to mental health problems. Many of these experiences are similar for both men and women; however, some variables are more specifically related to the female gender, because different kind and level of insecurity and violence are experienced by migrant men and women, based on social and economic conditions of home countries, of transit countries and host countries, and the relations of power between husband and wife .Although migrant women face gender-related specific addicted vulnerability, there is very little data focusing at the psychological and psychopathological status of migrant women. On the other hand, there is a significantly larger amount of literature on gender-based violence and abuse, which has been documented to have psychosocial consequences.Women are vulnerable to violence during the migration journey. Some of the violence is cross-cutting across all parts of the journey ; and some of it is particular to and experienced during the different parts of the journey.Sexual and Gender-Based Violence (SGBV) is the term generally used to define violence directed against a person on the basis of gender or sex. In the field of migration, SGBV is a recurring phenomenon, including five dimensions of violence: physical, psychological, sexual, socio-economic and cultural harmful practices, such as threats, coercion, or deprivation of freedom on the basis of a person’ sex or gender . SGBV li3.33.3.1The underlying reasons for women to migrate must be looked for in their country of origin where political, cultural and religious circumstances can push them to escape . In sub-In this cultural framework, she learns to see violence as a part of the marriage and as a right of husband to exercise control within marriage , 20. DesAlthough the magnitude of the issues and related results, it is difficult to have reliable data. For example, phenomenon of forced marriage is still relatively under-reported , even itMore data are available about physical and sexual violence against women. Even if SGBV is a universal reality, it appears to worsen as one goes south in the continent of Africa. Intimate Partner Violence Against Women (IPVAW) is a very common violence exercised by the husband over the woman  and, desAccording to a comparative analysis of 17 sub-Saharan countries, IPVAW is targeted as a justifiable act both by men and women, particularly in case of “neglecting children”, “going out without informing husband”, “arguing back with the husband” or “refuses to have sex with her spouse”. This practice seems to be more acceptable to younger , less edThe Female Genital Mutilation/Cutting (FGM/C), or female circumcision, is another common form of violence against women in sub-Saharan African countries. It is a practice determining the removal of all or part of the external female genital in the absence of medical needs .According to UNICEF data, 200 million girls and women from 30 countries mainly in Africa, the Middle East and Asia suffered this violence and 15 million girls are at risk of experiencing it by 2020 . HoweverThis violent practice is perpetuated because of specific religious, cultural and traditional variables determining the female gender role, such as: girls’ virginity before marriage, monogamy in marriage, sexual availability to husband, the production of legitimate male heirs in order to insure husband’s patrilineage.Worries about marriageability and social acceptance, and the concern to loss of protection by other women and all the community if a girl refuses to suffer FGM are further reasons why this violence is still going on .Studies conducted in South Africa are aimed at understanding the risk factors related to FGM. In Kenia, a study conducted on 0–14-year-old girls showed that daughters of cut women were highly likely to live the same experience. The likelihood of a girl being mutilated increased with the proportion of women who were cut, who supported FGM/C continuation, and who believed FGM/C was a religious obligation . Achia , found aet al. [In Tanzania, it is estimated that 7.9 million women and girls have undergone FGM . Accordiet al. , out of Others forms of violence are caused by political conditions: inthe war-torn regions, many women have been raped , have wiAccording to the Euro-Mediterranean Human Rights Network data , many inAll these experiences are the reasons why women can choose to leave their country, or they are part of their background, and they can be trigger for the development of additional traumatic events and for the onset of further psychological problems.3.3.2Many characteristics of the journey to the host country, including the duration of the journey, cause migrant women to be particularly vulnerable to experiencing psychological distress, violence, and other traumatic experiences. SGBV is part of the journey for most of the women , and conWomen’s experiences of SGBV on the migrant journey include being forced to have sex by smugglers, being used as a bargaining chip by their family to get a seat on boats, being compelled to sell their bodies in order to buy a seat for their dependents or to avoid torture and violence, or being used as exchange goods in exchange for prostitution or other illegal services . The useIn a study of women’s experiences of violence during migration, Syrian women on the Euro-Mediterranean transit region reported experiences with violence during the passage . The stuMigrants, including women, are subjected to violence at the hands of the state authorities . An examWomen were also at risk of attacks by various police or military forces in the countries crossed on the way to Europe , 46. Ins3.3.3Refugees are particularly at risk for poor mental health , 48. In The post-migration period can be defined as a long-lasting process of inclusion and acceptance of migrants in the core institutions, relations and statuses of the host countries. It can require enormous resources and personal skills for migrants to activate themselves in a process in which they must quickly learn a new culture, with its rights, and try to access to positions and statuses. Social inclusion process can be very long and opposed by various difficulties such as family separation, the lack of social support, the need to learn language, and facing with discrimination and poverty. Some of those stressors  are main themes influencing the mental health especially of refugee women .During the post-migration stage, it is also possible that migrants end up in refugee camps for months or even years, where living conditions are highly stressful and can expose them to the development of stress-related disorders, to which women seem particularly at risk of being exposed. Following exposure to a traumatic event indeed, women are approximately twice as likely as males to develop PTSD . The reaWomen often do not access treatment following the violence they have suffered not only during the journey but in some cases, even once they arrive in the host country .According to a study conducted to investigate violence experience among immigrants and refugees in Italy, 56% of the women had been victims of at least one form of violence  during their permanence in Italy and 28.5% experienced multiple incidents of violence . The reaMSF aid workers in Kos, Greece also reported that migrant women who experienced Intimate Partner Violence from their husbands or male partners were often unable to leave the abusive relationship due to the high level of social and financial insecurity faced in the country of destination .A study performed in Spain has similarly highlighted that there could be a strong association between immigration status characteristics such as personal, social support, family among immigrant women living in Spain and Intimate Partner violence .Even if the exposure to the risk of suffering further violence once arrived in the host countries for migrant women is very high, very few studies have highlighted this phenomenon -63.A study performed in Pavia has shown that only half (49.7%) of the sample of migrant women receive a diagnostic procedures and/or drug prescription and only a third had a preventive intervention or chronic disease control . There iSome studies have been carried out on the female population host in camps provided in border areas from which the migration process has started.Studies from refugee camps with Tuareg refugees in Burkina Faso have compared psychological distress in male and female people. The results show higher rates were present in women; particularly over 40 years old women were at higher risk for PTSD symptoms, probably due to their awareness , 65.Depression is present in terms of maternal depression among Syrian refugees in Lebanon, associated with younger age of marriage, illegal residence, increased exposure to domestic violence and a history of mental illness, more than among Lebanese mothers .Several studies implementing psychosocial approaches aimed at improving mental health of migrants have been performed, both in host countries and in borders hot spot. Studies that had been supported or conducted in group setting or with the help of someone of the same communities seem to be considered more effective .Some protocols involved family members or community activation of migrants in the host country and showed their effectiveness in facilitating access to care services -70.Anyway, there is a clear lack of interventions designed to meet the particular care needs of migrant women in order to produce positive mental health outcomes once they arrive in the host countries. Likewise, targeted policies to promote mental health and prevent mental disorders among women migrants offering social, emotional, support to address the barriers against mental health services in Western host countries seem to be totally absent.4This narrative review shows the lack of data about psychological status of women emigrating to countries of Mediterranean area and about the presence of devoted mental health services.Most of these women, when they arrive at the coveted countries, show wounds, signs and symptoms of violence suffered and of their psychological suffering. Unfortunately, too few studies have been conducted to collect data with the aim to have a plausible view of the experiences they lived, in the countries of origin or during the journey or at the arrival in the Mediterranean countries.5To our knowledge, this is the first narrative review about mental health status of migrant women in Mediterranean area.The main limitation that needs to be taken into account, is determined by the lack of specific data about psychological status of migrant women. No studies have been conducted to highlight specific mental health effects of migration on women, neither in native countries, during the journey and their arrival in the destination country. It has denied possibility of studying the issue and has determined the need for looking for data about physical and psychological violence experienced by women in every step of the migration journey.Despite migration is painful, stressful and traumatic both for males and females, there is a dearth in the literature about the psychological distress experienced by women. Our research did not yield enough results in order to be able to answer to our over-arching question about the psychological health of female migrants. We believe that further research is needed in order to better understand gender-specific variables for mental health during migration, including violence against woman, so as to be able to apply good practices of care and prevention.The existing data about Sexual and Gender-Based Violence during migration underlines the need for a different set of policies and care approach specifically aimed towards helping women not only manage their psychological and trauma-related disorders but also towards improving their resilience in the face of these variables . ImproviThe Lancet Public Health [We agree with the Editorial of c Health , which sOur idea is that all the stakeholders - at cultural, educational, national and international policy level - shouldfeel involved in this issue. An implementation of care system for women directed towards primary prevention of violence and psychological distress , and secondary and tertiary prevention in the countries involved in the migration journey is urgent.It is necessary to create a systematic approach, including cultural, social, political, educational and health perspectives, to give an answer to the psychological suffering of migrant women.