Guinea undertook health workforce reform in 2016 following the Ebola outbreak to overcome decades-long shortages and maldistribution of healthcare workers (HCWs). Specifically, over 5000 HCWs were recruited and deployed to rural health districts and with a signed 5-year commitment for rural medical practice. Governance structures were also established to improve the supervision of these HCWs. This study assessed the effects of this programme on local health systems and its influence on HCWs turnover in rural Guinea.An exploratory study design using a mixed-method approach was conducted in five rural health districts. Data were collected through semi-structured questionnaires, in-depth interview guides, and documentary reviews.Of the 611 HCWs officially deployed to the selected districts, 600 (98%) took up duties. Female HCWs (64%), assistant nurses (39%), nurses (26%), and medical doctors (20%) represented the majority. Findings showed that 69% of HCWs were posted in health centres and the remaining in district hospitals and the health office (directorate); the majority of which were medical doctors, nurses, and midwives. The deployment has reportedly enhanced quality and timely data reporting. However, challenges were faced by local health authorities in the posting of HCWs including the unfamiliarity of some with primary healthcare delivery, collaboration conflicts between HCWs, and high feminization of the recruitment. One year after their deployment, 31% of the HCWs were absent from their posts. This included 59% nurses, 29% medical doctors, and 11% midwives. The main reasons for absenteeism were unknown (51%), continuing training (12%), illness (10%), and maternity leave (9%). Findings showed a confusion of roles and responsibilities between national and local actors in the management of HCWs, which was accentuated by a lack of policy documents.The post-Ebola healthcare workers policy appears to have been successfully positive in the redistribution of HCWs, quality improvement of staffing levels in peripheral healthcare facilities, and enhancement of district health office capacities. However, greater attention should be given to the development of policy guidance documents with the full participation of all actors and a clear distinction of their roles and responsibilities for improved implementation and efficacy of this programme.Supplementary information accompanies this paper at 10.1186/s12960-021-00596-x. The situation of skilled healthcare workers (HCWs) in Guinea is characterized, on one hand, by a critical shortage, and on the other hand, a disparity in their distribution between rural and urban settings . For insNonetheless, in the aftermath of the Ebola outbreak, efforts were made by the Guinean government, with the support of development cooperation initiatives, to strengthen the health system, and to make it resilient to future epidemics, through improved availability and distribution of HCWs , 8. InitTo analyse the effects of the post-Ebola deployment of public healthcare workers on local health systems and services;To analyse barriers and enablers of the retention of public healthcare workers in rural areas;To assess the turnover of public healthcare workers one year after their deployment.Therefore, the main objective of this study was to document the implementation process of this post-Ebola HCW retention policy at the local (district) level and assess to what extent this policy would influence the turnover of HCWs in rural Guinea. Three main research objectives were identified:The relevance of this research resides in its potential for providing information on factors influencing the retention of HCWs in the post-Ebola context in rural Guinea. Such findings would support policy-making and programming and guide the post-Ebola Health Systems Strengthening (HSS) reform.The Bilodeau analytical framework  approach . BecauseA stratified purposive sampling technique was used to guide the selection of study participants for the qualitative component of this study . The firFor the quantitative component, HCWs under the post-Ebola retention programme that were present at their post during data collection were systematically enrolled in this study.Data were collected using a questionnaire, an in-depth interview guide, and a documentary analysis from April to June 2018.Two researchers from the Maferinyah National Research and Training Centre (CNFRSR), and respectively 10 research focal points and medical graduates  conducted 120 in-depth interviews with local government officials (4%), local health authorities (17%), community representatives (10%), health facilities and services managers (27%), and healthcare providers (42%). All interviews were conducted in French. Research focal points and medical graduates stayed in the study sites for two months, from 25th April to 29th June 2018, and collected data on absenteeism in two main stages. The first stage consisted of the interview of all new HCWs present at their post at the first passage of the data collectors. The second stage consisted of the inclusion of any new HCWs absent at the first passage but who showed-up within the two months of the data collection.The research focal points included HCWs under the post-Ebola retention programme with great interest in the study, and holding positions of responsibility: responsible for health human resources, planning, research, and training units at the district level. The medical graduates were selected from the Public Health Department of the University of Conakry and part of the study data were used for their theses. All the research focal points and medical graduates were trained on the research protocol and the data collection tools. The pre-test of data collection tools was conducted in health facilities in locations different from study sites.The documentary review focused on official acts, texts, payroll records, and HCWs’ registries available at the study sites.Interviews were transcribed and coded manually following a thematic analysis approach . Data weData from the questionnaire were entered into a dedicated EpiData database  and summarised using proportions or means (± standard deviation).A skilled HCW is a health professional holding academic and practical training from a public or private institution accredited by national, regional, or international standards. HCWs considered skilled in Guinea include medical doctors, nurses, midwives, health technicians, etc. HCWs turnover was understood as a result of job dissatisfaction, which can be measured by HCWs’ absenteeism, intention to quit, and the demotivation to stay . As for Based on the study objectives that guided the data analysis, the results are presented below according to the different emerging themes.Out of 611 HCWs officially deployed in the selected rural health districts in April 2017, 600 (98%) took-up duties. The distribution characteristics of these HCWs are depicted in Table Female HCWs accounted for 64% of them. Assistant-nurses (39%), nurses (26%), medical doctors (20%), and midwives (12%) were the most represented socio-professional categories.Overall, HCWs were mostly posted in health centres (69%) and district hospitals (26%). Moreover, 42% of medical doctors (49 out of 118), 71% of nurses, and 76% of midwives were assigned to health centres.Two main themes emerged from the interviews with participants when asked about the potential effects of the deployment of HCWs.First, respondents stated that the Ebola Virus Disease outbreak led to job-abandonment of many unemployed (volunteer) HCWs because of the fear of contracting the disease or the take-up of employment offers in epidemic control programmes, especially with international organizations. As such, according to them, the deployment of new HCWs helped to fill this gap and improved staffing levels. This finding correlated with quantitative data on publicly funded HCWs available on the study sites before and after the deployment of new HCWs in 2017, wherein as much as a 60% increase in staffing levels was reported Table .Table 3D... We have fully staffed, for the first time, our organic framework… Today many technical problems with our computers, or the making of patients’ consultations notebooks are solved on the spot by this personnel... Now, the units of statistics, planning, and training are held by medical doctors across the country... It helps to the rapid [timely] reporting of completed and good quality data... Second, according to participants, the deployment allowed the staffing of managerial positions with qualified HCWs owning several competencies, for example in computer processing, teaching, and care delivery. This, according to participants, resulted in better care organization through the sharing of tasks and workload among the staff but also in timely reporting of completed and good quality data.However, five challenges were reportedly faced by local health authorities, health facilities, and services managers during the posting process of HCWs.First, participants reported that many HCWs were unfamiliar with the delivery of primary healthcare in rural settings. This, according to them, was due to the fact that few had experience and acquaintance with medical practice or were rather accustomed to the delivery of care in hospitals and urban settings. Some local health managers reportedly organized intensive on-site training for HCWs, on the functioning of primary healthcare facilities, especially immunization and maternal and primary curative care.Second, the high proportion of female HCWs was another reported challenge as many were pregnant or breastfeeding at the time of the deployment. This pushed local health authorities to predominantly (re-) assign female HCWs to urban or easy-to-access rural health facilities and to compensate for it, unemployed HCWs  were reallocated to rural and hard-to-reach areas with some incentive packages .... We have worked for several years here but the district health director never manages to recruit us as public servants... We [eight of us] decided to create our private cabinet... We see over 300 patients per month [more than most health centres in the locality do] and the income we generate daily [from patients] is used to buy food and eat together... Patients prefer coming to us because of the trust we built with them over the years we were working in the public health facilities... Third, some local unemployed HCWs left public health facilities as a result of their frustration for not been recruited.Fourth, participants reported collaboration conflicts between new and former HCWs. These were mainly sustained, according to participants, by the perceived unequal treatment of HCWs vis-à-vis appointment at positions of responsibility which were in favour of new HCWs. This impacted healthcare organization and functioning in some health districts, especially in the conduction of health services monitoring and evaluation activities.To address collaboration conflicts, some local health authorities carried out a complete reshuffle of management positions in the frontline health facilities including sending former HCWs, especially health services managers, to places unfamiliar to them.... It is the traditional birth attendant and assistant-nurses who have being delivering births here and that has not changed even with our presence [after our assigning]... But it is difficult to do anything in this situation because no written document distinguishes the roles of an assistant-nurse, a nurse, or a midwife... We have been parachuted here without any documentation on our roles and responsibilities and this limits us in our work and the claiming of our rights... Finally, it emerged from interviews that HCWs were posted in local health facilities without a proper task description. According to respondents, this resulted in less accountability of HCWs and reportedly accentuated collaboration conflicts between them, as quoted below.This section on the barriers and enablers of HCWs retention follows the elements of attraction, installation, and integration, according to the Bilodeau analytical framework.Overall, 85% of the new HCWs reported that they were well received by local health authorities. Totally, 68% of participants were also reportedly well received by the local communities during the take-up of duties Fig. .Fig. 3FrFrom the interviews, three main reasons emerged as factors attracting HCWs in rural Guinea in the post-Ebola context.… Public servant status gives a lifetime guarantee… You can still be paid even when you are sick or retired… Working in the private sector represents a risk even though it pays well… First, the desire to become a public servant was an important attraction factor for rural practice. For some participants, the advantage related to the status of a public servant is that it provides a lifetime guarantee and requires fewer constraints and working time as usually required by the private sector. For some other HCWs, it offers an opportunity to become independent from the family or spouse after several years of dependency and its related-financial implications in, for instance, supporting education and living expenditures.... As a nurse, practising in rural areas gives a lot of learning opportunities... Here I have been taught how to examine a patient including using a stethoscope but in the national hospital I worked before, I could only inject patients or ensure their nursing... Second, working in rural areas was perceived by HCWs as an opportunity to continue practising medicine and learning from another context. For some HCWs interviewed, especially nurses and midwives, health facilities in rural areas are less staffed compared with urban settings, and in that sense, offer unique learning opportunities. For instance, some nurses and midwives reported that working in rural areas provides more responsibility and helps to acquire knowledge that is only dedicated to medical doctors in urban places.Third, HCWs stated that they were attracted by rural practice because of their vocation to help disadvantaged populations like those living in rural areas. They justified this by their involvement in humanitarian projects in rural areas, be it their actual assigned zone or not. This group of HCWs is interested in working anywhere if the need arises.The role of local health authorities and community representatives were repeatedly mentioned by HCWs as a favouring factor for their installation, particularly in rural areas. In some places, the facilitation of accommodation acquisition, the donation of food and cooking utensils to HCWs, and provision of means of transport  was reported.However, difficulties were reported by some HCWs during their installation. These were related to lack of housing especially in urban and mining areas, the working atmosphere, and local living conditions .First, participants reported difficulty in obtaining houses.It was reported that HCWs stayed in health facilities for a while before getting accommodation. Because of this, some HCWs temporarily left their assigned post. These participants highlighted that they were afraid of contracting nosocomial infections while they also had financial difficulties in bearing the costs of housing. They suggested that the state give installation bonuses to facilitate the HCWs installation process in rural areas.... It was not easy to work with them... It was not easy at all... I went back to Conakry and informed my parents ... They are the ones who encouraged me to come back to my post... My mother told me, it is a public service, not someone's property, you cannot leave your job because of someone’s attitude towards you... Second, some HCWs reported collaboration conflicts with the former workforce in their assigned positions. This, according to them, existed because the former staff considered them a threat to their position of responsibility. The role of HCWs’ parents was crucial, at this stage, for motivating them not to leave their posts.Other attitudes were also adopted by HCWs to cope with this situation; the most important of which were the exclusive focus on the provision of care  and the avoidance of calling oneself a civil servant.... I was assigned to “Mixi” [fictitious name]... Cars only go there once a week... When I arrived in the village [place of deployment], I cried and I said to myself—why did the state do this to me?... My first 2 nights here, I didn't sleep at all... I took it as a punishment from the state... Third, with regards to living conditions, we quote a HCW below:Up to 69% of HCWs surveyed were not satisfied with their living conditions. However, respectively, 62% and 74% were satisfied with their salary conditions and professional situation, and 85% felt secure at work Poor living conditions, low salaries, and limited learning environments were mainly identified as factors impeding the integration of HCWs in rural areas. With regards to living conditions, the difficulties of accessing schools for children, electricity, potable water, internet, and decent housing were considered major obstacles.... Being married and staying away from your husband for months is not well perceived by society... People often downgrade you... They think you are in extramarital relationships with your colleagues or managers or that you have no sense of social value... If you have a jealous husband or an annoying family-in-law, they will always ask you to choose between your work and your family... Issues such as difficulties for children to readapt to the new situation of the family, the fragile health status of a family member, and inaccessibility of the currently assigned zone were also reported. From some married female HCWs’ point of view, staying far away from ones’ husband and family is not well perceived in the Guinean context.Salaries were a major concern for many participants but with a different effect depending on individual characteristics. For HCWs with many people to care of (including their children) and previous exposure to private practice , the major concern was the insufficiency of salaries along with the lack of alternative sources of income in rural areas to cover actual expectations and needs of the family.In some study sites, local health facilities managers were allocating financial bonuses to HCWs to compensate for low salaries. This included the sharing of 10–20% of the healthcare facilities’ monthly income to HCWs as motivational bonuses. Exceptionally, in some mining zones, health facilities managers authorised HCWs to sell their medicines during night-shifts, but under the supervision of a regulatory committee that controls drug quality and sale prices.For HCWs posted in rural and hard-to-reach areas, the lack of financial compensation for geographic distances and difficult living and working conditions were reported as factors inhibiting their integration. For example, some HCWs complained that the current salary payment method was creating inequality concerning the disadvantages of HCWs posted in hard-to-reach areas compared to their peers working at the district level. HCWs posted in hard-to-reach settings have to pay part of their salaries as transportation fees for accessing them at the district health office—salaries are paid, by cash, at the district health office—while their colleagues staying in urban areas are not exposed to such extra expenses.Other elements inhibiting the integration of HCWs were the under-utilisation of health services by communities in rural areas. According to participants, the population in remote areas utilise health services once a week and exceptionally during three months of the rainy season—which corresponds to high malaria transmission period. Many midwives also supported that birth deliveries are attended in communities, by traditional birth attendants, and only a few of them are referred to them at the stage of complications.A total of 413 (69%) HCWs were present at their assigned posts 12 months later. This represented a 31% absenteeism rate among recently deployed HCWs Fig. .Fig. 5FrThe sociodemographic characteristics of the HCWs present at their posts 12 months after their deployment are presented in Table Figure None of the above reasons were documented at local levels, and interviews revealed an underlying factor: the lack of transparency and fairness in the decision-making of health system actors both at the central and local levels.... More than 80% of the health personnel affected in Coyah, Boffa, Kindia, and Forecariah were women... And most of them have their husbands working in different ministries and departments in Conakry... What can a health centre or a district health manager do when, for instance, a national director asks him to allow his wife to join him in Conakry for whatever reason? First, actors from the central and regional levels of the MoH were reportedly influencing decision-making processes regarding the management of some HCWs. For instance, participants reported that training leaves and redeployment acts were exclusively delivered by the central administration of the MoH and without prior consultation of local health authorities. Also, according to participants, some decision-makers from the central and regional levels were involved in leave-requests concerning their relatives, especially in the district surrounding the capital Conakry.Second, at the district level, maternity and annual leaves were allocated by local health authorities without proper coordination with community representatives, the local administrative authorities, and sometimes, local health facilities and services managers. Because of this, according to participants, some HCWs were exceptionally paid through money transfer platforms and thus, exempted from the regulatory (coercion) mechanisms currently in place such as requirements for physical presence before accessing salary.... We have visitors here not health workers... They come to visit us at the end of the month to benefit their salaries and go back to Conakry... We can’t blame them because they make the effort to come at the end of the month unlike others who left months ago and in full view of all... Third, at the facility level, the two above factors were influencing the attitudes of local health facilities and services managers towards absentees. Some of them paid no attention to management issues of the new HCWs either by the fear of receiving blame from supervisors  or for not favouring double standards in the management of the personnel.Overall, only 18% of HCWs present at assigned post 12 months after deployment expressed their intention to quit their position in the next 12 months Fig. . The priWe identified six main factors underlying the intention to stay for the next 12 months. Some of the factors are inter-related: the sense of engagement with the state, the fear of losing the job, deployment to a preferential zone, support and cooperation of the spouse, and the holding of a position of responsibility.I was indeed ready to come to the rural zone but I would prefer to be deployed to Kissidougou  where my mother stays, or to Siguiri where two of my brothers live... But I had to come if not I would have lost my job... For instance, some participants reported the fear of losing their job as a reason for staying at their current position. For participants of this group, they would have been more motivated to work if they were deployed to their preferential district.... Now we have a means of pressure on them [health workers] which is the salary... Several of them [health workers] had left their posts for unknown reasons and since they were prevented from receiving their salary, they have returned... At the moment, there is even a woman who had joined her husband and stayed there for more than 4 months; her salary is being frozen. Once back, she will have to stay at her post for at least 60 days before she has access to her entire salary... Similarly, the local salary payment serves as a coercive measure constraining health personnel to work in the deployed zones.My husband was cooperative... He supported me and encouraged me to take up my functions here... The only challenge we faced was how to reorganise our family to the actual situation... We agreed that I came with our last born and took the two others to my sister... She is a teacher and would take care of them as her own... Also, the agreement and support of the family, especially the spouse, was reportedly an influencing factor for taking up services. Many of these participants were married women and stated that the encouragement and support of their spouses in “family re-organization” was crucial in this process.In this section, a three-way discussion of the findings is undertaken, following the study objectives. First, the effects of the deployment of HCWs in terms of need-based distribution and relevance to the needs of the local health systems; second, the analysis of the post-Ebola retention policy; and finally, absenteeism of HCWs one year after their deployment.Our finding on the distribution of HCWs shows that some of the initial objectives of the post-Ebola HCWs reform were achieved. First, more than two-thirds of the workforce were assigned to primary healthcare delivery facilities, predominantly located in rural and underserved settings where the majority of the Guinean population stays and where healthcare delivery capacities were previously substantially limited because of the shortage of HCWs , 21. A pSecond, the data show that primary health facilities were mostly staffed by formal skilled HCWs. A valuable component of this was the medicalization of almost nine out of ten health centres in the study sites. Evidence sustains that the medicalization of health centres expands the range of health problems to be addressed at primary levels, increases the quality of service provision, and restores credibility to the health system . FurtherHowever, results revealed several challenges local health authorities and services managers faced to reorganize the health services and retain some HCWs in public care delivery following the posting of the new workforce. One of the challenges found and emphasized by local stakeholders was the gender imbalance with many deployed female HCWs, alongside their perceived challenges to cope with living and working conditions in rural areas. Previous studies in Niger, Ethiopia, and Rwanda have shown that female HCWs are less inclined to work in rural areas compared with their male counterparts , 27. LocLocal stakeholders faced difficulties in managing the former HCWs, especially volunteers and contractual workers, to make them adhere to the posting of the new workforce. Reasons for this included their frustration for not being recruited and the loss of positions of responsibility, resulting in job abandonment in the public sector and collaborative conflicts among HCWs. This is of particular concern given the role of volunteers and contractual workers in the Guinean health system . SeveralWe analysed that HCWs are strongly motivated to practice in rural settings during their recruitment; however, this motivation is reversed along with their deployment, installation, and integration phases. Reasons for this include the mismatch between personal choices and actual places of deployment, professional dissatisfaction, and inadequate living conditions.Findings show that HCWs’ attraction in rural Guinea is strongly affected by the desire to become a public servant and the learning possibilities that rural areas offer. These findings concur with other studies conducted in rural Senegal and Niger , 37. ThiShortly after their recruitment, participants indicated that factors such as the deployment in non-preferential locations, and for married women, challenges for family reorganization, and the opposition of spouse contributed to their discomfort towards joining their assigned locations. Nevertheless, this seems not to affect services take-up which was as high as 98%.A total of 18% HCWs intended to quit their post in the following 12 months. Private sector or public facilities in other locations different from the present were reported as potential destinations of the HCWs. This finding concurs with that of Reid et al. in 2018, which reported that many health care workers intended to migrate or go into private practice after their assignment to rural settings . This fiOverall, barriers for HCWs installation and integration in the current study seem to be multifaceted and related to the structural , organizational , socio-cultural  environments in which the local health operate as well as personal characteristics of the workforce . In response to these barriers, various coping strategies and mechanisms were undertaken by the workforce , local health authorities , and communities (provision of food and housing) to support the staff and facilitate its installation and integration. Despite the positives discussed above, this post-Ebola HCWs retention programme tends to privilege the “one size fits all” approach in the installation and integration phases of HCWs. This approach consists of considering salary only sufficient for motivating and retaining the workforce in rural areas. Indeed, the on-going retention programme in Guinea excluded financial  and non-financial (training and career development prospects) incentives allocation as core components of the successes of several rural retention policies in Western Africa and beyond . For insEvidence from previous studies in Guinea have shown an absenteeism rate of ~ 43% among public HCWs, and the underlying factors for this included low salary—pushing them to a dual practice phenomenon only possible in urban areas, and the centralized management of HCWs including salary payment . HoweverOur finding, however, revealed the poor monitoring and accountability of HCWs which might have led them to adopt a leave but stay tuned strategy. This strategy consists of leaving one's post without a valuable reason and joining as soon as a national mission is announced, especially in the districts surrounding the Capital. Indeed, our finding showed that up to 51% of absenteeism observed was of non-justifiable reasons; meanwhile, such reasons for absenteeism were not reported during the national supervision.Underlying causes for absenteeism pointed out by participants included the lack of transparency and effective coordination in decision-making processes for leaves allocation. HCWs absenteeism is known to compromise health system effectiveness and  healthcare services delivery, and led to important economic losses, particularly in under-resourced health systems, where salaries are a substantial part of the health budget—in Guinea, 80% of the budget allocated to health goes to HCWs salaries , 45. To Furthermore, it appeared that no policy and guidelines existed to orientate the post-Ebola retention policy in Guinea. Although this was not the focus of our study, it emerged as an important aspect during the research. The lack of policy and guidelines on the on-going programme has led to some confusion of roles and responsibilities between central and local stakeholders in the decision-making processes regarding the management of HCWs. For example, there existed no clear principle guiding and documenting the redeployment and allocation of training leaves by central administration. This may undermine the earlier positive effects generated by this policy. However, a national policy of HCWs development was elaborated in July 2019 with the aim of ensuring, by 2024, the availability—in adequate quantity and quality, in all professional and technical positions—of well-motivated HCWs who are individually and collectively committed to performing their duties in a decent work environment . A furthThis study has some limitations. First, the analytical framework used to guide this research is on the retention of HCWs, and not necessarily for evaluation of the implementation process of HCWs retention policy. Additionally, no baseline data were collected at the beginning of the deployment to include all HCWs who took up duties. If done, this would have allowed a comparison between baseline data and data collected one year after. This fact might have led to the underestimation of certain findings such as the intention to quit or dissatisfaction with the professional situation. Explicatively, it is likely that HCWs present on the study sites during data collection were more satisfied with their living and professional situation and therefore, less inclined to quit their job compared with those absent. Second, the subjective reporting of reasons for absenteeism could constitute an information bias. Indeed, in the absence of administrative documents justifying the absenteeism of HCWs, health facilities, and services managers were the main sources of information for this study variable. We also failed to contact the new HCWs absent from their post during data collection. If done, this would have helped to cross-check the reasons for absenteeism reported by health services and facilities managers. Third, this study took place in a moment where HCWs turnover was a sensitive issue for both local and national actors. It is, therefore, possible that some HCWs were contacted by their managers or colleagues to temporarily re-join their positions during the data collection period. This may have led to an underestimation of the absenteeism rate reported in this study. Another limitation, not the least, is inter-coding biases which should have been addressed by having two or more people coding the interviews separately and agreeing on findings upon team consultation. Because of time constraints, only one interviewer could code the interviews. Finally, as interviews were translated from French to English, possible bias related to language interpretation might be associated with findings.This study’s strength resides in its mixed-method design  and the diversity of the data collection tools and study participants that allowed triangulation . The datThis study is the first to document the implementation process of the post-Ebola healthcare workers retention policy in rural Guinea. This programme appears to have been successfully positive and met some of its initial goals of the redistribution of HCWs and the quality improvement of staffing levels  in peripheral healthcare facilities, and the enhancing of district health offices’ capacities (e.g. timely reporting of data). The delocalization of salary payment has relatively empowered local health authorities in the management of healthcare workers, and salaries serve as an instrument for the regulation of health workers’ absenteeism. As the results show, however, the effects of this programme could be improved by prioritizing local recruitment and deployment of healthcare workers and developing strategies to mitigate HCWs absenteeism. More attention should be given to the development of policy and guiding documents with the full participation of all actors  and a clear share of their roles and responsibilities for improved implementation and efficacy of this programme.Additional file 1: Annex S1. Data collection tools.


Our results show that strict government measures, areas of poor people and people with heart diseases have resulted in high COVID-19 testing due to the increasing infections, However, economic development and population density are not found to be rather insignificant towards the COVID-19 testing rates. Hence, both from policy and pandemic perspectives, it is inferred that these developing economies need to divert more resources and infuse more investment in the healthcare sector in the coming days.  Specifications Table In this study, we investigate infectious disease, human capital, and the BRICS economy during COVID-19 scenario. COVID-19 has led to an economic meltdown in emerging economies such as Brazil, Russia, India, China and South Africa which were the engine of global growth for the past two decades. These emerging economies have already become financially vulnerable due to falling of their primary exports due to the drastic decline in global demand The COVID-19 pandemic has resulted to a tremendous loss of human life around the world and poses an enormous threat to public health and millions of the people entered into the poverty trap The association between COVID infection rates, testing, population density and economy can be studied using a difference- in- difference (DID) method In our empirical strategy, intervention w.r.t time is taken especially from March 1, 2020 onwards. Intervention w.r.t space considers all 4 economies of India, China, Russia and Brazil except South Africa. This empirical setting of the study has considered the next 3 sets of equations to see the implementation of DID as an interaction between, time and treatment and time, treatment separately.In In this study, we empirically examine the relation between COVID infection, government measures and economic growth for BRICS economies over the time period Jan 1, 2020 to Oct 1, 2020. In BRICS economies, we have taken the usual 5 economies- India, China, Russia, Brazil and South Africa. We have considered numbers of COVID tests as the outcome variable. New COVID-19 infection, population, GDP and stringency are considered as the major explanatory variables. Poverty and Number of people with heart disease are considered as the control variables of the study. All the data pertaining to our study are taken from Ourworldindata on a daily frequency basis. New COVID-19 testing infection is defined as the numbers of testing for people to detect COVID on a daily basis. New COVID-19 infection is defined as the numbers of people tested positive for COVID on a daily basis. Population is defined as the total number of persons both in urban and rural areas on a daily basis. Population is also considered as the unique proxy for the market size. GDP is defined as the final goods and services produced in the economy. Stringency in this case is defined as the stringent measures taken by the respective government in terms of curbing the movement of the people, economic activities, and shutdown measures as well. Stringency index is here measured in a scale ranging from 0 to 100. Furthermore, the control variables in this empirical model are poverty and people with heart diseases. The rationale behind taking the variables implies that people mostly in poor conditions and with pre-existing diseases like heart diseases are highly vulnerable to COVID.Table-1 shows the DID regression results in presence of the major explanatory variables population. In case of time specific intervention, we notice that stringency has especially worked well in terms of increasing COVID testing rates over the days. Our empirical results also suggest that every 1% increase in stringency measures has led to nearly 0.29% increase in the COVID-19-testing rates. More so, coefficients of poverty and heart disease and time are steadfastly indicating positive and significant association with the testing rates over the days. In cases of considering country specific interventions, we notice that except population, other coefficients exhibit positive and significant relation with the COVID testing rates. However, we find that coefficients of treated and population are found to be negatively and significantly associated with the testing rates over the days.Next, we have considered GDP as one of the explanatory variables. InThis study documents the rapid emergence of the COVID-19 infection rates at the onset of rising economic development and several economic challenges. In our empirical experiments, we also find that areas with more economic development and high population density are often exhibiting lesser COVID testing incidents due to the lack of co-operation and under-reporting of COVID testing. Specifically, our empirical investigation shows that although testing rates have been increased positively with the infection rates, still people with lesser economic likelihoods are highly exposed to the coronavirus in these countries.This study has led to some policy suggestions. First, the developing economies must invest more of its resources towards the healthcare sector. Second, more of testing to common people along with opening hospital avenues can help curb and detect the exposure of common masses.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Since the outbreak of COVID-19, many parts of the world have fallen into deep recession. Governments in every country have adopted various measures to restrict social gatherings due to the need to control the pandemic. This includes restrictions on activities in homes and communities. Fundamentally, epidemic prevention relies on the measures individuals take. A community’s epidemic prevention measures become more critical as activities are held in houses or communities once again. From the perspective of the theory of planned behavior, this study investigates whether the various epidemic prevention measures and characteristics of a community affect residents’ perception of epidemic prevention. We use the truncated regression model as the primary research method. The empirical results show that the community’s epidemic prevention measures can change residents’ awareness of the importance of epidemic prevention. Moreover, the scale of the community and management committee are also found to have a partial impact. Since the outbreak of the new coronavirus at the end of 2019, the world has been severely affected by the pandemic. According to the International Labor Organization . This reCOVID-19 was caused by a coronavirus. Therefore, its transmission mode and characteristics are similar to that of other coronaviruses . AccordiIn comparison to the global pandemic and the severity of its impact, the control of COVID-19 in Taiwan has been relatively good. According to data provided by the Taiwan Centers for Disease Control, the total number of COVID-19 infections and deaths in 2020 was only 785 and 7 [From awareness and knowledge to implementation of epidemic prevention, these actions fall within the scope of the theory of planned behavior (TPB). Taking inspiration from  COVID-19In summary, if the overall effectiveness of the epidemic prevention relies on the epidemic prevention behaviors of residents, and the residents’ epidemic prevention behaviors are indeed affected by information and awareness relating to the epidemic, then the effective promotion of epidemic prevention information and the implementation of epidemic prevention measures are of great importance. Moreover, residents that reside in single or multiplex apartment buildings, regardless of the epidemic prevention regulations of the city, will be influenced by the immediate measures adopted from within the community.From present studies, we know the perception of epidemic prevention is crucial to epidemic prevention  and whatTherefore, it is crucial to understand whether epidemic prevention measures within a community indeed affect the awareness of epidemic prevention among residents. This study seeks to clarify the relationship between the residential community and the spread of the epidemic based on existing literature and research, and summarizes multiple factors that may affect the residents’ awareness of epidemic prevention. Additionally, using a questionnaire and quantitative methods, we clarify the impact and effect of the wider community on awareness of epidemic prevention among residents in Taiwan. The result shows that the community’s epidemic prevention measures could make residents pay more attention to epidemic prevention.Due to limitations in funds and technology, residential buildings built in the past were often poorly constructed. Frequently they lack sufficient space between building compartments, independent bathrooms, wastewater treatment systems, and other necessary subsistence systems. In addition, older buildings often use building materials of lower quality and lack adequate building management. Many studies have validated the relationship between housing and health. Taking building materials as an example, the use of lead pipes in water supply systems has been shown to be associated with excessive lead intake in the human body , as it cHousing conditions can impact the health of the occupants, as well as the spread of diseases.  showed tAn increasing number of studies have shown that transmission of coronavirus occurs via droplets and contact transmission , of whicTransmission of COVID-19 may also occur via the patients’ feces. Studies have confirmed the presence of the virus in patient feces . TherefoThe earliest research on awareness and behavior started with Fishbein’s research on psychological state and behavior , and forTPB argues that the behavior of a person is affected by behavioral intentions and perceived behavioral control. Behavioral intentions can be further subdivided into attitudes, subjective norm, and perceived behavioral control. These factors will affect the formation of behavioral intentions. Summarizing the above factors, there have been extensive empirical studies in psychology and in behavior prediction studies. The meta-analytic reviews of the TPB by  showed tEpidemic prevention behavior is a part of entity behavior and can also be predicted using the TPB model.  organizeAnother research stream related to TPB is protection motivation theory (PMT). PMT studies also focus on the perception of benefit, obstacle, and health . PMT andHowever, recent studies on epidemic prevention behaviors still lack observations of more detailed influencing factors such as attitudes and subjective norms on residential communities. Specifically, epidemic prevention attitudes and related awareness can indeed affect a person’s epidemic prevention behaviors, and there are also many additional relevant factors. However, the society or environment will affect the perceptions of members or residents . Similarthe property manager of the housing communitythe member of the management committeethe community householdTo test the relationship between the various conditions in the community and the residents’ awareness and attitude towards epidemic prevention, we distributed a questionnaire to collect the opinions of residents in different communities across the country on epidemic prevention awareness. The sample is the questionnaire data filled out from the Internet, there is no specific invitee for the answer to the online questionnaire. We used convenience sampling, attempting to recruit three types of respondents:In total, 200 valid questionnaires were collected from 18 counties and cities, which comes from most cities of Taiwan. Each questionnaire sought to capture residents’ awareness and attitudes towards epidemic prevention. The issuance and collection of the questionnaire occurred between March and September 2020. During this period, Taiwan moved from a period of strict epidemic prevention measures to conditionally resuming social activities. Most people in the country were understandably strongly impacted by the epidemic and this in turn affected attitudes towards the questionnaire.The entire questionnaire was composed of the control conditions of individuals and communities, various epidemic prevention measures in the community, and the respondents’ attitudes towards the importance of epidemic prevention measures. The individual control conditions included age and gender. The community control conditions captured the size of the community, whether a management committee existed and whether the building was built before 1995. The size of the community was mainly classified according to the number of households. Small communities consisted of less than 149 households, medium-sized communities contained between 150 and 300 households, and 300 households or more were classified as large communities. In addition, Taiwan established new apartment building management regulations in 1995, which stipulated that all new communities must have a community management committee or a management organization. Therefore, whether the community was established before 1995 was also included. However, not all early communities have a management committee. The question also assessed the age of the community, the details are list in The epidemic prevention measures implemented by the community are based on the various practices listed in the “Guidelines to COVID-19 responses: community management and maintenance” issued by the Central Epidemic Command Center of Taiwan , and theOur questionnaire asked residents in the community to provide responses using a Likert five-point scale, with 5 points being very important and 1 point being not at all important.The present study hopes to improve understand of the factors influencing residents’ awareness of the importance of epidemic prevention-related practices in the community, hence the dependent variable used was the score obtained for the awareness of the importance of epidemic prevention measures, as shown in The main theoretical variables are based on community-related conditions, which are composed of three factors: the scale of the community, the establishment of a management committee, and the execution ratio of the community’s implementation of epidemic prevention measures. Community size forms the main theoretical variable, which is a continuation of previous research . Since cAnother theoretical variable encodes whether the community has established a management committee. The variable takes the value of 1 denoted if a committee is established within a community, and 0 otherwise. In the early days, there existed relatively scant regulations requiring that communities establish management committees in Taiwan, hence there were many early communities lacking management teams. It was not until 1995 that “Management of apartment buildings” was enacted which mandates the establishment of management committees. This change further assured the quality of life of community residents. The management team of the community is a critical executive division which handles large and small issues in the community. The committee oversees the maintenance of important facilities in the community, the sanitation of public environment, the management of general affairs, and several services offered to residents. The epidemic prevention measures in the residential community are an important responsibility of the management committee. Therefore, the effectiveness of epidemic prevention measures between communities is likely to be impacted by the presence or absence of a management team. Based on the above reasons, the establishment of a community management committee was another important theoretical variable in our study.The last theoretical variable is the execution ratio of the community’s implementation of epidemic prevention measures. Awareness of epidemic prevention factors can stem from self-assessed risk attitude, societal commentary, personal knowledge of epidemic prevention and social norms . Social Other control variables included other items of the questionnaire, such as gender and age of the interviewee, whether the buildings were built before 1995, disaster prevention attitudes, attitudes toward community organizations, and whether interviewees were in the Greater Taipei area. A binary variable for gender was used which took the value of 1 for males, and 0 otherwise. Age was divided into three ranges, the first range was 18 to 44 years old, the second range was 44 to 65 years old, and the third range was 65 years old and above. “Management of apartment buildings” were enacted in Taiwan in 1995. Prior to 1995, there were very few management committees in the community. According to data from the Taipei City construction management office, as of the end of 2020, only 2941 had established management teams and reported to the government with a building use license in a 7 or more-storied building built before 1995. The filing rate was 36.12%. From 1995 to 2004 buildings with use license had a filing rate of 78.3%, which grew to 90.25% after 2004. However, as described an important factor was whether the community management committee was established or not. Therefore, this variable also captures the housing age of the residential community. Communities built before 1995 are more than 25 years old. Communities formed after 1995 represent relatively young buildings.There were two factors that demonstrated the awareness of the importance of general disasters and the importance of the general community operation determined by backward selection from 68 kinds of questionnaire question. (1) The community’s disaster prevention attitude that “reserves a certain amount of edible water and fast food for emergency use by service personnel”, and (2) the attitude towards community management operations that “pays attention to the protection of funds such as community management fees and the cash flow of public funds”. Additionally, implementation of the epidemic prevention in the community also encompasses disaster response, another responsibility of the community management team. Therefore, we speculate that the two factors above may also affect residents’ perception of the importance of epidemic prevention measures. Hence, they too, are added as control variables.The questionnaire asked if the interviewee lives in the Greater Taipei area which included communities located in Taipei City or New Taipei City. The variable took the value of 1 if the interviewee was in one of these two cities, and 0 otherwise. As Taipei City is the capital of Taiwan, it has the most industrial investment and the highest population density in the country. With the growth of urban development trend, Taipei City’s influence has gradually expanded to the neighboring New Taipei City area. New Taipei City became the living place for many laborers and practice of commuting to work in Taipei City increased. Greater Taipei area has become the most populous metropolis in Taiwan. Residents living in large metropolitan areas often have different attitudes towards epidemic prevention from those living in small cities or rural areas with a smaller population . TherefoThe dependent variables used in this study were the mean value of a five-point scale. Therefore, the minimum value was one and the highest value could not exceed five and exhibited typical data truncation characteristics. Given the dependent variable ranged from one to five and showed the characteristics of a continuous variable, traditional OLS was used for the empirical model. However, as the model does not specifically adjust for truncated variables, this raised the risk of obtaining larger errors . TherefoAs Taiwan’s communities scale are relatively small, households usually have a relatively high degree of understanding of the community. Furthermore, this questionnaire is not distributed to a specific minority of invitees, and there are many questions in this questionnaire. If they do not know enough about the community, it is difficult to answer all the content thoroughly. Therefore, we could observe from the result of the questionnaire. The result also shows all the questions filled, reflecting a higher degree of understanding of the community. Basically, we could compare the sample’s distribution with the distribution of houses unit in Taiwan. The house number data are from the population and housing census in 2010. From The indicator to exam the reliability of this questionnaire is Cronbach’s alpha. We perform it in The narrative statistics of various variables can be observed from t-test to compare whether there were significant differences between three different community sizes, the results are shown in t-test, some studies may consider using corrections for multiple comparisons . The paired sample t-test was conducted in After confirming the characteristics of the sample and the narrative statistics, we can now start to observe the focus of our study, i.e., the awareness of the importance of epidemic prevention. To understand whether the awareness of the importance of epidemic prevention among community residents differs due to the scale of their respective community, we first performed a basic paired t-test between committee and execution ratio. Most results were found not to be significant. Therefore, to evaluate the impact of the independent variables on the awareness of the importance of epidemic prevention, we included the aforementioned independent and control variables and performed an empirical test.In the table, it was clear that most of the importance awareness did not differ due to the size of the community. Medium-sized communities attached less importance to perception teach and perception surrounding than smaller communities. Larger communities attached less importance to perception prohibit than smaller communities. Large-scale communities attached less importance to perception equipment and perception admin than medium-sized communities. In addition, we also conducted a paired To ensure that the empirical model did not have a high degree of collinearity, we produced a matrix of correlation coefficients first, the results are shown in p-value.The empirical results of various awareness attitudes on the importance of epidemic prevention are shown in From the table, it can be seen that in most of the epidemic prevention attitude models, people who originally paid more attention to general affairs and the disaster prevention preparations also attached more importance to epidemic prevention measures. In particular, the community operation variable showed a significant positive effect in various models. Except for Model 9 that had a significance level of 0.1, the remaining models showed a significance at the level of 0.01. This demonstrates that residents who actively participate in community general affairs appear to be more attentive during the epidemic prevention period. Material reserve also showed a significant positive impact in most models, except for the three models which were Model 8, Model 12, and Model 13. This also reflected the fact that people who paid more attention when preparing for disasters during normal times, were also more aware of epidemic prevention measures.t-test results, except that the coefficients identified were of opposite sign. However, the empirical model at this stage has already controlled for many variables. Hence, we believe the results are reliable and reflect the fact that residents of larger communities attach more importance to entry restrictions. Committee also showed insignificant results in most of the models but showed a negative effect in the p follow model indicating that with a community management committee, residents counterintuitively paid less attention to related tracking and monitoring measures upon entry. Lastly, the E ratio also showed insignificant results in most models but showed a positive effect in the Model 3. This indicates that the rate of the implementation of epidemic prevention measures caused residents to be more aware of information about epidemic prevention and related measures.The three main independent variables did not show significance in most empirical models. Scale had no obvious difference and impact in most models. However, it was found to be significant in the Model 12. This was similar to the Among other control variables, residents in communities built before 1995 also had a greater awareness of the importance of epidemic prevention measures, and a lower awareness of the importance of entry restrictions in the community. Older communities paid less attention to disease tracking than newer residential communities. Great Taipei also exhibited a positive impact in the Model 3and Model 13, which confirms that residents of the metropolitan areas have a higher awareness and vigilance of towards the epidemic. Age showed no significant impact in most models, but was positively correlated with Model 12, demonstrating that older people attach greater importance to people who do not follow appropriate epidemic prevention measures upon entry to the community.The above empirical analysis results can only be used in a few cases to verify the hypothesis of the role of the independent variables, and it fails to show the expected result as the content of the literature and pre-existing theories above—however, these aspects of the current research design that could be assessed in more details. The regression summarized in It is shown in E ratio was found to be significant in three models: Model 1, Model 5, and Model 12. Model 1’s dependent variable was the mean of awareness of the importance of all epidemic prevention-related categories, the empirical results in Among other control variables, residential communities built before 1995 had similar effects to E ratio in Model 1 and Model 5, which were found to have a positive effect in medium-sized communities, but a negative effect in large-sized communities. The Model 12 showed negative impact in small and medium-sized communities but a positive impact on large communities. The Great Taipei variable only showed significance in large communities, and the results were found to be consistent with the positive impact reported in Communities formed before 1995 showed a negative impact in the presence of a management committee in Model 12. This was consistent with the results shown in Through the empirical analysis at each step, we confirmed that people are indeed affected by environmental factors. The awareness factor was one of the principally affected aspects. This was the focus of this article. If we can effectively change awareness factors, behavioral intentions can be influenced, and this will ultimately shape behavior. Epidemic prevention behavior is formed through epidemic prevention intention and attitude. Hence, the attitude and related awareness of epidemic prevention is critical. From current research, we find that the awareness factors of epidemic prevention directly affect the epidemic prevention intention of an individual . A furthTo answer the above issue, this article used a questionnaire as the basis of empirical research in Taiwan. A detailed interview was conducted on community conditions and measures related to epidemic prevention. Epidemic prevention implementation in each community and residents’ awareness of the importance of epidemic prevention was analyzed. t-test to observe whether epidemic prevention attitudes differed due to the size of the community. Based on the results in t-test.From the results of the questionnaire, we hoped to understand whether the relevant measures and conditions of a community affected the residents’ awareness of epidemic prevention. We first performed a paired The results of the first stage of our analysis provided negative answers to the questions that were posed. Yet to better understand the impact of the difference in community conditions more carefully, we performed a second- and third-stage regression analysis. The second analysis used 13 markers of awareness of importance of epidemic prevention as dependent variables. The empirical results in The third stage regression analysis uncover the E ratio’s positive effect on the perception of importance deeply. From From the overall empirical results, the larger the community, the more susceptible the residents to measures in the community and the more that resident was affected awareness. Large community naturally have more people who may gather. This is conducive to the spread of the virus. Hence such a community might adopt more epidemic prevention measures, and these are necessary from the perspective of epidemic prevention effectiveness or raising residents’ awareness of epidemic prevention. Although the presence of a committee may not be significant in all cases, under certain important awareness conditions, the E ratio increased, and therefore helped to improve residents’ awareness of the importance of epidemic prevention in the presence of a committee. From the perspective of operation, the presence of a committee makes operations more effective in improving residents’ awareness of the importance of epidemic prevention. This may stem from the mutual relationship between committee and operation. Funding of community organizations may be related to the projects implemented by management committees. It is more difficult to observe the use of funds in communities lacking management committees, hence, naturally people are likely to be less concerned. Residents who pay attention to disaster prevention preparations show that they are also attached to epidemic prevention-related matters, which is consistent with their interest in caring about day-to-day community operations.The main contribution of this study is to show the characteristics of a community could affect residents’ awareness of epidemic prevention, which answers the question in the introduction and supplementing the role of community in epidemic prevention’s perception studies. Stated differently, the management committee could affect residents’ perception indirectly; owning from the community’s implementation of epidemic prevention measures could affect residents’ perception directly.Another significant contribution of this study is to provide suggestions for future community epidemic prevention. The first thing that can be implemented is that for residential communities that have not yet established a community management organization or the management committee, the local government could guild the community to establish a management organization. Once the management organization is established, the necessary epidemic prevention measures can be implemented in accordance with the needs of the community, and community residents should also be encouraged to pay attention to the preparation for general disasters and the implementation of various community affairs. The promotion of these matters will directly or indirectly help make community residents have a more serious attitude toward epidemic prevention.The main research limitation of this article comes from the questionnaire design and questionnaire respondents. Because the online questionnaires distributed in this article are filled by property managers, management committee members, and residents, the residents’ responses may cause some errors in the actual implementation of the project in the housing community. Moreover, we have not used the stratified random sampling to distribute online questionnaires, which also makes the sample in this study not sufficiently random. The second limitation of the questionnaire is that we do not design questions to fill in household income, education, and price or rent information in housing communities. These variables may also affect attitudes related to epidemic prevention and ultimately may affect the awareness of the importance of epidemic prevention. The weakness of this study is also the start point for the following studies.In addition to the above limitations, the questionnaire results of this study are still consistent and reliable, and the results of the study are using appropriate econometric methods. For the current epidemic prevention research literature, conclusions of this study can still provide for scholars or local governments.


One of the most frequent cancers that affects males globally is cervical cancer (CC) that kills hundreds or even thousands of women each year, particularly in underdeveloped nations. The study focuses on human papillomavirus (HPV) that contributes to cervical cancer (CC) development. In the majority of Arab nations, there seems to be no public education or vaccination programs. In research, methodological rigor is employed to find solutions to both theoretical and practical difficulties. This research aims to assess the knowledge and awareness of the HPV vaccination among Emirati men. Results of the research showed that Emirati males had a poor understanding of HPV and its vaccination. According to the findings of this research, Emirati males lack a basic understanding of HPV, which necessitates the implementation of national HPV education initiatives. We have identified several critical knowledge gaps that can be filled in the future regarding HPV infection and vaccination. The human papillomavirus (HPV) is widespread in the United States, and the majority of sexually active persons will get the virus over their lifetime . ChronicThe U.S. Food and Drug Administration has authorized and licensed three HPV vaccinations for use as preventative measures. According to current recommendations, the most undervaccinated group is males; nevertheless, a two-dose regimen is currently suggested; yet, vaccination coverage across all eligible categories is still low, with males constituting the most undervaccinated segment of the population. 39.7 percent of females and 21.6 percent of males aged 13 to 17 got all doses inside the series in 2014. As a reference, vaccination rates for females have been shown to range from 60.5% to 91.5% in a number of nations [Research in public health indicates that adoption and uptake of the vaccination are dependent on public awareness and understanding about HPV. A recent study indicated that only 68% of participants from a representative sample of UAE individuals were aware of HPV and the HPV vaccination , 7, 8.Contrary to popular belief, the bulk of current HPV insight and perception research focuses only on cervical cancer in both men and women. Most people have no idea of the link among HPV and noncervical malignancies, according to studies looking into people's understanding of noncervical HPV-related health consequences.There may be substantial consequences for vaccination uptake if more research looks into knowledge and awareness about noncervical HPV-related malignancies, both on its own and in connection to other forms of HPV awareness and knowledge . There a11-12-year-olds are now advised to get the HPV vaccine as a preventative measure, with an option for catch-up vaccinations until the age of 26. This was the recommended upper age limit for HPV immunization until recently. For persons aged 27–45, the FDA authorized HPV immunization in 2018 because of the vaccine's safety and effectiveness. According to an advisory committee in June 2019, the HPV vaccination may be given to persons aged 27 to 45 years. This advice is based not just on safety and effectiveness, but rather on vaccination effectiveness and cost-efficiency [In the United States, a large percentage of adults are still unvaccinated for HPV, putting them at risk of developing malignancies linked to HPV because of the country's persistently low HPV vaccination rates among the country's most important cohort, teenagers, and among catch-up young adults. 15.8 percent of females and 3.2 percent of males between the ages of 27 and 45 have gotten at least one dose of the HPV vaccination, according to the National Health Interview Survey 2017 . AccordiThe Health Information Nationwide Trends Survey (HINTS), sponsored by the National Cancer Institute (NCI), collects data on how the public uses cancer-related information on a national level. An adult sample in the US has been surveyed using this data source in the past to determine their knowledge and understanding of HPV. Researchers have utilized HINTS to examine discrepancies in HPV understanding and information across racial and gender groups, as well as between men and women and throughout the country. According to previous research based on this dataset, males and non-Hispanic black or Hispanic individuals were equally likely to know about HPV and the HPV vaccination, whereas women were much more likely . A 54-yeMiddle Eastern civilizations and religious conservatism may be seen across the region from Morocco to Saudi Arabia. As a result, this suggests more restrictive sexual practices than those seen in other civilizations . The freCervical cancer rates in this area are thought to be lower than those in the rest of the globe, despite the lack of cancer registries. One reason for the change in introducing countrywide cervical cancer prevention initiatives in this region is that despite erroneous incidence numbers, breast cancer was diagnosed as the most frequent disease in women in Algeria and Morocco and the third most prevalent cancer in Tunisia, Qatar, and the United Arab Emirates .There is still a high incidence of cervical cancer in the Arab nations, despite the low prevalence. The launch of a safe and efficient anti-HPV vaccination in the Arab MENA region and the rest of the globe is a fantastic chance to eliminate cervical cancer as well as many other HPV-related illnesses in the region and throughout the world. HPV vaccination was authorized in June 2006 by that of the Food and Drug Administration for primary prevention of the disease. Cervarix, a bivalent HPV vaccination, and Gardasil, a quadrivalent HPV vaccine, are now on the market . Anti-HPThe study contribution finds out whether or not a representative sample of Emirati males was aware of and knowledgeable about HPV. HPV vaccination, awareness and understanding of HPV-associated cervical cancer, knowledge and awareness of noncervical or “other” HPV-associated malignancies, and general HPV awareness and knowledge were all examined in the research. The influence of sociodemographic factors on research and understanding was also examined , 23.This study aims at identifying the level of awareness and knowledge of Emirati men about HPV, where they got that information, and what exactly they know about HPV.e) studies aspects that cannot be quantified and hence cannot be susceptible to estimate and quantitative interpretation. In contrast, quantitative research (f) necessitates extensive use of tools and methodologies [Consider research as a broad phrase that incorporates a diverse array of activities. Methodological rigor is used in research to find answers to both theoretical and practical problems. There are a range of approaches available depending on the goal and context of the study, including the following: descriptive analysis, which focuses on amassing data that establishes the existence of a phenomenon. For instance, applied analysis in product design, design engineering, and policy formulation aims to answer practical questions but also aid decision-making; in theoretical research, on the other hand, research is conducted to pique scientific curiosity rather than to immediately apply findings in real-world applications. For the study topic, qualitative research  for not applicable, while sexually transmitted disease as indicated in As shown in As shown in As shown in As shown in As shown in As shown in As shown in As shown in As shown in As shown in As shown in As shown in There is a wide range of variation in the general public's understanding of HPV. Gender, age, education, marital status, wealth, and race were all shown to be linked with previous authors' estimates of general HPV awareness when looking at sociodemographic variables . It is iAll participants had a good understanding of HPV's relationship with cervical cancer, but they had little idea of the link between HPV and other malignancies. Noncervical malignancies' relationship with HPV has not been the subject of comprehensive inquiry or reporting in the research literature to this point. The results reported by the few research that have been published are consistent , 30.Previous studies have consistently indicated that women had higher levels of vaccination understanding and information than men. The results on vaccine understanding and information and gender are at conflict with this. It was shown that being a woman was a significant and favorable predictor of actual vaccine knowledge, but that was only true for males who claimed to have heard of the immunization. Analytical approaches and knowledge categories may be to blame for these differences, according to our hypothesis. Men may have heard about HPV vaccination, but when other sociodemographic criteria are taken into account, it has little influence on real knowledge of HPV vaccine .Considering the importance of vaccine effectiveness, it was surprising to discover that the majority of the respondents did not think the vaccination prevented cervical cancer. Despite no significant differences in the percentage of men and women reporting talking to someone like a doctor about vaccination, women were far more likely than men to have received a doctor's advice to vaccinate. Vaccination recommendations are more likely to be given to female patients and parents of female children, according to previous studies. A combination of sexism and the fact that the vaccination has only been approved for boys since 2011 may explain the present results , 33.Health education researchers and practitioners may benefit from this study's results, which are summarized below. First and foremost, there was a lack of understanding and awareness of many elements of HPV, despite continued attempts to do so. Many intervention studies have shown the beneficial impact of receiving information on people's willingness and ability to become vaccinated. Informational interventions alone may not be adequate for long-term increases in vaccination uptake rates, according to a new comprehensive evaluation of the evidence. Our findings indicate that more HPV education efforts are required. Priority should be given to evaluating the efficacy of educational interventions on their own and in conjunction with other approaches , 35.Another problem was the lack of public awareness and knowledge about the relationship between HPV and other types of HPV-related malignancies. This discovery is especially significant in light of studies indicating that vaccination decision-making might be influenced by personal significance. Individuals and parents are more likely to accept and plan to vaccinate when they have a greater estimation of their own HPV risk and a higher estimation of the vaccine's advantages. When HPV-related health effects particular to males, such as disproportionate incidence of oropharyngeal cancer and penile cancer, are highlighted, men are more likely to support vaccination uptake. Men and parents of boys may benefit from educational activities that stress the danger of noncervical HPV-associated cancers, according to these data .Noncervical HPV-associated cancer awareness and knowledge are also important for methodological reasons. There has been a lack of emphasis paid to HPV's relationship with noncervical HPV-associated malignancies in the current literature. Increased precision in measurement will add to the already existing corpus of information. Noncervical cancer awareness and knowledge may be assessed by including questions on awareness and knowledge , 38.Last but not least, a lack of vaccination awareness and a widespread misconception that the vaccine is ineffective in preventing cervical cancer point to the need of public education on the subject. Interactions between healthcare providers and their patients give an opportunity to dispel common misunderstandings regarding risk, effectiveness, and other important decision-making variables . PatientInteresting about our results is the significant desire to learn more about the vaccination and the readiness to be vaccinated or to have their daughters vaccinated, despite the dearth of understanding about HPV, its causative association with cervical cancer, and the availability of the vaccine. These findings point to a major potential for HPV and cervical cancer education and awareness campaigns. There seems to be a lack of political will for national cervical cancer prevention due to a lack of cultural barriers. On the basis of our results, a vaccination of this kind might be more widely accepted if the general public was made more aware of HPV's importance, danger, and possible problems , 41. A cSeveral features have an effect on people's general awareness about HPV, knowledge of HPV-related malignancy, and knowledge of the HPV vaccination. More has to be done to increase HPV vaccination uptake, especially among those populations identified in this research as having poor HPV awareness. Improving our understanding of HPV might be crucial to increasing vaccination rates in the future. That relationship between sociodemographic variables, HPV knowledge, and vaccination uptake has to be explored further via research to be clear. Given the significance of personal relevance in vaccination decision-making, studies that investigate knowledge of noncervical HPV-associated malignancies should be prioritized. Health educators will be better able to influence uptake if they continue to study and record the effectiveness of their intervention tactics. Patient–provider relationships are crucial for vaccination acceptability and should be further studied and practiced in public health.


Health literacy plays a crucial role during pregnancy, as the mother’s health behavior influences both her own health and that of her child. To the authors’ best knowledge, no comprehensive overview on evidence of the health literacy of pregnant women and its impact on health outcomes during pregnancy exists. Therefore, this review aims to assess health literacy levels in pregnant women, whether health literacy is associated with outcomes during pregnancy and whether effective interventions exist to improve the health literacy of pregnant women. A systematic literature search was conducted in PubMed and EBSCO, resulting in 14 studies. The results show mixed levels of health literacy in pregnant women. Limited health literacy is associated with unhealthy behaviors during pregnancy. Mixed health literacy levels can be attributed to the recruitment site, the number of participants and the measurement tool used. Quality assessment reveals that the quality of the included studies is moderate to good. The review revealed that randomized controlled trials and interventions to improve health literacy in pregnant women are rare or do not exist. This is crucial in the light of the mixed health literacy levels found among pregnant women. Healthcare providers play a key role in this context, as pregnant women with limited health literacy rely on them as sources of health information. Health literacy is widely defined as “[…] people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course”  p. 3). . 3]. IndAdequate access, understanding and application of health information is important, especially with regard to high-risk health behaviors and in vulnerable situations. One example of such a situation where health behavior becomes particularly important is pregnancy, since in this phase behaviors affect the health of both the woman and the fetus. During pregnancy, women are confronted with a variety of health information from different sources . This inIn recent years, research has mainly focused on the assessment of health literacy levels among the general population and particular at-risk groups such as older people, immigrants and people with a low socio-economic status, or has only taken particular focus on gestational weight gain  and reprTherefore, a systematic review was conducted to assess (1) health literacy levels in pregnant women; (2) whether health literacy is associated with outcomes during pregnancy; (3) whether interventions exist to improve the health literacy of pregnant women.A bibliographic search was conducted in PubMed and EBSCO. In addition to this, a hand search was conducted using Google Scholar. The search terms were kept general in order to maximize search sensitivity. Two authors  independently screened and evaluated all the abstracts. Where applicable, the articles were subsequently included for full-text review and data extraction.Relevant information from the retrieved studies, including the general characteristics of the study and the quantitative results, was extracted based on a predefined data extraction tool. Two researchers  independently extracted information related to the authors and the country of origin, the year of publication, the data collection setting, and factors that might have an impact on the health literacy level, such as the recruitment strategies, the underlying definition of health literacy, and the health literacy tool used.Quantitative results were extracted as provided in the studies, e.g., as percentages of women with limited or adequate health literacy, average health literacy scores, results of tests for group differences, and the respective significance levels. Quantitative data were extracted independently by two reviewers . Due to the diversity of the studies’ characteristics and the way the results were presented, the data were not summarized quantitatively in a meta-analysis.The methodological quality of all the studies included in the review was assessed using standardized checklists. Since this review included different types of study design, a number of different quality assessment tools were used. For randomized controlled trials (RCT), we used the RoB 2.0 risk assessment tool provided by the Cochrane group . This toThe included studies are summarized in n = 34 to n = 4999. Except for a minimum age of 18 years, the inclusion criteria for the study participants varied across the studies. The time of gestation at inclusion varied, with some studies only including women at the beginning of the pregnancy [Most of the studies were conducted in Europe, Canada and the USA. The sample size of study participants ranged from regnancy  and otheregnancy . The sturegnancy ,17; howeregnancy ,32, depeThree of the studies used the REALM, four studies used the S-TOFHLA, three the NVS and five the BHLS. Some studies utilized two instruments. One study used the 25-item version of the HLS-EU . Since eThe studies included in this review  show mixBased on the utilization of the S-TOFHLA, the participants in three of the studies scored adequately ,29,35. SLupattelli et al.  conducteSheinis et al.  split thHealth literacy is associated with a variety of outcomes, which can be categorized into ‘Beliefs/attitudes’, ‘Knowledge’ and ‘Lifestyle’ .Limited health literacy is associated with more negative beliefs regarding medicine  and a hiSmoking behavior was addressed in one study, which found that women with limited health literacy smoke during pregnancy . MoreoveWomen with limited health literacy gave more wrong answers in a questionnaire on the risks, benefits and safety of Tuberculosis and Hepatitis B vaccines , and an None of the studies included in the review were aimed at improving health literacy among pregnant women. One study conducted an RCT aimed at improving knowledge of prenatal genetic testing among pregnant women . The womAll the studies included in this review met at least 13 out of the 20 possible AXIS points (range: 13–19). Two of the studies achieved 13 points, three achieved 14, one achieved 15, one achieved 16, five achieved 17, one achieved 18 and another achieved 19 points.p-values), either directly in the Methods sections or indirectly in the results presented in the study. Additionally, all of the studies included in the review provided a discussion of their own limitations. However, some of the studies did not meet items of the quality assessment tool that have a significant impact on how a study is conducted. Eight of the studies included in the review did not provide grounds for their sample sizes. Only one study addressed and categorized non-responders. The response rate raised concerns with regard to non-response bias in five of the studies. Most studies (n = 8) applied convenience sampling. Twelve studies provided indications that there might be a lack in the representativeness of the sample.All the studies fulfilled the quality criteria reflected in the inclusion criteria of this review, such as specifying the target group and using a validated measurement tool. All the studies reported the use of a precision estimate . Women with limited health literacy had more negative beliefs regarding medication , whereasAlthough research in the field of health literacy has gained more attention in recent years, it was not possible to identify a study that was aimed at improving health literacy among pregnant women, and that therefore addressed our third research objective. Only one study conducted an RCT with an intervention in order to improve knowledge that resulted in health literacy sensitivity, meaning women benefitted equally regardless of their health literacy levels . This isThe studies included in the review reveal that the role of health professionals during pregnancy is crucial, since they provide women with prenatal counselling. It is therefore crucial for healthcare providers to ensure that women understand the health information they are given. Women with limited health literacy might benefit from additional explanation for genetic testing both prior to the test and after receiving normal test results , as womeThe results of this review must be viewed in the light of several limitations. Firstly, the studies included in the review were mainly of moderate quality. This is critical to the validity of this review, as studies with a good level of evidence are lacking. This can be attributed to the nature of the study designs, namely cross-sectional studies. However, the majority of the studies that exist in the field have a cross-sectional design, which indicates the need for RCTs in the field of health literacy among pregnant women. This way, causal associations can be evaluated. Additionally, the majority of studies indicate that the sample might not be representative, which is attributable to the sample size or sampling method. Moreover, educational level was not categorized in a standardized manner, which hindered separate analyses based on this characteristic. Secondly, no interventions exist for improving health literacy among pregnant women. Due to the lack of such studies, it was not possible for us to achieve the third objective of this review. Thirdly, we did not include databases that cover midwifery in our search. This might have led to the omission of relevant literature. Fourthly and finally, the decision to limit eligible literature to that published in English might also have led to the neglect of important studies.The results of this review indicate that health literacy levels in pregnant women vary across different studies. Even though most studies were conducted in western countries, limited health literacy was present and might be due to the socio-economic status of the study participants. Some of the studies included in the review recruited women from clinics that predominantly catered to low-income patients, which might be attributable to the low socio-economic status of such women. However, data formats did not allow for analyses, e.g., based on educational level. The association between health literacy and different health outcomes that are present in the studies of this review are well known for other populations as well. Health literacy research suggests that inadequate health literacy is associated with smoking, higher risk perception and negative beliefs about medication and non-adherence to prescribed medicines, which is also true for pregnant women. With the studies depicting low levels of health literacy, it is striking that no interventions exist to improve health literacy during pregnancy, not only because an adequate level of health literacy is important for the health of the women involved, but also because health literacy levels influence other health outcomes and behaviors during pregnancy, which will most likely affect the unborn child’s health and development. Additionally, to ensure informed consent in medical decision-making conforms to legal and ethical requirements, the effects of health literacy on providing informed consent should be investigated. Overall, randomized-controlled intervention studies are needed to build evidence-based strategies to increase health literacy for better health among pregnant women.