Long waiting times (WT) for Magnetic Resonance Imaging (MRI) are a challenge in many countries and demand is forecast to increase with ageing populations. Since MRI is essential for diagnosis in numerous medical conditions, timely performance is of the utmost importance.To describe the multi-faceted program developed by the Israel Ministry of Health (MoH) to shorten WT for MRI and increase efficiency, and to examine lessons that can be learned for other health systems.Data were obtained from the Israel MoH from 2015–2019.The plan used multiple strategies and comprised the following elements: providing additional scanners, dedicating additional personnel to MRI units, maximizing efficiency, establishing a training program for radiographers and a fellowship program for radiologists, introducing financial incentives to health maintenance organizations and implementing a computerized monitoring system.A substantial reduction in mean WT was demonstrated, from 52 days in 2015, to 24 days in 2016 and 2017. This was followed by a slight increase to 26 and 32 days in 2018 and 2019, respectively. The relative decline in WT from 2015 to 2019 was 38.5%. The number of scanners doubled during this period while the number of radiographers and radiologists with formal MRI training increased.The broad scope of this comprehensive reform was successful in addressing long WT and improving care provision from a wide perspective: economic, workforce and infrastructure. Bottlenecks in the MRI system cannot be addressed from a single angle, rather requiring a whole system approach. Imaging tests are an important component of diagnostic processes, treatment planning and patient monitoring, and in many cases are an essential step in the diagnosis of conditions requiring immediate treatment. Among imaging modalities, MRI is a widely-used and highly advanced yet costly imaging test, due to expensive hardware and software, and expert manpower required to operate them. There is high demand for MRI due its unique innovative characteristics, the safety of its non-ionizing features (in contrast to computerized tomography (CT)) and its importance in diagnosis, including new clinical indications . FurtherIn general, health policymakers are required to control health spending. Some Western countries adopted the ‘Choosing wisely’ approach which encourages both patients and clinicians to choose care that is necessary and to avoid superfluous tests . In IsraMany countries struggle with long WT for MRI, which are often unevenly distributed across the country. To increase accessibility and availability of these tests, different countries implemented a range of strategies, adapted to the local healthcare system. For many years England faced long WT for diagnostic tests including MRI. This led the NHS to introduce a 6-week target for diagnostic tests , and remOn the other side of the continuum is Australia, dealing with possible underutilization of MRI devices. MRI in Australia operates under a licensing system and two factors are prerequisite for an MRI scan to be eligible for rebate: the scan type must be included on the Medicare Benefit Schedule (MBS); and the MRI machine must be fully or partially licensed . The refAnother country which dealt with long WT for MRI is Canada, with large variations between provinces. In 2018, the average WT for diagnostic MRI was 69 days, reflecting a limited number of scanners, below the OECD average. Many of the available scanners were older models, and the shortage of up-to-date equipment meant that patients faced longer-than-recommended WT. The overall impact of excess WT on the Canadian economy in 2017 was estimated at $1.4 billion . WT recoIn Israel, health services are provided within the National Health Insurance Law (NHIL). Israel provides high-level healthcare while successfully limiting costs . Four heIn 2015, the Israeli national average WT for MRI was approximately 52 days for the most frequent test (adult neurology MRI), and even longer for special tests, for example MRI in children requiring anesthesia . InternaTo describe the multi-faceted program developed by the Israel Ministry of Health (MoH) to shorten WT for MRI and increase efficiency, and to examine lessons that can be learned for other health systems.At the end of 2015, the MoH decided to establish a National Program to shorten WT for ambulatory MRI exams. At the launch of the program, a WT target of 14 days for ambulatory MRI exam was publicly declared.The process included identifying the barriers involved in long WT from three perspectives: economic, personnel and infrastructure. On the economic side, utilization of existing devices was examined, while calculating the cost of running second and third shifts of MRI examinations, in coordination with demand from the insurers (the HMOs). In terms of personnel, the shortage of skilled radiographers in the operation of MRI, the lack of both interpreting radiologists and funded radiologist positions in government hospitals, was mapped. In terms of infrastructure, the shortage of MRI devices and work processes resulting in sub-optimal utilization of the existing devices, were identified.Several scenarios were calculated to estimate the number of devices required. The calculations took into account that the limiting factors in the provision of MRI exams were both an insufficient number of MRI scanners as well as the low availability of radiographers and radiologists with MRI-specific training. The personnel deficiency created a bottleneck in the system, which the mere addition of scanners could not have solved.MRI devices The guiding principle was that every hospital with an emergency department and an existing CT device would have at least one MRI scanner. In 2015 there were 23 MRI scanners in Israel, and over a period of four years this number almost doubled, reaching 42 devices in 2019. Several additional licenses have since been issued with new devices expected to start operating soon.Utilization of existing devices MRI is an expensive imaging modality in terms of infrastructure and personnel required for its operation. In order to maximize the use of devices, working hours were updated where possible to 24 h active over 6 days for regular exams and to 24/7 for urgent testing. This meant that MRI scanners started operating around the clock, day and night, where necessary.Personnel Along with the addition of a large number of devices in a relatively short time, reinforcement of personnel—especially radiographers and radiologists, was required.Radiographers Each MRI device is operated by two trained radiographers. Prior to the reform radiographers gained on-the-job experience in MRI, however there was no formal training program. To address the shortage of skilled MRI radiographers, the MoH established The National Center for Imaging Professionals (NCIP). A 17-week training course combines theoretical studies, simulators and practical training. During the first four years of the project, 2016–2019, 110 radiographers received training at the center. Parallel to the training of personnel, additional positions for radiographers were allocated.Radiologists The first Israeli radiology fellowship program, organized and funded by the MoH in collaboration with the Scientific Council and the Radiological Society of the Israeli Medical Association, started in 2016. Prior to this, most physicians had to travel abroad to obtain a fellowship in radiology. The program addressed the shortage of specialist radiologists in various clinical fields and enables physicians to undergo a year’s local training in MRI. Over a period of half a year, more than 21 MRI units were recognized for fellowship in special fields of MRI . More radiologist posts were opened and funded by the MoH, to expand the capacity for MRI interpretation. From 2015 to 2019, 34 radiologists completed the fellowship program. In 2016 and 2018 fellowships were around half men and half women, while in 2017 and again in 2019, around 80% of those completing a radiology fellowship were women. The proportion of female radiographers undergoing MRI training also increased between 2016 and 2019 from 40 to 53%.Computerized national database of MRI utilization Until the end of 2015, MRI units reported activity via a structured form sent annually to the MoH including volume of exams performed and frequency of different clinical indications. A significant component of the reform was the establishment of a computerized system for reporting MRI utilization on a monthly basis across all medical facilities licensed to operate MRI. All data on MRI utilization is measured retrospectively, except for the first available appointment, which is measured with a prospective approach, and enables calculation of WT. The national MRI database provides comprehensive up-to-date data from all healthcare facilities in the country.A financial incentive model was introduced in order to increase the number of exams authorized and funded publicly by the HMOs and to shorten WT for MRI exams. A dedicated annual budget was allocated by the MoH for this purpose, divided between the four HMOs. The guiding principle of the incentive model was that the HMOs receive substantial economic incentives for increasing exam volume, which is expected to decrease WT until it reaches the median 14-day threshold. After two years of incentivized activity, a 30% increase in the overall number of publicly funded MRI exams in Israel was observed and WT were reduced to a mean 24 days. At that point, the economic model was reconsidered and its impact on the structure of the national "MRI market" reviewed. The new model, implemented in 2018, added incentives for the reduction of WT in addition to increasing exam volume. The economic incentives received by the HMOs are dependent on the accurate computerized documentation of MRI activity by the institutions that operate MRI scanners. The incentive model further included financial aid to hospitals without an MRI to purchase their first scanner.In order to meet these diverse challenges and strive towards achieving the 14-day target, the National MRI Reform was allocated a defined additional budget, including the following components:Pre-intervention: The average WT for 2015 was calculated through a telephone survey conducted in the second half of 2015. Secret shoppers asked for the first available date for an adult neurology MRI scan through the hospital appointment scheduling system. Average WT was calculated based on results from all MRI facilities.The average WT for the first available appointment for an adult neurology MRI exam from 2016 onwards is measured at the beginning of each month.For the calculation of WT, the most common MRI exam—adult neurology, which comprised the largest category or 36% of all exams in 2015, was chosen. The WT presented here was calculated—based on the stages of the reform implementation—in the following way:The main changes made during the first 4 years of the reform are summarized at two time points: 2015 (before the implementation of the reform) and after 4 years of implementation 2).Fig. 2The national MRI reform was planned and launched with the main aim of shortening WT for MRI. The processes described in this article comprise a comprehensive multi-system MRI reform implemented for the first time by the Israeli MoH. The reform consisted of four pillars: (a) increasing the number of MRI devices; (b) creating economic incentives for the HMOs to increase exam volume, decrease WT, and help hospitals acquire scanners; (c) strengthening human resources by adding more positions, funding personnel, training radiographers and establishing a local MRI radiology fellowship and, (d) establishing a national database for ongoing monitoring of diverse process measures.The combination of these tactics created a joint national mission, involving the MoH and health providers, aimed at improving accessibility and availability of MRI exams. The reform resulted in increased volume of examinations and decreased WT. The number of MRI scanners was doubled and utilization of scanners was improved to maximize efficiency. Manpower resources were amplified and training formalized, with positions added for radiology specialists and radiographers. Extensive training of personnel allowed the quality of exams to be maintained, and even improved, despite an increase in volume.In the first two years of the reform there was a substantial drop in WT for MRI, and in the third year, once the market had stabilized, WT increased by 33% in the following two years. The subsequent increase in demand for MRI exams can be explained by the natural growth of the population and a continuous increase in the number of clinical indications as well a change in public expectations . SimilarAlthough accelerated training continues at the time of writing (October 2020), the Israeli healthcare system still experiences a shortage of both specialized radiographers and radiologists to perform and interpret MRI exams in a timely manner. This creates an imbalance between the availability of MRI infrastructure (scanners) and the growing demand for MRI exams. This imbalance is created due to different factors including the time required to train the increasing numbers of MRI staff and the difficulties in recruiting larger numbers of radiographers and radiology trainees.A significant achievement of the program is that the majority of radiologists now have the opportunity to obtain a fellowship in Israel. This helps to keep senior physicians in the country instead of pursuing their training abroad, thus losing valuable medical personnel during the years of training. It is interesting to see that this fellowship program has encouraged more female physicians to undertake their training and become MRI specialists in Israel, comprising at least half of the fellowship trainees since the start of the program.Striving to create balance in the health system, incentives were given to the HMOs which authorize imaging referrals for MRI. Based on the data collected in the system on exam volume and WT, economic incentives were adjusted annually. The incentives which the HMOs received (up to a certain threshold) facilitated a rise in the number of tests on the one hand, while controlling numbers on the other hand to mitigate an uncontrolled rise of exams en masse.The nationally coordinated computerized system established as part of the program, allows the monthly monitoring of a broad number of parameters, enabling more accurate surveillance and measurement of MRI activities at all sites and facilitating decision-making on an ongoing basis.Different countries have addressed the problem of long wait times for MRI with different tactics. According to the literature, Australia's strategy was to increase the number of scanners. The UK combined additional scanners and personnel to reduce WT. The strengths of the Israeli approach are that it tackled all aspects of the process, looking beyond the hardware and establishing a total system reform.The Israeli MRI reform adopted a holistic, multi-faceted approach to address a wide scope of issues relating to accessibility and availability of MRI exams. Throughout its implementation, it has become clear that it is essential to continuously monitor its outputs, in order to address diverse challenges that require adaptation of the original intervention plan.The MRI reform is a long-term ongoing process, continually updated, whose final fruits may not be seen for several years. Assessment of parameters at this point in the process indicates that the reform has achieved promising results and can be fine-tuned to succeed even further.Leadership is crucial, especially in a publicly funded system. This reform was led at a national level by the MoH. As a regulator, the MoH has the ability to harness necessary government funds and achieve cooperation with professional bodies to establish professionally accepted regulations and licenses.The combination of expanding the capacity of trained personnel and adding a large number of scanners, while increasing efficiency by lengthening operating hours, allowed an increase in the volume of exams performed and a parallel decrease in WT, the ultimate goal of the reform.Economic incentives were integral to the program’s success, enabling the shortening of WT and the expansion of exam volumes over the four-year period.The national MRI database provides comprehensive data from the majority of healthcare facilities, which are monitored monthly.The plan for MRI reform is a long-term endeavor, which continues to evolve, while resting on stable foundations that guarantee the long-term maintenance of the reform.Despite the notable achievements of the program there remain a number of challenges for the overstretched health system in Israel:Personnel for MRI performance and interpretation: there is still a lack of trained personnel employed in the health system which needs to expand. Professional training requires investment of time and financial resources. This expansion of manpower should be implemented with a holistic view, beyond the specific needs of MRI.Device utilization:—despite: increased efficiency in the use of scanners, some devices are still not used at their maximum capacity. Seven out of all facilities currently report capacity at 100% or more . According to OECD data Israel leads in the number of exams per scanner [Re-evaluation of the 14-day WT target: Based on 4-years’ experience with the reform, different targets may be appropriate. Evaluation should be conducted every few years to determine public and expert opinion of acceptable WT.Measurement approach: The system currently collects data for the first available appointment. This approach of calculating WT can cause bias, since it is sensitive to last minute cancellation and other unexpected events and might therefore, under-estimate WT. More accurate measurements, based on a larger number of available appointments, might be implemented [lemented .This comprehensive national plan led to improvements in the MRI system and reduced WT while remaining within the regulatory framework. The experience gained during the first years of implementation may be applicable to other countries, with a publicly funded national health system.Bottlenecks in the MRI system cannot be adequately addressed from a single angle, rather requiring a whole system approach. A comprehensive, multi-system reform was able to improve service accessibility by combining economic, human resources and infrastructure perspectives. The program will continue to be monitored on an ongoing basis and adapted to the changing healthcare market, with longer term re-evaluation. We believe that to date the program has managed to concomitantly improve diverse aspects of service provision to create shorter waits for MRI, thus improving patient care, and will continue to do so.With an ageing population and rising chronic disease, health systems must be prepared for continually increasing demand for MRI services. Future changes to the reform may consider taking into account patterns of demand for MRI. The COVID-19 pandemic is expected to further stretch health resources and have a significant impact on healthcare expenses.


When news consumers outside China first heard about a new form of pneumonia in Hubei Province in late 2019, it seemed like a distant concern Hon, . This chThe sounds of the COVID-19 health crisis, however, are center stage in a growing body of literature in music psychology that investigates the role(s) of music creation and/or consumption in mitigating the impacts of extended lockdown restrictions on personal health and wellness Chiu, . This reIn an ongoing study of the soundtracks from Western news coverage of the pandemic at the first major sites of infection and quarantine—-Wuhan (China), Tehran (Iran), and Milan —-we find preliminary evidence that the distribution of sound, silence, and music is regionally and nationally differentiated. These differences could be due to changing schemas associated with the pandemic over time, e.g., as new information becomes available, but as our data shows, early coverage can also reflect cultural biases and potentially promulgate stereotypical and prejudicial representations of race and place. This gives us reason to question the accuracy and fairness of such reporting, as well as to advocate for increased investigations into the sonic elements of COVID-19 reporting as a key area for ongoing pandemic studies. If the sounds of news reports are “the ultimate hidden persuader[s]” Cook, , p. 128,Studies of pandemic news reporting can draw upon a robust body of literature about prior global infections, most recently about the H1N1 epidemic of 2009–2010 Duncan, . For COVYet it seems that scholarship has neglected the soundtracks of news reporting, with the ocularcentrism of communication and media studies predominating in analyses of audiovisual pandemic coverage . One cannot rule out the possibility that the bases for such images and sounds reside in what some commentators designate as “racialized Islamophobia,” rooted in Orientalism and Colonialism  and NOW Corpus .Nevertheless, the preliminary findings are based on a relatively small dataset. Augmenting the data sources would be desirable to obtain a more robust confirmation of results. That would involve consulting a larger number of audiovisual items from a greater spread of professional news providers, as provided in the media sub-corpus from the Moreover, our sources include only news reports generated by and for the Anglophone world, which does not account for other national perspectives and soundtracks . Then they could undergo quantitative analysis, to determine the comparative prevalence of voices, sounds, music, and silences in soundtracks as sorted by location. It would also be possible to use the database for quantitative assessment of bias, according to procedures developed for analyzing news videos by cultural sociology (Al Ibrahim and Shi, JD designed and conducted the study, analysed the data, and created a first draft of the manuscript. CL contributed to the presentation of data analysis, the development of a narrative for final presentation and revisions to the manuscript. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Emerging research suggests environmental exposures before conception may adversely affect allergies and lung diseases in future generations. Most studies are limited as they have focused on single exposures, not considering that these diseases have a multifactorial origin in which environmental and lifestyle factors are likely to interact. Traditional exposure assessment methods fail to capture the interactions among environmental exposures and their impact on fundamental biological processes, as well as individual and temporal factors. A valid estimation of exposure preconception is difficult since the human reproductive cycle spans decades and the access to germ cells is limited. The exposome is defined as the cumulative measure of external exposures on an organism , and the associated biological responses (endogenous exposome) throughout the lifespan, from conception and onwards. An exposome approach implies a targeted or agnostic analysis of the concurrent and temporal multiple exposures, and may, together with recent technological advances, improve the assessment of the environmental contributors to health and disease. This review describes the current knowledge on preconception environmental exposures as related to respiratory health outcomes in offspring. We discuss the usefulness and feasibility of using an exposome approach in this research, advocating for the preconception exposure window to become included in the exposome concept. Emerging research suggests that environmental exposures, long time before conception in parents and grandparents, may contribute to the development of allergies and lung diseases. This research is in its infancy. There is, on the other hand, a vast body of research on how environmental factors can more directly affect these outcomes in one generation and, in the last few decades, there has also been a major development in the scientific understanding of how exposures occurring during intrauterine life and early childhood may affect life-span respiratory health. This knowledge is, nonetheless, inadequate to fully understand the origins of asthma, allergies, and lung diseases. New research explores mechanisms by which exposure effects may be transferred across generations and act in concert with the genome through epigenetic modifications that may ultimately influence offspring health and disease ,2,3,4. HThere is growing awareness that the traditional methods of exposure assessment fail to capture the full extent of environmental exposures and their impact on fundamental biological processes . The humThe exposome is defined as the cumulative measure of external exposures on an organism, and the associated biological responses, throughout the lifespan, from conception and onwards. This term includes exposures related to the environment, individual characteristics, such as prematurity and infections, lifestyle choices, behavior, and endogenous processes at work and in daily life ,13,14. UIn this review, we describe the current knowledge on the association between environmental exposures during the preconception period and the future offspring’s respiratory health in humans, including asthma, allergies, and lung function (Table 1). Furthermore, we discuss the feasibility of using an exposome approach to characterize the complex environmental exposures in the preconception window. To be noted, literature on the time window shortly before conception, and on the optimizing conditions prior to conception and pregnancy, is beyond the aim of this review. Furthermore, human studies are the main focus of this review, since animal studies are rarely used for an exposome approach that aims to embrace a complexity of exposures. We identified an animal study that used an exposome approach to investigate lung health, but in a one generation setting . Hence, Tobacco smoking in different exposure windows may cause malignant and non-malignant diseases of the respiratory system , and it In 2005, Li et al. published an analysis of data from the Children’s Health Study in Southern California, showing that a grandmother’s smoking during the mother’s fetal period increased the asthma risk in her grandchildren, independent of whether the mother smoked herself or not . The fin1) and forced vital capacity (FVC). The paternal grandmother’s smoking in pregnancy had a negative indirect effect  on the grandoffspring’s FEV1/FVC ratio, suggesting a second-generation increased risk of airflow obstruction. Probabilistic simulations showed that unmeasured confounding would only have a low impact on these estimates.In addition to supporting the results on grandmother’s smoking, the role of the father’s smoking in early puberty  on the respiratory health of future offspring has been demonstrated in concordant findings from three epidemiological studies: the European Community Respiratory Health Survey (ECRHS), Respiratory Health In Northern Europe (RHINE), and Respiratory Health In Northern Europe Spain and Australia (RHINESSA) cohorts ,29,30. IIn summary, there are several publications using different analytical approaches and data sources, finding adverse effects on the respiratory health of offspring secondary to the grandmother’s smoking  and to the father’s early-onset smoking. Asthma and asthma phenotypes are the most studied outcomes, and there is one study with lung function as the outcome. All the studies show the harmful effects of preconception smoking, with more asthma or lower lung function, both regarding the intrauterine and the male early-puberty exposure windows. The analyses show relatively strong estimates. For instance, the associations with the father’s early-onset smoking were comparable to, or even stronger than, the associations with maternal smoking in pregnancy. The adverse effects of the father’s smoking in prepuberty on the offspring’s asthma and lung function have alarming implications from a public health perspective, as smoking in boys aged 11–15 years has increased in Europe over recent decades .With regard to the smoking effects across generations, there is substantial mechanistic literature to support the findings from epidemiological studies. We will not review this literature, only briefly mention that the adverse effects of the grandmother’s smoking in pregnancy, and the father’s smoking in prepuberty could be explained by epigenetic alterations  in developing germ cells, as tobacco smoking may cause heritable modifications of the epigenome ,38. The Studies on animals have demonstrated that preconceptional exposure to paternal smoking regulates the spermatozoan microRNAs (miRNAs) and possibly affects the offspring’s body weight in early life . In anotIt is well-known that the occupational exposure in adulthood to a multitude of allergens and irritants can give rise to asthma in the exposed worker ,44. A feIn an analysis of the RHINE cohort, Svanes et al. found that the father’s self-reported welding before conception, over at least ten years, was associated with a doubled risk of nonallergic early-onset asthma in future offspring . The finIn summary, there is some evidence that parental occupational exposures may influence the respiratory health in future offspring, and that the possibility of effects on future offspring needs to be considered in further research on the health effects of occupational exposures.Air pollution is among the main known environmental threats to respiratory health . Exposur10), sulphur dioxide (SO2) and nitrogen dioxide (NO2)] and indoor environmental factors (renovation and mold/dampness) during the preconception, prenatal, and postnatal periods, with allergies in the children. Several associations were found for prenatal/postnatal exposures. Regarding the preconception environment (one year before pregnancy), exposure to renovation was associated with rhinitis-like symptoms [A large study of kindergarten children from China assessed the associations between outdoor [particulate matter , and ozone (O3). Exposure to PM2.5 and PM10 in the mother’s childhood was associated with a higher risk of offspring asthma, and exposure to PM10 was associated with a higher risk of offspring hay fever. The father’s exposure to O3 was associated with more offspring hay fever; however, the father’s BC exposure was associated with less offspring asthma. The study suggests that parental air pollution exposures before the age of 18 years may increase the risk of asthma and allergies in children. Further studies are needed, and there is a need to disentangle the different air pollutants through improving the methodologies of multipollutant models.Kuiper et al. investigated the preconception exposure to air pollution in the childhoods and adolescences (0–18 years) of the parents in relation to asthma and rhinitis in their future offspring . ChildhoA farm environment is considered a proxy of microbial diversity, and may also reflect lower air pollution, higher greenness, specific chemical exposures, etc. A range of studies find a lower risk for allergies in persons brought up on a farm, while Timm et al. investigated whether parental and grandparental farm upbringing was associated with asthma in offspring, in an analysis of the ECRHS and RHINESSA cohorts . The repA murine study on water pollutants reported that the offspring of male mice exposed to the water pollutant, microcystin-leucine arginine (MC-LR), via drinking water before conception showed growth deficits and thickened alveolar walls, as well as collagen deposition in the lungs at postnatal day 180 . PaternaOverall, an association of the parental exposure to air pollutants at age 0–18 years with offspring asthma was found in a solid study, in which exposure data were derived from the geocoding of residential addresses. One large study indicates a possible effect of indoor factors the year before conception, while a role for parental and grandparental farm upbringing seemed unlikely given the consistently negative findings.Overweight and obesity are recognized as major risk factors for asthma in both childhood and adulthood ,61,62,631, FVC, and FEV1/FVC). The gender of the offspring was included as a potential moderator, and the adult height and being overweight in childhood were included as potential mediators in the pathway between the parents being overweight and the offspring’s lung function. Statistical models developed for causal inference, on the basis of observational data, were used for this analysis. The study showed that the father’s being overweight, starting before puberty, had a negative effect on the adult lung function, FEV1 and FVC, in their sons. The effects were partly mediated through the sons’ adult height, but not through the sons themselves being overweight. No causal associations were found between mothers being overweight and the offspring’s lung function.In the RHINESSA generation study, Johannessen et al.  investigHormonal factors are closely linked with metabolic status. An analysis of the Tokyo-Children’s Health, Illness and Development Study (T-CHILD) found that the use of oral contraceptive pills (OCP) before pregnancy was associated with a higher risk of wheeze, asthma, and rhinitis in their children at 5 years of age. Importantly, a longer period of use of the OCP conferred a higher risk for wheeze and rhinitis in offspring . An analIn summary, three human studies support the concept that the metabolic environment in male prepuberty might influence the respiratory health of offspring, and the role of the exogenous sex hormones before conception cannot be disregarded. Although extensive for some other outcomes, animal studies on the metabolic preconception environment, specifically related to the lung health of offspring are not available and would be useful to elucidating the specific mechanisms.Schistosoma mansoni infection displayed increased ovalbumin-induced allergic airway inflammation compared to offspring from uninfected mothers, while offspring from mothers who were pregnant during the Th1 phase, or the regulatory T cell (Treg) phases of the infection were protected from such an allergy [It is well-established that maternal exposure to infections plays a role in determining the health of offspring and their risk of allergies. Offspring born to mothers with experimental influenza A virus infection had lower weights and length gains in the first weeks of life with reduced hematopoietic development and deviated pulmonary immune cell populations . Straubi allergy . Potenti allergy . Materna allergy , but mat allergy . Further allergy ,82, induJogi et al. suggest that the parental exposure to helminths might increase the odds of allergic manifestations in the offspring . In thisMycobacterium tuberculosis or Candida albicans. The T cells were identified as specific for antigens against these pathogens [Toxoplasma gondii infection in male mice, in which the infection caused small RNA profile changes in their sperm and led to subsequent altered behavior in the offspring [These findings from human studies are supported by murine studies. With regard to helminth infections, there are studies suggesting that maternal helminth exposure prior to pregnancy may have enduring consequences on the health and immune responses of offspring, effects that may last well beyond childhood: one study found that preconception helminth infection may alter the offspring’s immunity and microbiome , and anoathogens . Severalathogens . There aathogens ,99. Overathogens ,96, cytoathogens , alteredathogens , antigenathogens , and genathogens . Anotherffspring .Given these results, we hypothesize that parental infections, even years before conception, might contribute to immunologic and epigenetic changes that could result in allergies in the next generation.The genetic inheritance of asthma across generations is well-known; however, one may question whether disease activity may influence the germ cell environment or other factors (such as the microbiome) that, in turn, may affect the development of asthma and allergies in future offspring. Based on data from the ECRHS cohort, at different time points during the study participants’ reproductive age, Bertelsen et al. found that the parent-reported asthma and hay fever of offspring were more strongly associated with a parent’s preconception bronchial hyperresponsiveness and specific immunoglobulin E (Ig-E) levels than with the parental levels of these measures after the birth of the child . In otheAn analysis based on Swedish national registry data studied the association of maternal depression or anxiety at different periods  with asthma in her child. It evidenced that cumulative “exposure” to depression or anxiety was associated with offspring asthma, but the study was unable to identify a specific window when this association was stronger .Altogether, these studies suggest that parental disease activity may need to be considered as potential risk factors for the respiratory outcomes of offspring, and that further research is needed.The reviewed literature strongly suggests that preconception exposures may be important for the development of asthma and lung health outcomes in future offspring. Associations with lung health outcomes of offspring are suggested for a range of single chemical exposures , hormonal metabolic exposures , and disease processes . In the context of preconception exposures, there is more evidence on the paternal line, and, in particular, for the childhood and early puberty exposure windows in males. The importance of these exposure windows may possibly be high; for instance, the associations between the father’s smoking starting before the age of 15 years and the offspring’s asthma risk appear to be at least as strong as for the associations with the mother’s smoking in pregnancy. Within the maternal line, associations with the asthma of a grandmother who smoked tobacco in pregnancy are reported in several studies. There is also some evidence of a maternal preconception exposure window in young adulthood.The literature on the importance of preconception exposure for allergies and lung diseases in future offspring is supported by the evidence on preconception exposures for other health outcomes, such as obesity and growth ,105. FurThe exposome concept is divided into three different domains: the general external exposome, the specific external exposome, and the internal exposome ,106,107.To have a beneficial or adverse effect on human health, the environmental exposure in question must interact with the biological system at some level, i.e., it must be bioavailable for the target cell at the right time and be able to interact with biomolecules. An optimal assessment of the exposome during the preconception period would require access to the germ cells of the parent and, perhaps, of previous generations, as well as (surrogate) target tissues in the next generation . The humThe first obstacle for applying the exposome approach in the preconception period is the need to document the bioavailability and exposure intensities of the compounds of interest at the target cell. While the external exposome domain does not give us any information on the bioavailability of the compound, the endogenous exposome accounts for uptake from all sources  and routes  of exposure. The use of the biological monitoring of exposure  in the assessment of health risk or prognosis requires that the biomarker is quantifiable, sufficiently correlated to the exposure of interest, and biologically relevant for the health effect or biological effect. Hence, although the internal concentrations of the environmental compounds of interest can be measured as proxies in accessible tissues  in future parents from birth and until conception, the true concentration available for the target cells or tissues (germ cells) during specific time points is not available.For the same reasons described for bioavailability above, when judging whether it is biologically plausible that the human germ cells may be affected by preconception environmental exposures that also affect the immune and respiratory systems of future generations, we must rely on proxies of both exposures and effects, from existing and future human cohorts, combined with data from mechanistic and animal studies. The latter provides, for example, the possibility to gain detailed knowledge on how, and at what stages during testicular development and epididymal maturation, environmental information is transferred to the spermatozoa, and how the transfer of spermatozoan epigenetic information to the oocyte regulates transcriptional programs in the early embryo and the resulting later phenotypes. The experimental manipulation of epigenetic information, e.g., by injecting noncoding RNAs of interest into the early zygote, may potentially establish a cause–effect relationship.In parallel with the increased use of exposome technologies and the collection of high-resolution and high-dimensional data in health sciences, there is also a continuing need to address the ethical, legal, and social issues related to biobanking, archiving, and analysis of the large amount of biological material and data generated. These issues apply to all types of health research, but future offspring is a particularly vulnerable population. A main concern for discussion in large-scale epigenetic and genetic studies is the procedures for reporting pertinent and incidental findings back to the participants. This issue also applies to exposome research. At present, there seems to be a consensus that at least three requirements should be fulfilled prior to reporting research results: the results must be analytically valid, clinically significant, and actionable ,110. HowFor studies that investigate how the exposome at the preconception time window may affect future offspring, informed consent is provided by the parents or previous generations, but not by the subject at risk. This raises several ethical considerations for reporting back research results to the study participants and their offspring. How can we ensure that the offspring want to know whether he or she has an increased susceptibility to respiratory diseases in adult life, and how will this information affect future choices with respect to education and occupation, family life, or leisure time? Moreover, will his or her future employer or insurance company have the right to obtain this information before employment or before accepting him or her as a customer?Finally, although there are analytical methods that allow examinations of thousands of chemicals in biological samples among the general population, the health risk for most of these chemicals cannot yet be determined. This hinders a liable risk communication back to the participants and, consequently, the biomonitoring of these chemicals is not performed. However, if we do not start collecting this type of biological material and information in ongoing and planned cohort studies for use in later agnostic and untargeted analysis, there will be important limitations in understanding exposure effects and interactions in the future.There are considerable challenges related to addressing the preconception environmental impact on the health of offspring in studies of humans, for whom the reproductive cycle spans over decades. Few cohorts have exposure data from parental prepubertal and pubertal years. Statistical methods for the optimal analyses of complex multigeneration data, with multiple mediators, confounders, exposures, and outcomes, in several generations, are becoming available, but there is a need for statistical expertise and methodology that also combine omics and exposure data representing the exposome across generations. Even with advanced methodology, the interpretation of negative results may pose a particular challenge, as they may reflect truly negative findings or a sum of limitations in complex data. Two partly negative papers have been published, showing an attention to publishing negative papers, but the publication bias of the statistically significant and stronger results is likely, as in other areas with less complexity.Overall, the literature is sufficient to justify major research efforts on the preconception origins of asthma, allergies, and lung health. The research may have wide public health implications, indicating the potential benefit of interventions—or harm from negative exposures—for not only the exposed person, but also for future generations. Thus, it is urgent to bring this research forward. We argue that the benefits of an exposome approach in addressing complex, multiple, and concurrent lifestyles, behaviors, and exposures that interplay with each other may be equally important when considering the preconception environment as when addressing exposures during the life span. An exposome approach may be particularly useful to elucidating the germ cell environment at different developmental stages, from intrauterine life until the reproductive age of the parents. Exposure information from the preconception time window will, however, often be far more limited than for other life-stages, and the biomaterial from the preconception stages is generally not available, except for sperm, rarely available in humans and, if so, sampled after the offspring were born. This underscores the need for the close integration of epidemiological and mechanistic studies. Still, obtaining valid information about the preconception period should be kept in mind when planning questionnaires, the collection of biomaterials, the use of novel technologies, and data for validation analyses, in future inter- and transgenerational studies. We advocate for explicitly including the preconception period in the exposome concept in the quest to identify the environmental contributors to health and disease .


Errors in emergency ultrasound (US) have been representing an increasing problem in recent years thanks to several unique features related to both the inherent characteristics of the discipline and to the latest developments, which every medical operator should be aware of. Because of the subjective nature of the interpretation of emergency US findings, it is more prone to errors than other diagnostic imaging modalities. The misinterpretation of US images should therefore be considered as a serious risk in diagnosis. The etiology of error is multi-factorial: it depends on environmental factors, patients and the technical skills of the operator; it is influenced by intrinsic US artifacts, poor clinical correlation, US-setting errors and anatomical variants; and it is conditioned by the lack of a methodologically correct clinical approach and excessive diagnostic confidence too. In this review, we evaluate the common and uncommon sources of diagnostic errors in emergency US during clinical practice, showing how to recognize and avoid them. Ultrasound (US) is a routine imaging procedure that is frequently the initial course of action for emergency care and plays a critical role in the diagnosis of patients in the emergency room. Because of the subjective nature of the interpretation of emergency US findings, it is more prone to errors than other diagnostic imaging modalities. The misinterpretation of US images should therefore be considered as a serious risk in diagnosis . FurtherUS diagnostic errors in the emergency setting can be classified into three groups as follows:Environmental factors;Patients;Technical skills of the operator.Errors dependent on:A common malpractice claim scenario takes place in an emergency room. Overcrowding in emergency rooms, a large number of investigations of differing appropriateness, and quick diagnosis and management all contribute to a high-risk setting. These variables can affect the quality of US examinations, by putting the medical operator under stress ,2 when pPatients in the emergency room are unlikely to be adequately prepared for unanticipated US examinations, such as fasting status and bladder distention. Some patients may be unwilling to cooperate, suffer extreme pain from the probe’s pressure, or be under the influence of alcohol or drugs. These factors can complicate the performance of the US examination, especially by providing a poor panoramic view ,2.. Furthermore, knowing the intrinsic US limits also represents at the same time the achievement of a good awareness of US imaging, the so-called “right measure”, so as to be able to better combine this imaging modality with others in order to achieve good diagnostic performance, and at the same time, make US a concrete diagnostic opportunity. The training and advanced study of US techniques, thorough knowledge of human anatomy, the study of US artifacts, and ultrasonographic semiotics are all crucial tools, and according to the increase in the supply of US performance and its clinical use in emergency scenarios, the need to implement universally accepted guidelines of US training courses appears imperative.The accuracy of the US examination is directly related to the operator’s skill, training, and experience. The medical operator’s responsibilities include fully exploiting the diagnostic capability of US, knowing what to look for, and having the competence to interpret the findings based on understanding the physiology and pathological changes of the examined organs ,2. FurthBad artifacts;Chest artifacts with no clinical context;US-setting errors;Anatomy and anatomical variants.Image artifacts are commonly found with US and can be confusing to the physician who encounters them. Some artifacts may be avoidable and result from an improper scanning technique. Other artifacts are generated by the physical limitations of the mode . In clinA powerful reflecting surface settled out of the main US beam generates echoes that the transducer may detect .An example is given by the “pseudo-mud” which is observed at the bottom of the bladder or in the gallbladder . In thisWhen the US of the primary incident beam passes through a curved interface with high specular reflection capacity , the structure close to this interface can be reproduced on the US image both in its real position and in a symmetrical opposite position, beyond the reflecting surface  . Mirror-This happens when the ultrasonic beam passes through the propagation medium at a much slower speed than expected 1540 m/s), causing the return echo to take longer to be decoded by the scan converter and to return . The ech40 m/s, cWhen the US beam encounters an interface that attenuates the sound to a greater or lesser extent than in the surrounding tissue, the strength of the beam distal to this structure will be either weaker or stronger than in the surrounding field . This ocBecause the US beam is reflected back and forth several times between two highly reflective parallel surfaces (“reverberates”), the US transducer interprets the reflected echoes as happening at deeper structures because they take longer to return to the transducer  3]. Thi. Thi3]. Real-time image processing methods have been developed to improve the contrast resolution of US images by focusing on texture details and reducing noise and artifacts . Edge-enIn musculoskeletal applications, this is a common occurrence. It occurs when the US beam strikes a structure with a fibrillar structure , causing the majority of the insonating sound beam to recede from the transducer. The fibrils have aberrant echogenicity, which the transducer interprets as a hypoechoic zone . This anIntrinsic or patient-related artifacts (such as subcutaneous emphysema), the coexistence of several pathologies that increase or decrease the sub-pleural air content , or existing fibrotic interstitial lung disease, can all be confounding factors in the interpretation of lung US (LUS) findings in the acute setting, and are heavily influenced by the patient’s age . LUS hasTo avoid errors, a thorough understanding of the functionality and underlying mechanics of the US equipment is required. The goal should always be to produce the highest possible image quality by employing a check-list procedure to configure the correct system settings as well as the correct Doppler parameters, which are critical for interpreting clinical US findings  6,9,10,,10,11,12Some anatomical structures and variances might yield difficult-to-interpret pictures, which can lead to errors if not fully understood . The mosThis phenomenon depends on several items, such as the lack of a methodologically correct clinical approach, excessive diagnostic confidence generated by superficiality and/or lack of experience . Due to Furthermore, poor image quality, as well as inconclusive and inadequate US reports, can often relate to errors of underestimation  13,14,1,114,15.It is important to document in detail the US findings found, as well as to provide for their archiving safeguarding in case of future medico-legal disputes. In the same way, an accurate and detailed report emphasizing the importance of the description of pathological changes detected should not be ambiguous, but easy to understand and timely with respect to the clinical question .In this new era of cutting-edge medical advances, artificial intelligence (AI) has emerged as a subset of computer science involved in human-like processes such as learning, adapting, and solving complex problems. The current branches of AI in medical imaging mainly include machine learning (ML) and deep learning (DL), consisting of algorithms that can make predictions or decision tasks without prior explicit programmed rules . ML algoUS quality is operator-dependent and subjective to interpretive error. Following specific rules concerning technique and interpretation and always integrating emergency US findings into the broader clinical context could avoid many misdiagnoses and thus enhance patient safety. Knowledge of common sites of artifacts and their typical/atypical appearances will help to prevent misinterpretation of these findings and may lead to improved diagnostic accuracy. Furthermore, the development of artificial intelligence (AI)-based US represents a useful additional tool of imaging modality. This aids the clinical decision process, making US scans both more detailed and easier to read. This article discussed the most common and uncommon diagnostic errors and mistakes in US examinations. Similarly to other diagnostic tools, it is a fact that errors may occur in the emergency room. Therefore, whether we are talking about common or intrinsic errors rather than uncommon dynamic or variable errors, the risk of a mistake remains. Besides that, the increased complexity in the interpretation of dynamic errors emphasizes the importance of proper training and credentialing for the operator. It is, however, understood that, beyond any technological progress, with a knowledge of the intrinsic limits of US and of its potential “bad” artifacts, as well as a standardized US approach, mistakes can be avoided. This helps to safeguard patient health and prevent potential medico-legal disputes associated with such mistakes.


The WHO Systematic Assessment of Rehabilitation Situation (STARS) tool was developed by WHO to facilitate effective prioritization and strategic planning for rehabilitation in countries. The objective of this paper is to present the results of the fourth phase of its development, its field testing in seven countries focusing on its completeness, usefulness, accessibility and feasibility. Field testing occurred in Jordan, Myanmar, Sri Lanka, Solomon Islands, Laos, Haiti, and Guyana. Evaluation occurred through structured interviews and rating exercises with 17 government representatives, international consultants, WHO country or regional office staff and rehabilitation experts who were actively engaged and familiar with the STARS assessment and who were knowledgeable of the rehabilitation situation in the countries. STARS was appraised as relevant, complete and accurate in describing the country situation. Areas of inaccuracy were mostly linked to challenges in describing areas of services similarly when significant diversity existed. Feasibility and accessibility were mostly confirmed and more complex components of the tool as well as the guidance to the assessment process were slightly revised in light of the field-testing results. The field testing of WHO STARS confirmed its completeness, usefulness, accessibility and feasibility, and concerns raised by the interviews informed the last refinement of the tool. STARS is part of the WHO Rehabilitation in Health Systems-Guide for Action, available online, by September 2021, STARS had guided 21 country situation assessments.  Recognizing the growth in rehabilitation needs in populations, yet the limited and under-resourced services that exist in many countries, the strengthening of rehabilitation is a growing priority . Indeed,Strengthening health systems to provide rehabilitation requires integration of rehabilitation into the components of a health system. The health system building block framework  helpfullA comprehensive and standardized HSA tool will facilitate more accurate assessments of the rehabilitation situation so as to identify priority areas for integration and action. Accordingly, a HSA tool shaped to rehabilitation was developed: The WHO Systematic Assessment of Rehabilitation Situation (STARS). The features of HSA tools were analyzed during the development of STARS and overwhelmingly they were tailored to the area of health that they assess, as this helps to guide a comprehensive assessment of the area . In this way they generate comprehensive findings that are important for informing prioritization. The tool is a key element and the first component of the WHO Rehabilitation in Health Systems-Guide for Action , a resouSTARS underwent a participatory development process with four phases; conceptualization; drafting; consultation and preliminary field test; and field testing, this process is outlined in Kleinitz et al. 2021 . The objThis study received ethical approval from the WHO Ethics Committee.The first three phases of the development of STARS resulted in the version of the tool that was ready for field testing and have been described in detail elsewhere .The purpose of STARS is to facilitate an accurate assessment of the rehabilitation situation that will inform planning through identifying priority areas for integration and action. STARS has three parts, the first part is the Manual which guides the overall process, it is structured by the 4 steps for undertaking STARS in countries, these are; 1. Preparation; 2. Collection of data and information; 3. Conducting the assessment in the country, and 4. Report writing and dissemination. The Manual provides practical step-by-step guidance and includes samples of timelines, budgets, itineraries in countries, Rehabilitation Technical Working Group (RTWG) terms of reference and composition, frequently asked questions and a template for writing the report. The second component is the TRIC which guides information collection, it is structured by the building blocks, including a section on rehabilitation needs and emergency preparedness, it is designed to be sent to the Ministry of Health—Rehabilitation focal point approximately 8 weeks before the in-country assessment and completed by them, often aided by the country’s RTWG. The information collected is reported and informs the descriptions of the situation in the STARS report. The third component, the RMM defines the rehabilitation components for assessment and describes these across four levels on a maturity continuum, a system reflecting the ‘stages of growth’. The RMM (an excel document) is structured by integrating the health system building blocks and services outcomes along the logic model, this supports assessment of what capacity exists , what services are available  and how these perform to achieve the desired outcomes, e.g., population coverage. The RMM is designed to be completed in the country with a consultant and the RTWG reflecting on where they are along the maturity continuum, the results (presented as tables and figures) are incorporated into the written report. The STARS development  provides further detail regarding tool components. In this paper we are evaluating all three parts of STARS.A range in low- and middle-income counties (LMICs) representing as many WHO regions as possible, with large and small populations, a diversity of health system characteristics , were targeted to pilot test STARS in a context as close as possible to the future scope of the tool. Nevertheless, the LMICs invited to participate in the STARS field testing represent a convenience sample of countries for which the Ministries of Health had previously engaged with WHO or a development partner on rehabilitation strengthening initiatives and demonstrated interest to utilize the STARS tool. Given the time and political commitment required by a Ministry of Health (MOH) to conduct comprehensive health systems assessments, the agreement and readiness of a MOH to conduct STARS was a core inclusion criterion in the selection of the countries.STARS was implemented by consultants, selected based on their experience in rehabilitation and situation assessments, and trained in how to use STARS during a three-day workshop on the 13–15 June 2018, in Geneva. This training entailed presentations, small group work, case studies and simulations that facilitated familiarization, engagement with the tool and likely scenarios in countries. Consultants were not necessarily familiar with the countries where they utilized the STARS. Therefore, we ensured a structured preparation phase including reviewing the information within the TRIC, and then in-country site visits, interviews and discussions to familiarize them with the country situation.The evaluation entailed brief structured interviews with key individuals who met the twin criteria of being actively engaged and familiar with the STARS assessment and having direct knowledge of the rehabilitation situation in the country. For recruiting the participants, invitations were emailed to the international consultants who conducted the STARS, ministry of health rehabilitation focal points and other rehabilitation experts living in or working with the selected countries, and relevant WHO country and/or regional office staff.Interviews included open-ended questions with a corresponding rating exercise , and resKey information from open-ended answers and comments was extracted and consolidated into a single document focusing on the core points of each question . The anaDescriptive statistics  were estimated for the 5 key informant questions, and the mean, median, absolute numbers and percentages were calculated for the rating scales of the RMM components, all using Microsoft Excel.The field testing occurred over a 20-month period, from July 2018 to March 2020. Selected countries included Jordan, Myanmar, Sri Lanka, Solomon Islands, Laos, Haiti and Guyana. They represent four WHO regions, include LMICs, countries with large and small populations, and health systems with large and small proportions of non-government providers. Altogether 21 invitations were sent out and 17 structured interviews conducted. The RMM rating was undertaken by 16 people, as one interviewee from a WHO country office declined the task due to being unfamiliar with rehabilitation. In this case, 12 interviews were conducted over the telephone and five face-to-face, two of the interviewees were WHO Regional Advisors that shared their experience across two countries in their regions (America’s and Western Pacific regions). See Completeness explored to what extent STARS covers all aspects relevant to rehabilitation. Out of all aspects of STARS, its completeness scored most positively: 100% of interviewees scoring it eight or higher, with a mean of 8.88 and median of 9 and score range from 8–10 . In the Usefulness explored to what extent STARS provided an accurate picture of rehabilitation in the country. 76% of interviewees rated usefulness positively with a score of eight or higher, the mean was 8.12, the median was 8 the score range was 5–10. Areas of inaccuracy or imprecision that were reported included descriptions of private sector rehabilitation provision, geographic differences within a country and quality of rehabilitation. Five interviewees (three consultants and two WHO staff) reported challenges when undertaking STARS to progress beyond ‘particular people’s perspectives’ and past ‘gatekeepers’ to describe the ‘real’ situation.Accessibility assessed the extent to which STARS was considered easy to implement and complete.STARS Manual: 16 out of 17 interviewees scored accessibility of the Manual moderately high (seven or more), meaning it was relatively easy to use. The mean was 7.76, the median was 7 and the score range for this was 6–10. The interviewees welcomed the Manual’s step by step and practical guidance. Seven of the interviewees did not identify any areas for improvement. Suggestions for improvement included the need for the Manual to be translated to country languages, the need for government familiarization and training on the manual and creation of sub-steps.STARS Template for information collection: 13 out of 17 interviewees scored accessibility moderately high (seven or more). The mean was 7.12, the median was 7 and the score range was from 2–9. A concern was that the template asks for information that many governments could not provide, e.g., rehabilitation expenditure. The government stakeholders in three countries misunderstood the instructions and requested multiple stakeholders to complete it, which then required consolidation. Suggestions for its improvement focused on strengthening the guidance for how it should be completed.STARS Rehabilitation Maturity Model. 11 out of 17 interviewees scored accessibility of this moderately high (seven or more). The mean was 6.47, the median was 7 and score range was from 1–8. In comparison to the other parts, over 50% of interviewees characterized the RMM as ‘complex’. Some components were considered difficult to score for being “subjective” and it required more time with government to complete than what had been indicated in the guidance. Suggestions for improvement related to: reducing component numbers; removing use of sub-components; clearer differentiation between maturity levels; translation to local languages; training of on its purpose and how to complete it; and managing governments expectations about likely scores and their interpretation.14 out of 17 interviewees scored feasibility as moderately high (seven or more). The mean was 7.35, the median 8 and score range was 3–10. Two areas of concern were mentioned. First, the length of time it took to complete the assessment in a country, suggesting that the recommended two weeks was not long enough for larger and/or more complex countries. Second, the necessity of additional partners, such as the WHO country office and an international non-government organization, to be engaged and supporting government through the process.The mean score was calculated for each component and 14 out of 56 scored 3.5 or less, the remaining 42 components had a mean above 3.5 . The 14 Analysis of data included looking for trends across stratified groups, either across countries or stakeholder groups, this was accomplished by comparing the means and with a small sample size the analysis did not reveal any significant trends.Interviews revealed commonalities regarding the positive features and concerns regarding specific components of STARS, as well as exploring reasons for these and considerations of what could be carried out to improve the tool. Bringing stakeholders together in countries through RTWGs mostly worked well. It increased the quality of input and amount of information shared, contributing to greater insights regarding the country situation, as reported for five countries . In Laos and Jordan working groups were considered less effective at generating information and insights from development partners was valued, particularly by consultants.The comprehensive guidance of the RMM was appreciated and its structure supported the development of conclusions related to overall access and outcomes of rehabilitation, that help to ‘tell the story’ of what rehabilitation had achieved, or not. The consultants valued the tool’s prompts to consider overall outcomes such as service coverage, sustainability, and equity. However, they also reported that this section of the report was difficult to elaborate with limited data to draw upon and therefore the conclusions had to be cautiously made. The visual scoring was considered valuable and facilitated quicker comprehension of results.Interviews explored the reasons given for the concerns raised about areas of inaccuracy or imprecision related to descriptions of the private sector rehabilitation provision, these were described similarly and related to the limited access to the private sector services during the in-country assessment period due to the MOH focus on government services and few private services visited. The reason for concerns about difficulty to describe the situation across geographic areas was explored and reported to be because the 2-week period in a country prevented visits beyond major cities and a small selection of rural areas. The reasons for concerns about describing quality of services were reported to be because of significant variations across facilities and the need to rely on observation and stakeholder reporting rather than any objectives measures which were mostly unavailable.Finally, comments directed towards what could have been carried out differently during the STARS process in the country yielded similar responses to the questions focused on what improvements could be made to the tools. However, the need for engagement from senior government officials during the process and the value of WHOs role to support government prioritization of rehabilitation was also stressed.Revision to the STARS Manual focused on creating more clearly defined sub-steps under each step and expanding guidance for the preparatory phase. For example, preparatory guidance was adjusted to include development of a detailed concept note prior to commencement, and more instructions for how to use the RMM with governments. Small revisions were made to the information collection template and its name was changed to reduce the misunderstanding that multiple people should complete it, a note was added that limited available data for some questions is common and need not be a concern to governments. The RMM underwent changes including explicitly mentioning rehabilitation for people with hearing, vision and mental health needs, refining definitions of components, increasing differentiation and uniformity in maturity level descriptions through consistent use of the terms ‘emerging, minimal, moderate and high’, and reducing the number of components. The RMM now has 50 components with revised overall maturity descriptions. The STARS is available on the WHO website.We present results of the WHO STARS field testing in Jordan, Myanmar, Sri Lanka, Solomon Islands, Laos, Haiti, and Guyana. The interviews conducted targeted the completeness, usefulness, accessibility and feasibility of STARS. Results confirmed that STARS can effectively guide an HSA to accurately reflect the rehabilitation situation in countries and that this best occurs through collaboration between the government, consultants, rehabilitation experts, and development partners, including WHO. Concerns raised in the interviews guided the last revision of STARS, now available as part of the WHO Rehabilitation in Health Systems-Guide for Action .Participatory approaches in the development of HSA tools are important to achieve relevant, accessible, and feasible tools that governments want to use . Key staThe Rehabilitation 2030 Call for Action stresses the importance of integrating rehabilitation into all health system components, therefore a tool reflecting this breadth was necessary, and high levels of completeness were sought during STARS development. The breadth of information is important as studies have highlighted the diversity of issues in countries, such as inadequate rehabilitation workforce , and gapThe ability of a tool to provide an accurate picture of a country situation is crucial, especially as its findings are used during planning to determine which of multiple priorities requires greater attention. Interviewees considered STARS reports accurate, with two exceptions. The first area reported was an inaccuracy in the descriptors used for particular components of rehabilitation services . When explored, this inaccuracy related more to an ‘inadequacy’ or imprecision in descriptions, reports overly characterized services similarly in an attempt to keep descriptions brief. Linked to inaccuracy, the challenge of describing the ‘real’ situation including politics and power hierarchies was also reported. This challenge is not specific to STARS and innate in most HSA processes, and often descriptions of the politics and power hierarchies are intentionally omitted due to their sensitive and sometimes subjective nature. Both of these areas highlight the challenge of all HSAs as they try to achieve a balance of features, for example being accurate and complete but also remaining succinct and sensitive to differing local perspectives.Many HSAs tools have incorporated grading systems with some of these characterized as maturity models. Maturity models, or ‘stages of growth’, are based on the premise that people, organizations, programs move through a process of development towards a more advanced state and that this occurs over multiple levels . In healThe added value of STARS is its ability to generate comprehensive overviews to the rehabilitation situation in many LMICs, these provide decision makers with evidence and insights into their situation and improve their national rehabilitation planning efforts. For all of the seven countries included in this study, conducting STARS was the first comprehensive rehabilitation situation assessment they had undertaken. Indeed, few comprehensive rehabilitation situation assessments have been published and governments have often made planning decisions with limited data mostly because rehabilitation hasn’t been well integrated into health information systems making data unavailable . STARS dLimitations. Our study must be interpreted in light of its limitations. Although a broad range of diverse countries were included in the field-testing, and STARS was positively evaluated, different results might be obtained in other settings, and challenges were observed for settings in which the population is large and the health system more complex. Moreover, we aimed to check completeness, usefulness, accessibility and feasibility, but we are aware that formally checking those characteristics would require a more systematic approach. For instance, confirming completeness could involve a systematic review of rehabilitation features and a structured comparison with STARS. Nevertheless, the approach used in the field testing was sufficient to fulfill our goal of generating a final version of STARS. Future utilization therefore should include further evaluations of its strengths and weaknesses and revisions to STARS should be anticipated.The field testing of WHO STARS in seven countries broadly confirmed its completeness, usefulness, accessibility and feasibility, and concerns raised by the interviews with rehabilitation experts (government and non-government), international consultants and WHO staff informed the last refinement of the tool. STARS is part of the WHO Rehabilitation in Health Systems-Guide for Action, available online. By September 2021, STARS had guided 21 country situation assessments and reports have been successfully used to inform rehabilitation strategic planning and integration into other national health planning processes. In this way, situation assessments conducted with STARS became a crucial element to strengthening rehabilitation in health systems, as demanded in the Rehabilitation 2030 Call for Action.


N = 1,022) was conducted with subsamples from the United Kingdom (n = 502) and the Netherlands (n = 520). The results highlight the importance of people’s support for, and perceived efficacy of, the measures and preventive behaviors. This also applies to the perceived norm of family and friends adopting these behaviors. The networks in both countries were largely similar but also showed notable differences. The interplay of psychological factors in the networks is also highlighted, resulting in our appeal to policy makers to take complexity and mutual dependence of psychological factors into account. Future research should study the effects of interventions aimed at these factors, including effects on the network, to make causal inferences.Preventive behaviors are crucial to prevent the spread of the coronavirus causing COVID-19. We adopted a complex psychological systems approach to obtain a descriptive account of the network of attitudes and behaviors related to COVID-19. A survey study ( In either case, the effectiveness of the behavioral guidelines in limiting the spread of the virus depends on the degree to which people (are willing to) adopt them  and displays interactions between these attitude elements (edges). The nodes include cognitive, affective, and behavioral elements that form attitudes, and edges represent mutual dependencies between nodes . To illuconnectivity of the network provides information about the network’s strength and impact on behavior . To optimize our understanding of adopting preventive behaviors during the unprecedented and complex COVID-19 pandemic, we expand the model’s application to other relevant factors and thus aim to further meet the complex systems objectives. We aim to demonstrate the value of such a broad approach, encompassing attitudes complemented with relevant factors based on the TPB and HBM and other relevant factors derived from the literature, such as trust, personality, and health variables.The current study has two aims. First, we aim to provide a descriptive account of the network of attitudes and behaviors related to COVID-19. In doing so, we do not limit ourselves to a set of factors in a particular model, nor do we make predictions about causality. Second, we examine whether national differences can be observed in the networks by investigating two countries with different policies: the UK (quite strict in its lockdown) and the NL (with a more advisory approach). Differences between countries in terms of their approach toward the preventive measures and promoting compliance may lead to different patterns in terms of how the psychological factors  relate  were excluded. This resulted in a total sample of N = 1,022, with subsamples of n = 502 from the UK and n = 520 from the NL (see For a moderately sized network (maximum of 30 nodes), a sample size of 500 participants is likely to result in accurate network estimation , indicate NL see .As described in the introduction, we identified constructs in the literature that were associated with preventive behaviors during pandemics. Based on these constructs, we developed a survey see .After collecting the data, we constructed the psychological factors as nodes either with a predetermined combination of items or based on components in the data as identified through principal component analysis (PCA). The nodes on adopting behaviors  were predetermined by the behavioral guidelines as described in the next section. The node Risk Perception was the product of likelihood and severity of an infection. Other predetermined nodes were validated scales  and single-item nodes  was calculated by multiplying the scores on the items.Two nodes were identified for affect, namely Affect Negative  and Affect Positive . The items on worries resulted in the node Worries Personal  for worries about events in the pandemic that affect their personal life and Worries Society  for worries about events that affect society.The behavioral factors of attitudes measured the intention to get vaccinated if a vaccine were available (Vaccination Intention). Attitude toward measures, including preventive behaviors, resulted in two nodes: Measures Support and Measures Efficacy, with items measuring the degree to which participants supported the measures and preventive behaviors needed to prevent the spread of the coronavirus and the degree to which they were perceived as efficient, respectively.The survey contained the following scales tapping into attitudes about the pandemic relevant in the present context, divided into cognitive, affective, and behavioral factors of attitudes:The social norm resulted in two nodes: Norm Society, about trusting others to (and thinking the majority does) display the preventive behaviors, and Norm Family and Friends, about the perceived degree to which family and friends adopted the preventive behaviors.Perceived control was measured by the degree to which people felt they could avoid infection with the coronavirus, resulting in the node Control Infection.The node Trust Authorities was measured with general trust and separate items  and suffered from a health condition (node Illness) known to increase the health risks of COVID-19.I prefer not to answer in the health-related items and Other as gender, as indicated by n/a in The answer option n = 1,002 . The network analyses were conducted with this final valid sample.Information about preliminary and network analyses can be found in the Supplement (S2). Participants with missing values were deleted listwise due to the small number and the methodological challenges pairwise deletion would impose on the network analysis. This resulted in a final valid sample of Although it is unknown whether differences in countries’ trajectories of the pandemic affect the relations between the nodes in the networks, it is important to consider the different contexts in each of these countries at the time of data collection.  The nodes represent the psychological factors as measured by a combination of items in the survey. The edges represent the mutual dependence between nodes. More specifically, an edge indicates a relation between two nodes after controlling for every other node in the network. These edges are weighted  and undirected . A complete overview of the edge weights for this and subsequent networks is provided in the Supplement (S2). Edge weights relevant for the edges discussed in the text are provided within parentheses. Broadly speaking, we label the communities as social norms, trust, and behavior related to the pandemic (green); attitude toward measures and preventive behaviors (purple); worries and negative affect (yellow); general health and risk perception concerning health (orange); health change compared to before the pandemic (red); and stable, personality-based characteristics (blue). White nodes did not consistently belong to one community.The communities  indicate a difference in interconnectedness between clusters, meaning that nodes within communities are more connected to each other than to the remaining nodes. This means that the relations between the nodes Preventive Behaviors with Norm Family Friends, Measures Efficacy, and Measures Support were of comparable strength, with exclusively positive relations. This indicates that, for example for the node Norm Family Friends, an increase in perceived social norm among family and friends of adopting the preventive behaviors is associated with an increase in adoption of preventive behaviors, and vice versa. The nodes Trust Authorities, Worry Personal, and Control Infection were also directly related to Preventive Behaviors , Measures Efficacy (0.20), and Measures Support (0.21). These edges were highly accurate, and there was no significant difference between the strength of these edges.Regarding health, Health Mental was positively related to Health Physical (0.48) and negatively related to Affect Negative (−0.25). This indicates that an increase in mental health co-occurs with an increase in physical health and a decrease in the experience of negative emotions. Examples of relations with binary nodes are those between Illness and Age (0.41) and Illness and General Health (−0.49), indicating that increasing age or decreasing general health is associated with a higher probability of a participant reporting an illness. The caption of Centrality measures provide information about the relative importance of nodes in the network by indicating the effect that influencing one node can have on the entire network. These measures also provide an indication of the predictive value of nodes for behavior . It shou (provided in text in parentheses) of the nodes in the COVID-19 network. High node strength suggests that the concerning node is an important variable for people’s attitudes and behaviors related to the COVID-19 pandemic . The nodes relevant to Preventive Behavior (1.30), that is, Measures Efficacy, Measures Support, and Norm Family Friends, differed in strength. The node strength of Measures Efficacy (1.80) and Measures Support (1.70) was relatively high and comparable to each other . In relation to the dynamics of attitude change, high node strength suggests that changing such a node is likely to have a profound effect on the network. More specifically, it is expected to affect the interplay and mutual dependence of the psychological factors in the network, due to affecting many other nodes. However, influencing a central node will likely be difficult since it is the nature of these nodes that they are held in check by the other nodes they are connected with (ted with . The nodp = .444).Connectivity of the networks is calculated by the average shortest path length (ASPL), indicating how quickly any given node can reach any other given node in the network on average. The ASPL of the COVID-19 networks is 11.80 for the UK subsample and 13.02 for the NL subsample. This indicates differences between the networks, but the global strength measure (a different measure of connectivity) of the Network Comparison Test (NCT) did not differ significantly , indicating that only there, older participants perceived more risk. The positive relation between Gender and Affect Negative also differed significantly. In both samples, women showed higher negative affect than men, but this relation was more pronounced in the UK (0.29) than in the NL (0.10).The current research provides a descriptive account of the network of attitudes and behaviors related to COVID-19, thereby providing insight into the complex psychological system related to the COVID-19 pandemic. Moreover, we compared the psychological systems of two countries to explore whether differences between countries can be observed in the psychological COVID-19 networks.First, we found that attitudes toward the measures and preventive behaviors had the strongest (positive) relation with the degree to which people adopted them. More specifically, this applied to the degree to which people support the measures and behaviors and perceive them as effective. Furthermore, we found that the perceived norm of family and friends adopting the preventive measures was also associated with adopting preventive behaviors. These findings are in line with the TPB and earlier research pointing toward attitudes and social norms as important predictors of behavior during pandemics . We compMoreover, our results provide insight into how attitudes and additional factors  relate to each other within a network and thereby contribute to understanding attitudes and preventive behaviors related to COVID-19. The psychological networks in this study provide a first insight into how interventions aimed at one node can affect other nodes. This can be relevant for the choice of which node to target, for instance, by targeting a node that is easier with limited effect on the network, or a node that is more difficult to perturbate, but with the potential of more sustainable change in the network. In the context of the current study, the results suggest that although changing the support for, and perceived efficacy of, measures and preventive behaviors is likely to be more difficult than changing the perceived norm of family and friends, the effect on the rest of the COVID-19 network is assumed to be more profound. Future research should study interventions to affect these nodes in order to make causal inferences and examine the effect of interventions on the interplay and mutual dependence of the psychological factors in the COVID-19 network.Second, we observed that the UK and the NL showed similar psychological networks of factors related to the COVID-19 pandemic, with some specific differences. The COVID-19 networks showed differences in clusters of nodes with higher interconnectedness, the relative importance of nodes for the rest of the network, and the relations between specific nodes. We also found that changes in health during the pandemic likely have a larger effect on the COVID-19 network in the NL than in the UK. The opposite applies to change in social norms, which will likely have a larger effect on the network in the UK. Possible explanations for these differences between the UK and the NL should be examined in future research. A potential explanation is that data collection in the UK took place during an upward trend in terms of severity of the pandemic, whereas the data in the NL were collected during a downward trend. It is, however, unknown whether differences in the COVID-19 networks are caused by a difference in timing, trajectory, policies, or media attention during the pandemic, or other cultural or preexisting differences. Despite these differences, the countries show comparable psychological networks, and future research could investigate whether the specific cross-national differences observed here are indeed meaningful.Limitations of this study predominantly concern the boundaries of the presented networks. As is almost inherent to complex systems, we expect more nodes to be relevant to explain attitudes and preventive behaviors related to COVID-19 than included in the present study. Future research could further increase the ecological validity of the psychological networks by including other relevant nodes. Furthermore, given the duration of a pandemic, the relative contribution of nodes is assumed to fluctuate and can differ, for instance, between the initial and perseverance period or during an upward or downward trend in severity of the pandemic. Consequently, future research should shed light on the temporal dynamics of the mutual dependence of the psychological factors that influence preventive behaviors during pandemics.The objective of this research was to study the complex psychological system that are attitudes and behaviors in the COVID-19 pandemic. Accordingly, we compared the psychological networks of two countries. Based on our results, we advise to study interventions aimed at the support for, and perceived efficacy of, the measures and behaviors combating the pandemic, and the perceived norm of family and friends adopting the preventive measures. Moreover, we would like to appeal to policy makers to take mutual dependence of psychological factors into account. Finally, while the networks in both countries were largely similar, we observed some cross-national differences that can possibly inform national strategies and policies.Click here for additional data file.Supplemental Material, sj-docx-1-spp-10.1177_19485506211002420 for A Psychological Network Approach to Attitudes and Preventive Behaviors During Pandemics: A COVID-19 Study in the United Kingdom and the Netherlands by Monique Chambon, Jonas Dalege, Janneke E. Elberse and Frenk van Harreveld in Social Psychological and Personality Science