Due to the rapid digitalization of health care, leadership is becoming more complex. Leadership in digital health services is a term that has been used in the literature with various meanings. Conceptualization of leadership in digital health services is needed to deliver higher quality digital health services, update existing leadership practices, and advance research.The aim of this study is to outline a concept analysis that aims to clarify and define the concept of leadership in digital health services.The concept analysis will be performed using the Walker and Avant model, which involves eight steps: concept selection, determination of aims, identification of uses, determination of defining attributes, construction of a model case, construction of additional cases, identification of antecedents and consequences, and definition of empirical referents. A scoping literature search will be performed following the search protocol for scoping reviews by the Joanna Briggs Institute to identify all relevant literature on leadership in digital health services. Searches will be conducted in 6 scientific databases , and unpublished studies and gray literature will be searched using Google Scholar, EBSCO Open Dissertations, and MedNar.An initial limited search of MEDLINE was undertaken on October 19, 2020, resulting in 883 records. The results of the concept analysis will be submitted for publication by July 2021.A robust conceptualization of leadership in digital health services is needed to support research, leadership, and education. The concept analysis model of Walker and Avant will be used to meet this need. As leadership in digital health services appears to be an interprofessional and intersectoral collaboration, defining this concept may also facilitate collaboration between professionals and sectors. The concept analysis to be conducted will also expand our understanding of leadership in digital health services.PRR1-10.2196/25495 This italized . Althougitalized , the vieitalized -9. Healtitalized ; howeveritalized -13. Nursitalized . This maitalized . It has,italized .physician leadership in eHealth have been used [However, the literature provides little clarity as to what leadership in digital health services means or entails ,18. Reseeen used . The exieen used  concludeConceptualization of leadership and leadership-related issues is quite common in health care research. Previous concept analyses relating to health care leadership have focused on transformational leadership , staff nPs: people, processes, and (computer) programs [Previous studies have mainly examined leadership in digital health services from the viewpoint of HIT implementation and adoption ,13. A reprograms . The infprograms .Several studies have aimed to define the concept of e-leadership ,37; howeTo conclude, conceptualization of leadership in digital health services is needed to better understand how leadership can support health care digitalization and improve the likelihood of successful HIT implementation. For example, the integration of HIT is necessary for nurse leaders to lead effectively in the future . AdvanciPrecise conceptualization of leadership in digital health services is needed to support health care leaders working on digitalization on the frontline and at middle and senior management levels, to help create better digital health services, to facilitate continuously evolving leadership, and to advance research. To this end, the concept of leadership in digital health services was analyzed using the concept analysis model of Walker and Avant . The useThe protocol outlines a concept analysis procedure designed to clarify and define the concept of leadership in digital health services.The concept analysis model of Walker and Avant , which hThe concept analysis process starts with the selection of a concept to be analyzed —in this The next step is to define the aims or purpose of the study . Our speThe third step involves first identifying all previous uses of the concept when collecting material for analysis . In thisa cluster of attributes that are frequently associated with the concept [After identifying the different uses of the concept under investigation, the uses will be read through to find the characteristics that appear repeatedly to define the key attributes of the studied concept . This process will generate  concept .the use of concept that includes all the critical attributes of the concept [This step involves developing one or more model cases to represent a real-life example of  concept . This wiAfter identifying at least one model case, additional cases relating to the concept under investigation will be identified. This is necessary because it will not be possible to complete the concept analysis if there are overlaps between the identified attributes or contradictions between the defining attributes and the model case . The puroccurrence of the concept.Antecedents and consequences will be identified in the penultimate step. Walker and Avant  defined The final step of the concept analysis will be to integrate the critical attributes with real-world empirical referents. According to Walker and Avant , empiricTo identify all relevant literature on leadership in digital health services, a literature review will be conducted in accordance with the search protocol for scoping reviews by the Joanna Briggs Institute (JBI) . ScopingThe Population, Concept, and Context (PCC) framework will be applied when defining eligibility criteria for the scoping review . InitialInclusion criteriaPopulation: Studies on health care leaders regardless of their management position or health care fieldConcept: Health care or service leadershipContext: Digital health servicesExclusion criteriaPopulation: Studies on leaders working solely with information technology managementConcept: Not related to health care or service leadershipContext: Health services with no digitalization of any kindBoth peer-reviewed publications and papers from gray literature will be included in the review. The studied population will consist of health care leaders or managers regardless of their management position and health care field. Leaders working solely with information technology management will be excluded because they are not responsible for clinical health services and management. Publications eligible for inclusion in the review will be those that somehow define or clarify the concept of leadership in the context of digital health services.A 3-step search strategy  will be The databases to be searched will include CINAHL, MEDLINE, Scopus, ProQuest, Web of Science, and the national Finnish database Medic. These databases collectively provide a comprehensive coverage of publications relating to health care leadership and digital health services. Searches for unpublished studies and gray literature will be conducted using Google Scholar, EBSCO Open Dissertations, and MedNar. Gray literature types eligible for inclusion will include editorials, opinion papers, and dissertations. Papers published in English, Finnish, and Swedish will be considered for inclusion. Only papers published between 2010 and the present (2020) will be considered for inclusion because the rapid digitalization of health services over the past decade  makes olAll citations identified by implementing the search strategy described earlier will be collated and uploaded into the Covidence systematic review systematic software package (v2422), which will also be used to remove duplicates. Titles and abstracts will then be screened by two team members independently using the inclusion or exclusion criteria. For papers without abstracts, the full text will be retrieved. After title and abstract screening, the potentially relevant studies will be retrieved in full. Two independent team members will assess these studies in detail and evaluate their suitability based on the inclusion criteria. Reasons for exclusion will be reported for studies that do not satisfy the inclusion criteria. Any disagreements at any stage of the study selection process will be resolved by discussion or by asking the opinion of a third team member. The results of the search will be reported in the final study and will be presented in a PRISMA  flow diagram . All seaThe extracted data will include definitions of leadership in digital health services; its key domains; the setting and population of the study described in the paper; and data needed for the 8-step concept analysis, such as attributes, antecedents, and consequences . Two resAs concept analyses use only secondary publicly available data from primary research studies and gray literature, no research ethics approval will be needed.Several activities will be performed to enhance the study’s validity and rigor, including the following:Method: The scoping review, which will identify all relevant literature on leadership in digital health services, will be conducted following the JBI guidelines .Search: An information specialist with expertise in health sciences and management research will be consulted when developing the search strategy to increase credibility. In addition, several databases and gray literature sources will be included to ensure the richness of the data.Screening, data extraction, and synthesis: Each of the previously mentioned phases will be conducted independently by 2 team members. Having 2 independent team members to select papers, extract data, and conduct synthesis will enhance reliability.All members of the research team will repeatedly evaluate the manuscript during meetings that will be held as the process progresses.The search for the relevant studies was performed on November 31, 2020, resulting in 2861 studies after duplicates were removed. The screening of the studies will be completed by the end of January 2021. We expect to begin other phases of concept analysis in February 2021. The concept analysis is anticipated to be ready for submission by July 2021.In recent years, leadership in digital health services has been scrutinized in relation to issues including HIT adoption and implementation ,13,50, iThe literature indicates that all health care leaders, regardless of their management position, are involved in health care digitalization ,13-15 anactions and inactions of senior leadership. This may be because health care leaders might have insufficient informatics skills. For example, according to Sharpp et al [black box for some health care leaders, and this issue should be examined more thoroughly [Glaser  suggestepp et al , some nupp et al ,29,58. Horoughly .The preliminary search of MEDLINE conducted while developing this study protocol retrieved many potentially relevant papers. Therefore, the search strategy  will involve only title and abstract searches to ensure that the review balances feasibility with comprehensiveness. Limiting the searches to titles and abstracts may cause some relevant studies to be excluded from the concept analysis. However, title limitation appears to be quite common in reviews focusing on health care digitalization ,59. The There is a clear need to conceptualize leadership in digital health services because leadership in health services seems to be incoherent, providing no consistent perspective on the phenomenon. In addition, this study shows that the concept analysis model of Walker and Avant  is suitaOur evaluation of the need to conceptualize leadership in digital health services made it clear that in addition to providing a basis for further research, defining and clarifying the concept of leadership in digital health services could facilitate the development of higher quality digital health services by actualizing the roles and responsibilities of leaders in digitalized health care. A clear definition may also help educational and health care organizations to provide better education and training for health care leaders in ICT, which would, in turn, support the digitalization of health care.


The types identified differed with regard to the accumulation, combination, and use of their conscious and unconscious defense and coping mechanisms in the superordinate areas of behaviour, relationships, emotions, reflexivity and time focus. The typological classification could offer psychotherapeutic interventions tailored to individuals and their defense and coping mechanisms, which could lead to improved therapy use and compliance.This work strives to develop a typological classification of the use of conscious and unconscious defense and coping mechanisms based on methodically and structurally collected data from a qualitative survey of 43 former soldiers in Germany. Seven coping and defense types were identified:  If the individual considers control or escape impossible, he/she usually reacts with passive mechanisms .Recruiting potential participants took place via a project-owned website and the psychiatric ward of the GAF Hospital Berlin. Former soldiers of the GAF who had participated in at least one foreign assignment were included. Thus, it was possible to identify 103 potential participants, of whom five could not ultimately be contacted. Short telephone interviews were conducted with the remaining 98 participants. They were asked about their motivation for participating and to provide their socio-demographic data. The inclusion criteria were checked as well. In all, 43 of the remaining 98 participants were eventually invited to phase two of the project, the open interviews. The participants were initially selected at the Bundeswehr hospital in Berlin using opportunistic sampling , to a detailed thematic analysis and compared the resulting concepts with the remaining 27 interviews.The included sample comprised former soldiers of different ranks (from soldiers to senior officers), organizational units  and federal states of Germany (12 out of 16). Four (9.3%) participants were female; the age span of the participants was between 26 and 69 . Some participants had just left the GAF, and others had been civilians for several years. According to the former soldiers interviewed, 19 (44%) suffered from a service-incurred disability, and three (6.9%) were in treatment time, which is a time span used for clinical and occupational rehabilitation in Germany during which soldiers, although not on active duty, cannot be discharged from military service.The data were collected in personal, open interviews. The interviews were conducted jointly by two of the authors, with one of them moderating the discussion and the other responsible for the equipment and accompanying field observations. This also included his/her own counter-transference experience and observations of emotional reactions of the interviewees and in some cases, for example, their interaction with relatives or partly present pets, etc.Conscious coping mechanisms  were reported during the interview, sometimes without being asked and sometimes directly asked at a later point in time. Unconscious coping and defense mechanisms were identified in the very detailed descriptions of the participant’s situation and action processes  or observed during the interview . The entire interview was recorded in MP3 format and then transcribed by an external transcription service pledged to confidentiality . In the second step, thematic categories were identified by combining, contrasting and merging similar or interconnected coping and defense mechanism codes. For example, the code “crying” was then combined with other codes such as “expressing sadness or anger” or “showing feelings”, and the category “show emotions” was created. The third step included the review and analysis of the thematic categories found to identify underlying thematic structures, motifs, functions or specific combinations of coping and defense categories using new raw data from the ongoing data collection and analysis. To continue illustrating with the above example, the passages and codes were read again, the codes were compared, and the intensity and context in which emotions were shown or not shown were examined or other codes with emotional content were added to the category. The fourth and final step was to develop a typology based on the combinations of mechanisms found in the material, constantly cross-checking it with new material and also including current literature and existing models. Thus, for example, different manifestations of the area “emotion” arose and a model continuum with the superordinate area “emotion” was created, consisting of the three emotion categories “defensive”, “partially permissive” and “affirmative”   and integrated into a prototypical classification  cannot be answered with absolute certainty. Our analysis showed that some emotions such as disappointment, anger and bitterness were frequently addressed and named, while others, such as sadness, guilt, shame and fear were hardly expressed or mentioned. One possible interpretation of this discrepancy could be that feelings such as disappointment, anger and bitterness were often directed to the external military or civil system and are also better compatible with the soldiers’ self-standard  soldiers with mental illnesses use psychosocial services in the USA, Great Britain and Germany  therapy, in accordance with proven guidelines and recommendations, would then be the second step. The same may be true of the Partisan, who would most likely benefit most from a mentalization-based therapy since it seems to be  more a structural problem that prevents him from leading a balanced and successful life than a question of conflict.Rüsch et al. also emphasized the relevance of fear and experience of stigmatization and discrimination among soldiers in their qualitative work on the self-revelation of psychiatric disease  mechanisms. Would it be an opportunity for all groups who find therapeutic access difficult to think about including coping and defense much more consciously in their therapy planning? This approach would mean that coping styles could be used to enable therapy by changing and reducing the individual’s defenses.Although critical opinions of typological constructs must be considered, it has to be stated that many of these concepts are well-known and are currently widely used, such as the Myers-Briggs-Test or the concept of Typus Melancholicus , and analysed and included in the evaluation by the conscious handling of counter-transference experiences and regular team intervention and supervision.The open nature of the interview design with its low limitations, the lack of requirements and the possibility of asking questions led to very detailed, individual, subject-related descriptions of the internal and external processes. For most of the participants the interview situation, especially the conversation about stressful events in the war zone, was a challenge in itself. Therefore, some defense and coping mechanisms were already apparent during the interview which we were able to experience “live”. Through the shown or not shown affect, the choice of words, the tone of voice and they kind of description, mechanisms were already recognizable in the interview situation. Our approach therefore involved, on the one hand, the analysis of the mechanisms remembered and narrated by the participants themselves, and, on the other hand, the consideration of the unconscious mechanisms and behaviours recognisable from the narrative. By the additional analysis of those mechanisms directly occurring in the course of the interview, we believe we counteracted a conscious or unconscious selection or distortion process, as occurs in any form of (retrospective) survey. In other words, these phenomena helped us to better understand the (unconscious) fears, values and motives of the former soldiers interviewed.Although we have paid great attention to differentiated sampling with the aim of achieving the greatest possible heterogeneity and have always oriented our data collection and analysis to the quality criteria of Stamer et al. the Fighter, the Comrade, the Corpsman, the Strategist, the Partisan, the Self-Protector and the Infantryman. The types identified differed in the accumulation, combination, and use of their conscious and unconscious defense and coping mechanisms in categories in the superordinate areas of behaviour, relationships, emotions, reflexivity and time focus. The typological classification could offer psychotherapeutic interventions tailored to individuals and their defense and coping mechanisms, which could lead to improved therapy use and compliance. Nevertheless, further research is needed in the field of trauma management and validation and verification of our results in follow-up studies.This work strives for the first time, to our knowledge, to develop a typological classification of the use of conscious and unconscious defense and coping mechanisms on the basis of methodically and structurally collected and analysed data from a qualitative pilot survey of former soldiers in Germany. Seven coping and defense types were identified:


Using a bottom-up qualitative approach with quantification of responses, this study explored how prominently relationships featured as meaning sources compared to other domains of life and then, in particular, the motivations for the importance of various types of relationships as found in four African samples: a Ghanaian urban group (n = 389), a South African multicultural, English-speaking urban group (n = 585), and two South African Setswana-speaking groups . Findings showed that the relational domains of life, namely, family, interpersonal relations, spirituality/religion, and community/society, made up a large proportion of responses on what provides meaning in life−in particular family and spirituality/religion with community/society occurring the least. The reasons for meaning experienced in various relationship types included domain-typical relational descriptors, such as contributions made or rewards received. However, many intrapersonal motives also emerged: inner well-being, happiness, joy, a sense of competence, and own growth. Material needs and harmony also surfaced as motivations for relational importance. Findings are aligned with African philosophical perspectives as far as the importance of relationships and the value attached to spirituality/religion are concerned, but contributed additionally by showing that different types of relationships vary in importance: close relationships are more important than community/societal relationships. Unearthing the reasons for the importance of relationships points toward a dialectic pattern of African individualism–collectivism in which independent and interdependent orientations flow together. Such knowledge is vital for the promotion of mental health and well-being in these contexts.Afrocentric paradigms reflect assumptions of the overarching importance of interconnectedness and social bonds in meaningful experiences. It is, however, not known if types of relatedness vary in importance as meaning sources in the subjective experiences of laypeople, or what the reasons are that they ascribe to the importance of relationships. The empirical and theoretical substantiation of philosophical assumptions is needed to provide a scientific basis for appropriate well-being interventions in African contexts. Therefore, this study aimed to empirically explore the relative importance of various types of relationships as sources of meaning and in particular  Meaning in life is about what people value most. Various sources of meaning in life had been identified, with relationships  being one of the most often cited meaningful things for people across cultures e.g., . Howeverwhy relationships or particular kinds of relationships are meaningful to people  had not been explored in an African context as far as we can ascertain. The why in this sense is seeking the reasons or motivations for the indications of what is important for meaning. Although it is well-known that horizontal  as well as vertical  relationships are very important in African collectivist contexts, given specific cultural values  well-being outcomes. This is the case from African as well as Western philosophical perspectives, but also in some theories and empirical studies . Metz 2. Thus, tstructural components of meaning. More recently, A leading Western model of meaning is that of sources of meaning  can be found, and in many of these studies, relationships are seen as an important source  model by reasons for the importance of relationships. Despite an abundance of philosophical assumptions, theorizing about the dynamics of relatedness had been neglected in the African context. Developing African cultural models in psychology is hinged on validating philosophical assumptions on the importance of relationships, with extensive empirical research on why relationships are important in the first place. Therefore, this study empirically tapped into the verbal responses of laypeople elicited by two semistructured questions on what the most meaningful things are for them and why they find these things meaningful. Then, we applied a developed coding process to code each verbal response after which coded answers were transformed into quantitative data. We will focus from a bottom-up perspective specifically on the reasons why relationships are meaningful for four groups of laypeople from Ghana and South Africa. The two samples were selected because they represent two distinct but related settings: one a developing middle-income country with a strong racially divided context (South Africa), and the other an upper low-income country with a higher level of cultural integration (Ghana). These two contexts have the potential of unearthing unique dynamics for enhancing our understanding of the relational motives for meaning.The importance of relationships in African values and meaning systems is abundantly described in philosophical perspectives, but very little empirical studies in well-being research had been conducted, and there is a gap in knowledge about the relative importance of different types of relatedness and the why relationships, in particular, in the relational domains of family, interpersonal relations , spirituality/religion, and community/society, are meaningful to people. As this is an exploratory descriptive study, no specific hypotheses are stated. The method used for all four samples is described below.Our specific aims are to: (1) determine the relative importance of various relational domains (types of relationships) and (2) gain a deeper understanding of Four samples were selected. Samples 1 and 2 were adults from urban areas in Ghana and South Africa, respectively, in which participants had at least a secondary school education and were 18 years or older. Participants completed the questionnaires in English. The South African sample was multicultural. Samples 3 and 4 were Setswana-speaking older adults with lower educational levels from rural and urban areas in South Africa, respectively. They were selected in line with inclusion criteria for the Prospective Urban and Rural Epidemiological Study for South Africa (PURE-SA) cf. . ParticiIn each of the four samples, data were collected in a one-off cross-sectional design including the same semistructured, open-ended questions to which written responses (samples 1 and 2) or fieldworkers capturing verbal responses (samples 3 and 4) were given by participants. Data gathering for samples 2, 3, and 4 formed part of the FORT3 research program . In the See For all four samples, the sociodemographic questionnaire included gender, age, educational level, marital status, practicing of religion, and employment status.The present study used two open-ended questions on meaning from the Eudaimonic–Hedonic Happiness Investigation (EHHI) , namely,After obtaining ethical approval for the various studies, participants were selected according to the inclusion and exclusion criteria. Trained fieldworkers invited participants to answer the semistructured questions mentioned previously, as part of a larger battery of questionnaires . In samples 1 and 2, the participants provided written answers, whereas in the cases of samples 3 and 4 , participants answered verbally, and their responses were captured in writing by the fieldworkers. All responses were then coded, categorized and clustered in life domains, and then transformed to quantitative data for further analyses .Trained fieldworkers obtained written informed consent from participants  and made sure that participants understood what was expected from them, that participation was voluntary, and that they had the right to withdraw at any point in time during data gathering. Anonymity was safeguarded by separating the signed consent forms from the corresponding answer sheets, and all confidentiality concerns were upheld. The University of Ghana Ethics Committee for Human Research approved of the study reported in sample 1  and the Health Research Ethics Committee of the North-West University, South Africa, approved the studies reported in samples 2, 3, and 4 .Participants’ written responses to the semistructured questions  were coded using the formalized manual for a coding system developed by what and why categories and domains to which each code belongs. One trained coder coded the Ghanaian data, and another trained coder coded the South African data. Spot checks of coding were performed by the first two authors.Trained coders coded the responses to the questions on meaning sources and motivations for meaning sources according to the EHHI manualized coding system. Coders were instructed to assign one code to each of the responses on the meaning sources question , which implies that each participant could have had a maximum of three codes for meaning sources (less if the participant mentioned fewer than three sources). For the motivations for meaning sources question, coders had to assign a maximum of two codes to each of the responses, which means that each participant could have had a maximum of six codes indicating motivations for meaning sources . Because the data were available on code level after coding was done, we used lookup functions in Excel to add variables that represent the Using SAS 9.4, we first determined what percentage of sources of meaning was in each of the domains of life distinguished in the EHHI coding system which revealed the relative importance of the various relational domains/types of relationships. Although other life domains were also prominent in participants’ meaning sources , we focused for the rest of the analyses specifically on the reasons/motivations provided for relational meaning sources, that is, the motivations for meaning sources in the family, interpersonal relationships, spirituality/religion, and community/society domains. For each sample, we will report the five most frequent domains mentioned in motivations, the 10 most frequent motivation categories, and the 10 most frequent motivation codes for meaning sources in each of the four relational domains, respectively. Thus, only the most prominent domains, categories, and codes are shown. Note that, because the same domains emerged in the development of the formalized EHHI coding system for meaning sources and motivations for meaning sources, it is possible that, for example, “family” could be coded as both a source of meaning and a motivation for a source of meaning reflecting the intrinsic importance of the domain.From what the most important sources of meaning are for them and also for why these sources are important, i.e., motivations or reasons for the meaning sources, were first coded, followed by the categorization of the codes, and thereafter clustered under life domains including various types of relational domains. Life domains and categories are thus abstracted groupings similar to themes and subthemes in narrative qualitative analyses, whereas the codes refer to the specific verbalizations as captured in the manualized EHHI codebook. In the following section, the findings will be reported by first referring to the abstracted domains and categories and then illustrated in verbatim quotes captured in codes.See why question. Notably, family was the domain most frequently referred to in motivations for all groups, except for the multicultural South African group where personal life was the domain containing the most motivations. Important motivation categories that emerged across the samples were that participants felt that they could contribute to their family by, for example, loving them, caring for them, respecting them, and supporting them; that they experienced support from these relationships; that they get some form of personal reward from family members, for example, by getting love from family members, being looked after by children at old age, or enjoying the presence of children; that family gave them a sense of sharing and reciprocating, for example, love and happiness; and that family is intrinsically meaningful or provides meaning and value to their lives. Other top life domains mentioned in the motivations for the importance of family as a source of meaning were spirituality, standard of living, interpersonal relations, and life in general.The vast majority of motivations for family being an important source of meaning emerged from references to facets associated with the family and personal life domains as mentioned in answers to the On code level, prominent motivations for the family as a source of meaning included that participants experienced that they get support  from their family members and that they love their children. For the two older Setswana groups, being looked after by children at old age was a frequently occurring code, whereas experiencing family as a source of joy and positive feelings was a common code among the Ghanaian and multicultural South African groups.For all groups, the domain that featured most in participants’ motivations for (non-family) interpersonal relations being important was the interpersonal relations domain itself. Personal life was the second most common motivation domain. On category level, motivation categories that emerged frequently across the groups included getting personal rewards in the form of, for example, getting help, support, or understanding from friends or neighbors or having a sense of belongingness or integration; experiencing support; sharing among others experiences or good and bad times, to enjoy being together, or to help or respect each other; experiencing harmony or balance in interpersonal relations; and contributing to others’ lives by, for example, loving them. Common codes across all groups included getting help or support from friends or neighbors; getting support  from others, helping each other; and enjoying being together or experiencing the relationships as being a source of joy and positive feelings. Notably, for the rural Setswana-speaking groups, experiencing harmony and balance in interpersonal relations was an important motivation.why question.See In the reasons for spirituality/religion being an important source of meaning to people, spirituality/religion and personal life were the most frequently occurring domains mentioned in the reasons for importance, with spirituality/religion being the most frequent domain for all groups but the multicultural South African sample. Across all groups, faith cultivation was by far the most frequent category emerging in participants’ motivations for spirituality/religion being meaningful. This category included responses such as living up to one’s purpose by serving, witnessing, pleasing, or honoring God, receiving God’s mercy or blessing, getting everything from God or experiencing the specified source of meaning as God’s gift, emphasizing the importance of getting close to God, eternal life, loving God, realizing God’s purpose, getting inspiration for living daily life, or trusting in the Lord. Other prominent motivation categories across the groups were that spirituality/religion provided participants with value or meaning in their lives and that it provided them with personal identity and a sense of harmony. Prominent codes included expressing that we get everything from God or that life is God’s gift; living up to one’s purpose by serving, witnessing, pleasing, or honoring God; the importance of getting close to God; and to get inspiration for living daily life.First, it is important to note that the total number of motivations for community/society being a source of meaning was small for all samples, especially for the Ghanaian sample where only 17 codes were assigned to motivations for community/society as a source of meaning. Interpretation should therefore be done with caution. The most common domains in which motivations fell, in this case, were community/society itself and personal life. Interestingly, for the rural Setswana-speaking sample, interpersonal relations were the most frequent domain. On category level, a category that emerged prominently across all samples was personally contributing to the community by, for example, helping or loving others. Codes that commonly occurred across the samples included helping others or helping people in need and personally contributing to the community.The present study aimed to determine the relative importance of various types of relationships as important sources of meaning for people in African samples and to explore the motives for meaning in relational domains as manifested in four samples from Ghana and South Africa. The motives for meaning were explored in the relational domains of family, interpersonal relations (close but not family), spirituality/religion, and community/society. The findings of the study showed that relational domains of life made up a large proportion of sources of meaning for participants in all samples, with community/society occurring the least. Most important relational types showed not only some similarities with findings in the West, but also differences. Motives for sources of meaning in the relational domains revealed, apart from domain-informed relational reasons, also personal experiences and needs, reflecting a dynamic dialectical pattern of individual and collectivist experiences. Findings suggest a reconsideration of traditional assumptions about collectivism in the African context. Altogether, the insight into philosophical assumptions in the African context provided by findings regarding sources of meaning and the motivations for their importance offers a scientific basis for appropriate well-being interventions in African contexts. These findings will be discussed in more depth below in the light of relevant literature.The four relational domains  together made up a large proportion of meaning sources across the 11 domains of life included in the coding system, namely, 51.36%, 63.69%, 41.08%, and 72.98%, respectively, in the cases of samples 1, 2, 3, and 4. The fact that the rural Setswana group showed a relatively lower percentage of meaning sources in the four relational domains may be because some relational meaning sources might have been allocated to the life-in-general domain, which is much higher in this sample than in the other samples. This finding reflects an integrated, more holistic experience of meaning by this rural, more indigenous/traditional sample of participants. Among this group, this finding also reflects the notion that relationships might be seen as encompassing all aspects of an individual’s life.Our finding that family is the most often mentioned relational context providing meaning is in line with previous research e.g., . Note thThe spiritual/religion domain of life is the second most prominent relational domain to provide meaning to life in the case of three samples as could be expected considering the importance attached to spirituality in African philosophical perspectives cf., . This isThe lowest percentage of meaning sources in the relational domains was ascribed to the community/society domain of life. This is also surprising as it could have been expected that communities are of particular importance in collectivist African groups. It is, however, possible that facets of community/society are accepted as so self-evident or as an integral part of all other aspects of life and that it was not mentioned as standing out. Nevertheless, the finding that community/society is seldom mentioned as a source of meaning in life is in line with the findings of a multicountry study by Our findings about the huge role played by relational domains in all four African samples can also be contextualized further by noting that work was the second most important life domain providing meaning in the case of the more educated and younger Ghanaian and South African samples, whereas standard of living was the third most prominent life domain reflected in sources of meaning in the case of the older, less educated Setswana samples. The latter groups with their lower levels of education probably struggle more with material needs, which can explain why several participants provided reasons for relationships being important such as to be looked after by children in old age, but also wish to have something to give away to others (response not shown in above tables that include only the highest rankings). Although work and standard of living are not relational life domains, it sometimes happens that relational motives are provided when work or standard of living is listed as sources of meaning. For example, where work is mentioned in people’s sources of meaning, the reasons for the importance of work sometimes refer to relationships with work colleagues, or where the standard of living is a source of meaning, the motive is sometimes that it enables the participant to care for the family as found by Our findings across all four relational domains  indicated that the motivations for sources of meaning are described primarily in domain-specific qualities as can be expected, but also in terms of intrapersonal descriptors as classified under the personal life domain. Across relational domains, domain-typical reasons referred to, for example, contributions made to or rewards received from that relationship, sharing/reciprocity in the relationship, support needed or given, the intrinsic value of that bond, nurturing that valued bond, and harmony experienced in the context of that domain of life. These reasons resonate strongly with African perspectives on the importance and quality of interpersonal relationships.Noteworthy, our findings showed that many motivations for the things that are meaningful to people emerged from a personal experience or perspective as classified in our scoring system under the personal life domain. Such personal motives include resonance experienced with own value system, support felt, personal growth experienced, the experience of satisfaction, happiness, joy, pleasure, inner state of well-being, or a sense of competence and mastery. The fact that personal life plays such an important role in the motivations for meaning reflects an internal, self-reflective stance not commonly described in traditional African perspectives. It can, of course, also be argued that many categories and codes included in the personal life domain represent facets and responses (as captured in the EHHI coding system) that implicitly reflect relationships to others, such as the experience of support, harmony, and loving feelings.1. Inglehart and Welzel showed shifts in world cultural patterns as manifested in pattern changes on the dimensions of survival versus self-expression values, and traditional versus more secular–rational values. The second marker on both dimensions is linked to individualism and a more independent relational orientation. Longitudinal evidence from the World Values Studies (WVS) based on Schwartz’s model showed that emancipative orientations including mostly self-expression values are rising across all countries  might have facilitated explanation of some findings. Nevertheless, this study contributed to a deeper understanding of motives for meaning in relational domains as manifested in the traditionally collectivist African context pointing to a dynamic, dialectical pattern of individualistic and collectivistic values as manifested in the experiences of contemporary laypeople.Relational domains of life are major sources of meaning to laypeople in two African countries, Ghana and South Africa, reflecting African philosophical notions of relational embeddedness. The relative importance of relational types/domains is in line with some findings in the West (importance of family), but also differed . Different from what might have been expected in a collectivist African context, communal/societal bonds were less important than close personal relationships. The motivations for the importance of these relational domains reflect, apart from strong relational domain–nuanced reasons, also a personal orientation enriching our understanding of contemporary laypeople’s experiences showing a dynamic pattern of integration of individual and collectivist values. In the African context, relational embeddedness blurs the lines between existing categorizations of different forms of relationships. Findings may, however, be in line with the globally noted cultural shifts taking place as indicated in the Inglehart–Welzel model and illustrated in the world cultural map. See also This study contributes to a deeper understanding of motives for relational meaning sources as manifested in two African samples, highlighting a dynamic pattern of integrated individualistic and collectivist notions in meaning attributions and motives. Findings link to notions of a dialogical self not previously described in the African context and provide empirical support for facets of a recent African model of meaning and relatedness. Further research is necessary to understand the relatively low percentage of motives for meaning manifested in the community/society relational domain of life in all four samples. This percentage could have been expected to be higher given the traditionally described more collective cultural orientation in African countries. In-depth qualitative research is necessary to explore the tapestry of experiences that rural people had in mind when they referred to life in general and whether these experiences also included spiritual facets as suspected because of their relatively lower ranking of the spiritual/religious domain in comparison to the other samples. It can also be revisited to what extent the traditional (and sometimes stereotyping) notions of individualism and collectivism are still viable and applicable cultural explanatory concepts in the changing global landscape.The datasets generated for this study are available on reasonable request to the corresponding author.The Health Research Ethics Committee of the North-West University, South Africa, approved the studies reported in samples 2, 3, and 4 , and the University of Ghana Ethics Committee for Human Research approved the study reported in sample 1 . The participants provided their written informed consent to participate in this study.MW, AW, and LS conceptualized the study and supervised the coding and capturing of qualitative data. MW and LS collected the SA data as part of the funded FORT3 project led by MW. AW supervised the Ghanaian data collection. WS and LS conducted the statistical analyses. MW drafted the first version of the manuscript with major inputs into the literature review by AW and SC. LS and WS drafted the “Results” section and parts of the “Materials and Methods.” MW integrated author comments. LS supervised technical editing of the manuscript. All authors made inputs on the manuscript as a whole in following versions and approved the final 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.


Glaucoma is an extremely significant public health issue, since it is the most common cause of irreversible blindness worldwide, nevertheless it is still widely undiagnosed because of its devious nature. Glaucoma diagnosis criteria are well-defined and have to be strictly observed and recognized: the earlier the disease is diagnosed, the earlier the patient can undergo the most suitable treatment, the better can be the prognosis. The three levels of prevention are essential in the approach to the disease and its pathophysiological features make it eligible for screening. This review provides an overview of the current state of the art in glaucoma management, starting from its prevention and coming to the hub-and-spoke organization. This model applied to glaucoma aims to direct patients toward professional and not professional figures who may guide them in integrated care pathway. This path should be designed in accordance with best practice to coordinate glaucoma prevention, diagnosis, treatment and follow up with the best cost-benefit ratio, protecting both the interests of the patient and of the society. Glaucoma is a very ancient term and, as the etymology indicates, was used to denote the bluish-green color of pupil, that is typical of the end stage of this disease. Until the 18th century, glaucoma was mistaken with cataract: Brisseau was the first in 1700 to prove that glaucoma and cataract differ greatly from one to another , pseudoexfoliation syndrome (PEX), high myopia (greater than −3 diopters), thinner central corneal thickness (CCT), family history of glaucoma, low ocular perfusion pressure, drugs   and therThe IOP is the main risk factor for the development of glaucoma and its progression and it is measured by tonometry . The meaCorneal pachymetry is another significant test to perform at least once in life in the screening of all patients with risk factors or suspected glaucoma , becauseFor differential diagnosis among the different types of glaucoma (open or closed angle), gonioscopy with or without indentation with direct or indirect viewing of the iridocorneal angle should be performed. The Spaeth gonioscopic grading system is the most detailed, but also Shaffer and Kanski grading systems are used, based on angle width and visibility of the structures. Predicting factors in detecting angular variations are high hypermetropia for closed-angle glaucoma, medium-high myopia and diabetes in the open-angle glaucoma cases.Ophthalmoscopy, performed with an indirect non-contact fundus lens with sufficient magnification, allows to determine qualitative and quantitative evaluation of the optic nerve head and the RNFL. The examination should assess the shape of the neuroretinal rim, the appearance of the RNFL , the possible presence of optic disc hemorrhages, the position of the vessels at the optic disc as well as parapapillary atrophy . The cup/disc ratio (CDR) of the optic nerve head was used to determine glaucoma damage, but it widely depends on the size of the disc. Considering that individual variations are frequent, comparison with the contralateral optical papilla is essential: collecting photographic documentation of the appearance of each glaucomatous or suspected papilla and its evolution is helpful, in order to evaluate the stability or progression of the damage and the effectiveness of possible antiglaucomatous therapy. Furthermore, the morphology of the optic nerve head has an extremely high inter-individual variability: the clinicofunctional correlation is not always the same in different patients, especially in those with high-grade myopia.Imaging instruments help to quantify the optic nerve damage and the glaucoma progression, using software based on normative databases: Heidelberg Retina Tomography (HRT), scanning laser polarimetry (GDx-ECC), optical coherence tomography (OCT) with study of ONH, RNFL, RGC and morphometric study of the angle.The gold standard of functional damage assessment is static computerized perimetry: this consists in a subjective examination, relatively long, which needs confirmation if it results altered . This examination detects even minimal changes in visual field, it allows an accurate control of patient’s fixation and also a comparison of each examination with the previous ones of the same patient . The manEye diseases lead to impaired quality of life, affecting all of its aspects and therefore have a serious impact on the health, as well as social and economic welfare of the individual and the society.In order to find satisfactory solutions to these issues, “VISION 2020: The Right to Sight” has been the outcome of collaboration between the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) in 1999. It consists of the global proposal to fight and eliminate avoidable blindness by 2020. Nowadays, this project has been replaced by the Global Action Plan for the Prevention of Avoidable Blindness and Visual Impairment 2014–2019; however, its eye-opening message to promote “A world in which nobody is needlessly visually impaired, where those with unavoidable vision loss can achieve their full potential” has focused global attention on this humanitarian emergency and remains an appealing challenge . WorldwiAccordingly, the diagnosis and early treatment of these pathologies would undoubtedly entail enormous benefits . In this1.one eye examination per year for patients over 65 years of age, with or without risk factors;2.one eye examination every 2–4 years for patients aged 40 to 64, with or without risk factors;3.one eye examination every 10 years for patients between 30 and 39 years of age, without risk factors, or one every 2–4 years if with risk factors; and4.one eye examination every 10 years for patients between 20 and 29 years of age, without risk factors, or one every 3–5 years if with risk factors .In this context, unequal literacy and access to facilities always have to be considered.According to IAPB Onlus data, in the world these recommendations are not implemented and the collective sensitivity to eye health is poor: for example, 18% of Italian adults have never been visited by an ophthalmologist, 61% were visited once, but not checked in the last 5 years, 21% have had an eye examination in the last 5 years .Faced with these facts, in order to raise a greater responsiveness to these pathologies, all the institutions have to improve information and support prevention programs, for increasing the propensity of population to adhere to monitoring projects over time, which have to be invested in. As for any kind of medical condition, eye diseases prevention is divided into three levels.www.iapb.it). The Italian Ophthalmology Society (SOI) is also active in this field: the “For the citizen” website section, the “Together for the sight” foundation, the “Save the Vision” campaign. In glaucoma, primary prevention consists in making the disease known, as well as its risk factors. For example, subjects with narrow angle and high hypermetropia have an increased risk of developing acute angle-closure glaucoma, therefore it should be assessed whether adequate preventive monitoring of the IOP is necessary and possibly also the execution of a laser prophylactic iridotomy case by case basis . Some instruments of primary prevention in Italy promoted by IAPB ONLUS are the following: eye consultation toll-free number, The World Day of Vision, “The Ophthalmologist Says” forum, the “Social Ophthalmology” publication, the IAPB website , to manage its complications and to prevent progression.Tertiary prevention is also the management of disability through pensions, benefits and allowances. Various approaches of rehabilitative therapy are an additional resource to treat the advanced stage of glaucoma, in particular educating how to use residual vision and training patients through visual stimulation strategies. Before scheduling these, the application of functional magnetic resonance imaging (fMRI) has proved to be particularly effective in evaluating plasticity of visual nervous system beforehand and for predictive purpose . RegardiIn the panorama of glaucoma prevention, the congenital glaucoma deserves a separate discussion, because its pathophysiological mechanisms are still unclear and so early diagnosis (secondary prevention) represents the first bulwark against the disease. Primary congenital glaucoma (PCG) represents the majority of the pediatric glaucoma cases and it is due to incomplete development of trabecular meshwork before and/or after birth. Most cases are bilateral and diagnosed within the first year of life (>75%), more frequent in males and related to family history. It is rare and can be easily misdiagnosed and undetected. The earlier it is diagnosed, the earlier the patient can undergo angle surgery, the better can be the prognosis. The prognosis is better if diagnosed between 3 and 12 months of age . Care muGlaucoma affects the health-related quality of life in many ways: risk of unemployment, social issues with negative impact on relationships, diminished ability to read and drive, loss of independence in activities as sports and hobbies are typically associated with the progression of the disease. Furthermore, visual field loss and blindness associated with glaucoma have a significant economic impact on society , particuTherefore, glaucoma is a real issue of public health. In Italy, its inclusion in Essential Levels of Assistance (LEA) “has been defined fundamental” as mentioned in the Ministerial Decree DPCM n. 26/2001. Primary open-angle glaucoma (POAG) has the ideal characteristics for early diagnosis: it is a chronic disease with high prevalence, it is asymptomatic in the early stages and has a long latency period. The natural history of the disease is known, its diagnosis is easy and non-invasive, its treatment is possible and its prognosis is better as soon as it is diagnosed. Three are the main approaches to screening patients for POAG: IOP measurement, ONH and RNFL assessment and evaluating visual field, either alone or in combination. Despite these characteristics, however, there is no active screening program in Italy at national level, as well as in other countries . The mosGlaucoma is a chronic disease whose care pathway requires quick and easy access to clinical and instrumental controls, including IOP measurement, that is essential in order to prevent glaucoma. Despite the limitations described above, there is no doubt about the role of IOP in the development and progression of the disease. It is universally recognized that reducing IOP, regardless of other risk factors, decreases the risk of disease progression . In doubConsidering, however, that the functional and anatomical damages due to glaucoma are mostly irreversible and that first defects of the visual field can be only found with traditional perimetry when 40% of ganglion cell fibers are already damaged (in necrosis or apoptosis), early detection remains an important strategy to prevent vision loss . All thi2+ channels in the TM cells and so promoting their relaxation in order to promote the outflow of aqueous humor to the Schlemm’s channel. According to our experience, the functional damage of the trabecular cells in glaucoma is inversely proportional to the electrical stimulation of effectiveness. Less trabecular function in more advanced glaucoma results in less efficacy of the procedure and greater necessity to replicate it. Therefore, it is our opinion that electrical stimulation could be more useful in early stages of the disease. This concept further underlines the importance of early detection. Additional studies are needed to evaluate the maintenance of the IOP lowering effect over time after the treatment. Considering the above, molecular targets play an increasingly important role in the field of early detection and treatment of glaucoma (Another important early detection instrument is electroretinography (ERG), that allows to objectively quantify the retinal function by detecting retinal electrical responses. In addition, electrical stimulation has been performed as a novel approach to decrease IOP in open-angle glaucoma . Preclinglaucoma . It has hub = center, spoke = radius).The term “Hub and Spoke” is borrowed from the vocabulary used in aviation. “Hub and spoke” is a model to develop the airline network, consisting of a hub where most flights are concentrated. The term was created by analogy with the bicycle wheel , taking into account the status of the glaucomatous disease and without losing any particular of the patient damage in the coded path .According to the “Hub and Spoke” theory , patientFurthermore, it is necessary to develop and use more and more advanced diagnostic methods, such as the various technologies of eye hemodynamics and Echocolourdoppler, the Heidelberg retinal flowmeter, the short wavelength automated perimetry (SWAP or blue-on-yellow perimetry), the high-pass resolution perimetry, the frequency doubling technology (FDT) perimetry, the pattern ERG, the chromatic visual evoked potential (CVEP), the detection of apoptosing retinal cells , the telemetric contact lenses (recording IOP fluctuations over 24 h) and the genetic tests  . These dIn the end, the only hub-and-spoke management can lead to focus treatment of this serious social disease with an adequate and efficient sanitary network. Indeed, glaucoma is increasingly insidious and widespread and it must be approached with a neuro-restorative attitude, becoming more and more clinicobiological, especially in relation to prevention and plastic condition of peripheral and central nervous system .The purpose of early diagnosis and treatment of glaucoma is to preserve the residual sight from any further deterioration, since it is not possible to regain what has been lost.Therapeutic–preventive struggle against this devious disease should not be underestimated and implemented extensively for the following directives:–anti-glaucomatous propaganda, in particular by the general medical practitioner (GMP);–sending of at-risk subjects and suspected glaucoma patients to specialized antiglaucomatous centers, also by GMPs;–development of telemedicine and teleglaucoma, especially in places where patients have poor access to diagnosis and treatment, as well as prevention;–evidence of coexistence of glaucoma with other systemic diseases, particularly for the progressive increase in average life;–medical approach focused on drug-drug interactions: for example, antihypertensive drugs reduce IOP, while corticosteroids, antidepressant drugs and tranquilizers increase it; carbonic anhydrase inhibitors stimulate ventilation and therefore accentuate dyskinesis in patients with various bronchopulmonary diseases, while the administration of beta-blocker eye drops in patients with heart failure results in asthenia with dyspnea and bradycardia, that may lead to erroneous cardiovascular conclusions;–it is necessary to establish an ever closer collaboration between the ophthalmologist, the general practitioner and the other specialists for the good and interest of patients, also through the creation of an updated computer network (database) that can be consulted in real-time;–the GMP must know that all glaucoma patients need long-term therapies that are often associated with systemic therapies, as well as he should report if patient lack of compliance is present;–the family doctor has the crucial task to identify glaucoma risk factors, including familiarity, subjects age, diabetes, high blood pressure and hyperlipidemia;–from an interdisciplinary perspective, all doctors shall refer all patients at risk to make an ophthalmologic screening, especially focusing on tonometry and perimetry; this is important because the cost-benefit ratio increases when such screening is implemented in patients aged between 40 and 60, as already describe above; and–it is required to know and explain how cataract surgery, when required, lowers IOP significantly by 3–4 mmHg and clearly improves the vision, as well as the optic nerve head monitoring and the obtainable perimetric data.Moreover, in health education, anyone should obey the following precautions:–do not wear tight collars or clothes (that are too tight) around the neck;–do not keep the head down for a long time;–no drinking copious amounts of liquids in a short time;–do not drink coffee and smoke more than five cigarettes a day or halve the use of electronic cigarette;–avoid constipation; and–avoid repeated psychic emotions and excessive physical fatigue, as well as the consequent excessive use of antidepressants or tranquilizers.In conclusion, it is therefore essential to create an high-performance pyramidal “Hub and Spoke” system, that will have as central figures on the territory the optometrist, the GMP and the district nurse, the ophthalmologist and the territorial outpatient optometrist, while the hospital landmarks will be the eye hospital wards and the third level specialized centers. This organization, with the constant support of telemedicine and real-time computer network, will inevitably lead to an ever greater stabilization of this chronic disease in the early stages . Furthermore, it will have undoubted social implications thanks to the preservation of the eyesight, that after life is the most important function to modern society.All the authors gave an equal contribution in a balanced way to the realization of the article, in particular for the abstract and discussion, as well as for the subchapters: Introduction, Glaucoma Diagnosis, Eye Diseases Prevention, Glaucoma Screening, “Hub and Spoke” Management of Glaucoma.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.


Some recent randomized controlled trials (RCTs) assessed the efficacy and safety of polyunsaturated fatty acids (PUFAs) for the treatment of autism spectrum disorder (ASD). To optimally inform the Italian guideline for the management of ASD in children and adolescents, we reviewed the impact on equity, acceptability and feasibility for developing a pilot recommendation for PUFAs.We performed a rapid systematic review of observational and experimental studies on PUFAs for children and adolescents with ASD, extracting data on resources required, equity, acceptability, and feasibility of PUFAs. We followed the framework provided by the grading of recommendations assessment, development and evaluation (GRADE) methodology, and we assessed risk of bias and methodological quality of included studies. Results were synthesized both narratively and quantitatively to address clinically relevant questions on equity, acceptability, and feasibility.We found 14 papers related to equity. PUFAs did not seem to impact equity importantly. We did not find variation in effectiveness across subgroups and in a base case scenario, the cost of a 12 weeks cycle of therapy with 1.155 g/day of PUFAs was €65.51 euro.The acceptability of PUFAs was evaluated in 17 studies, 9 of which were RCTs. PUFAs were widely used among children and adolescents with ASD (18 to 51%), and 50% of parents considered nutritional supplementation as useful. Difficulty in swallowing capsules and bad taste were identified as possible causes of poor compliance, but treatment adherence, when measured in included RCTs, was judged to be good to excellent. Discontinuation due to any cause for PUFAs could not differ from placebo (low certainty of evidence).The feasibility of using PUFAs was assessed in 12 studies. PUFAs were probably sustainable, and no particular critical issue emerged from the feasibility assessment. However, the evidence appeared scarce and indirect.We found the administration of PUFAs in children and adolescents with ASD to be potentially equitable, acceptable and feasible. These results are limited by the limited number and quality of retrieved documents, and need to be viewed in light of efficacy and safety data to formulate clinical recommendations. Children and adolescents with autism spectrum disorder (ASD) suffer from a broad set of early social communication deficits and repetitive sensory–motor behaviors. This symptomatology, that causes reduced functioning, regardless of intellectual ability, is associated with a strong genetic component as well as other causes .In Italy, one of every 77 children 1.2%) in the age range between 7 and 9 years suffer from ASD % in the .The costs of ASD are enormous for both families and society. A recent review in the United States and the United Kingdom has estimated a total lifelong cost of about 2 million euros to support a child with ASD and intellectual disability and about 1.2 million euros to support a child with ASD in the absence of intellectual disability , with hoWhile the body of evidence supporting the efficacy of psychosocial interventions is large, these treatments have limited accessibility, due to their high cost and the intense labor and parents’ involvement needed , so thatA number of health supplement foods are on the market, and products for children have also increased . The potPolyunsaturated fatty acids (PUFAs) are fatty acids containing at least two carbon-carbon double bonds in their carboxylic chain, and classified into omega-3, omega-6 and omega-9 . Their rFeasibility and adherence to PUFAs administration are not clear. Children often display difficulties with swallowing tablet-form and liquid-form medications , and theThis systematic review was performed to support the development of the Italian National Institute of Health  evidence-based guidelines for the diagnosis and management of children and adolescents with ASD. In accordance with the ISS methodological manual for clinical practice guidelines (GL) development , the ISSWhat would be the impact of PUFAs on health equity?Are PUFAs acceptable to key stakeholders?Are PUFAs feasible to implement?Children and adolescents aged 0–18 years, of both genders, with a primary diagnosis of autism spectrum disorder.Any type and any dose of PUFAs.Equity, defined as the presence of plausible reasons for anticipating differences in the relative effectiveness of the intervention for disadvantaged subgroups or different baseline conditions across disadvantaged subgroups that affect the absolute effectiveness of the intervention or the importance of the problem .Acceptability, defined as the likelihood for the key stakeholders to accept or agree with: the distribution of the benefits, harms and costs; the costs or undesirable effects in the short term for desirable effects (benefits) in the future; the values attached to the desirable or undesirable effect ; discontFeasibility, defined as sustainability of the intervention and the capability to address potential barriers to using it .We initially searched for systematic reviews and overviews of the literature on acceptability, equity and feasibility.Because we did not find any existing systematic review focusing on the specific domains mentioned above , we searched for primary studies. For each considered outcome we included both observational and experimental studies on PUFAs. The literature search was conducted up to October 2018. No language filters were applied.https://www.farmadati.it/) [1) For equity, we searched national cost data on national databases (such as Farmadati- ati.it/)  on costi2) For acceptability, we searched Medline through PubMed for systematic reviews and primary studies of both experimental and observational studies. The full search strategy is available in the Additional file 3) For feasibility, we searched PubMed for systematic reviews and primary studies dealing with feasibility of treatment with PUFA through the search strategy presented in Additional file Two reviewers  independently screened titles and abstracts of all publications that were obtained by the search strategy. The same authors independently assessed the full text of potentially relevant studies for inclusion. Disagreement was resolved by a consensus meeting or by a third reviewer (SM).Two reviewers  independently extracted dataResources required may have an impact on equity. We reviewed data on resources needed to implement the treatment with PUFAs. In detail, we extracted the prices of the supplements, the dosage of PUFAs administered daily in RCTs, and the length of treatment according to RCTs. We also reviewed non-randomized studies that analyzed other socio-economic and cultural aspect that could have an impact on equity. We extracted data on the influence of several factors  on the absolute effectiveness of PUFAs or the importance of the problem , 34. We Systematic reviews and primary studies were inspected and relevant data described narratively. We also evaluated the acceptability in term of discontinuation due to any cause from RCTs.We inspected the background and discussion sections of the retrieved RCTs on efficacy and non-randomized studies to look for data, consideration and additional references on barriers to the implementation of therapy and sustainability of the intervention.Different approaches were used to synthetize data for the different outcomes considered in our systematic review, in detail:For equity, we performed a quantitative synthesis of data on resources required, in order to obtain the estimated cost of a day of therapy and of a treatment cycle; data on diverse anticipated effectiveness across subgroups were synthetized narratively. For acceptability, we synthetized narratively data on actual use and adherence extracted from both RCTs and non-randomized studies; discontinuation due to any cause was synthetized through calculating the Risk Ratio and its confidence interval.For feasibility, we summarized narratively data retrieved from systematic reviews and primary studies regarding feasibility. Moreover, we included equity and acceptability features  in the qualitative synthesis of evidence on feasibility.For RCTs, we used the Cochrane tool for risk of bias assessment . The folWe used the Risk Of Bias In Non-randomized Studies – of Interventions (ROBINS-I) tool  for asseWe used the Quality of Health Economic Studies (QHES) instrument for rating the quality of included cost-analysis studies ; qualityWe retrieved 786 citations from database searching, 33 records from trial registers and one additional document from other sources. After removing 228 duplicates, we excluded 554 citations from title or abstract. Of the remaining 38 full text articles, 15 were excluded for various reasons , and are fully borne by the family of the patient.We found two cross-sectional studies , 58 repoAccording to Salomone et al. , parentsWe found four cross-sectional studies , 52–54, A survey aimed at exploring parental perspectives on use and benefits of CAM in children with ASD showed that the use of nutritional supplement in this population seems to be quite widespread, with 55% using at least one nutritional supplement; PUFAs were used by 18% of the individuals . AccordiAccording to a survey that assessed the parent-reported adherence to ASD treatments, the average adherence to treatment with an alternative approach, such as the use of PUFAs, was significantly lower than adherence to drug therapy or evolutionary therapy, while it was comparable to adherence to behavioral therapy. According to this study, an important predictive factor of adherence was the perceived burden of the therapy on the family in terms of time, energy, and money .Difficulty with swallowing the capsules may be another challenge in administering PUFAs supplements to children with ASD . An alteWe found results reported on adherence and discontinuation in ten RCTs –49 and iDiscontinuation due to any reason for PUFAs does not differ from that of placebo in clinical studies , and was studied in 7 studies –45, 48 wSeveral RCTs also evaluated adherence to treatment, both subjectively and objectively . In these studies, adherence was considered good to excellent , 47–49. An observational study  seems toWe found four cross-sectional studies , 54, 58,Huang et al.  showed iAmong the barriers to the implementation of therapy with PUFAs we believe that the lack of adherence is a result of the difficulties in convincing children or adolescents with ASD to take the medication  , 54, 56,We performed a systematic review to evaluate factors related to a potential treatment of ASD that are increasingly considered critical for decision making in general and for guideline recommendations in particular: equity, acceptability and feasibility. We found a number of studies that provided results which were used by the guideline panel to formulate recommendations about PUFA for ASD. Despite this, some uncertainties remain in the three domains related to equity, acceptability and feasibility. About equity, uncertainty in the cost assessment results from the lack of data on the specific cost for children and adolescents with ASD; there are also uncertainties regarding the cost of tablets with EPA dosages plus DHA below 500 mg/day. In fact, among the class A drugs for the secondary prevention of cardiovascular disease, there was no tablet with a dosage of less than 500 mg of PUFA , while fThe main study limitation is related to the nature of retrieved literature, as the assessment of feasibility, acceptability, equity was limited due to the scarce number of publications, and poor design quality: also due to the nature of the rapid systematic review , our finWe addressed an emerging field in systematic review research, the conduct of evidence synthesis of contextual evidence that influences recommendations. This evidence has in the past been used only anecdotally and guideline developers often failed to systematically look for evidence.We believe that this early example of systematically attempting to summarize this evidence provides a strength to our work.The resources required for the implementation of PUFAs therapy in children and adolescents with ASD are likely to be limited, and PUFAs are not expected to have any negative or positive impacts on equity. Patient and caregiver acceptability of treatment could be good in terms of both adherence and discontinuation (low certainty of evidence). Difficulties in pill-swallowing could be lessened by behavioral training . PhysiciAdditional file 1. Search strategy.Additional file 2. References for included and excluded studies.Additional file 3. Quality of Health Economic Studies (QHES) instrument rating for included cost-analysis studies.Additional file 4. Newcastle-Ottawa Scale for included cross-sectional studies.Additional file 5. ROBINS-I for included before-after studies.Additional file 6. Risk of bias summary for included randomized controlled trials.


In Uganda, the numbers of new coronavirus disease cases have continued to increase slowly since the first case was confirmed. Given that the disease is likely to be holoendemic, the role of primary care (PC) with its features of comprehensiveness, accessibility, coordination and continuity, functioning at the heart of a primary healthcare (PHC) approach, will be important. The elements of PC are applicable in the epidemic preparation, case finding and management, follow-up and post-epidemic phases of responding to this pandemic. This also presents opportunities and lessons for strengthening PHC as well as for reflections on missed opportunities. The effective use of available resources in response to the epidemic should mainly focus on community mobilisation and PHC teams for the prevention, screening, testing and treatment of mild and moderate cases. Before that a great deal of anxiety had been experienced in the country, given that all the neighbouring countries already had confirmed cases. Although expected, this pronouncement by the Ministry of Health worsened the anxiety and created anger amongst the citizens, given that the case was a recent traveller who should have heeded the government warning not to travel.Since the confirmation of the first case, the number of new cases has continued to rise albeit slowly with a total of 53 cases at the time of writing this article. The threat of coronavirus disease-2019 (COVID-19) is likely to end when a critical number of people develop herd immunity either from a vaccine or from direct exposure. This will flatten the epidemiological curve. The threat is both to the lives and livelihoods of people. This calls into play elements and principles of primary healthcare (PHC) in order to improve and sustain the health of individuals, families and communities. It is likely that the disease will become holoendemic. Therefore, primary care (PC), functioning at the heart of PHC, with its features of comprehensiveness, accessibility, coordination and continuity, will be important.In Uganda, PC is based on a decentralised district health system. This district-based PC system consists of different levels of health facilities, with each level providing a different range of services. The health system is linked with the community through the village health teams (VHTs) and community health workers (CHWs). This structure and organisation is intended to strengthen PC. More than 80% of the population live within a 5 km radius from the PC health facility. This article explores the need to strengthen and engage PC and PHC in the fight against COVID-19 in Uganda.The importance of PC in the epidemic preparation, response and post-epidemic is clear, given the expected spread of the disease. Strengthening PC services and delivery systems is of paramount importance. However, the approach to preparation for and response to the epidemic has not had PHC at the forefront. It was noticeable within the medical fraternity that senior medical doctors desired a more comprehensive approach that included PHC and not just a focus on hospital-level intensive care:intensive care unit] beds already and many (people) now do not have access to ambulatory care that could prevent hospital admission and ICU care.’ ‘There are not enough ICU [‘My personal view is that more effort should be made on other things not ICU. We need ICU in a system that is functional, COVID or no COVID.’ (A professor’s comment on WhatsApp)There were ongoing preparations in anticipation of the first cases. Mass sensitisation of the population was attempted at all levels: village or community, district, regional and national levels.3 The President emphasised behavioural and cultural change. He encouraged and directed citizens to avoid risky cultural practices like frequent handshaking and mass attendance of funerals and weddings.National level health education targeted the prevention of the disease through proper handwashing and personal hygiene. This was spearheaded by the President through regular addresses to the nation.The Presidential directives were disseminated through a decentralised system at the district and community levels. District and community leaders were responsible for ensuring that no gatherings happened, public places had water and soap for handwashing and that handwashing happened.The preparation phase in the health system, however, had a significant focus on high-level intensive care and hospitals. Critical care health staff were trained by the Ministry of Health (MOH) in collaboration with the World Health Organization (WHO). This phase greatly neglected PC providers, who see most patients, particularly those in private practice, who can assist with identifying, testing and referring suspected patients.Only one laboratory, the Uganda Virus Research Institute (UVRI), is available in Uganda where samples are analysed. Sample collection centres were established in tertiary and district hospitals. No community-based sample collection centres were planned. Therefore, people must travel to hospitals for sample collection and samples must then be transported to the sole laboratory centre. Therefore, laboratory testing is very limited, with a long turnaround time of up to 36 h.4 All the cases had mild to moderate disease. Home care is not yet being done because patients are still few, and also because of the prevailing panic and anxiety. It was thought that families would not be comfortable having the patients in their homes. Patients were also likely to suffer serious stigma and violence. Before the first case was confirmed, there were instances of community members calling police to investigate their neighbours who were suspected of having the disease.5 There was also no certainty that strict self-isolation in the home, to avoid infecting the family and community members, would be feasible.All patients who tested positive have been isolated and admitted to hospitals according to WHO recommendations.The whole country went into complete lockdown to minimise the person-to-person contact in order to prevent or minimise community transmission that would overwhelm the available health facilities. However, no PHC re-organisation was done to comprehensively deal with the pandemic and effectively maintain the essential health services.The activities listed below have been done in response to the crisis created by the pandemic. If sustained, they would strengthen PHC because they are clear examples of its principles:6The pandemic has acted as a catalyst to innovations like the development of a low-cost ventilator by Makerere University researchers for use in hospitals.7 Recognition of vulnerable populations and addressing their welfare and health needs are an act of promoting equity.Government provided food to poor people and powdered milk to pregnant women during the lockdown.8Community action for health was demonstrated through donations by non-governmental organisations, religious groups and the business community.9Political re-awakening more than ever before particularly on health financing is needed. This can be an opportunity to generate and sustain momentum for Universal Health Coverage.Inter-sectoral collaboration in the formation of the COVID-19 taskforce that drew members from laboratory, clinical, public health, security and immigration sectors.Community participation, a principle of PHC, was low, as most of the measures were dictated and enforced by security and military personnel. This scared away the potential patients who would have come for testing and created resentment of the prevention measures.Poor inter-sectoral collaboration between the relevant ministries, for example, the Ministry of Works and Transport could not avail permits for movement early enough during the lockdown. As a result, maintaining essential health services became challenging as health workers could not easily move.Failure to use the existing systems in communities and PC facilities to identify suspected patients for testing.Neglect of the role of CHWs and VHTs in health education. These would have been instrumental in household-level health education, for example, regarding social distancing within the household.The pandemic response should focus more on PHC to address the limitations of screening and testing, innovations on isolation at home, management of mild and moderate cases in the community, as well as active case and contact follow-up. This will protect the scarce hospital-based resources for managing severe and critical cases and promote a people-centred response to the epidemic. Effective use of resources during the response is key to sustain an effective health system post-pandemic. Private health providers can play a key role in the response to the pandemic and should not be neglected.The response to the epidemic mainly centred around hospitals and higher levels of the health system and focused on treatment of severe cases rather than mobilisation of communities and PHC teams for the prevention, screening, testing and treatment of mild and moderate cases, which were the most common. Preparedness for the epidemic should be part of PHC systems and simulated trainings should be regularly conducted to maintain relevant competences.