The aim of this article is to present the development of cross-country comparable food reference budgets in 26 European countries, and to discuss their usefulness as an addition to food-based dietary guidelines (FBDG) for tackling food insecurity in low-income groups. Reference budgets are illustrative priced baskets containing the minimum goods and services necessary for well-described types of families to have an adequate social participation. This study was conducted starting from national FBDG, which were translated into monthly food baskets. Next, these baskets were validated in terms of their acceptability and feasibility through focus group discussions, and finally they were priced. Along the paper, we show how that food reference budgets hold interesting contributions to the promotion of healthy eating and prevention of food insecurity in low-income contexts in at least four ways: (1) they show how a healthy diet can be achieved with limited economic resources, (2) they bring closer to the citizen a detailed example of how to put FBDG recommendations into practice, (3) they ensure that food security is achieved in an integral way, by comprising the biological but also psychological and social functions of food, and (4) providing routes for further (comparative) research into food insecurity. In a moment in which 18.8% of the global burden of disease has been attributed to unhealthy eating ,3,4,5,6,While ecologic approaches and upstream actions have been argued to be indispensable to effectively tackle the situation, actions addressed to the individual are still timely ,8,9. FooSince there exists a strong link between diet and the most prevalent diseases in developed societies, the development and implementation of FBDG has the potential to substantially influence the burden of disease within its citizenship, to the extent that the quality of such tools may accentuate or blur diet-related health inequalities between and within countries ,12,13,14In 1996, the FAO and WHO published a set of recommendations on the development of FBDG that remains a point of reference for policy makers on the field . In EuroFifteen years later, we conducted a similar research to the EURODIET project, in which the FBDG available in 26 EU Member States were analysed in the light of the previously mentioned guidelines . Our findings were consistent with the conclusions of previous studies ,19,20, iIn this paper, we present food reference budgets (RBs) for 26 EU Member States, as a tool that can complement regular FBDG to better orientate the dietary intake of low-income groups. RBs are defined as illustrative priced baskets of goods and services that represent the minimum necessary resources for well-described types of families that allow for an adequate diet. In this context, not only the biological function of food is taken into account, but also the social, hedonistic and gastronomic role that food has in current societies . While fThe aim of this article is to discuss the development of cross-country comparable food reference budgets in 26 European countries, as well as their added-value for FBDG for tackling food insecurity in low-income groups.The research that we describe here is part of the pilot project for the development of a common methodology on Reference Budgets in Europe. The pilot project was funded by the European Commission’s DG Employment, Social Affairs and Inclusion to develop a common methodology to construct high-quality comparable reference budgets in all EU Member States   and the necessities for a minimum level physical activity, as recommended in many FBDG, in this paper we report only on the part related to having access to a healthy diet. The main reason is that the nature of collecting robust budgets for the other functions of food and physical activity required more time and resources than were available in our project. As a result, the budgets for the other functions of food and physical activity are not sufficiently robust and comparable. Obviously, in order to be able to afford a healthy diet, one should also have access to kitchen equipment, clean water, and energy to cook. However, due to the specific requirements to estimate their cost, also these are not considered here (see  for a di(1)a single man [35–45-years-old](2)a single woman [35–45-years-old](3)a couple (4)a single woman [35–45-years-old] + 2 children .(5)a couple [35–45-years-old] + 2 children .Given the large variation in needs between individuals and households, and our objective to construct cross-country comparable baskets that represent what is needed at the minimum, in all countries the food baskets were developed for household types with the same specific characteristics:-The household types are assumed to live in the capital city of each participant country. This point is particularly relevant in terms of the pricing of the items and the frequency in which people rely on the production of food for own consumption.-All meals are prepared and eaten at home. All food is acquired, prepared and consumed in the most economical way possible. This means families are well-informed about prices and are able to shop in the most economic retailers that are accessible with public transport. However, we do not assume that people can always buy all their ingredients in the cheapest available supermarket. Hence, we allowed for a certain freedom of choice to shop within a range of cheap retailers.-All household members are in good health and do not have specific dietary requirements. The reason for this assumption is not so much that this is the most common health condition, but rather that the cost of a diet varies depending on the kind and severity of health problems, each having different implications for the needs of the person affected.-The ingredients should give families access to healthy, tasty and well varied meals. The food basket should be acceptable for citizens with different background characteristics provided that the healthy aspect is not compromised.-Finally, we assume that the budget for food is allocated to each household member in accordance with her/his needs.Furthermore, for assessing and pricing the concrete lists of items, the following assumptions were made:(1)For the first milestone, the national experts provided a clear description of the scientific basis (DRVs) of the national FBDG, the results of the last food consumption survey and the model of health education in their country.(2)In the following step, in cooperation with a nutritionist, country teams translated the FBDG into a concrete list of food items, including the necessary amounts for each hypothetical household.(3)For the third milestone, three different focus groups were organized in the capital city. Several focus group trainings were organized and instructions were developed by the coordinating team to make sure that the focus groups were conducted and analysed in a standardized way (cf. Annex 1 in ). The naEach focus group followed a predefined topic list, with an estimated time of three hours. The first half of the discussion was devoted to evaluating the broader theoretical framework  and the underlying assumptions we made (characteristics of the reference family), and the second half was used to discuss the acceptability, feasibility and completeness of the food basket, the kitchen equipment and the other non-physical functions of food—as well as the related purchasing patterns. For the purpose of this article, we only make use of the second part of the focus group discussions, which had an average duration of approximately 90 min. To facilitate the discussion, an illustrative weekly menu was developed by the nutritionist, in accordance with the proposed food basket.The results were analysed by the country teams in accordance with a common template of analysis. Each focus group was recorded, and, during the discussion, an assistant wrote down the various arguments in a structured template. For each topic a final column was completed with the overall conclusions and general remarks on interaction processes, proxemics and paralinguistic information. In literature they call this a micro-interlocutor analysis , which a(4)Next, the food baskets had to be adapted in function of feasibility and acceptability, based on the arguments put forward during focus group discussions. This was done in accordance with a common decision procedure that country teams had to follow to ensure that the healthy character of the diet was respected and to facilitate the consistency and robustness of the results across countries (cf. Annex 2 in ). (5)The last milestone consisted of estimating the minimum feasible cost of the food basket. Again, several common assumptions were made. First of all, the food budget should represent the minimum resources that people need to get access to all essential food items. Further, people should have a minimum acceptable degree of freedom in the choice of shops and products. Thirdly, market prices are used, unless other purchasing patterns are common practice, but no sales prices are used. Another important guideline was that economies of scale in buying and preparing food should be taken into account. For the choice of shops to buy food, the national teams had to choose a few retailors or markets which were suggested by the participants in the focus groups. The retailers had to meet the following criteria: (1) they offer a wide variety of food items of acceptable quality at low prices, (2) the shops are well spread over the city, (3) the shops are well accessible by public transport. Being well spread over the country was another criterion that could be considered, as this could facilitate the future pricing of reference budgets developed for other regions.All countries priced the food baskets between March and April 2015 . Prices were collected on the basis of a small-scale survey, carried out by researchers from each country team, making use of a standardised excel sheet . To price pre-packaged food, the lowest price of suitable products had to be chosen. With regard to fresh food and food categories which contain a large variety of products, country teams had to follow a specific predefined pricing procedure, such that a weighted price could be estimated which takes into account the available range of relevant products. The food categories for which a weighted price procedure had to be used are the following: fresh fruit, canned fruit, fruit puree, frozen fruit, dried fruit, fresh vegetables, frozen prepared & unprepared vegetables, canned vegetables, fresh fish, frozen fish, canned fish, lean meat, fat meat, charcuterie and cheese.For instance, the cost of fresh fruit is based on a weighted average of all fresh fruit available in the shop, taking from each type of fruit the cheapest alternative of sufficient quality . The cheapest products are weighted 5/7, whereas the average weight of the more expensive items is given a weight of 2/7, while discarding the 10% most expensive fruits. This procedure aims to meet the dual objective of identifying the minimum cost to prepare healthy menus that still offer sufficient variation  or to differences in FBDG, e.g., some countries differentiate between fruit and vegetables while others formulate a joint recommendation. The amount of dairy products varies more across countries, ranging from 215 g in Latvia to 710 g in Finland. Also, for the group of meat, fish and eggs, variations fluctuate between less than 100 g per day  to 339 g per day (LU). These variations reflect not only differences in guidelines but also, for instance, cultural differences in the composition of the meals. Countries with higher amounts usually include a portion of these foods in two of their meals per day, while others only include them for one daily meal. For the liquids group, the large variation is partly due to whether or not countries included wine and beer, and by the varying amounts of coffee and tea across countries. Water was the basic beverage in all countries and products like fruit juices or sodas were not included in this group, as they are not recommended on a regular basis. Milk was placed in the dairy group. With regard to the amount of grains includes foods such as bread, rice, pasta, pulses and potatoes. Nutritionally these items are considered as exchangeable, but the size of the portion in a daily meal varies considerably . The fat group mainly includes cooking oil/fat. The Mediterranean countries nuts were also included in this group following some national guidelines. The type of fat included varies across countries. In Mediterranean countries the main source of recommended fat is olive oil and nuts, while in most of the other countries, butter and other spreadable fats are the most common type of fat. Hence, it is important to bear in mind that comparing food group amounts among the different countries does not necessarily provide information about the nutritional value of the baskets, since food items belonging to the same food group may have a different nutritional composition and/or different portion size. For some food groups, the variation can also be explained by the differences in the type of foods. For example, the food group residual group is the food group with the highest variations, with amounts ranging from 25 g to 155 g. These differences are likely to be a consequence of the lack of guidelines with regard to these kind of products. All the countries include some salt, sugar and spices, but also sauces (such as mayonnaise and ketchup), dressings and sweets, especially for children, albeit with large variations. The In this section, we present the results of the food baskets, priced in the capital cities in March-April 2015. When we compare the total food baskets, we observe large variations between EU Member States. The highest price can be found in Denmark, while the lowest cost can be observed for the Czech Republic. In Denmark a single woman needs about three times as much (312 EUR) for eating healthily as compared to a single woman in the Czech Republic (82 EUR). Even if we leave out Denmark (in which the pricing procedure was somewhat different), the difference between the most expensive food basket (Finland) and the cheapest one remains quite large. This substantial variation between countries is mainly a combination of differences in dietary guidelines on the one hand and price differences on the other hand.At the same time, it is well known that the level of average household incomes varies a lot between EU Member States. In the context of food security, it is therefore relevant to consider the cost of a healthy diet also in relation to the level of incomes. Therefore, Pilot Project for the development of a common methodology on Reference Budgets in Europe. We follow a normative perspective [In the text above, we have described the process of development and the content of the Food Reference Budgets for 26 European countries, as constructed in the framework of the European Commission’s DG Employment, Social Affairs and Inclusion funded spective , and useofficial healthy way of eating, while they leave out a myriad of other possible ways of following a healthy diet. In this sense, future research should be able to take into account a greater variation of reference situations in terms of age, cultural background, personal choices and health conditions. Fourth, the pricing procedure that was applied could be further improved to increase representativeness and reliability by working with a larger, random sample of food products. Fifth, due to their detailed character, the budgets risk to be used in a prescriptive way. Given previously mentioned limitations, food reference budgets do not pretend to define what people should eat, but to illustrate a way in which an adequate diet can be achieved, and how much that would cost at the minimum. Finally, when using the food budgets for comparative research, researchers should be aware of the limits to their comparability that we have highlighted above. In particular, it should be clear that is the healthy food basket is comparable only in the sense that it reflects everywhere the state of affairs of FBDG in 2015. We are well aware that the extent to which the FBDG are an adequate cultural and scientific reflection of what a healthy diet should be in different national contexts can be criticised [The process of building food reference budgets is confronted with several limitations. First, there are a number of unavoidable arbitrary choices that condition the final budgets, such as the decision of not including promotions or discounts, the assumption that people are sufficiently informed and skilled to follow a healthy diet, or have enough time to do so. While we are aware that skills and capability to shop and cook healthily as well as time availability are important constraints towards a healthy eating ,35, and iticised . Notwithstanding these limitations, we are convinced that food reference budgets hold interesting contributions to the promotion of healthy eating and prevention of food insecurity in low-income contexts in at least four ways: First, because they show how a healthy diet can be achieved with limited economic resources, they constitute not only a guideline in terms of budgeting, but also offer policy-makers more insight into the cost of a healthy diet and how this may be a hurdle to achieve a healthy eating pattern. Second, food reference budgets also bring closer to the citizen a detailed example of how to put general recommendations (as the ones contained in FBDG) into practice. Several studies show that the main motivators in the choice of food differ depending on the socioeconomic and educational level. We know that even though the price is a great determinant of the intake, culinary skills and food knowledge is also a determining factor among low-income people ,37. FBDGThird, if, when ensuring food security, we really aim at promoting a bio-psycho-social understanding of the person, healthy eating promotion must compulsorily include foods to share, foods to enjoy and foods to celebrate. This is something the focus groups laid bare. In all countries, FG participants stressed how food is not only about being in a good health, but it is an essential part of cultural and social life. Eating and drinking is playing a crucial role for social activities and gatherings with family, friends and colleagues in all different cultural contexts. The people in FGs emphasize the importance of cooking and dining together but also of eating out in order to maintain social relations and to socialize. Food can be a means to show care and respect, to create hospitality and to create a feeling of belonging. Further, the FG participants often mentioned the role of food in the preservation of traditions and in the expression of a certain cultural, religious or personal identity. These foods and activities are not essential for a healthy diet, nevertheless, they are seen as important to participate adequately in society. As mentioned above, in this project, the inclusion of these items was not done in a very standardized and cross-nationally comparable way, which is why we did not report their estimated levels. Nevertheless, we should acknowledge the importance of these functions in order to create more acceptable and complete food baskets that allow for adequate social participation in the different EU countries. Ultimately this is the only pathway to work toward narrowing diet-related health inequalities in a comprehensive and empowering manner. Therefore, it would be worthwhile to spend more time and resources on collecting high quality information on this aspect of an adequate diet.Finally, it is worthwhile pointing out that although there is quite some variation between countries in the cost of a healthy diet, this variation is much smaller than the variation in median disposable household incomes we find in the EU. For instance, while the cost of a healthy diet is about 214 EUR/month in Finland as compared to just 102 EUR per month in Romania, its median equivalent disposable household income in EUR is about ten times higher . As a reIn this paper, food reference budgets are presented and their potential utility as a complement for FBDG in low-income contexts is discussed. These reference budgets are built upon cross-nationally comparable food baskets which reflect the minimum cost for a healthy diet, taking national food patterns and recommendations into account by starting from national FBDG. Food baskets were constructed for the capital city in 26 countries, including all EU Member States except Ireland and the United Kingdom. In Denmark and the Netherlands, the procedure that was applied was not fully comparable. The figures show that even though cross-national differences in the minimum cost of a healthy diet are large, they vary much less than net disposable median incomes. We are convinced that the part of the food baskets which relates to having a healthy diet is comparable across countries in the sense that it reflects dominant institutionalized expectations regarding what constitutes a healthy diet, as embedded in national FBDG, and so will be useful for further comparative research. The procedure we set up for developing and pricing the cost of a healthy diet has been conceived to optimise the balance between the following objectives: (1) It should allow for a healthy diet in line with recommendations in the applicable food-based dietary guidelines; (2) It should be the most economical option possible, while allowing some room for choice; and (3) It should be acceptable, tasty and feasible for the wider public, that is, it should be in line with local food habits. This setup seemed to work well and led to reasonable outcomes. However, further efforts should be undertaken to develop strategies to also collect comparable information on the cost of other functions of food, kitchen equipment and national recommendations regarding physical activity.We are strongly convinced that the food reference budgets offer a useful tool for the promotion of healthy eating and prevention of food insecurity in low-income contexts in at least four ways: (1) help with budgeting for a healthy diet and making the financial hurdles for realising a healthy diet visible to policy makers; (2) educational illustration of how to cook in accordance with national food recommendations as embedded in the FBDGs; (3) showing that also other functions of food matter, apart from having access to a healthy diet; (4) providing routes for further (comparative) research into food insecurity.While the results of this pilot project have proven to be very useful, we have also pointed to several limitations that indicate the potential for further improvement. Overcoming these limitations is strongly dependent on having access to better data, including price data and comparable food consumption surveys in all EU Member States. Also, to make the food baskets more comparable in the sense of the minimum necessary for an adequate diet, it would be welcome to have up-to-date high quality FBDGs everywhere.


Mindfulness metacognitive practice that can be performed in the workplace. Drawing on the theory of conservation of resources, we test a moderated mediating model of how and when employee mindfulness has a positive effect on work engagement. Via analysis of data from 311 employees from 83 teams at different times, this study investigates the relationship between employee mindfulness and work engagement as well as the moderating effect of team mindfulness and the mediating effect of recovery level. The results from this multi-wave field study show that the mindfulness of the individual employee has a positive influence on work engagement and that recovery level plays a mediating role. Team mindfulness positively moderates the relationship between individual mindfulness and work engagement. This conclusion may bridge the relationship between mindfulness and work engagement theory. An increasing number of researchers and managers are now focusing on how to deal with the anxiety and distraction of employees and improving their level of well-being and work engagement. Mindfulness is receiving growing attention from scholars and organizational managers as a means of solving these problems. Mindfulness means attention to the present, with awareness and non-judgmental processing . When miWork engagement is defined as “a positive, fulfilling work-related mental state characterized by vitality, dedication and concentration” . RecentlAccording to the field dynamic theory, individuals in an organization are embedded in the environment, and their individual attitudes and behavioral expressions are the interacting results of their own characteristics  and contextual factors  . As a reThe concept of mindfulness can initially be traced back to the process of Buddhist practice, and early scholars considered mindfulness as a state of attention to the present; Mindfulness provides teams and employees with a high level of attention to the quality of the moment, and previous studies have found that this particular quality significantly improves the physical and mental health of behavioral subjects . Thus, tAccording to conservation of resources (CORs) theory, the acquisition of initial resources will bring more resources to individuals, and a scarcity of resources will lead to further depletion of resources in future . When peExisting research has found that mindfulness has a positive effect on work engagement. For example, H1: Individual mindfulness is positively correlated with work engagement.According to CORs theory, individuals tend to prevent their losses or acquire new resources . EmployeA high level of recovery may promote the process of work engagement or improve investment of cognitive and emotional energies in the workplace . EmployeH2: Individual mindfulness is positively correlated with work engagement via recovery level.Individual mindfulness is beneficial for employees according to CORs theory. Individual and situational factors can affect the reactions of preventing loss and acquiring new resources . EspeciaWork states might influence the response model of how employees react to work stress. One work state that is highly correlated with individual mindfulness is team mindfulness, defined as “a shared belief among team members that team interactions are characterized by awareness and attention to present events and by experiential, non-judgmental processing of within-team experiences” . IndividH3: Team mindfulness moderates the positive indirect effect of individual mindfulness on work engagement via recovery level, such that the strength of this indirect effect is positively correlated to team mindfulness.SD: 5.06), and the average level of education was 2.04 (SD: 0.69).This study chose three service companies in Eastern China as its research sources. The study was supported by the senior management teams of these companies. In order to test the causal relationship, the data were collected at three times, and 350 members from 89 teams were invited to participate in the survey. At time 1, the research team required employees to fill in a survey about their scores for trait mindfulness, recovery level, and work engagement. Meanwhile, demographic information such as gender, age, and length of working day was provided by the human resources department of the surveyed enterprises. Three months later, at time 2, a second questionnaire was collected. The employees who had participated in the time 1 questionnaire were asked to report their team mindfulness and recovery level. Three months later, at time 3, a third questionnaire was collected, and the employees who had participated in the time 2 questionnaire were asked to fill in their work engagement scores. Finally, the data of 311 employees from 83 teams were obtained. In these samples, the proportion of women was 42%, the average age was 25.13 .Firstly, this study preliminarily verified the correlation between variables through a correlation test. Then, using confirmatory factor analysis (CFA), it examined the discrimination validity of key variables in the research model, including individual mindfulness, team mindfulness, recovery level, and work engagement. Given that the data at the individual level was nested in the team, the hypothesis test was conducted in this study using the multi-level structural equation modeling in Mplus 7.0. In addition, in order to isolate the cross-level influence from inter-group team interaction and avoid detection of false cross-level effects , in datar = 0.21, p < 0.05), individual mindfulness was positively related with work engagement , individual mindfulness was positively related with recovery level , and recovery level was positively related with work engagement .The mean values, standard deviations, and correlation coefficients are shown in 2 = 721.43, df = 428, CFI = 0.97, RMSEA = 0.05) than a three-factor model combining recovery level and work engagement  and other models. As a result, the four-factor measurement model  had good discriminating validity.The CFA results indicated that a four-factor model  achieved a more ideal state , supporting hypothesis 1.As shown in SE = 0.09, p < 0.001), and recovery level was significantly positively correlated with work engagement , supporting hypothesis 2.Aiming at testing the mediating effect, individual mindfulness was significantly correlated with recovery level . To further verify hypothesis 3, as shown in The interacting effect of team mindfulness and individual mindfulness on recovery level was tested; the results are shown in Based on CORs theory, this study reveals the process by which mindfulness helps employees to improve their work engagement through the mediating process of recovery level. The results show that there is a positive indirect relationship among individual mindfulness, recovery level, and work engagement. The results also show that team mindfulness plays a moderated role in helping employees recover from work stress. These results further reveal the mechanism by which mindfulness affects work engagement, and this study has some theoretical contributions and practical value.This study further explores the effects of mindfulness on employee work behaviors and attitudes. Although some scholars have previously studied the effect of mindfulness on employees’ work engagement, we study this mechanism with recovery level. This provides a new perspective on how mindfulness influences work engagement. Specifically, mindfulness help individuals to accept and focus on the present in order to recover from work stress. Therefore, employees can adjust their emotions and psychology and return to their original state of mind, and they can engage in the workplace.The research findings are helpful for understanding the effect of mindfulness from the interactive perspective of the team and individual levels, and also increase the predictive effect of theory. Previous studies have focused on the effects of individual mindfulness on individual behavior and attitudes. Individuals work in teams, and their behaviors are bound to be influenced by team factors. This study explores both individual mindfulness and team mindfulness, which allow us to understand the concept and function of mindfulness from different research levels better. We creatively integrate group mindfulness into the influencing mechanism of individual mindfulness and work engagement. On the individual level, mindfulness encourages employees to focus more on their work by affecting their own attention and awareness. On the team level, team mindfulness is a construct above the individual level, which can moderate the behavior of team members. The role of team mindfulness is explored from the moderated boundary. Team mindfulness is different from individual mindfulness, but it can help individual mindfulness to maintain psychological resources. As a result, this conclusion makes the model more complete and responsive to the boundaries of positive effects in mindfulness. We adopt a new perspective for future research on mindfulness. At the same time, the conclusion also supports previous research, such as that showing the promotion of mental health in mindfulness. In short, the study explains that the team and individual mindfulness have different effects on employee behavior and thus further expands the breadth of the research subjects. It also supports results showing mindfulness to be a kind of trait that contributes to better work engagement and why and when mindfulness influences work engagement. The intermediary mechanism is unearthed from the aspect of recovery level.From the perspective of resource conservation, this study analyses the mechanism operating between individual mindfulness and work engagement. The CORs theory emphasizes that individuals will take the initiative to acquire resources and protect the resources they originally possessed to meet their own needs. Firstly, the research results support the viewpoint of this theory. Individual mindfulness makes employees accept and not waste additional resources to deal with negative things. Individuals need resources to achieve a good recovery level. Recovery saves more energy and resources, allowing employees to pay more attention to their work. The acquisition and preservation of resources contributes to the establishment of this mechanism.The research has practical significance. Firstly, work engagement has a positive effect on employee performance. More and more research works are focusing on the antecedents of work engagement. Our research reveals some antecedents of work engagement, and provide a reference for enterprises to effectively promote employees’ work performance.Secondly, in view of the positive effect of individual mindfulness in helping to restore and improve work engagement, mature mindfulness training programs should be adopted in organizational training and development to improve employee mindfulness. Currently, the most popular mindfulness training methods are mindfulness stress reduction and mindfulness cognitive therapy. The effective period of these training methods is relatively long. Thus, enterprises can bring the short training methods of valuable mindfulness training to their employees according to their own situations. From the perspective of employees, they can consciously cultivate their own mindfulness, and improve their level of mindfulness through participating in formal or informal training so that they can recover psychologically more quickly. Finally, given the positive effect of team mindfulness on employee mindfulness, managers can actively promote team mindfulness through team development and collective mindfulness training. This will enable the team to finish tougher tasks involving more conflicts or challenges. After mindfulness training, the team can use special time to meditate and think, to strengthen their level of mindfulness, and to help individuals promote resource recovery.First, this study uses a single of source data from employees and a causal relationship design, but single-source data shows common method biases . The resSecond, given the boundary conditions of the mindfulness effect, there should also be negative conditions at the team level that inhibit the mediating effect of recovery level on the relationship between mindfulness and work engagement. Such negative boundary factors will be explored in the future. Third, the survey samples in this study are relatively similar. In order to increase external validity, different sample groups need to be selected to improve the universality of the conclusion. In addition, this paper studies the effect of trait mindfulness on work engagement. We suggest that to predict the effects of mindfulness interventions on employees in the future, it should be explored whether individuals who have received mindfulness training have improved recovery level and work engagement. This will enable mindfulness to be better applied in the workplace.Finally, recovery requires the individual to accumulate mindfulness continuously in the natural scene. but this study only used cross-sectional data from three time points, which cannot fully reflect the continuous natural state of employees recovering from stress. Moreover, we only discussed the influence of mindfulness level on work engagement but did not research how the improvements of employee mindfulness and team mindfulness influence it. In the future, experiencing samples within the personal level can be used to explore the continuous influence of mindfulness on recovery level. Moreover, scholars can further verify the influence of mindfulness training on individual mindfulness level and how to make individuals accept mindfulness intervention.lsm19801222@126.com.The datasets analyzed in this article are not publicly available. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by the Interdisciplinary Committee on Ethics in Human Research (ICEHR). The patients/participants provided their written informed consent to participate in this study.SL designed the moderated mediating model and wrote the literature review and hypotheses. HX wrote the data collection and analysis. LS wrote the introduction. JH wrote the results. JL wrote the discussion.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


However, it did not influence differences of energy value and nutrients intake between groups, except for the intake of lactose and vitamin B2 per 1000 kcal, which was lower  in UC patients  than the control males . It was observed that the differences in food products intake between the UC individuals in remission and healthy controls were only minor and did not contribute to any significant differences in their nutrients intake. It was concluded that UC patients should be educated not only about the potential influence of food products on their well-being but also about healthy diet recommendations.In spite of the lack of evidence of diet therapy efficacy to sustain remission of ulcerative colitis (UC), the dietary counseling may be beneficial, as a number of patients restrict intake of some products with no medical consultation. The aim of the present study was to analyze the nutrients and food products intake of Polish males with UC in remission in comparison with a control group. The UC group of 44 male patients with the confirmed remission, as well as the pair-matched group of 44 male controls, matched by their age and concurrent diseases, was recruited for the study. Their dietary intake was assessed based on three-day dietary records  and information about food products excluded from their diet, and compared between respondents. It was observed that the intake of food products did not differ between the compared groups, except for the intake of potatoes and sugar, which was higher ( The rolA, and D . At the A, and D .The IBD patients may choose to restrict their diet in an attempt to control symptoms, which disturb their everyday lives, including work, education, and social relationships . MoreoveThe existing dietary recommendations for IBD patients in remission are very limited  and seemIn spite of the previously indicated lack of evidence of the effectiveness of diet, it has been stated that dietary counseling has an association with symptomatic improvement observed in UC patients. However, this improvement does not result from any single nutrient or food product included to, or excluded from the diet , but mayThe aim of the present study was to analyze the nutrients and food products intake of Polish males with UC in remission in comparison with a control group. It was hypothesized that there are specific differences between males with UC in remission and healthy males that may be basis for the future nutritional counseling in this group.The presented study was conducted at the Dietetic Outpatient Clinic of the Department of Dietetics, Faculty of Human Nutrition and Consumer Sciences, Warsaw University of Life Sciences (WULS-SGGW). The study was conducted in accordance with guidelines of the Declaration of Helsinki, while all the procedures were approved by the Ethical Commission of the Central Clinical Hospital of the Ministry of Interior in Warsaw (No. 35/2009) and the Ethical Commission of the National Food and Nutrition Institute in Warsaw (No. 1604/2009). All participants provided their written informed consent to participate in the study.The study was conducted in the group of 44 male UC patients, as it was stated that for them such analysis may be especially interesting as male IBD patients rarely undertake any dietetic modifications or other non-pharmacological treatment options . ParticiThe individuals included in the control group were assessed using similar inclusion and exclusion criteria as participants in the UC group , but witThe first stage of the study was the assessment of BMI and body composition, as well as the comparison of the obtained results between the UC patients and control individuals. As it was found that the BMI, as well as the share of individuals with excessive body mass, did not differ between groups, while only minor differences were found in the body composition assessed using bioelectrical impedance method (extracellular water and body cell mass index) , it was The second stage of the study was the assessment of the respondents’ diet, based on their three-day dietary records  and information about food products excluded from the diet, and comparison between the groups, as presented in To assess the diet, the participants were asked to conduct their three-day dietary records (self-reported data). They received detailed instruction in a standard structured form and were asked to record all the food products and beverages consumed during three random typical days that are not consecutive (two weekdays and one weekend day) . They weThe study participants were also asked to record the serving sizes of all the food products consumed, as well as the food products consumed as elements of dishes—they were allowed to declare the serving sizes either in grams  or using a typical household measure. After obtaining the three-day dietary records, the serving sizes declared by the participants were verified by a professional dietitian, who used the Polish Atlas of Food Products and Dishes Portion Size and attributed the mass in grams .1, B2, niacin, B6, folate, B12, and C. The intake of nutrients was recalculated per 1000 kcal of diet to allow comparisons between groups, independent of the energy value of diets [The energy value of the three-day dietary records, as well as the intake of nutrients, was calculated as the mean daily value. The Polish dietician software Dieta 5.0  with the Polish database of the nutritional value of food products  was usedof diets . At the same time, the unadjusted intake values were also compared as the dietary reference intake values, being independent from the energy value of diet, present the required total dietary supply . They weThe three-day dietary records were also used to calculate the intake of food products, while the following products were included to the analysis: milk and dairy beverages, cottage cheese, rennet cheese, eggs, meat, processed meat products, fish and fish products, vegetables, legumes, fruits, potatoes, bread, other cereal products, oil, margarine, butter, cream, sugar, jam and honey, chocolate sweets, cakes and cookies, tea, coffee, alcoholic beverages, sweetened beverages, nuts, and mushrooms. Afterwards, the intake of food products was recalculated per 1000 kcal of diet to allow comparisons between groups, independent of the energy value of diets, similarly as done for the intake of nutrients.Additional information about food products deliberately excluded from the diet was provided by all the respondents. The participants received a structured questionnaire and were asked to indicate the specific food products which were excluded by them from diet or the intake of which was limited due to gastroenterological symptoms (open-ended question). Then, these food products were attributed to a food product group to verify if within the group any food products were excluded from the diet.2 test. The p ≤ 0.05 was accepted in order to verify the significance. The statistical analysis was conducted while using Statistica software version 8.0  and Statgraphics Plus for Windows 5.1 .The normality of distribution of the obtained data was verified by using the Shapiro-Wilk test. Based on the distribution, either a parametric Student’s t-test, or non-parametric Mann-Whitney U test was applied. The shares of respondents declaring exclusion of products from diet, as well as the shares of respondents characterized by the intake below reference intake values were compared by using chiThe macronutrients intake in the groups of UC males and control males is presented in p = 0.0425) in UC patients  than the control males .The macronutrients intake per 1000 kcal in the groups of UC males and control males is presented in The minerals intake in the groups of UC males and control males is presented in The minerals intake per 1000 kcal in the groups of UC males and control males is presented in The vitamins intake in the groups of UC males and control males is presented in 2 intake per 1000 kcal, which was lower (p = 0.0444) in UC patients  than the control males .The vitamins intake per 1000 kcal in the groups of UC males and control males is presented in p = 0.0033, p = 0.0092, respectively) in UC patients  than the control males .The food products intake in the groups of UC males and control males is presented in p = 0.0047, p = 0.0065, respectively) in UC patients  than the control males .The food products intake per 1000 kcal in the groups of UC males and control males is presented in The food products declared as excluded from diet in a group of UC males and control males are presented in The comparisons of the minerals and vitamins intake with the age-dependent reference intake estimated average requirement (EAR)/adequate intake (AI) values  in a groIn the presented study it was observed that the differences in food products intake between the UC patients in remission and healthy controls were only minor and did not contribute to any significant differences in their nutrients intake. The hypothesis that there are specific differences between males with UC in remission and healthy males that may be basis for the future nutritional counseling in this group was not confirmed. Lack of differences in macronutrients intake is comparable with the results of the study by Taylor et al. , in whicHowever, while analyzing the studies of other authors, it must be noted that the results observed for intake of vitamins and minerals are not consistent, as some of them state lower intake by IBD individuals than the control groups ,40,41,42Furthermore, no statistically significant differences were observed between the groups in the present study, with respect to the food products declared as excluded from the diet. Such a lack of differences may be interpreted as that the UC individuals were not following any specific diet or any diet that is not typical for healthy individuals in this age group. Similarly, in the study by Limdi et al. , which wIn the research of other authors, it was observed that the most common dietary approach of IBD patients is to neither follow any specific diet nor include any beneficial food products, but just avoid some of them . SimilarIt should be emphasized that IBD patients should, above all, not only avoid products that cause gastroenterological symptoms but also provide adequate amounts of nutrients, because nutrient deficiencies may occur even in apparently well-nourished patients or in patients without laboratory abnormalities . Thus, eWhile the food products intake was compared, the differences between UC patients and control males were only minor and were associated with the higher intake of potatoes and sugar in the UC group. Similarly, in the study by Opstelten et al. , for somIn spite of the fact that between the analyzed groups there was no difference in the intake of milk and dairy beverages, it should be indicated that 32% of UC males and 20% of control males declared exclusion of these food products from their diet. In addition, although lactose intolerance is more common in women than in men , the freMoreover, as some potential factors that may allow for the induction of remission or its maintenance in IBD patients, such as low refined carbohydrates content , are ind2). Moreover, not only unadjusted intake was assessed, but also intake per 1000 kcal that allowed more reliable comparison between groups. At the same time, not only nutrient intake was analyzed, but also the corresponding food product intake. Last, but not least, it must be indicated that in a number of studies of IBD patients, they are compared with healthy subjects while analyzed combined, while there may be some differences between UC and CD patients, as even dietary risk factors may differ for them [While comparing the obtained results with the results of other studies, it should be emphasized that the presented own study provided a more complex analysis than a number of other studies, including the study by Principi et al.  on 150 Ifor them .In spite of the fact that the presented study provided the novel observations associated with the issues that were for the time being rarely studied—namely micronutrient intake and food product intake in UC males while compared with the control individuals, the further directions of the research should be suggested. While analyzing the food product intake, it would be valuable to assess separately unprocessed and processed fruits and vegetables (as was conducted for meat products in the presented study). Moreover, conducting similar complex analysis also for female UC patients would allow deeper analysis.It was observed that the differences in food products intake between the UC individuals in remission and healthy controls were only minor and did not contribute to any significant differences in their nutrients intake. UC patients were characterized by similarly inadequate intake as healthy controls, that was stated especially for potassium, calcium, magnesium, and vitamin D. Therefore, it can be concluded that UC patients should be educated not only about the potential influence of food products on their well-being but also about healthy diet recommendations.


Many brain regions communicate information through synchronized network activity. Electrical coupling among the dendrites of interneurons in the cortex has been implicated in forming and sustaining such activity in the cortex. Evidence for the existence of electrical coupling among cortical pyramidal cells, however, has been largely absent. A recent experimental study measured properties of electrical connections between pyramidal cells in the cortex deemed “electrotonic couplings.” These junctions were seen to occur pair-wise, sparsely, and often coexist with electrically-coupled interneurons. Here, we construct a network model to investigate possible roles for these rare, electrotonically-coupled pyramidal-cell pairs. Through simulations, we show that electrical coupling among pyramidal-cell pairs significantly enhances coincidence-detection capabilities and increases network spike-timing precision. Further, a network containing multiple pairs exhibits large variability in its firing pattern, possessing a rich coding structure. Synchronized neuronal activity in the cortex is essential for information processing underlying many cognitive functions, such as learning, attention, and memory formation  were measured to be rare, occurring only pair-wise between cells that have touching or overlapping soma, with a coupling probability of 5%  receive varying levels of synchronized input from an upstream network. Neurons in the downstream network are modeled using the Hodgkin-Huxley (HH) neuronal equations and are organized on a grid, with biologically-relevant connection probabilities and strengths for both synaptic and electric connections and for populations of both inhibitory (interneurons) and excitatory  cells, see below for details. Each neuron, including the electrotonic pair, receives a Poisson background drive modeling incoming spikes from neighboring regions. Since realistic features of network dynamics during sensory stimuli may not be adequately captured by Poisson statistics, we simulate an upstream network using conductance-based Integrate-and-Fire (IAF) neurons. The output of this IAF network is used to mimic sensory information transmitted to the electrotonic pair(s) in the downstream network. The activity and synchrony of the downstream patch are analyzed as a function of the input synchrony, or amount of coincident spikes, received by the electrotonic pair(s).The following subsections discuss the details of the mathematical models of both the downstream model network and upstream input network. A description of the methods used to quantify synchrony is included in this section as well.ith model neuron in the IAF upstream network satisfy the set of equationsThe dynamics of the vi(t) is the voltage, or membrane potential, of the ith neuron, gL is the leak conductance, and jth presynaptic neuron at times Q = E, and inhibitory, Q = I, synaptic inputs. The second sum models incoming spikes to neuron i at times fQ that originate from outside the model network. These external spikes are modeled by a Poisson spike train with rate ν. The dynamics of the voltage are such that the incoming spikes from other neurons in the network and inputs from the Poisson spike train increase (excitatory input) or decrease (inhibitory input) the voltage and, in the absence of incoming spikes, the voltage decays exponentially toward the resting potential, ϵR. If the voltage is raised such that it reaches a threshold, determined by ϵT, the neuron is said to have spiked, the spike time is recorded, and the voltage is set to the reset value, ϵR. The procedure for calculating the spike time and efficiently implementing the time-evolution equations can be found in Shelley and Tao , the synaptic interactions are no longer event-driven, but instead depend on the value of the voltage of the presynaptic neuron. The second term in Equation (1) sums over all pre-synaptic neurons j, which are chosen randomly with probabilities as described in Note that by using a smooth function l in the horizontal direction and m in the vertical direction is given byWe simulate 400 HH neurons organized on a 20 × 20 grid with their probability of connectivity decaying exponentially with distance, capturing the exponential decrease in synaptic connectivity with cell distance as was done by McLaughlin et al. . Then, tr = 20. The external drive to both networks is drawn from a Poisson process with rate ν and strength fQ, for the upstream, IAF network, and νback and fback for the background drive to the downstream, HH network. This models input from neurons external to the patch of neurons that is explicitly being modeled. In addition, a fraction of the downstream population (20% of inhibitory cells and 30% of excitatory cells) receives an additional external drive modeling input from neurons external to the network that are firing in response to a sensory stimulus, mimicking the increased activity of a subset of neurons during a sensory experience. This additional sensory drive is modeled using a Poisson process with rate νsens and strength fsens. Note that all figures were generated using 30 realizations of simulation runs for 5 s of simulated time in each trial.where network-driven electrotonic pair (NDEP), is selected from the set of all electrotonically-coupled pairs in the network to be driven by a subset of neurons from the IAF network; the NDEP is denoted by the green and black triangles in fsens. The input neurons are chosen randomly from the IAF network such that ~9–10 IAF neurons project to one neuron in the NDEP (the average firing rate received by each neuron in the NDEP is ~100 Hz), with no IAF neuron projecting to both cells in the NDEP. The spike times of these input IAF neurons, shown in G4 variable at the input neuron spike times).The inhibitory neurons are coupled with a gap junction with a coupling probability of 60% and neighboring excitatory pyramidal cells are coupled with a probability of 5%, reflecting experimental findings. One pair of electrotonically-coupled neurons, denoted the We postulate that synapses between the NDEP and the inhibitory cells are stronger than the average synapse between other cells in the network. The NDEP excites the gap-junction connected inhibitory cells to fire synchronous action potentials, which allows the synapses between the NDEP and the interneuron population to be preferentially enhanced through synaptic plasticity and classic learning rules Feldman, . As a reThe following sections describe the methods used to quantify the synchrony of the upstream IAF neurons' spike times, as well as the synchrony exhibited by the downstream network.Input synchrony is a measure of the amount of synchronous input received by each neuron in the NDEP from the IAF upstream network. We determine it as follows. First, the instantaneous firing rate in each trial is calculated by binning time into 2 ms-sized bins and counting the number of spikes from the IAF network that occur in each bin , with the following equation:The van Rossum method determines a distance, in time, between two pairs of spike trains by adding exponential tails to each spike time for each neuron and integrating the square of the difference between these exponential-tailed spike times  is the Heaviside function. The smeared-spike function for the second neuron, y(t), is defined analogously. Finally, the van Rossum distance between the spike trains is defined as the integral of the square of the difference,where D2 is large for spike trains that do not align in time (are unsynchronized), and small for those that do (are synchronized). In this work, the time constant for the exponential tail, τc, is set to 5 ms as was done in previous modeling studies  method to detect small changes in synchrony. Due to the gap-junction connectivity among the interneurons, the network exhibits synchrony for nearly all types of external drive, as well as in the presence or absence of a rare number of electrotonic pairs. The intuition is as follows: Once the network is sufficiently excited to induce firing, the interneurons fire synchronously due to their extensive gap-junction connections, causing a network synchronous event (NSE). Specifically, at the time of the NSE, the excitatory neurons are firing sufficiently to excite the interneuron population to threshold, creating a wave of inhibition that suppresses the activity of the entire population for a brief period of time succeeding the NSE. This can be seen in The SD method measures, for each NSE, the amount of synchrony exhibited by all neurons that participate in the event. The procedure is as follows. The time of the NSE is found by recording the times at which the magnitude of the average voltage of the interneuron population increases by 70 mV. This magnitude is kept constant throughout the simulations and the results do not change with moderate changes in this choice of magnitude, see We begin by considering the effect of EC between one pair of neurons that is embedded in the downstream network and receives input from a subset of upstream IAF neurons exhibiting varying amounts of synchrony. First, we note that the two pyramidal cells in the NDEP have synchronized activity due to their EC, which strongly couples the voltages of the two neurons, resulting in almost identical spike trains. As an example, We quantify the amount of synchrony exhibited by the spike trains in both cases (EC on and off) using the van Rossum distance, see Due to the gap junctions that ubiquitously couple the network of inhibitory neurons, input from the excitatory population  creates synchronized firing events called NSEs (as described previously in the Methods section). The synchronization of neuronal spiking is often observed in response to sensory stimuli, with the timing of these synchronized events thought to be important for downstream communication  or from sets of neurons in two different IAF networks (DIAF) that have identical parameters (statistics), but differ in their incoming spike times . We investigate the dynamics of the downstream network in response to both types of IAF upstream input.Since Wang et al.  identifiFor the case in which two NDEPs receive DIAF input, we observe that the two NDEPs compete with one another through the inhibition evoked by each NSE, resulting in network behavior that is more variable than the case in which just one NDEP is present. The dynamics of a network containing two NDEPs differs from that containing one NDEP in several ways. First, we investigate how the average number of NSEs varies in each regime . Networks of neurons may communicate through changes in firing rate and synchrony; however, an important component of both types of communication is the pattern of this synchronized firing activity. The neurons that convey this information are the excitatory, or projection, neurons, whose axons innervate many networks. The activity of the excitatory neurons is modulated by the inhibition generated by each NSE, allowing for a variety of network firing patterns in response to the timing of the NSEs. Due to the competition between the NDEPs in the network containing two NDEPs receiving DIAF input, we observe a firing pattern that is much more variable than a network containing just one NDEP  of the excitatory population crosses a threshold of 1 Hz. For an example of the behavior of the excitatory neurons, for each regime, for one realization, see Specifically, we are interested in the pattern of the timing of each of these excitatory events, see gray filled squares in Notice that the distribution of the inter-event interval for the network containing two NDEPs (purple) is broader than for one (blue) and for the case when EC is turned off (pink), as shown in To confirm that the difference in the CV of the inter-event interval is not simply an effect of difference in firing rates, we show that the average firing rate of the neurons in each regime are similar, see We have developed a model patch of a cortical network, organized in a way that elucidates a possible biological function for a rare number of electrotonic pairs, whose properties agree with experimental results. Measurements of EC between pairs of pyramidal cells in the adult cortex have been elusive to many experimentalists, having only recently been detected and their properties measured , while the tight synchrony of the NDEP keeps the timing of the NSEs very precise (spike-timing coding). This contrasts the network in which EC is turned off and an NSE can be induced only when a large percentage of excitatory neurons in the network are activated, resulting in high network firing rates and imprecise spike timing.Coincidence detection in the cortex is an important property of pyramidal cells, in that it enables an efficient response to synchronized sensory input and organizes network activity (Azouz and Gray, In addition, studies have shown that the activity of interconnected inhibitory interneurons can modulate and influence the activity of the projection cells (Traub et al., All datasets analyzed for this study are included in the manuscript and/or the supplementary files. Computer codes and raw data are available upon request.DC and GK contributed conception and design of the project. JC wrote the code, ran the simulations, and analyzed the results. DZ contributed to the interpretation of the results and generating new ideas. JC wrote the first draft of the manuscript. DZ, GK, and JC contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The Israeli Ministry of Health has set up the foundations of a National Pharmacovigilance System. The next step is to adopt the best of the international ideas, trends and approaches which are shaping the future of pharmacovigilance. Specifically: 1) The risk management approach requires proactively preventing or minimizing risks, starting in early clinical development and extending all along the lifecycle of a pharmaceutical. 2) Drug safety is a multidisciplinary discipline where all stakeholders should be involved. 3) Clinical trials provide an ideal safety profile limited to the restrictive conditions of the trial. Only real-world data, from the post marketing period, will reveal the real risk/benefit balance for the use of a pharmaceutical in regular clinical care. 4) Artificial intelligence is needed to analyze the large amount of data collected through the post-marketing studies, electronic medical records and the internet. Many AI tools have been developed to support better use of pharmaceuticals. 5) Quality-oriented, thorough inspections and audits are critical for achieving patient safety. 6) Patients should be recognized as active players in their treatment who can, and should, have access to safety information through the major agencies’ websites.Israel can benefit from several of its key assets to reach a higher level of pharmacovigilance: 1) Israel’s four HMOs are organized in a way that allows them to have quick and efficient dialogue with healthcare professionals and with patients. Moreover, a new project named, Big Data in Health, will pool the epidemiologic databases of the HMOs, providing precious information for understanding risk factors, detecting alerts, and developing personalized medicine. 2) Formal risk management activities have long been part of the culture of hospitals and should be applied increasingly to ensuring drug safety.Israel has the organizational, scientific, technological and cultural resources needed to quickly overcome the challenges and go beyond its current state to build a unique pharmacovigilance system which could serve as an example for other countries. Pharmacovigilance (PV) is defined as the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other drug-related problem. The WHOThis occurred in Israel, following the Eltroxin® case: a change in the excipientsThe system required the creation of a new department and a new regulation on pharmacovigilance. Lessons were quickly learned from the EU and USA, and the main source of Israeli Pharmacovigilance Procedure #6 is the European regulation , 5. TrueAs is the case everywhere, the main requirements of the Israeli system are aimed at the pharmaceutical industry, and the industry has understood the need to reach international standards. Continuing education and courses were implemented in several universities to train professionals and build this new discipline. Furthermore, the Israeli regulatory requirement for the role of Qualified Persons for Pharmacovigilance (QPPV) applied not only to industry, but also to each of the medical centers and HMOs.With the latest Israeli regulation requiring the pharmaceutical industry to implement RMPs (Risk Management Plans) for high-risk products, the Israeli Ministry of Health is taking a new and important step toward international standards.The creation of the Israeli Chapter of the ISOP   has coinThe basis for a sound pharmacovigilance system has been established. The next step for Israel is to reach, and possibly exceed, the level of the advanced countries. Not only does Israel have the means to build a unique model, it has various strengths in its healthcare system that can help make this happen.The last 20 years have seen a tremendous evolution of pharmacovigilance concepts. However, adverse drug reactions remain the 4th to 5th leading causes of death in USA  and EuroThe risk management approach has brought a change of paradigm from passive data collection to proactive detection by the industry of potential risks and thorough evaluation of identified risks –11. The Risk management is holistic and should be implemented all along the life cycle of a product, from early clinical development to the post-marketing period  . It hasThe regulations we have mentioned are designed for organising the relationships and requirements between regulatory authorities and industry. Even if risk management activities are meant to involve all stakeholders, including healthcare professionals, patients, and health funds, the obligations have weighed only on the pharmaceutical industry. Much of the necessary experience and knowledge are located within the industry, while healthcare professionals had neither obligations nor awareness of risk management plans. In reality, the direct involvement of healthcare professionals, patients, and HMOs in risk management plans has been minimal.Pharmacovigilance has remained limited far too much to experts and to clinical pharmacologists or clinical pharmacists. It is a common understanding in other high-risk industries, such as aeronautics and nuclear power, that management of risks can only be efficient when applied by a multidisciplinary team and considered across the entire system. Healthcare systems are still lagging behind, and the healthcare professions continue to act in silos. The future of pharmacovigilance lies in its becoming truly multidisciplinary. , 14ISMP, the Institute for Safe Medication Practices  has beenSystem safety is the part of system engineering that uses modeling and analysis to identify hazards and to design the system to eliminate or control them. STAMP is used as a safety engineering static and dynamic modeling and analysis approach to healthcare systems to provide a rigorous way to evaluate the efficacy of potential policy changes as a whole. System engineering techniques can be used in re-engineering the system as a whole to achieve the system goals, including both enhancing the safety of current drugs while, at the same time, encouraging the development of new drugs.’ [The System Theoretic Accident Model and Procedures (STAMP) , develop drugs.’ to outline the interactions between the different pharmaceutical system components, identify the safety control structure in place and understand how this control structure failed to prevent the marketing of an unsafe drug which killed an estimated 27,000 people in the United States” [The Vioxx issue has been analyzed in articles and theses “ States” . This neIt is clearly understood today that clinical trials take place under ideal conditions, and as a result clinical trials do not expose the true benefit/ risk profile of a drug. It is only during the wide and uncontrolled use of medications in the post-marketing period, that a more comprehensive benefit-risk balance is unveiled. It is a long and continuing process. This understanding has led to the need for real-world data, gathered through post-marketing studies and the use of pharmaco-epidemiologic methods. Collection of real-world data is now expanding beyond the scientific field, through the search for unstructured safety information exchanged by patients on the internet via various forums and social media.Additionally, Electronic Medical Records (EMRs), produce a huge amount of precious data which brings a more accurate and personalized understanding of a medicine’s safety profile.Risk minimization activities and public health decisions will be driven not only by science-based evidence but also by real-world evidence on medication utilization within specific populations, on the public health and environmental impact, and eventually on economic data.Gathering and integrating these real-world data, outside of the usual scientific borders, require time for analysis beyond human capacity. This is where Artificial Intelligence (AI), is now developing rapidly . In pharIsrael has one of the highest number of start-ups dedicated to healthcare and drug safety in the world. Some of their tools are already implemented in leading medical centers in Israel, such as The Chaim Sheba Medical Center in Tel Hashomer. Leading the innovations beyond Israel’s borders are companies such as Data2Life , MedawarWith the development of the international and harmonized regulation in pharmacovigilance, departments of inspection have been established in many countries . An inspAround the world, the accreditation process for medical centers includes compliance with pharmacovigilance regulations. This is also true in Israel. On the other hand, pharmacovigilance inspections of pharmaceutical companies still have to be developed in Israel. An inspection program is a necessary step for enforcing compliance and building a real safety culture, while raising the quality and efficiency of the whole pharmacovigilance system. The same should apply to the Israeli Ministry of Health’s pharmacovigilance department, which should be audited by an independent party, mirroring FDA and EMA and other advanced authorities.Transparency has been a cornerstone since the European regulation of 2010, and it represents a cultural revolution. From being strategic confidential data in the past, safety data are now largely shared and published in all languages through the 28 Member States in Europe. The same applies to the U.S. Food and Drug Administration. Major deficiencies following industry inspections, infringement procedures, penalties, judicial procedures, and fraud settlements with the U.S. Department of Justice, are immediately published online on the authorities’ website. This, though, refers mainly to industry.This level of transparency has not yet reached Israel, especially in the healthcare system. The proliferation of la suits has even led to a culture of opacity. The Knesset, Israel’s parliament, is currently considering a new law to ensure strict independence between any investigative body and the healthcare system. Patients do not have easy access to their medical records, and the medical records are not always complete nor accurate. Awareness and concern regarding this issue are expressed by patients and medical associations –27, but Israel, the Startup Nation, has the resources to overcome the challenges, with its built-in culture of entrepreneurship . Israel Overcoming these challenges relies on two main pillars: its HMOs, and the risk management units in medical centers.For more than 20 years, the Israeli HMOs have had extensive databases including accurate epidemiological data on the whole Israeli population. This allows, potentially, the detection and analysis of safety signals as well as identification of risk factors. The HMOs’ organizational network allows bilateral exchange of information with healthcare professionals and patients. They could quickly advertise and implement public health decisions, nation-wide. However, the data owned by the four national HMOs are considered as their private property despite the impact they could have on public health. For historic reasons, the Ministry of Health has limited authority over accessing the data of the HMOs and imposing harmonized actions for risk prevention or minimization.This asset, which is one of the most valuable of resources in Israel, is today far from being fully and effectively centralized; but the announcement in Davos by Israel’s Prime Minister heralds a groundbreaking change. In March 2018, he announced the launching of a project costing one billion shekels “to make data about the state of health of its population available to researchers and private companies” . This meWhat is presented today as a major tool for research and development and epidemiology can also prove immensely efficient for improving medication safety.In medical centers are also involved in the detection of safety concerns from healthcare products, be they pharmaceuticals, medical devices or medical practices. Even if the first objective of these units has been to manage the medical center’s legal liability for poor or fatal outcomes, they are also used in several medical centers for risk analysis and implementation of actions to prevent or minimize errors and risky situations. In addition, the remarkable Medical Simulation Center  of ShebaThe long experience and culture gained by Israel in risk management, not only in healthcare, is a strong asset that can be applied to pharmacovigilance: THINK ACTION is a motto which is a daily routine in Israel.Converging voices are heard in Israel to move things forward and reach or exceed international standards in drug safety. These include the new patient safety associations , the newIsrael has all the organizational, scientific, technological and cultural resources to quickly overcome the challenges and build a uniquely strong pharmacovigilance system which could serve as an example for other countries.


This study examines the development of the connected health (CH) research landscape with a view to providing an overview of the existing CH research. The research field of CH has experienced rapid growth coinciding with increasing pressure on health care systems to become more proactive and patient centered.This study aimed to assess the extent and coverage of the current body of knowledge in CH. In doing so, we sought to identify specific topics that have drawn the attention of CH researchers and to identify research gaps, in particular those offering opportunities for further interdisciplinary research.A systematic mapping study that combined scientific contributions from research in the disciplines of medicine, business, computer science, and engineering was used. Overall, seven classification criteria were used to analyze the papers, including publication source, publication year, research type, empirical type, contribution type, research topic, and the medical condition studied.The search resulted in 208 papers that were analyzed by a multidisciplinary group of researchers. The results indicated a slow start for CH research but showed a more recent steady upswing since 2013. The majority of papers proposed health care solutions  or evaluated CH approaches . Case studies  and experiments  were the most popular forms of scientific validation used. Diabetes, cancer, multiple sclerosis, and heart conditions were among the most prevalent medical conditions studied.We conclude that CH research has become an established field of research that has grown over the last five years. The results of this study indicate a focus on technology-driven research with a strong contribution from medicine, whereas the business aspects of CH have received less research attention. Health IT, eHealth, Telemedicine, and Health Informatics. In the early 2000s [Connected Health (CH) began to appear. It did so in the context of research that investigated how information and communication technologies could advance health by connecting people, knowledge, technical artifacts, and organizations. Some years later, Poon and Zhang introduced a new CH information system based on a “four-layered architecture: personal, home, community, and hospital” [A variety of terms and concepts exist that describe the use of technology in health including ly 2000s , the terospital” :Connected Health encompasses terms such as wireless, digital, electronic, mobile, and tele-health and refers to a conceptual model for health management where devices, services or interventions are designed around the patient’s needs, and health related data is shared, in such a way that the patient can receive care in the most proactive and efficient manner possible. All stakeholders in the process are connected by means of timely sharing and presentation of accurate and pertinent information regarding patient status through smarter use of data, devices, communication platforms, and people.The European Network for the Joint Evaluation of Connected Health Technologies defines the CH vision as “a paradigm shift looking after the individual and community health in a process that speaks to the health journey of the person, through the entire lifespan, leveraging a variety of technologies to do so” . AchieviGiven the recent growth in CH research, we set out to map its evolution up to the present day. We use a systematic mapping study to chart the research landscape combining scientific contributions from the research disciplines of medicine, business, computer science, and engineering. Although previous CH reviews do exist, they are confined to descriptions of how CH solutions are being used in specific conditions such as cancer ,7 or in This paper followed a systematic mapping study method . SystemaThe method was used to examine the body of existing research conducted by researchers in medicine, business, computer science, and engineering to understand the nature of research conducted in the area of CH. A systematic mapping study was found to be suitable for this task as it provided a high-level framework for combining interdisciplinary research efforts as well as an analytical framework that spanned disciplinary boundaries.The aim of this study was to present an overview of the available publications pertinent to CH. Following the systematic mapping study method, the study was guided by a set of mapping questions. As CH is inherently interdisciplinary, our goal was to use the systematic mapping method to study research contributions on the topic across disciplines. We, therefore, searched papers from the most recognized scientific literature databases in each of the chosen disciplines.The papers of the study were retrieved from 7 databases of scientific literature, namely, (1) Institute of Electrical and Electronics Engineers Xplore Digital Library, (2) Association for Computing Machinery Digital Library, (3) ScienceDirect, (4) SpringerLink, (5) MEDLINE and PubMed, (6) Business Source Complete (EBSCO), and (7) ABI and INFORM Collection (ProQuest), with the help of the corresponding search engines. The search was performed in October 2018. Different search strings were proposed and discussed over the course of joint meetings to arrive at a set of primary keywords. Two of the authors tested different strings of potential keywords such as “Connect Health,” “Connecting Health,” “Connect-Health,” or “Connecting-Health.” After evaluating the search results, the authors agreed to proceed using the following search strings:  OR .The search was applied to the title, abstract, and keywords to include relevant papers. On the basis of our methodology, we included a wide selection of papers on the first iteration and thereafter relied upon the inclusion criteria and EC to identify the relevant literature .The search results that were retrieved from the 7 chosen search engines were merged in a single list and saved in a spreadsheet document. Duplicate entries were removed based on the digital object identifier (DOI) and the intertitle lexical distance  with the help of a custom Python script . A totalThe final list of papers was distributed to all authors for analysis. On the basis of the area of expertise, pairs of authors were assigned to analyze papers retrieved from each database. A total of 3 areas of expertise were identified as follows: technical (computer science and engineering), medical, and business. Each pair of authors reviewed the title, abstract, and keywords and made a recommendation as to whether that paper should be included or excluded. Discrepancies across coding teams were resolved through further scrutiny of the paper.The inclusion criteria were limited to studies that discussed CH. In total, 240 papers were identified after the removal of duplicates, whereas 32 papers were excluded after meeting at least one of the following exclusion criteria: EC1—papers that focus on CH comorbidities, that is, the paper discusses the connection between health conditions, not CH as a concept; EC2—papers that focus on law; EC3—papers that focus on medical procedures only, without connection to CH; and EC4—papers that focus on evaluating climate but not in relation to CH. The selected studies were analyzed to collect information that would give answers to the MQs according to the data extraction strategy outlined in body-worn sensors and wearables). Similarly, with regard to the medical condition examined, no predefined classification was used that allowed coders to assign the medical condition, if any, of each CH paper. Again, the resulting condition list was curated to develop a more consistent list .MQ6 comprised 2 parameters: the topic of the paper and the medical condition examined within it. With regard to the topic of the paper, we did not have a predefined list of topics but relied on an open coding process where the researchers conducting the analysis selected a descriptive word for the topic of the paper. To identify the main topics of the included papers, the authors relied on the title, abstract, and keywords. After compiling all topic words, we curated the topic list to come up with a consistent list  enumerating the number of papers per publication channel and the number of papers per bibliographic source per year; (2) enumerating the primary studies that are classified in each MQ’s response; (3) presenting visualizations for the classification results, which have been used in the analysis; and (4) presenting a narrative summary to discuss the principal findings.This section describes the results related to the systematic MQs presented in The majority of the CH papers were published in scientific journals , whereas 32.9% (68/208) were published in scientific conferences. This section discusses the results and main findings of this study. First, each mapping question is discussed in its specific subsection. Finally, the limitations of this study are discussed.Journal of Medical Systems, Studies in Health Technology and Informatics, Telemedicine and eHealth, and Journal of Medical Internet Research. This indicates that CH research efforts to date have focused on the establishment of a body of knowledge. On the other hand, conferences offer a dynamic environment that enables researchers to communicate with colleagues, exchange research interests, and receive specialized feedback. Conference publications could, therefore, be considered innovation-laden venues that denote the evolution of research in a field, as they often facilitate the presentation of novel ideas based on preliminary results. Conferences appear to be channels for the introduction and establishment of innovative research to experts of a particular area of research [Publication channels provide information about how research activities in CH have been established in the scientific community. The results of this study show that the majority of CH publications appear in peer-reviewed scientific journals . Although both journals and conferences aim to disseminate research and contribute to the development of a field, journals are typically considered more prestigious because of manuscript review criteria and acceptance practices. In addition, journals usually present more extended pieces of research work and contribute toward the establishment of a knowledge base for a field. Although the process of publication is longer compared with conferences, journals potentially have a larger impact in terms of visibility and audience reach -222. CH research -222. Theresearch -225. Thitelemedicine to patient-centered services may have then driven the publication of CH-related papers. The growth of publications after 2009 can be attributed to various factors. The emergence of CH in the past decade coincides with a demographic shift where the older population is ultimately projected to outnumber the young people [internet of things in health care over the last decade [The papers matching our inclusion criteria, while spanning a publishing period from 2000 to 2018, show that CH research has attracted increasing attention since 2013. A publication gap between 2001 and 2004 coincides with the infancy of the CH field, likely reflecting the fact that the evolution of CH research was a slow and gradual process underpinned by the fermentation of experts from different academic disciplines. Overall, g people . This ing people ,227. At t decade , along wt decade ,229,230.t decade . Taking t decade . In termt decade .Our results show that CH researchers focused primarily on suggesting novel solutions or extending existing research to explain, identify, and provide details of the CH approach . The 23.5% (49/208) of papers that centered on evaluation also represent attempts to comprehend and develop previous research through evaluating a solution with a valid approach ,15. Thishow and why questions, real-life contexts, and the building of theory [gold standard in engineering and health research.Our findings support the idea that over half of the CH studies are based on empirically informed approaches. More specifically, the majority of the solution proposals were empirically validated with case studies , followed by experiments , whereas 13.4% (28/208) used surveys. Case studies have been shown to be particularly suited to f theory . They off theory . In partf theory . This prf theory . The higThe results for this MQ show that the majority of the included papers belong to other types of studies , which means that they used approaches that were not defined by our classification scheme. This finding could arise from a variety of factors. More than half of the included papers were from the medical discipline, a fact that has given rise to classification challenges, as reviewers were not able to fit them into one of the defined categories. Although mapping studies are common in the medical discipline , classifThe topic analysis shows that technical and medical disciplines dominate the research topics of the papers, with some references to related disciplines such as education or innovation research. The topic descriptions show a large body of papers discussing measurement-based monitoring with sensors and wearables. This reflects the fast development of body-worn sensors and wireless communication methods that allow the transfer and storage of large amounts of data for further analysis. Another body of papers focused on patient perspectives in CH solutions through a consumer viewpoint or user-centered design, which might reflect an increasing interest in patient empowerment and self-management solutions. The growth of CH as a research field might also reflect regulatory moves toward a data economy where rules for using personal data are clearer . Related topics included security, privacy, and interoperability issues. It has been suggested that leveraging interoperable CH technologies for chronic disease management can have multiple positive effects not only on patients but also on clinical outcomes, thus contributing, for example, to the promotion of outpatient care . AlthougDiabetes, cancer, and chronic heart conditions dominate the medical conditions covered. This is unsurprising given that these are leading health problems on the global stage . This matopic and condition parameters. Nevertheless, for the analysis of results, the authors relied upon the interpretation of descriptive statistics and visualizations, thus decreasing the threat to validity. In the same vein, to alleviate the authors’ influence on the classification process, the development of the classification scheme relied on widely accepted guidelines [Owing to the interdisciplinary nature of our topic, we used an interdisciplinary team of researchers for analysis. Having researchers with different backgrounds could decrease inter-rater reliability, especially where we did not have a predefined list of values, as with the idelines . The difThe differences in publication practices between the disciplines probably had an influence on how the results of MQ1 were interpreted, as the role of conference and journal publications differs between disciplines . For exaother for the parameter approach. In the joint analysis meetings, the coding authors shared experiences of their difficulties in classifying the papers within the agreed analysis parameters. Alternative solutions were discussed, but it was difficult to reach a consensus that would have been satisfactory across disciplines. Ultimately, we decided to use the classification parameters proposed by our methodology. The validity of our conclusions is only applicable within the CH context.As the methodology of the systematic mapping study that we used in this research was originally developed in the context of software engineering, it is likely that some of the analysis parameters were less optimal in other disciplines. This is reflected, for example, in the large number of studies classified into the category To limit the threat related to the identification of primary studies and to include as many relevant papers as possible, 2 of the authors ran several iterations to test different strings of keywords. The adoption of the final set of keywords was used as it returned the largest number of studies. However, the list of studies might be incomplete, as additional or different terms might have an impact on the final selection of papers . NeverthOur search strategy and inclusion criteria have omitted studies that are referenced in grey literature. However, the literature search was conducted in the world’s most leading and comprehensive databases for scientific knowledge. Furthermore, to alleviate the threat of publications’ nonavailability because of subscription paywalls, we performed the initial screening using a combination of university libraries to improve our access to papers. To address validity threats because of duplication, duplicate entries were removed based on the DOI and the intertitle lexical distance with the help of a custom Python script, which was ultimately manually reviewed to ensure duplicate removal.cure rather than a prevention mode. Cutting-edge technologies and redesigned care pathways may fail if they run contrary to the flow of health care finance. Our findings emphasize the need to increase business research in the area of CH or to find the vocabularies and keywords necessary to link existing business research with CH endeavors.On the basis of our results, we can conclude that CH research is an established field of research. The interdisciplinary nature of the field can be seen especially in papers at the intersection of the medical and technical disciplines. The number of papers in the business research publication forums is still smaller. However, business-related themes are visible in topics of papers, such as consumer orientation and innovation research, although at a much smaller scale than the topics of more technical and medical nature. For CH to succeed, money needs to move differently around the health care system. Most developed health care systems continue to reimburse care in a There is a growing need to involve and engage patients in their own care and, by extension, in the design of digital solutions to improve their efficacy. Tailored CH interventions may more effectively reach the intended audience in a meaningful way, but this requires in-depth understanding of the condition’s needs, barriers, and facilitators. The important role that health care professionals play in the health care system is in contrast with their lack of involvement in the design of CH. In the same vein, recent research suggests that health care professionals’ education in Europe is lacking in the area of health care information technologies . EmerginGiven that CH research has become far more widespread in the years since 2013, perhaps it is time to devote more research resources to the scalability of CH as reflected in empirical approaches that facilitate the use of larger populations.We see our findings as the foundations of a research roadmap for CH researchers that challenge current thinking in health care. Such a research agenda would go beyond investigations into the feasibility of individual technical solutions to examine and develop ecosystems of stakeholders, technologies, and infrastructures that together form new kinds of systemic solutions. Such an agenda would require more focus on research that addresses interdisciplinary methodological questions alongside the creation of vocabularies and frameworks for researchers working in different disciplines to effectively collaborate and examine interdisciplinary research questions through joint methodological approaches.