I2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is “an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias.” Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: ;  P = 0.561). However, the immunization rate increased by about 3% in both arms of the trial compared to the baseline (previous year). At the same time, a decrease in coverage of 2.4% was observed district wide by public health authorities. As our trial targeted a change in behavior in primary healthcare, we considered the possibility of a Hawthorne effect (HE) to explain this difference and felt the need to have greater insight regarding this effect  was first observed in relation to six, partly overlapping, experiments carried out from 1924 to 1933 at the Hawthorne plant, a large factory complex of the Western Electric Company in Cicero , also reputed to have generated Al Capone’s original fortune . Elton MIn 2010, French and Sutton published a narrative review calling the changes in the people being measured in an experimental environment “measurement reactivity.” They merged this designation with other terms including “assessment reactivity,” “mere measurement,” “question-behavior effect,” or “self-generated validity” . FurtherIn 2014, McCambridge et al. published an often-cited systematic review to elucidate the existence of the HE, the conditions of its appearance, and its estimated size . They noIn 2020, Purssell et al. conducted a systematic review and meta-analysis regarding the HE in hand hygiene (HH), based on the many publications in the field related to the guidance for HH promoted by the World Health Organization (WHO) (“My Five Moments for Hand Hygiene” initiative) in 2009 . It confNoting the considerable inconsistency regarding the phenomenon, the primary objectives of this review were (1) to refine the definition of the HE and outline the progress of research since 2012 (last inclusions in McCambridge’s review) on the HE in terms of its existence and characteristics and (2) to estimate its size in primary care studies, expecting the already described heterogeneity.Considering the definition, publications related to research in the medical field, in particular those regarding health professionals and patients, were included. Reports needed to contain a clear definition or outcome measuring the HE. Included methodologies were clinical trials and their reanalysis, quasi-experimental or observational studies, or historical comparisons. Reports published in French or English, with an available abstract, were included. Only reports published after the review by McCambridge were considered (publication range: January 2012 to March 2022). We ensured that no reports were overlapping with McCambridge’s review .Reports outside the field of medicine or human behavior related to health and those citing the HE without definition or outcome measurement were excluded. Narrative or systematic reviews with meta-analysis were considered for discussion and to retrieve unnoticed reports from the reference lists, but excluded from this review. Didactic records and letters to the author or editor were also excluded.post-hoc analysis of RCTs, historical comparisons (pre–post comparisons), or observational studies. Studies conducted in hospital wards, in particular HH studies, were excluded.Considering the appraisal of the size of the HE, included reports had to be conducted in primary care, in outpatient clinics, or in healthy persons. Only published outcomes were considered and only primary outcomes were computed, without limitation. Included designs were RCTs, The use of the term “Hawthorne effect” in health sciences is gradually increasing though its definition remains unclear. It is still more often used without any connection to the original studies in the Hawthorne plant, with a meaning of alteration of behavior related to an experimental background. In other disciplines, its meaning has mutated over time to become still more controversial . As our The search used PubMed as the mean search engine. As McCambridge  and PursInitial selections of records were independently undertaken by two reviewers based on the availability of the record, the type of report, the title, and the abstract. All full-text reports meeting the inclusion criteria at this point were read. Reports retrieved from the reference lists of the papers and meeting the inclusion criteria were treated similarly. A consensus meeting of the two reviewers led to the final list of reports included in this review. All reports included were independently fully analyzed by the same two researchers.The same two researchers independently appraised the risk of bias and the level of evidence during the review of the selected full-text reports using the Cochrane tool .®.Publication bias was assessed by a funnel plot using Review Manager 5.3The narrative results regarding the definition of the HE have been summarized in ® table. Studies included in the meta-analysis are summarized in ® to compute effect sizes and standard error. The generic inverse variance was used, adjusting for the direction of the HE . The odds ratio (OR) and 95% confidence interval (95% CI) were computed using random effects in the context of an important difference in weight of the studies. Heterogeneity was computed using the I2 statistic. The result is presented as a forest plot. A supplementary sensitivity analysis was computed to differentiate odds ratios and heterogeneity by study design  have been included in a Microsoft Excely design  and by ty design  as the sNo ethical statement is required in France for systematic reviews reusing already published data (research method classification MR-004).The redaction of this review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement update 2020  –39, two post-hoc comparison of the RCT population to a non-RCT population  in different hospital wards or primary care and the community. The most commonly studied outcome was the World Health Organization (WHO) guidance for hand hygiene (HH) [“My Five Moments for Hand Hygiene” initiative ] in 13 sBased on this review, our definition of the HE in medical studies is “an aware or unconscious complex behavioral change in a study environment, related to the interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias, and observation and measurement bias.”The subject agreeing to participate in a study is interested in its outcome, expects a benefit, and trusts the investigator , 92. ChaSigning the informed consent, the subject agrees to comply with the artificial experimental life rules and is willing to respect these rules as much as possible, far more than in real life . This isAs described by McCambridge, the “awareness of (…) having behavior assessed engenders [in the subject] beliefs about researcher expectations. Conformity and social desirability considerations then lead behavior to change in line with these expectations .” This iThe HE is often mitigated to the observation bias, without going more in depth into the concerns of this effect. The awareness of being possibly observed, assessed, and singled out engenders in the subject and in the investigator a special emphasis regarding the three previous biases , 58, 87.We found important differences across studies or within individual studies regarding the HE. Four main groups of factors seem to determine this heterogeneity: education and literacy or professional position, mental health conditions, environmental factors of the study setting, and the type of outcome measures.There were important differences between nurses (more prone to HE) and physicians, and in physicians between medics (more prone to HE) and surgeons , 79. In The presence of symptoms such as anxiety and depression contribute to enhanced behavioral changes when people are aware of observation , 48, 70.Regarding HH, the effect was clearly more marked in medicine wards than in surgery or anesthesia wards in hospitals , 79, 89.The more the main outcome is linked to psychological or behavioral factors   and by tI2 computing at 97% illustrates that the whole of the variance can be explained by heterogeneity. However, this heterogeneity is to be imputed to observational studies and studies with a poor methodology. Sensitivity analysis found that heterogeneity and the significance of the HE for binary outcomes disappear in well-designed controlled studies.Regarding heterogeneity in the meta-analysis of all the studies, it is notable that the Regarding the overall publication bias, the chimney plot did not illustrate an exaggerated risk with a well-balanced distribution of the results around the total OR  cannot exemplify a complex system. We note that adding “apples and oranges” may cause suspicion, but brought up less heterogeneity than HH studies using the same comparator in different hospital wards. This is related to the fact that the computed data for comparison in the meta-analysis are effect sizes and standard errors.Considering the literature, this heterogeneity in the analysis of all studies was expected and we could have decided not to publish the computation of the meta-analysis as per Purssell et al. . In lineRandomized controlled trials (RCTs) in parallel groups are prone to the HE, but as groups are equally exposed to the effect, its impact on the main outcome might be reduced . This miRandomized controlled trials are often cluster randomized in primary care for feasibility reasons. The randomization level is mainly the GP investigator, and the cluster is defined as the group of patients of this GP. As a matter of fact, this emphasizes the influence of the selection of investigators on the results. The introduction of the intra-class correlation coefficient in the calculation (ICC) of the sample size is supposed to erase the effect of this bias on the results of the main outcome, but in most cases this ICC is estimated without certainty, based on the literature. Knowing the heterogeneity of the HE, the feasibility of computing exactly this ICC seems inaccessible.The main risk, when the HE is not correctly mastered in an RCT, occurs when the effect size of the main outcome is small. If the size of the HE turns out to be important, it might overwhelm the results of the main outcome and lead to a negative trial . This isAs noted, patients change their behavior by the start of the trial, and baseline values are prone to the RTM , 43, 51.Implementing an RCT in primary care also means a profound disruption in the patient–doctor relationship. The latter changed during the past decades from a paternalistic model to a more balanced model of mutual participation . This reBased on the findings of this review, we assessed whether the RCT we implemented regarding the impact of posters and pamphlets in GPs’ waiting rooms had been biased by a HE . The desThe HE probably has more consequences for the outcome of observational studies than RCTs, as it directly influences the results, without the balance of a control group. This statement matches the findings regarding observational studies in our meta-analysis.The selection of the investigators in primary care will be influenced by the interest of the investigator in the topic and the prevalence of the studied condition among his/her patients. If patients are in general comparable, the way they are managed and educated by their physician might deeply differ due to a different level of commitment  . For simObservational studies will also ignore all the persons who are affected by a condition but are not aware of it or are not willing to address the condition. Similarly, it will ignore people who are not participating in diverse screenings. This highlights the problem of blind spots in primary care research.Compared to usual care, conformity and social desirability will probably change the managing behavior of the investigator, the level of adherence and compliance of the patient, and the data collected in the CRF. Retrospective data will be altered also by conformity as well as by memory failure, with a trend to embellish vague recollections.Qualitative research collecting data rooted in semi-structured individual or group interviews will probably be biased by the HE when the interviewee is a patient or a doctor and the interviewer is a doctor him/herself. The relationship between a patient and a doctor or between two doctors will tend to increase social desirability bias and conformity bias because the interviewee is willing to meet the interviewer’s supposed expectations. This deviance might be even more underlined by the signing of a consent form and the recording of the interview that accentuates the need to provide an interest . As a crAlong the same lines, people who have a poor level of literacy or education will be more prone to refuse the interview as they are frightened they will not be able to reach the expected level of interest in the interviewer’s supposed expectations. Persons who feel guilty about breaking the rules in light of the norms of their social group  will refuse the interview due to shame or fear of being discovered, or may not be willing to go further into transgression. In both cases, essential information will be lost to evidence.The Hawthorne effect results from a complex system of interacting psychological and social phenomena and appears in all experimental research thereby diminishing external validity. It combines the mobilization of feedback loops at different levels and time, encompassing social selection, individual motivation, commitment and congruence, social conformity and desirability, and the awareness of being observed, several times assessed, and singled out. There are overlapping areas with the regression toward the mean and the placebo effect. Observational studies or studies with a poor level of evidence are more prone to a HE.The original contributions presented in this study are included in the article/CB designed the study, searched, selected, and analyzed the published reports, conducted the meta-analysis, and wrote the manuscript. OB searched, selected, and analyzed the reports and wrote the first draft. JF designed the study and tracked the conformance of data management. MC designed the study and amended the first draft. CC copyedited and revised critically the reports for important intellectual content. LP and PV supervised the design of the study and revised critically the manuscript for important intellectual content. All authors gave their final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved.


Despite recommendations, mammography screening is often insufficiently integrated into specialist breast centres. A national, cross-sectional, voluntary, online survey on this issue was carried out among the Italian breast centres associated with Senonetwork, the Italian network of breast cancer services.A 73-item questionnaire was created, pre-tested and piloted. Centres integrating and not integrating a screening programme were compared using the unified theory of acceptance and use of technology (UTAUT) model. Centres’ clustering was performed using the Gower’s distance metric. Groups and clusters were compared with the equality-of-means test.The response rate was 82/128 (65%). Overall, 84% (69/82) breast centres reported a collaboration with a screening programme in performing and/or reading mammograms and in the diagnostic work-up of women with abnormal screening results. The same proportion was observed among those centres responding to all questions (62/74). Performance expectancies , satisfaction and motivation were higher in those centres collaborating with the screening programme. Effort expectancy indicators (or the degree to which the respondents believe that the integration is easy to implement) and those concerning the existence of facilitating conditions were lower both in centres collaborating and not collaborating with the screening programme. Among the former, six clusters of centres, distributed from ‘no integration’ to ‘high’, were identified. In cluster analysis, the highest level of integration was associated with higher agreement that integration eases the job, offers better opportunities for professional growth, and makes the working environment more satisfactory. The least integrated cluster assigned the lowest score to the statement that local health authority made available the resources needed.While confirming the positive effects of integrating screening programmes into breast centres, this survey has brought to light specific difficulties that must be faced. The results provide insights into the importance of integration focusing on the perspectives of professional career and motivation. The deficiency of facilitating conditions to integration is modifiable. Screening professionals’ societies may have a role as initiators of the integration. Other supporting actions may be included in health laws at the national and regional level. A breast centre  is defined as the place that provides all breast care services on a multidisciplinary basis, including genetics and prevention, treatment of primary tumour, care of advanced disease, supportive and palliative care, survivorship care and psychosocial support . Since oThe EUSOMA  position paper in which the correct standards for the set-up of breast centres were first issued was published in 2000 . In 2003This is also the case for the integration of mammography screening programmes into breast centres . The EUSScreening providers have suggested other –and equally compelling– reasons for recommending that mammography screening services be part of breast centres . First, Despite this, another Joint Research Centre survey has reported that, in 40% of the EU countries, the processes and services constituting the breast cancer care pathway differ in the level of supervision for organisation and quality by an external authority . The levIn Italy, the situation is ill-defined. Although the Italian Group for Mammography Screening  endorses the recommendation of the EUSOMA , there aThe survey was designed considering that (i) the process of creation of breast centres, in Italy and elsewhere, is incomplete  and qualIntegration of care is a multidimensional concept that has received enormous attention in the health care research domain. More than 170 overlapping definitions are available  making iMoreover, the survey included items aiming at investigating the perception of professionals in working through the integration process. Perception (human factors) has considerable relevance in the processes of acceptance and facilitation of the introduction of changes in work practice because expectations have a significant impact on behaviour. Exploring the mechanisms that influence the intentions to implement specific behaviours and the behaviour itself is useful for bringing out what can be the determinants of a high/low level of acceptance of change. In the literature, the model of the Unified Theory of Acceptance and Use of Technology (UTAUT), developed through the revision and integration of eight dominant theories and models of the behavioural and organisational sciences, offers an interesting reading on the intentions to implement specific behaviours  and the behaviour itself (use behaviour) . AccordiThe performance expectancy represents how much an individual believes that technology will help him to obtain advantages in carrying out his work, also in terms of greater usefulness and better performance results. The effort expectancy is understood as the level of ease of use of the technology and represents how much an individual believes that the use of technology is easy. Social influence is defined as the degree to which an individual believes that those who are important in the context of implementing the technology believe that the technology should be used and strongly recommend it. In fact, it represents the positive influence that those deemed influential have with respect to the use of technology. The facilitating conditions are defined as the degree to which an individual believes that the technical and organisational infrastructure exists to support the use of the technology. In the UTAUT model, the first three constructs, namely performance expectancy, effort expectancy, and social influence, have an effect on the intention to use the technology, while actual use is conditioned by the intention to use and the facilitating conditions.The UTAUT model has been developed and widely used to analyse the level of acceptance and use of innovations in different fields and sectors , includiThe quali-quantitative analysis reported in this article was specifically aimed (i) to determine the proportion of breast centres collaborating with a screening programme, and to evaluate the correlates of collaboration versus non-collaboration, (ii) to cluster the breast centres collaborating with the screening programme based on the taxonomy of integration, and (iii) to identify the correlates of these clusters.In Italy, the national legal framework implementing the 2003 and 2006 resolutions of the European Parliament , 5 was iThe project was developed and implemented following the survey conduction best practices proposed by Burns et al. . The queThe questions on the integration of screening programmes into breast centres were developed using an adaptation of the taxonomy proposed internationally , 16. A mThe final version of the questionnaire consisted of 73 questions under the following domains: (i) breast centre’s identification and main characteristics including, among others, the certification according to the EUSOMA standards   is available at the website of the GISMa .An ancillary article reporting on a secondary endpoint, that is, the provision of follow-up care for women with a history of breast cancer, has been previously published .https://it.surveymonkey.com/) and successfully piloted by one volunteer breast centre for technical functionality of the online instrument.Before full deployment, the survey was pre-tested on a sample of three breast centres from different administrative regions – supposedly characterized by different breast centre models. Based on their feedback, we refined and clarified unclearly-worded, ambiguous, misleading, or non-relevant questions. The survey was subsequently loaded onto the SurveyMonkey platform  targeting the centres associated with Senonetwork, which number is known, in order to calculate a response rate and (ii) using the proportion of participating centres that reported being appointed by a regional administration as an indicator of unselected composition of respondents.An invitation to participate was sent via e-mail to the clinical leads of eligible breast centres, or the main contact persons. The e-mail contained a link to the online instrument. The survey was conducted between July 2020 and October 2020. To increase the response rate, a reminder e-mail was sent. No financial incentives were offered.For the purposes of the present analysis, selected items from the questionnaire were used. Standard statistics, including frequencies, proportions, medians, ranges, and interquartile ranges, were used to summarise the characteristics of respondents to the survey.For the items developed under the UTAUT framework on the perception of utility, effort required, acceptability of the integration, and facilitating conditions, the homogeneity of the mean of the reported scores from 0 to 100 between breast centres integrating and non-integrating a screening programme was evaluated with the equality-of-means test. To rule out confounding, the two groups were compared for a set of control variables including the number of years of professional experience of the clinical lead, the number of working years at the breast centre, age, and gender.Clustering of respondents was performed using the Gower’s distance metric. The choice of the number of clusters was made by using the agglomerative clustering, which minimises the distance between elements of each cluster, and by visually inspecting the results on the dendrogram. The variables included to classify the clusters were based on the dimensions of integration , 16, thaP < 0.10.For all analyses, the level of statistical significance was set at Of the 128 breast centres associated with Senonetwork on 1 July 2020, 82 (65%) replied to the survey and 74 (58%) responded to all questions. Fifty-three (65%) of total 82 questionnaires were from northern Italy. Respondents reported a median of 345 new breast cancer cases seen per year . All of them but one (99%) reported a number of breast cancer cases seen per year > 150. The median number of breast radiologists was five . The median number of mammograms per year was 15,000 . Sixty-one (74%) of respondents were regionally-appointed. There were 24 (29%) breast centres certified according to the EUSOMA standards.Overall, 84% 69/82) breast centres reported a collaboration with a screening programme – the same proportion observed among those centres responding to all questions (62/74). In Table  breast cSeventy-four valid responses were analysed for these endpoints, including the 62 respondents declaring to have an integration with the screening programme and the 12 professionals who reported no integration. As shown in Table As regards effort expectancy as well as facilitating conditions, the scores were all lower and non-significantly different between the two groups of responses.The clinical leads of breast centres collaborating with the screening programme expressed a greater agreement with the two statements concerning satisfaction and motivation, and agreed more often than their colleagues about the importance of integration of screening programmes into breast centres.Among the 62 valid questionnaires completed by professionals reporting some type of integration with screening programmes, six clusters of breast centres were identified based on the observed level of integration by dimension of integration. This choice was based on the agglomerative clustering and the distance between elements of each cluster.Table  P < 0.04), number of radiology technicians or radiographers , and a greater mammogram reading volume .Table With respect to performance expectancy, the same centres reported a greater agreement that integration eases the job and offers better opportunities for professional growth. In parallel, centres with low or no integration disagreed more often with the statements that integration makes professionals more confident both of the clinical quality of patient care and of patient convenience, and that it offers better professional opportunities.Regarding effort expectancy, the centres classified as highly integrated expressed a greater agreement that the management skills needed for the integration are easy to acquire, which was paralleled by an opposite finding among low-integration centres.With respect to social influence, low-integration centres reported a significantly poorer agreement that peers think that the integration is important.Unequivocal findings were obtained as to facilitating conditions, focusing on the role of local health authority. Highly integrated centres responded more often affirmatively to the question of whether the organisation did enable the clinical lead to acquire the management skills needed and did develop an official protocol for breast cancer care. The opposite occurred among low-integration centres.As a final remark, the section of the questionnaire concerning ‘satisfaction and motivation’ showed that poorly integrated centres agreed less often with the statements that the integration makes the working environment more stimulating and more satisfactory. Regarding the latter, the clinical leads of highly integrated centres had an opposite opinion.Incidentally, the cluster with the lowest level of integration assigned the lowest score to the question of whether the organisation made available the resources that are needed for the integration.The above results may be summarised as follows. On the one hand, the proportion of breast centres reporting that they collaborate with the local screening programme was higher than expected, and was associated with the annual number of treated breast cancers and the BCCert certification.On the other hand, however, the quality of integration varied greatly and was medium to low in most instances. Overall, the survey confirmed the positive effects of integrating screening programmes into breast units but, more important, the results brought to light some specific difficulties that must be faced.Performance expectancy may be viewed as the degree to which the respondents believe that the integration has improved (or will improve) breast services, that is, its perceived usefulness. We evaluated four indicators and found that they were all significantly higher in those breast centres integrating a screening programme, which was also the case for the indicators of satisfaction and motivation. The statement that integration makes more confident both of the clinical quality and the convenience of patients and eases the job was largely agreed upon, indicating that there are beneficial effects for the staff of breast centres as well as the attending women.The findings were different for effort expectancy indicators, which measure the degree to which the responding breast centre clinical leads believe that the integration is easy to implement. The scores were lower in both groups of responses. This means that feasibility concerns may discourage those who have never undertaken the integration and are shared by those clinical leads who did it. The many problems affecting the creation of breast centres in all European countries  have been described .This consideration brings us to another predictable finding. Those survey participants who had experienced the integration of a screening programme reported that no particular facilitating conditions were promoted for the integration. Compared with respondents reporting no integration, they did not receive more institutional support with respect to resources and managerial training. Unexpectedly, the availability of an official protocol for the management of breast cancer, which is expected to facilitate the unification of breast services, had not any such effect. Overall, these findings would suggest that a successful integration depends greatly on the personal commitment of the clinical lead rather than reflecting institutional strategies and policies. To some extent, this confirms the view publicly expressed by the GISMa  that an Cluster analysis was performed in order to obtain a more detailed representation of the many and multifaceted differences associated with different levels of integration of screening programmes. The results confirmed the marked heterogeneity of Italian breast centres. A higher number of breast radiologists and radiographers and a greater mammogram reading volume were expected characteristics of those breast centres classified as highly integrated with a screening programme. Also, this cluster reported a significantly higher agreement that integration eases the job, offers better opportunities for professional growth and makes the working environment more satisfactory. Noteworthy, the availability of an official protocol for the management of breast cancer and the local health authority’s support, which did not discriminate significantly between centres integrating and non-integrating a screening programme (see above), were two correlates of this cluster alone. These are key observations, because they indicate two essential prerequisites for an optimal integration.The clusters with the lowest level of integration or no integration expressed a lower level of agreement with most statements, with a combination of poor expectancies, poor social support, poor facilitating conditions, and poor propensity. The –by far– lowest score was assigned to the question of whether local health authority has made available the resources that are needed. This is another finding worthy of consideration.There are some major methodological issues in this study that need to be addressed. The first regards the representativeness of participating centres. Since an official national list of breast centres was not yet available, we targeted for the survey the pool of centres associated with Senonetwork, which we consider to represent an acceptable approximation. The response rate was 65%, a figure sufficient to ensure that the validity of results is not threatened by a substantial nonresponse bias. Two-thirds of responding centres were situated in northern Italy, but this reflects the higher density of breast centres and the two-fold greater prevalence of active and efficient local screening programmes in the north of the country, with > 85% of women aged 50–69 years being regularly invited to mammography versus approximately 40% in southern Italy , 28. TheThe second methodological issue to consider is that this study is a cross-sectional survey. Consequently, we cannot exclude the biases related to this kind of design , 30. To Third, a reason for caution in interpreting the results is that the operational difficulties caused by the COVID-19 crisis has led to a delay in the roll-out of the survey after pilot and in the discussion of the findings before publication. For the same reason, however, it is highly unlikely that the observed problems have been overcome –or at least partially addressed and remedied– since the survey was done. Many countries, including Italy, have suspended or limited cancer screening services as part of their response to the pandemic .As regards policy implications, it is important to note that the deficiency of facilitating conditions  is modifiable. In particular, screening professionals’ societies may have a role as initiators of the integration, and this role can be boosted by sharing the screening principles with the clinical counterpart and by promoting research and education initiatives in a multidisciplinary environment. Other supporting actions can be included in health laws at the national and regional level, such as raising the minimum activity volume threshold for breast centres, making an official integration protocol available, and providing support, resources and managerial education.The results of the survey provided insights on the importance of the integration of screening programmes into breast centres focusing on the perspectives of professional career and motivation. This is a pivotal element in the process of facilitating the organisational innovation. Although requiring additional effort, integration seems to be a powerful lever to promote professional interests. The deficiency of facilitating conditions is modifiable. Further research will have to update the baseline described here and give due attention to elucidating the relationship between the degree and dimension of integration and the whole breast cancer care pathway.


Empirical studies undertaken in developed countries have shown that urban expansion may exert both positive and negative impacts on residents’ health, depending on the planning strategy; however, the impact of rapid urban expansion on public health in developing countries is understudied. This paper takes Jiawang, China, as an example of rapid urban expansion and carries out a health impact assessment (HIA) on its regulatory detailed plan to better understand the interaction of the built environment and public health. We establish an HIA framework and select a series of indicators as health determinants. On this basis, we examine what impact the urban expansion will exert on the health equity of the residents by conducting a bivariate spatial autocorrelation. The finding shows that:1) Urban expansion produces positive health impact through the health determinants of public facilities, road transportation and land use. 2) Urban expansion will reduce health disparities between the old and new town and between the urban and suburban areas, especially between the old and new town. 3) The impact of expansion exerts on health equity will be generally positive. Low-income neighborhoods in the old town will significantly benefit from urban expansion in terms of road traffic and land use, but will not fully benefit in terms of public facilities. Low-income neighborhoods will no longer benefit from the accessibility to commercial facilities and will suffer from health inequities in terms of accessibility to healthcare facilities. 4) The government’s development strategy of emphasizing on an even distribution of public resources will unintentionally contribute to improving health equity. The significant promotion of health equity will mitigate the negative impacts of the previous urban development. Small city is the dominant urban administrative unit in China. According to the division standard of urban scale issued by the Chinese State Council in 2014, a city with a permanent population of less than 500,000 can be defined as a small city . This urA unique characteristic of urbanization in China is that the urbanization of land is faster than that of the population . ResearcHealth impact assessment (HIA) is an analytical tool and research method that focuses on human health to work toward environmental justice and health equity . AccordiResearch on the impact of urban expansion on public health was first provided by an HIA conducted in Humboldt County, California, in the United States. According to the HIA, unrestricted growth and expanded development could cause decreased physical activity and social cohesion, and greater dependence on cars . CurrentIn this paper, we use a regulatory detailed plan to establish a scenario for future urban expansion in China and study the connections between the regulatory detailed plan, the built environment, and public health. The aim of the current study is threefold: firstly, we aim to establish an HIA framework applicable to the evaluation of China’s small cities, and to examine the extent to which urban expansion will impact public health through a case study; secondly, we determine how the urban expansion will affect existing health disparities in the city by comparing the spatial differentiation of health determinants in the built environment before and after urban expansion; thirdly, we examine what impact the urban expansion will exert on the health equity of the residents by examining the correlation between housing prices alongside the distribution of health determinants.The theoretical framework for this study is based on the theory of "urban health niche" , which iAccording to the theoretical model of the urban health niche, the impact of urban planning will be decipherable through multiple health-defining processes . As a poThere is wide ranging research establishing how the built environment affects individual behavior and living habits at the meso scale. Based on existing literature, we summarize the impact paths of urban planning on public health as obtaining public services , reducinJiawang epitomizes the vast small city that dominates China’s geography. It is located in the northern Yangtze River Delta, a relatively underdeveloped area in one of the most developed regions in China. Jiawang has experienced rapid development in the past twenty years. Although its population only increased from 496,900 to 520,700 between 2000 and 2015, the ratio of agricultural households to non-agricultural households shifted from 65.28:34.72 to 44.50:55.50, indicating that at least 20% of the population underwent urbanization within those 15 years. During the same period, Jiawang’s GDP increased from 5.523 to 28.425 billion yuan, and recorded annual investments in fixed assets increased from 818 million yuan to 21.965 billion yuan.https://usgs.maps.arcgis.com/home/item.html?id=474c65ab3e1941468511785495eb8987). Due to Jiawang’s rapid urbanization, a new town emerged on the east side of the old town  combined with China’s urban management system. A regulatory detailed plan follows a master plan with a focus on land use control. This type of urban planning specifies land use types, land use intensity and environmental design as the basis for urban planning management. In addition, by providing regulations for land lease and transfer, a regulatory detailed plan directly guides urban development and construction. This form of systematic planning has a comprehensive impact on the built environment by specifying an ordinance that all development projects should follow; therefore, a regulatory detailed plan can be used as a projection of future urban expansion. In Jiawang, the regulatory detailed plan divides the city into multiple control units, and determines land use, building codes, transportation and public facility availability for each control unit. The control unit is deployed as the unit for spatial analysis in this paper  at the neighborhood-level and city-level are selected to assess whether and to what extent the plan will improve public health, compared with the current status . The selFor school coverage, according to China’s regulations on the allocation of educational facilities, the service scope of kindergartens, primary schools and secondary schools is determined as 500m, 1000m and 1500m respectively. The service area is simulated based on the road network model built with ArcGIS 10.5 software. The data of various educational facilities is obtained from the area and distribution in the current and planned land use map.For accessibility, based on the road network model built in ArcGIS 10.5 software, the OD matrix is used to calculate the shortest travel distance and travel time. The travel probability from each junction to each destination is calculated, and the average weighted travel time is calculated to obtain accessibility. The road network is acquired from the planned land use map. The population in the plan is estimated based on the current residential density and the residential land area in the plan.In our analysis of the residential environment, the impact of construction quality and noise pollution is considered. We do not consider air quality because it is lack of variation due to the relatively small size of the city. First, we calculate the total residential area in each control unit that is designated a poor construction quality according to the land classification in the current land use map. Second, we calculate the total area in each control unit suffering from noise pollution. The noise sources are designated to be industrial land, logistics land and public transport station, and the noise level is set to be 79dB by averaging the noise levels of different types of vehicles. Based on the standard for urban residential area planning, the noise level in a residential area shall not exceed 50dB. According to the natural attenuation of noise, a 200m buffer zone is required for a 29dB (79dB-50dB) noise reduction. Therefore, we calculate the total area of residential land that is within the 200m buffer of the above noise sources in each control unit. The data of the residential area, industrial land, logistics land and public transport station is acquired from the current and planned land use map.Mi represents the level of mixed distribution of different land use types within a certain range [K is the number of land use types. Pk,i is the area proportion of K land in control unit i. The land use mix values usually range from 0 to 1, with 0 representing a homogeneous, single land use environment, and with 1 representing a perfectly heterogeneous neighborhood comprising all possible permutations and combinations of land use categories. The data of land use type is acquired from the current and planned land use map.We use land use entropy to evaluate land use mix. The land use mixed degree in range . The calhttps://xuzhou.anjuke.com/?from=) in 2021. We collect 249 residential areas. Among them, 145 residential areas are matched to the map using GIS. We retain a total of 97 residential areas out of a possible 145 by filtering out repeated addresses, residential areas that cannot be accurately located and residential areas located outside the study area. The distribution of Jiawang’s housing prices is obtained through kriging interpolation, and the average housing prices of the control units are calculated  suggests that localities with a larger presence of disadvantaged residents are in need for better access to public services and goods . TherefoUsing GeoDa software, we perform bivariate spatial autocorrelation analysis. The queen contiguity approach with the first order of neighbor was chosen to manage the spatial weights. Moran’s Index and cluster maps are obtained through bivariate spatial autocorrelation measures. Moran’s Index ranges from −1 to 1, with 0 indicating a completely random spatial arrangement. Four types of spatial association can be identified in the cluster maps, which are High-High, Low-Low, High-Low and Low-High. High-High and Low-Low types indicate a positive spatial association between one unit and its neighbor units, while High-Low and Low-High indicate a negative spatial association between one unit and its neighbor units.We calculate the average value of all control units for the current and projected expansion scenarios, and calculate the percentage change between these two scenarios .As shown in The values of the 14 health determinants for the 71 control units before and after urban expansion are shown in Spatial differentiation is pronounced both in the current situation in Jiawang and in the improvements seen with the regulatory detailed plan. These spatial differentiations are thus also reflected differently in the health determinants. The spatial differentiation is mainly reflected between the urban and the suburban areas. In addition, it is also reflected between the old town and the new town in some indicators. For instance, in the current situation, significant spatial differentiation exists across the public facilities, road transportation and land use. Accessibility to green space, recreational facilities, healthcare facilities and commercial facilities shows significant mono-center agglomeration in the new town. Accessibility to educational facilities is also highly concentrated in specific areas, such as the urban area of the old town and just south of the new town. Green spaces are relatively concentrated in the suburban area. The urban road network density and intersection density is higher than that in the underdeveloped suburban area. Significant spatial differentiation exists in land use between the urban area and suburban area as well.In the plan, the spatial differentiation of health determinants between urban areas and suburban areas will continue to exist, only weakened compared with the current situation. Green space related indicators still will be higher in the suburban area. Accessibility to green space, educational facilities, recreational facilities and healthcare facilities will all show patterns of spatial differentiation in Jiawang, but will not highly concentrated in some areas. Notably, accessibility to commercial facilities will be highly agglomerated in some areas such as urban areas, the Moonlake area, and the Fengminghai area. The spatial layout of land use and road traffic will be similar, and will be relatively higher in the urban area.Based on the HIA of the regulatory detailed plan, we carry out bivariate spatial autocorrelation to explore the possible spatial association between housing prices and health determinants, as well as to examine the differences between the current situation and the post-expansion plan. Moran’s Index between housing prices and the health determinants is shown in In the current situation, half of the 14 bivariate Moran’s Indexes are statistically significant, and the number will increase to 12 after expansion. Bivariate Moran’s Index of housing prices and commercial facility accessibility is only significant in the current situation. Spatial correlation of housing prices and six health determinants will be only significant in the plan, which are service area of educational facilities , accessibility to recreational facilities, urban road network density, and residential environment. Among them, recreational facility accessibility will be positive while the other indicators will all be negative.The results of bivariate Moran’s index indicate that the change of spatial association between housing prices and significant health determinants will occur in three ways after expansion: 1) changing from a positive association currently to a negative one in the plan, including land use mix, accessibility to healthcare facilities, proportion of green spaces and per capita green space. This is the most common pattern of change. 2) Changing from a negative association currently to a positive one in the plan, which only occurs to housing prices and green space accessibility. 3) The bivariate Moran’s Index of housing prices and intersection density is negative with larger absolute values in the plan, thus indicating that they will have a stronger negative association.As is shown in In the current situation, Low-Low association is mostly found in the Moonlake area, while High-High association is mostly found in the urban area of the new town, indicating that in these regions, wealthier neighborhoods can enjoy a healthier built environment while poorer neighborhoods suffer from a lack of health resources. Low-High association mainly appears in the urban area of the old town and High-Low association mainly appears in the Fengminghai area in the suburban.After expansion, fewer positive association and more negative association patterns including High-Low and Low-High are shown. Negative association will be found between housing prices and almost all health determinants. Most High-Low neighborhoods will be situated in the Fengminghai area of the new town while Low-High neighborhoods will be situated in the central area of the old town, indicating that poorer neighborhoods will benefit greatly from the expansion. Both High-Low and Low-High distributions will be relatively concentrated. In some cases, High-Low neighborhoods will also appear outside the Fengminghai area. For example, High-Low blocks will be situated in the south of the new town in terms of housing prices and proportion of green space, per capita green space and service area of educational facilities. Low-High neighborhoods will appear in the Moonlake area regarding three green space relating health determinants and accessibility to recreational facilities.High-High association will be found between housing prices and accessibility to recreational facilities, healthcare facilities and commercial facilities, and these will mostly appear in the new town. Low-Low association will still mainly appear in the Moonlake area. However, compared with the current situation, Moonlake’s Low-Low association will only be found between housing prices and accessibility of healthcare facilities. Also, the number of Low-Low control units will be less than that of the current situation.According to the cluster maps, health inequities between areas with different housing prices will continue to exist after the enaction of the plan, however, the spatial association patterns will change. The High-Low and Low-High associations in the plan will be strengthened, while the High-High and Low-Low associations will be weakened.According to the analysis of various determinants, the built environment regarding public health will be significantly improved after urban expansion. This improvement will be mainly reflected in terms of better access to public facilities, more appropriate land use and less congested road transportation.In the process of urban expansion, the road network is often the primary focus for urban planners. Therefore, it is common to see a positive impact on public health in relation to road transportation. In the plan, the complicated and chaotic road network in the urban area of the old town is redesigned, and systematically extended to the suburban area. Therefore, in terms of road traffic, network density and intersection density will see significant improvement.As the road network is adjusted, so too will land use be reassessed and reallocated simultaneously. The rearrangement of various types of land use in the plan will have a significant impact on land use patterns in Jiawang overall. Currently, land use is structured in a relatively simple way in the remote suburban areas of Jiawang: the plan will increase the land use mix in these areas. With the increasing demand for residential areas, residential land will expand. As a result, the residential density in the suburban area will increase. The residential land with poor environment in the old town will be redeveloped, the overall residential environment sees beneficially shifts.The plan also pays attention to the distribution of public facilities. For example, with the growth of population and the expansion of residential areas, recreational facility and commercial facility accessibility will be greatly improved, especially in the suburban area. The plan for green space mainly focuses on a large-scale green space development in the suburban area since, with the development and utilization of the suburban area in the expansion, the amount of green space in the suburban area will decrease. The educational facilities are also rearranged by delimiting the service area. In doing so, the service area of various educational facilities will be significantly improved, and the distribution of educational resources will be more even across all areas.Urban expansion in the plan will change the spatial differentiation patterns across various health determinants. This spatial differentiation corresponds to the expansion process of Jiawang, between the old town and the new town, and between the urban area and the suburban area.Currently, the spatial differentiation between the old town and the new town mainly exists in the realm of public facilities. The main reason is that during the urbanization process, the government vigorously supports the development of the new town through superior public resource allocation. The river and surrounding natural environment that originally separated the old town from the new town will provide better access to green space in the new town. The urban structure will revolve after the planned expansion, resulting in significant functional differences between the old town and the new town. New town and old town will no longer be separated from each other, but functionally interconnected. The spatial differentiation between the old town and the new town will thus be greatly weakened.The spatial differentiation between the urban area and the suburban area lies in almost all health determinants of public facilities, road transportation and land use. Currently, this is mainly due to the mono-central structure of the urban area. The planned expansion will still result in relatively low residential density in the suburbs while the allocation of public facilities will be enhanced in this area. The spatial differentiation between the urban area and the suburban area will be reduced compared to the current situation, such as accessibility to various types of public facilities. The almost ubiquitous gap between the urban area and the suburban areas can be regarded as a reasonable decision based on the efficiency of resource allocation and a typical phenomenon in the expansion of small cities ,48.Given the health disparities existing in the current and after expansion, our research focused on the possible health inequities and how particular subgroups might be affected. The current bivariate Moran’s Index suggests low-income neighborhoods suffer from health inequities in several health determinants, especially in terms of public facilities. In the current situation, high housing price concentrations are associated with land use mix, green space accessibility, proportion of green space and per capita green space, whereas low housing price concentrations are associated with healthcare facilities accessibility, commercial facilities accessibility and intersection density.Compared to the current situation, expansion influences health equity among several health determinants. Low-income neighborhoods will benefit from the improvement of the amount of green space, green space accessibility, service area of educational facilities, recreational facility accessibility, urban road network density, intersection density, residential environment and land use mix. Among them, the improvement of green space will be relatively more significant. However, it is unlikely that urban expansion will have a positive impact on health equity in all respects. Low-income neighborhoods will no longer benefit from accessibility to commercial facilities after expansion. Low-income neighborhoods in the old town will suffer from inequities in accessibility to healthcare facilities.Overall, the expansion will result in significant improvements in health equity. Results suggest that low-income neighborhoods will not be disadvantaged in land use and road transportation, but will not fully benefit from public facilities. We speculate that the development strategy will be the possible explanation for this positive health outcome. The development strategy of emphasizing on an even spatial distribution of public resources is deeply involved in the regulatory detailed plan, as well as the functional positioning of different areas. The functional positioning of old town to provide public services will give low-income neighborhoods an advantage in various health resources such as recreational facilities and educational facilities. Besides, the compact urban form of the old town will unintentionally benefit the low-income groups in terms of road traffic and land use. Therefore, the improvement of health equity is not an entirely planned outcome, low-income groups will be benefiting from the urban expansion in an unintentional way. The current housing price differentiation was exacerbated by the government’s development strategy in previous expansions, including the prioritization of improving public facilities, the natural environment and the living space in the new town. Rather than saying health equity will be greatly improved by expansion, we argue the fact is that the health inequity left by the previous rapid urban development will be partially remedied.The association between housing prices and health determinants is an issue worth discussing. Housing is a commodity with high demand, and housing prices are closely related to resident income level and quality of life . Health Contrastingly, in Toronto, Canada, it is observed that housing prices are negatively correlated with accessibility and positively correlated with distance to transit stops, cultural centers and schools . For bigAlthough numerous studies have provided both theoretical and empirical evidence on urban planning’s impact on public health, no universal framework of HIA for urban planning has been established, largely due to the problem-driven nature of HIA in practice. We argue there is no one-size-fits-all HIA method and its implementation should be case specific. For instance, one limitation of our framework is that we did not consider the weight of the health determinants. Perhaps a more convincing weight distribution can be obtained through meta-analysis as propose , by asseThe regulatory detailed plan of Jiawang reflects the typical urban expansion process seen across China as small cities continue to rapidly expand. To our best knowledge, this is the first HIA to evaluate the health impacts of urban development in small cities in China. The results are as follows:1) According to the health impact assessment of the urban expansion that the regulatory detailed plan outlines, there will be positive health effects across public services, land use and road transportation when a plan is in place. 2) The spatial differentiation pattern of health determinants will change after expansion, as the health disparities between the old town and the new town will be greatly alleviated, and the gap between the urban and the suburban areas will narrow. 3) Health equity will be greatly promoted after expansion. Low-income neighborhoods usually will not be disadvantaged in road transportation and land use, but may suffer from health inequities in healthcare facility access with regard to public facilities. 4) It is the previous rapid urban expansion that has exacerbated the housing price differentiation. The improvement of health equity is an unintentional health outcome of the government’s development strategy. The positive impact on health equity that low-income neighborhoods will enjoy is a by-product of urban expansion.For small towns in China, urban expansion will have significant positive health impacts on land use and road transportation, but may have negative impacts in terms of public facilities. Therefore, we put forward the following suggestions for small cities’ expansion in China:First of all, more attention should be paid to the dynamic impact of expansion on residents’ spatial distribution before making decisions, and a more reasonable spatial association should be constructed at a larger scale in the process of expansion. Secondly, the differences of functional positioning between areas often lead to spatial differentiation in public facilities, which may exert negative health impacts on low-income neighborhoods due to allocation of public facilities. A series of measures can be taken, such as improving the allocation of recreational and healthcare facilities, so as to provide residents with diversified health-promoting public facilities. Thirdly, few health impact assessments have been carried out in urban planning in developing counties such as China. It is recommended that health impact assessment be applied to analyze the current health disparities and health inequities and to address health issues resulting from the rapid urbanization.S1 Fig(TIF)Click here for additional data file.S1 File(CSV)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.


Numerous studies have addressed the indirect consequences of the COVID-19 pandemic for children such as social isolation or increases in reported child maltreatment. Research on the economic and sociopolitical consequences is scarce as they can only be evaluated with a time lag. To improve our understanding of future, long-term developments in the context of the COVID-19 pandemic, we gathered findings from the still unexploited empirical literature on the aftermath of earlier pandemics, epidemics, and other infectious disease outbreaks. On top of this, we scrutinized research on past economic crises to interpret the link between changes in the economy and the health of children. Many of the side effects of battling the spread of the current pandemic, such as school closures, the stigma of infection, or conflicts about vaccines, are not novel and have already been documented in connection with previous infectious disease outbreaks. Results highlight that changes in the financial situation of families and socio-political challenges affect the situation and daily routine of children and youth in the long term. In consequence, the already pronounced socioeconomic inequalities will likely further increase. On top of this, due to reduced revenues, child protective services are likely to face challenges in the availability of human and financial resources. At the start of the COVID-19 pandemic, direct consequences of the lockdown measures for children and adolescents were observed, such as an increase in family violence and social isolation , but lonIn addition, during the pandemic, the life situations of children and families with supposedly ‘secure’ social and financial circumstances in the past can change. With an aggregation of factors that lead to financial difficulties, such as reduced income due to short-time allowances, unemployment, and rising rent levels, there is a danger that in the long term, families that before the pandemic had sufficient financial reserves will need support. A survey conducted by the Leibniz Institute for Economic Research found that about a third of the households surveyed in high-income Germany expected future pandemic-related financial losses .The pandemic also had a strong impact on education and children’s social lives. School closures occurred as an intervention in the COVID-19 pandemic in more than 190 countries around the world to prevent further infections. Globally, over 94% of students were affected . StudiesFrom a social point of view, pandemic-related changes in everyday situations have opened up new perspectives and chances for the family environment that can also enrich daily life in the future. Both parents and children see spending more time with the family as a positive aspect. Although children felt burdened by restrictions on contact with friends, they found new ways to communicate with each other via digital media . In addiHowever, already after the first months of the pandemic, children reported having more arguments in the family, and “parents reported that arguments with their children escalated more often”  (p. 828)The waves of infection brought similar public health measures and contrary opinions on vaccination in many countries. With the increasing infection rates and the discussion on vaccinating children, school leaders in Germany, for example, feared there would be increasing conflicts between parents, school children, and teachers regarding quarantine regulations and willingness to be vaccinated . When coParticularly aggressive parents pose a challenge to the schools beyond the organizational implementation of protection measures . In a GeThese German examples that are similarly available from other countries around the world show the great extent to which social and economic challenges can have direct effects on children’s everyday lives. In addition, according to a recent study, the psychological well-being of children and adults has worsened since the pandemic, especially in families experiencing multiple hardships . MoreoveThis study aims to identify, in the economic and social policy context, pandemic-related factors that can have long-term effects on children’s everyday lives and health. It will examine whether current developments have already occurred during previous outbreaks or crises and if we could learn from these findings.For this review, which was developed during the ongoing pandemic, we aimed to continuously respond to new phenomena and trends by searching for evidence on the topic from previous outbreaks of infectious diseases. In accordance with this aim, we were not able to only conduct searches with a predefined combination of terms but were constantly striving to adapt our searches to new developments. Obviously, this approach does not provide a comprehensive systematic review. Keyword search (English and German) in scientific databases  was conducted in order to determine whether these or analogous topics had already been addressed in previous disease outbreaks or crises. Afterward, articles that were closest to the current topic were chosen for citation.As there have not been any pandemics with similar global impacts and challenges in recent decades, there are only a few studies on earlier infectious disease outbreaks and a small number of current studies on which to draw for analysis of social factors. For economic factors, research findings on past economic crises can provide starting points concerning the impact on children’s health and will be included in the analysis.The selected literature presented does not claim to be exhaustive. It rather falls in line with the scope and method of a scoping review that, in its first step, identifies and analyzes “key characteristics or factors related to a concept” and “knowledge gaps”  (p. 2). outbreak of infectious disease takes place in a specific location and time and with an expected number of occurrences. An outbreak is called an epidemic when there is a higher-than-expected, sudden increase in cases of a disease or health event. A pandemic is an event in which an infectious disease affects a large number of people and spreads across several countries [The World Health Organization’s (WHO) ‘One Health’ concept is an approach to achieving better public health outcomes by taking the environment in which we live into account . In addiountries ,29.A different situation compared to today, especially in the area of caring for children, is revealed by a study that examined the effects of the Spanish Influenza pandemic on the health and mortality rates of children in 1918 and 1919 . Reid foResearch in the social policy area on later infectious disease outbreaks has focused mainly on topics such as vaccination, school closures, or the stigma associated with infection. The analyses frequently take the arising economic consequences into consideration. A majority of the studies available examined the spread of influenza and H1N1 swine-flu virus ,32,33, EPrevious studies on vaccination examined priorities for vaccination interventions , the posOther studies examined factors influencing vaccination willingness. Findings revealed that both rates of hospitalizations for influenza and influenza vaccination uptake differed depending on socioeconomic status and age . In empiPrevious studies also examined the economic and social effects of school closures  and theiRegarding content, the areas of vaccination and school closures are directly related to children’s everyday life. However, the existing studies examined mainly economic and social effects and challenges for parents. There are few studies that look at the direct effects on children. A literature review by Villegas et al.  for examIn total, the joint analysis of studies that looked at the impact of school closures on the well-being and health of children during the pandemic point to negative consequences . In someUsing data from 174 countries on past school closures due to various causes, Azevedo et al. [Eyles et al.  also higAccording to Kaffenberger’s  estimateThe results underpin the concern that school closures during the COVID-19 pandemic have had negative impacts on children at numerous levels. This holds especially for children who were at risk already prior to the pandemic, such as children with low socioeconomic status. Besides school closures, a lack of child protective services could also have an impact here. The simulations show that it will take a lot of effort to catch up on learning. Interventions need to be planned at the political level and accessed on a large scale.Stigma in the context of (infectious) diseases means that people with a disease experience negative reactions from others and are excluded from social activities . At the To assess stigma in the context of COVID-19, reviews on infectious disease outbreaks in the past provide a suitable basis. Previous research on infectious disease-related stigmatization dealt mainly with HIV, tuberculosis , and EboHaink et al.  found thRegarding the current COVID-19 pandemic, Bagcchi  reportedPrevious research on the economic effects of infectious disease outbreaks examined private and public health costs. Although the medical and health economics conditions are hardly comparable, a study on the 1918 Spanish influenza pandemic found that the cost of operating a hospital in Uppsala, Sweden from 1917 to 1920 doubled due to the outbreak . The autThe worldwide influenza A (H1N1) outbreak in 2009, which the WHO rated as a pandemic , also reOther studies have modeled the costs of infectious disease outbreaks in dependency on various factors. For instance, Al Kazimi et al.  compiledIn view of the literature cited in the section above, there are only a few research findings available for outbreaks of infectious disease in the past from which any economic effects of the COVID-19 pandemic on children and adolescents can be derived. Due to the high relevance of the economic impact as outlined above, we now turn to the findings of empirical studies on past recessions and economic crises. Taking these research findings into consideration can provide starting points for identifying factors affecting the health and life circumstances of children in challenging economic times. The factors presented do not represent a definitive list but instead serve as illustrative examples of potential factors.Literature reviews based on international data found that at an aggregate level, economic crises have a negative impact on children’s physical and mental health and lead to an increase in child maltreatment ,65,66. HAnalysis of some empirical studies yields a differentiated picture of the equal opportunity of children with different socioeconomic backgrounds. Findings show that especially children that had been disadvantaged financially and socially before economic downturns were affected more severely by an economic crisis ,69,70. TSome of the studies listed in In summary, analyses of a variety of economic indicators indicate that the economic trend has an impact on children’s health. A direct association has also been found regarding services for children—as documented by Van Dolen et al. , a rise Since the worldwide financial crisis of 2008, approximately 76.5 million children have lived in poverty in the world’s 41 richest countries . GustavsRegarding the current COVID-19 pandemic, Lietzmann and Wenzig  found thThis review addresses the impending economic and social policy challenges arising in the COVID-19 pandemic and relates them to existing research on pandemics, epidemics, infectious disease outbreaks, and economic crises in the past. The aim was to examine whether learning effects for today’s situation can be derived from literature on earlier crises. Although the expectation that long-term effects are difficult to predict has been confirmed due to the lack of robust data from a comparable pandemic, there are nevertheless surprising analogies to challenges from earlier times. The review of the literature shows that social policy issues, such as school closures, vaccination willingness, and stigmatization of infected persons, were examined by previous studies on infectious disease outbreaks in the past. Moreover, the effects of economic downturns on children’s health show a unified picture: particular economic costs and social challenges arise mainly in regions with low average income and for target groups with low socioeconomic status.Furthermore, research studies available already before the COVID-19 pandemic drew attention to hypothetically arising social, economic, and health economy effects of an infectious disease outbreak. Many of these predicted consequences were confirmed in earlier pandemics. Still, the long-term impact in particular of the arising and newly developing social conflicts that are in part also due to the effects of the economic developments, is unclear—as is the further course of the pandemic itself.Numerous examples presented in the Introduction section above highlight the tensions of conflicts of interest that children and adolescents can be exposed to when coping with everyday life. The first study on the effect of wearing masks on children’s health  providesAccording to , the eveA look at research studies on economic crises in the past makes it clear that economic stressors have a consistently negative impact on the physical and mental health of children and adolescents. Here again, the impact is greater on children with higher health and social risk factors than on children from supposedly more secure circumstances. Ajduković et al.  found thIt will be essential in the future to conduct studies on the long-term economic and social consequences of the COVID-19 pandemic for children and adolescents in order to identify influencing factors and to address needs that have changed in the areas of children’s health and support from child protective services. The review of the literature presented above does not claim to provide a conclusive description of economic and social policy factors. Moreover, the previous study findings have only limited applicability today, as there were no pandemics in recent decades with such comprehensive effects in a comparable global infrastructure. Additionally, because the pandemic is now ongoing, regarding the resulting social consequences only case examples of conflict areas can be described and analogous conclusions derived.The Competence Area Mental Health Prevention in the Competence Network Preventive Medicine Baden-Württemberg in cooperation with the Competence Center Child Abuse and Neglect Baden Württemberg , will determine and analyze economic and social policy effects of the pandemic, with the aim of mental health prevention. Incorporating the WHO’s One Health approach will play an important role as previous studies have shown that the progressing climate change will have an impact on the mental health of children and adolescents not only due to the increased risk of the spread of infectious diseases but also due to change of the social, ecological, economic, and cultural environment . In this


In the forensic field, most studies employing virtual reality (VR) interventions have focused on offenders. The validity and safety of VR applications for victims of crime are still unclear. Following PRISMA guidelines, a systematic review on VR interventions for crime victims was performed to assess the efficacy, acceptability by patients, and cost‐effectiveness of these interventions compared to in‐person care. We identified 34 potentially eligible studies from 188 records obtained from database searches ; four additional articles were identified via alternative sources. In total, nine articles were included for the qualitative synthesis. Patient satisfaction with VR interventions was found to be equivalent to face‐to‐face interventions. Both VR exposure and control groups found relief from posttraumatic symptoms, with differences either statistically insignificant or in favor of VR. Despite the increased costs linked to the technology required, VR appears to be a promising alternative to in vivo exposure, but further research is needed. Limitations of the review include the varied experimental protocols, which did not allow us to conduct a quantitative analysis and comparison of findings across different studies, and the generally poor quality of the studies included. Further research, preferably in larger groups, is needed to shed more light on the effectiveness of VR interventions for traumatized victims of crime. Ideally, VR users should not be able to distinguish the sensory experiences, feelings, and interactions associated with the virtual world from those elicited by the real world  guidelines  AND  AND . The second step involved two authors performing an additional electronic search based on the manual mining of the reference lists of the retrieved articles. We then screened the abstracts of the articles identified during these two steps for eligibility, and articles deemed eligible for inclusion in the review were then further assessed based on a full‐text reading. Discrepancies were resolved through consensus with a third author.We examined the following outcomes: acceptability and patient satisfaction, efficacy, and cost‐effectiveness. The inclusion criteria were (a) randomized controlled trials (RCTs), nonrandomized control trials (NCTs), or pre–post studies; (b) the investigation of the effects of VR interventions for victims of crime; and (c) adult samples . We excluded articles written in languages other than English, Italian, or Spanish; reviews, retrospective studies, and case reports; and articles for which we were unable to obtain the full text even after contacting the corresponding author.Titles and abstracts were screened by two reviewers independently, in duplicate, to determine whether the retrieved studies met the previously outlined inclusion criteria. Full texts were obtained for studies that appeared to meet the inclusion criteria and those for which a decision could not be made from the title and/or abstract alone, and a detailed review of the criteria was performed. Full texts were independently assessed for eligibility by two reviewers, and discrepancies were resolved by an initial discussion or consultation with a third reviewer, when required, until a complete consensus was reached.A standardized form was used to extract data from the included studies to assist in the evaluation of study quality and synthesis of evidence. Extracted information included study focus, participant characteristics, details of the intervention and control conditions, study methodology, dropout rate, outcomes and assessment times, and information needed for risk of bias (RoB) assessments. Extraction was completed by two reviewers independently, in duplicate. A third reviewer was consulted when needed.The quality of the included studies was assessed using the RoB assessment tool developed by the Cochrane Collaboration for randomized studies ; one did not provide the necessary data, which were unable to obtain after contacting the study author; and five contained duplicate data. The process of identifying eligible studies is outlined in Figure The characteristics of the included studies are summarized in the Supplementary Materials. Four studies . This may also signal the importance of involving actual victims in the development of VR interventions designed to help this population with regard to the process and potential functionalities. In general, from an ethical perspective, researchers have argued that with respect to VR in medicine, vulnerable patient voices should be included in the design phase . The list of the excluded studies is on the Supplementary Materials.Supplementary Data file 1Supplementary Data file 2. Studies included – description and resultsClick here for additional data file.