The emphasis on implementation of value-based healthcare (VBHC) has increased in the Dutch healthcare system. Yet, the translation of the theoretical principles of VBHC towards actual implementation in daily practice has been rarely described. Our aim is to present a pragmatic step-by-step approach for VBHC implementation, developed and applied in Amsterdam UMC, to share our key elements. The approach may inspire others and can be used as a template for implementing VBHC principles in other hospitals.The local approach is developed in a major academic hospital in the Netherlands, based at two locations with 15,000 employees in total. Experience-based co-design is used, building on our learning experiences from implementing VBHC for 14 specific patient groups. The described steps and activities devolved from iterative and participative co-design sessions with various experienced stakeholders involved in the implementation of one or more VBHC pathways.The approach includes five phases; preparation, design , building (outcome set integration in daily practice), implementation  and the continuous improvement cycle. We described two cases for illustration of the approach; the Cleft Lip and Palate and the Chronic Kidney Disease patient groups. For a good start, involvement of a clinical leader as driving force, ensuring participation of patient representatives and sufficient resources are needed.We have experienced that several defining features of the development and implementation of this approach may have contributed to its completeness and applicability. Key elements for success have been organisational readiness and clinical leadership. In conclusion, the approach has provided a first step towards VBHC in our hospital. Further research is needed for evaluation of its effectiveness including impact on value for patients.The online version contains supplementary material available at 10.1186/s12913-022-07919-1. In 2006, Porter and Teisberg introduced the principles of Value-Based Health Care (VBHC). These principles are intended to reduce costs in healthcare, while at the same time increasing the quality of healthcare by increasing the value for patients [.Worldwide, healthcare systems face the challenge of increasing costs . In 2006patients –5. Measupatients . Analysiatients [.Despite the overwhelming popularity of VBHC, there is also ambiguity about the interpretation and operationalization of the VBHC concept –12. Stei“No one should expect the value framework to be easy to implement. The measurement of outcomes and costs, the organisation of clinicians into teams focused on improving care for patient populations ( …) are all formidable tasks” [The path for transforming current health care towards value-based healthcare is challenging, because it entails both a new collaborative relation between healthcare professionals and patients, as well as fundamental change from an organisation structured around medical specialisation towards an organisation centred around a multidisciplinary care pathways for patient groups. This transformation may be regarded as a complex socio-technical intervention that requires organisational readiness for change among healthcare professionals, including cultural change –19. As oe tasks” .The emphasis on VBHC has also increased in the Dutch healthcare system, in line with the widespread international uptake of VBHC. Vision and mission statements of formal institutions, such as the Dutch Healthcare Institute and Netherlands Federation of University Medical Centres (NFU), mention VBHC as a key element with a focus on improving outcomes in daily practice that matter to patients or populations while optimizing resource utilization –8. SeverAs VBHC is such a complex intervention, many start with implementing only one aspect that seems most feasible for them at the time , 24. In how these principles may be applied in practice. The translation of the theoretical principles of VBHC towards actual implementation in daily practice have rarely been described [Porter et al. elaborated on various important principles of VBHC, but did not specify escribed , 16, 27.escribed .Hence, this study aims to describe a pragmatic step-by-step approach focusing on the process to get started with the implementation of VBHC in practice, applied in a tertiary centre. In this article, we illustrate the implementation process by two practical examples of multidisciplinary care pathways in Amsterdam UMC, the Netherlands.In the Dutch Healthcare system, (basic) medical insurance is compulsory for all citizens and care is delivered by private and public health care providers, who have agreements with health insurance companies. There are 69 hospital organisations in the Netherlands, including 8 university medical centres. Amsterdam University Medical Centre (Amsterdam UMC) is a major academic hospital, with two locations and 15,000 employees in total. The board of directors is responsible for its management and strategy, which is carried out in a line organisation, comprising 10 divisions and several staff services divided over two locations; the Amsterdam Medical Centre (AMC) and VU University medical centre (VUmc). Enhancing patient value by delivering personalized care throughout the full cycle of care is one of the main strategic pillars of the Amsterdam UMC strategy.The principles of VBHC were introduced in Amsterdam UMC by the hospital’s Strategy and Innovation (S&I) department in 2017, inspired by the Karolinska Institute’s strategy and organisation of care in Sweden. The purpose of introducing the VBHC principles in Amsterdam UMC was to improve quality of care for multidisciplinary patient groups, based on clinical, patient-reported and process outcomes by strengthening the process of continuous quality improvement using VBHC principles. Amsterdam UMC first started with the implementation of a continuous improvement cycle with regard to the process of care and health outcomes .From an organisational point of view, the overall goal was to learn from each patient to make future care more effective and efficient. These goals were translated into a local VBHC program, commissioned by the board of directors. The organisation and implementation of this program was delegated to the department of S&I.From the start, the VBHC program in Amsterdam UMC has been directed by a steering committee chaired by the chief medical officer Fig. . The steValue teams executed the VBHC approach. A value team in Amsterdam UMC served as an Integrated Practice Unit (IPU), which means a multidisciplinary care team around a specific patient group, comprising staff and patients who are involved in this care pathway [ pathway . The valOne general expert team guided the value teams. This team was formed by consultants from the S&I department, data- and IT experts and various experts for specific themes . They guided the different value teams with procedural experience and knowledge, during the implementation of VBHC. The expert team has evolved over time. At first, an external consultant, experienced with implementing VBHC in other Dutch hospitals, was employed to ensure a quick and adequate start of VBHC implementation in Amsterdam UMC. This consultant was engaged in the first 4 value teams. Value teams were guided by the clinical lead and supported by the external consultant together with an internal consultant. These first implementation cycles were seen as the pilot phase of the VBHC-program. Based on the experiences in the pilot phase, a structured implementation approach was established. With this, internal consultants facilitated the value teams to implement VBHC. Currently, 14 teams in Amsterdam UMC were working on, or preparing for, the implementation of VBHC.The method for implementing VBHC in Amsterdam UMC is based on “experience-based co-design” (EBCD). This design combines a user-centred orientation (“experience-based”) and collaborative change processes (“co-design”) to identify and co-design improvements . This apThe lead author (F.H.) was one of the expert team members and followed the process during implementation for the last 3 years. To describe the step-by-step approach, data was collected from multiple sources alongside the co-design and implementation process, and made available by the clinical leaders  and a team member (M.vdS.) who was involved in both cases. We collected documents and field notes from the workshop meetings during the design phases and related meetings of the value team throughout the implementation. In addition, existing qualitative semi-structured interviews to assess facilitators and barriers for implementation with the clinical leads of the CLP and CKD teams were used . FinallyPatients are members of the value team. This ensures the inclusion of wishes and needs of the patient group in the enhancement of the care process and that relevant outcomes are selected to measure in a later stage. The design of this approach is based on learning experiences from value teams, including the workshop meetings where patients were involved.To illustrate the described methodology for implementing VBHC in current clinical practice in Amsterdam UMC we described two cases: the multidisciplinary Cleft Lip and Palate (CLP) team and Chronic Kidney Disease (CKD) team, see Table The CLP team started with implementing VBHC in 2017 as one of the pilot teams. Cleft lip and/or palate is a congenital anomaly with different manifestations. Cleft care is complex and prolonged, starting at a prenatal age until the age of 22 years. Due to its complexity, various medical disciplines are involved during the care pathway. Simultaneously with participation in the VBHC program, two formerly local CLP teams based at the two locations of Amsterdam UMC were merged into one team.The second case, the multidisciplinary CKD team, started at the end of 2017 with implementing VBHC principles for patients with a glomerular filtration rate (eGFR) of 20 ml/min or lower that had not yet started with renal replacement therapy (RRT). These patients visit the nephrology outpatient clinic in order to slow down the progression of kidney failure by medication or diet. This outpatient clinic is organised in such a way that patients can see several care professionals from different disciplines during one visit. At the same time these patients are being educated about kidney transplantation, dialysis or conservative therapy. Structural recording of outcomes that matter to patients was missing at this outpatient clinic. To learn whether they are offering the right care to this complex group of patients was one of the reasons to start with VBHC .The experiences and lessons learned of multiple teams have resulted in this pragmatic and iterative approach that includes five phases as shown in Fig. A detailed description of the approach, divided into phases with their goals, tasks and tools, is specified in Table multidisciplinary care pathway around a specific patient group. To meet this requirement, the team must have improvement goals for this patient group that match the VBHC principles. These goals may relate to different elements of the VBHC approach. For example, the CKD team mainly focus on offering the right care for our patients and the CLP team on redesign of care, including outcome measurement.In order to give the team a good start and to ensure organisational readiness, both from the support services and the department of the proposed ‘value’ team, we define the following certain preconditions: First, select an appropriate clinical leader as driving force on behalf of the multidisciplinary team. This clinical lead must be a healthcare professional with enough time, motivation and resources to support this process. In both of our cases, this was a medical specialist.Second, it is necessary to involve an enthusiastic patient representatives should be available to participate with the multidisciplinary value team during the design and implementation process. Each team did this in its own way. The CLP team involved patients in various ways (questionnaires or during workshops). In contrast, the CKD team ensured structural patient participation during the design phase and then on by hiring a patient to continuously give feedback on how to improve the delivery of care.Subsequently, resources need to be available both from the support services and the healthcare department itself. In addition, departments’ willingness to implement changes in their work process need to be present. These are important parts to ensure organisational readiness [Lastly, eadiness . When thA team can indicate that they wish to start with VBHC via an intake form. When the steering committee approves this intake, by matching their goals and mutual expectations with regard to motivation, the team starts. In this approach, each phase has its own goal and key points with associated activities and stakeholders see Fig. . First kWhen the building phase starts depends on the capacity of data-IT experts. Therefore, the duration of this phase can vary between teams. After the design sessions, the proactive multidisciplinary value team immediately starts working on a regular basis with the defined actions and already available outcomes, for example the PREMs (patient-reported experience measures) or process outcomes. This was not yet applied during the pilot phase, but was taken into account as a lesson learned for further deployment of this VBHC approach, thus also in the CKD team.As soon as the clinical and patient-reported outcomes are built in the EHR-system, the implementation phase starts after training the healthcare professionals to apply it in practice. To accomplish the building phase, the registration of the outcome set is embedded in the care process and the IT department delivers a dashboard for the value team where the outcomes are visualised.The final two phases, implementation and continuous improvement, regularly overlap each other. The implementation of various elements of VBHC are incorporated in the care process of the specific patient group. As part of this, the healthcare professionals receive training for shared-decision making in the consultation room and the value team monitors regularly the outcomes together. Feedback is taken into account during the implementation again.We have experienced that several defining features of the development and implementation of this approach may have contributed to its completeness and applicability. These were categorized into five elements, which will be discussed below; organisational readiness, clinical leadership, experience-based co-design (EBCD), role of expert team and monitoring outcomes. All elements are important on their own, but for a successful VBCH approach, their combination has proved essential.Organisational readiness is a shared psychological state in which organisational members feel committed to implementing an organisational change and confident in their collective abilities to do so . Within As stated before, to implement VBHC in a “traditionally organised” hospital, fundamental changes in daily practice are needed which require clinical leadership. Within this approach, the clinical lead, who heads the value team, serves as the primary clinical leader. Several factors were found to contribute to the success of this role. First, the leader needs to have the skills to bring about change, which include enthusiasm, good advocacy skills, effective communication and creating ownership together with the team. Second, a clinical lead with mandate and authority is needed, endorsed by the clinical team and their departments . Our advExperience-based co-design has, as mentioned earlier, a user-centred orientation in combination with collaborative change . We did The expert team played a central role in our approach. They ensured connection between value teams, the supporting and facilitating departments  and the steering committee. The involvement and level of guidance of the value teams varied in our cases. We have learned that the autonomy of value teams had a positive impact on ownership by the team to ultimately ensure improvement in quality of care. When getting started with VBHC, make sure the value team is not pampered by central support. This may prevent lack of capacity and ownership. When scaling up and implement VBHC, the value team must take ownership for itself. Thus, the role of the expert team is to pay attention to ownership from the start and help the healthcare teams do the implementation themselves in which the consultants are primarily involved as experts rather than executors. To ensure knowledge sharing and sustainable employability of the experts, the expert team initiated a PROM expertise point within Amsterdam UMC and developed a VBHC toolbox. With the toolbox the value teams can get started themselves by choosing a focusing element for their start with the implementation VBHC, so that it becomes a little more manageable.Lastly, it is important during implementation to monitor progress towards implementation goals . Our expValue-based healthcare was introduced in Amsterdam UMC in 2017. In this article, we describe a pragmatic approach for the implementation of VBHC among value teams in Amsterdam UMC. At present, 14 value teams are working on improving the quality of care for their patient groups by using this approach.The approach described here serves as a first step for the implementation of VBHC, knowing that it only incorporates a number of key principles from Porter’s strategy . We haveStrength of the present study includes the applied and tested approach which was developed over four pilot cases and refined during ten subsequent cases. As far as we know, we are the first who describe a detailed VBHC implementation with a learning approach based on evolving insight. Some limitations also need to be mentioned. First, team members of the VBHC expert team and two clinical leads were involved in development of the approach and writing process of this manuscript which may have limited the objectivity of our observations. However, this engagement also ensures valuable reflection. The impact of this close involvement of the clinical leads has been reduced by assessing the approach in iterative sessions with a wider delegation of stakeholders. Second, this approach, with associated expert team and infrastructure, will possibly not be applicable in every hospital, which reduces its potential for scalability. In addition, implementation often took a long time and therefore the effects of the outcomes and the activities of our approach are only visible at a later stage, but our advice to start immediately with the available outcomes will ensure an early start of the improvement cycle.In conclusion, this approach has provided a good starting point for implementation of VBHC in a tertiary hospital. The approach evolved over time, while simultaneously the implementation process improved. This blueprint provides guidance for the implementation of VBHC in daily practice, to ultimately ensure care that is of personal and measurable value for the individual patient. So far the focus of the implementation in Amsterdam UMC has been gaining insight in the clinical-, process- and patient reported outcomes. The description of this pragmatic approach intended to serve as an inspiration for others who want to start implementing VBHC. In the future, this approach and the implementation of VBHC on an individual and population level will be evaluated, in order to ultimately improve the quality of care in our hospital and nationally.Additional file 1. VBHC approach illustrated by the Cleft Lip and Palate and the Chronic Kidney Disease cases. The main differences are highlighted by using*.


The Nursing and Midwifery Council (NMC) require data to be collected to enable regulatory functions, with nurses re-registering every 3-years, which provides a powerful picture of the workforce. This could answer questions to inform the NMC, as well as policy makers. Linked to other data, opportunities for impact are considerable.This pilot project, funded by the Economic and Social Research Council, aims to use NMC data captured at two time points – March 2018 to give a snapshot before the pandemic, and March 2021 during the pandemic - in research that enables a better understanding of the dynamics of the nursing profession in the UK, pre- and hopefully moving towards post-pandemic. An observational study using anonymised administrative data collected and held by the NMC as part of the registration and revalidation process on approximately 700,000 registrants across the United Kingdom.This emerging pilot study will report the initial results as to likelihood of ceasing registration by relation age, gender, and geographically.This pilot study will give an indication of the groups within the nursing profession who are at particular risk of leaving. Findings will provide an opportunity to understand the potential of NMC registrant data to enable future studies into the workforce as well as workforce policy implications.


In recent years in Western Europe, studies on entomophagy have drawn the attention of many researchers interested in identifying parameters that could improve the acceptability of insect consumption in order to introduce insects as a sustainable source of protein into the future diet. Analysing the factors involved in consumer acceptability in the Mediterranean area could help to improve their future acceptance. A cross-sectional study was conducted using an ad-hoc questionnaire in which 1034 consumers participated. The questionnaire responses allowed us to study the areas relevant to acceptance: neophobia, social norms, familiarity, experiences of consumption and knowledge of benefits. Only 13.15% of participants had tried insects. Disgust, lack of custom and food safety were the main reasons for avoiding insect consumption. Consequently, preparations with an appetising appearance need to be offered, with flours being the most accepted format. The 40–59-year-old age group was the one most willing to consume them. To introduce edible insects as food in the future, it is important to inform people about their health, environmental and economic benefits because that could increase their willingness to include them in their diet. The substantial improvements in people’s health status, hygiene conditions and life expectancy, in the majority of countries over the past 50 years, means that the world population is predicted to increase considerably by 2050 . The risThe use of insects as human food could meet these demands and prove to be a valid strategy for improving global food security FAO . CompareNeophobia, or the refusal—in this case—to try new foods, is one of the main factors influencing the acceptability of edible insects ,19,20,21Entomophagy was a common practice among our ancestors and has been acknowledged as an important role in human development ,27. NumeProviding information about, having positive experiences of, and—at a gastronomical level—incorporating insects into usual recipes together allow their consumption to be endowed with familiarity and proximity ,29. PrepTo date, insects have been very much off the menu in Western cuisine. China, Thailand, Japan, Colombia, Mexico, Peru, Brazil and several African nations are the countries with the greatest tradition of insect consumption ,34. The The aim of this study is to explore the opinions of consumers in Mediterranean Europe of insect consumption. Based on questionnaire responses, the study aims to show the differences between the sociodemographic groups surveyed; to identify which type of insect authorised by the European Food Safety Authority (EFSA) is the most consumed, and in what context; to explore the reasons for refusing to consume them; and to identify which presentations are considered to be the most attractive and what factors might influence potential marketing or consumption to improve the acceptability of insect protein as food for humans in the future. An observational, descriptive, cross-sectional study was conducted to collect data on the consumption of insects and the potential factors influencing their acceptance as a new source of alternative protein in a Spanish population sample. The data collection tool was an ad-hoc questionnaire created from a review of previous studies ,19,20,21The study population comprised adults who mainly resided in Catalonia (Spain) and who voluntarily agreed to answer the questionnaire.The questionnaire was created on the Qualtrics platform which specialises in online surveys, and was distributed via social media in September 2022. The first screen contained general information about the study. Prior to completing the questionnaire, each participant had to give consent to participate. To ensure the confidentiality of the results obtained, the questionnaires were anonymous and participants could not be identified.The study was conducted in compliance with the ethical principles for research involving human beings and the processing of personal data contained in the Declaration of Helsinki and was approved by the Ethics Committee of the Open University of Catalonia, CE22-PR28.p < 0.005 were deemed statistically significant. The results obtained are shown in descriptive tables for the demographic characteristics of the sample, tables of the relationship between the dichotomous variables and their distribution by the participants’ gender and age group and descriptive tables of the preferred consumption formats or contexts.All responses were analysed using the SPSS version 15.0 for Windows. Yes/No responses were considered nominal and dichotomous categorical variables. Pearson’s χ² test, which considers a non-parametric test to measure the differences between an observed distribution and a theoretical one, allowed the relationship between these dichotomous variables to be analysed. In the descriptive analysis of data, demographic characteristics and questions with multiple options were expressed as absolute and relative frequencies. For all calculations, a 95% confidence interval was used and relationships of The survey was answered by a total of 1034 participants, of whom 68.85% were women and 66% were over 40 years of age. N = 162) and on which information was available, the most preferred options, in descending order, were the following: powders, flakes, sweets, burgers and meatballs. Among those who stated that they had eaten insects, the most consumed one was the cricket (5.2%), followed by mealworms (4.8%). While most participants (79.8%) expressed interest in trying new foods or being innovative with their cooking, only 48.2% reported that they had tried new foods in the past year. Of these, quinoa and plant-based foods for vegetarians or vegans were the most widely chosen options. Sushi or soya were also among the most frequently mentioned foods. In terms of insect consumption, 86.9% of participants indicated that they had not consumed them and were unwilling to cook them (71%) or to include them in their usual diet (82.2%). Disgust, followed by lack of custom, and safety concerns were the main reasons given by the participants to justify their lack of interest in consuming insects. However, flour-based preparations were the most attractive option in the event of having to consume them (23.5%), followed by biscuits and bars (around 6%). Of those in “Others” (p < 0.001) between men and women regarding their willingness to consume insects, with women being less willing to cook and include them in their diet in a usual manner  had done so mostly while on holiday (53.77%). Regarding the other foods, most acknowledged that they had introduced them after consuming them at someone else’s home (19.87%) or for health reasons (19.27%) . Althougp = 0.001). Although the majority of study participants would not include insects in their usual diet (82.2%), they were much more positive about their future incorporation . Furthermore, knowing their potential benefits for sustainability improved their willingness to consume them. As the results in This study investigated consumer perception of the inclusion of edible insects in human food and showed their poor acceptance by the studied population. Consistent with the studies by ,18, neopSome previous studies have suggested that young people may be more attracted to insect consumption and, for that reason, their degree of neophobia of trying new foods is lower than other age groups, such as young adults or older adults Verbeke et al. . HoweverConsistent with other studies , male reAccording to the results obtained from the survey, insects were mostly consumed during a trip to countries where there was a tradition of eating them. While such an experience may be an initial opportunity to try the product and then to incorporate it if the experience is positive , in manyTenebrio molitor larva) [Locusta migratoria) [Acheta domesticus) [Social and cultural norms are also factors that determine food customs and the incorporation of foods . Social r larva) , the migratoria)  and the esticus)  as novelesticus)  could heesticus)  and contesticus) . Globallesticus) , so greaThe nutritional benefits of insects and their value as a more sustainable source of protein are of great interest to Western society . These bInformation on the benefits associated with insect consumption influences their acceptance . The resWhile the study does not mention any potential health benefits of insect consumption, health was one of the most common reasons given for including other novel foods by those who had already done so. This suggests that informing people of the potential health benefits of insect consumption could also improve the willingness to consume insects, as is the case with sustainability. The implementation of novel, sustainable food production strategies, as is the case with insects, may help to meet several United Nations sustainable development goals as defined by Moruzzo et al. . HoweverOne of the potential limitations of this study is that the convenience sampling method used may have led to a bias relating to the participation of people who were more interested in or motivated by the subject, or who had a higher educational level. Another aspect to consider is that the majority of the responses belonged to the binary Yes/No option. No acceptance scales were used and no account was taken of whether respondents were following any kind of diet. Finally, the survey uses the term insect, which evokes an association with visible and whole insects , so percIn the near future, edible insects may appear in Western food in response to the need to look for new and more sustainable sources of alternative protein within the framework of sustainable development goals. Our data corroborate the low consumer acceptance of the inclusion of edible insects in human food through areas relevant to acceptance: neophobia, social norms, familiarity, experiences of consumption and knowledge of benefits. Disgust, lack of custom and food safety are the main reasons for neophobia. Neophobia has previously been studied in other populations, but not in a large sample of the Mediterranean population until now. At the gender level, men are more willing to consume insects, and so too are those in the 40–59-year-old age group.The environmental and nutritional benefits of this type of product can open the door to the consumption of this novel food, which has been accepted by the EFSA in Europe. Informing people of such benefits for the health of the planet can improve their perception of insects and encourage them to consume them. However, the need to go further and offer products that make edible insects more familiar to Western society is identified. Producing commonly used flour-based products  and offering culinary preparations closer to regional culture are ways to do that.


Big Five Inventory; Fagerström Test for Nicotine Dependence; Impact of Event Scale; Brief Emotional Intelligence Scale. The results obtained from the mediation analyses highlighted that the indirect effect on the relationship between the psychological impact of the diagnosis and smoking behaviors was partially mediated by neuroticism . Additionally, the data suggested that the relationship between the psychological impact of the diagnosis and smoking behaviors was partially mediated by the utilization of emotions dimension of emotional intelligence . Overall, this study suggests the importance of designing interventions to support smoking interruption based on the “mapping” of individual needs and emotional regulation strategies.The smoking behaviour of patients following a cancer diagnosis is a critical risk factor for several physical diseases; it can increase the risk of second primary tumors and lower cancer treatment efficacy. Despite this, a great number of survivors continue to smoke after the diagnosis. This observational, cross-sectional on-line study aimed to assess the relationship between the impact of cancer diagnosis on survivors and their smoking behavior, and whether emotional intelligence and personality might mediate this relationship. Ninety-four Italian survivors completed a set of questionnaires:  As reported by the International Scientific Community around the World, tobacco smoking behavior is a critical risk factor for several respiratory, cardiovascular, and oncological diseases. Considering the cancer disease occurrence, 30% of all cancer deaths and nearly 90% of lung cancer deaths are caused by tobacco cigarette smoking . In addipersonality and affect regulation as two of the foremost predictors of smoking behaviors. Eysenck and colleagues conducted original studies on the relationship between personality and smoking in 1960, which stressed that smokers are more extroverted, less rigid, and more neurotic compared with non-smokers ) see .β = −0.047, s.e. = 0.105, p = 0.652, 95% CI ). In the same line, the mediation analyses highlighted that the path (direct effect) from the tendency to avoid certain ideas or feelings related to the cancer experience to Appraisal of own emotions , Appraisal of others’ emotions , and Utilization of emotions  was negative and statistically significant. In contrast, the direct effect form IES-Avoidance and Regulation of own emotions  and Regulation of others’ emotions  was not statistically significant. The path (direct effect) from the Appraisal of own emotions , Appraisal of others’ emotions , Regulation of own emotions , Regulation of others’ emotions  to smoking behaviors was not statistically significant. However, the direct effect of the Utilization of emotions on smoking behaviors was negative and statistically significant . The data suggested that the relationship between intrusively experienced ideas or feelings about cancer and smoking behaviors was partially mediated by the utilization of emotions dimension of emotional intelligence  on smoking behaviors was not statistically significant . The direct effect of the intrusive thoughts about cancer on openness to experience, conscientiousness, extraversion, and agreeableness was not statistically significant . In contrast, the direct effect of intrusive thoughts about cancer on Neuroticism was positive and statistically significant , indicating that people who showed higher intrusive thoughts related to their cancer experience showed a higher score in neuroticism traits. Similarly, the direct effect of Openness to Experience, Extraversion, and Agreeableness to smoking behaviors were not statistically significant . In contrast, the direct effect of Consciousness  and Neuroticism  on smoking behaviors was positive and statistically significant, suggesting that people who scored higher in Conscientiousness and Neuroticism are more likely to smoke after cancer. In summary, the data suggested that the relationship between intrusively experienced feelings about cancer and smoking behaviors was not partially mediated by Openness to Experience, Conscientiousness, Extraversion, and Agreeableness but was partially mediated by Neuroticism  and personality traits. The path (direct effect) from the Intrusion dimension of IES to smoking behaviors is not statistically significant . The direct effect of Avoidance on Conscientiousness, Extraversion, Agreeableness, and Neuroticism were not statistically significant . In contrast, the direct effect of Avoidance on Openness to Experience  was negative and statistically significant, indicating that people who tend to be avoidant of their feelings relating to their cancer diagnosis showed a lower score in Openness to Experience. The direct effect of Openness to Experience, Extraversion, and Agreeableness to smoking behaviors were not statistically significant . Whereas, the direct effect of Consciousness  and Neuroticism  on smoking behaviors was positive and statistically significant. Overall, the data highlighted that the indirect effect on the relationship between the avoidance of feelings about cancer and smoking behaviors was partially mediated by Neuroticism  and the five personality traits. The direct effect from the IES-Avoidance to smoking behaviors is not statistically significant .rtainty” . Other srtainty” ,16,20.M = 2.18; SD = 1.68) and a medium/high level of emotional intelligence . Additionally, all the participants were females with a history of cancer. Future studies may include people with different levels of smoking dependence to form a deeper understanding of the decision to quit or not quit smoking after oncological diagnosis. Additionally, future research may explore the proposed model among people of both sexes and in different chronic populations. The cross-sectional nature of the design allows us to be cautious in hypothesizing causal relationships between the explored variables because the data collection could expose us to a defensive stance or false responses because of sensitive topics. Future studies must explore the role of contingency factors as possible contributors to the explored relationship. For example, by assessing how dark triad traits, which tend to be negatively related to health behaviors and the rumination of life experiences, may contribute to explaining the explored relationships better. This aspect would be consistent with the previous literature that suggested that dark triad traits were negatively related to healthy behaviors [A possible limitation of this study is the fact that the participants involved in this research received different cancer diagnoses. Although this aspect might be helpful in understanding the impact of oncological diagnosis on smoking behavior, this prevented us from attaining a deeper understanding of the impact of a specific kind of diagnosis on the explored relationship. For example, future studies could involve survivors who received a specific diagnosis of cancer, such as lung cancer, to understand the specific role of psychological dynamics and traits on smoking behaviors. Another limitation of this study is that the participants included in the study showed a low dependence index of smoking (as determined by the Fagerström Test for Nicotine Dependence index: ehaviors .The study sheds light on the possible relationship between the traumatic experience of cancer diagnosis and continued smoking behaviors during active and extended survivorship, considering the key mediation role of personality traits and EI. Our results suggest that specific personality traits and individual strategies to manage emotions might act as inner determinants of continued smoking in cancer survivors to face the traumatic experience of a cancer diagnosis. In particular, two milestones seem to be suggested by our study. The first is related to the neuroticism that might increase in cancer survivors’ negative emotions related with their past diagnosis, supporting the adoption of health behaviors, such as no-smoking behavior. The second is the role of positive emotions for problem solving used by smoker survivors to reduce their avoidant thoughts related to the cancer; this, in turn, reduces the difficulty of remaining in contact with their thoughts related to the disease.mapping” of individual needs [Overall, the results highlight the importance of designing interventions to support smoking interruption based on the “al needs ,62 and eal needs .


Frontiers in Public Health research topic, “Investigating exposures and respiratory health in coffee workers” present research findings that better characterize exposures to diacetyl and 2,3-pentanedione and inform our understanding of the health risks posed by these exposures. Although various research groups and organizations have conducted risk assessments to derive occupational exposure limits (OELs) for diacetyl, differences in the data used and assumptions made in these efforts have resulted in a wide range of recommended OELs designed to protect human health. The primary drivers of these differences include the decision to use data from human or animal studies in conducting a quantitative risk assessment, and the application of uncertainty factors (UF) to derive an OEL. This Perspectives paper will discuss the practical implications of these decisions, and present additional commentary on the potential role that the recent investigation of human exposures to relatively low concentrations of α-diketones, specifically diacetyl and 2,3-pentanedione, may play in supporting qualitative or quantitative human health risk assessments.The articles published as part of the  In 2016, the U.S. National Institute for Occupational Safety and Health (NIOSH) recommended an 8-hour time-weighted average (TWA) occupational exposure limit (OEL) for diacetyl  of 5 ppb. OELs can take various forms, but generally speaking are all science- and health-based upper limits of exposure derived by government and professional organizations to protect worker health. NIOSH's recommended exposure limit (REL) for diacetyl was supported and informed by an extensive and comprehensive review and analysis of the scientific literature, including qualitative and quantitative risk assessments from animal toxicological and human epidemiologic investigations  selection of different health endpoints upon which to base an assessment, (2) use of different types of data, such as that from animal laboratory studies vs. data from human observational investigations to derive OELs, (3) methods for estimating exposures in epidemiologic investigations, (4) applying different protocols for interspecies extrapolations – for example, using allometric scaling, incorporating pharmacokinetic information, or using different inhalation dosimetry methods, (5) new data and changes over time in perceived acceptable levels of risk, and 6) efforts to adequately address uncertainty, variability and confounding. Ideally, differences in methods are adequately described in the peer-reviewed scientific literature and will lead to healthy dialogue and scientific debate. Increasing transparency helps to reduce, but does not completely eliminate, confirmation biases of individual scientists – a common tendency to seek answers that support preexisting views or hypotheses   used strThe three animal-based assessments used three different studies as their primary data source. Maier et al.  was baseSeveral factors may have contributed to the observed differences in the risk estimates for diacetyl, including selection of animal-based or worker-based data sets, and there are advantages and disadvantages to using animal data or human data. In animal studies, there is certainty about the exposures , a homogenous population, and few confounding factors to consider. With human data, exposures are estimated in the species of concern to risk assessors (humans), but exposures are often estimated with wide confidence limits and may be confounded by other exposures and other factors that can influence exposures or health effects of concern. In animal-based risk assessments, uncertainty factors are typically applied to account for interspecies and inter-individual differences in susceptibility and when data on metabolism and disposition of a chemical are not available. When human data are available, risk assessors may apply uncertainty factors to measured exposures or conduct regression analyses to extrapolate risks to working lifetime exposures. In the case of diacetyl, NIOSH used the epidemiological data to estimate the risk of changes in lung function beyond the range of the available data to a working lifetime, assuming that chronic exposure to low levels of diacetyl would result in accumulated and persistent damage. In the absence of evidence to the contrary, this health protective assumption impacts how risks are determined. SCOEL used the summary epidemiology data to derive an OEL by extrapolating to 40 years, adjusting the value for a bias in the exposure assessment and dividing by an uncertainty factor of two. In both cases, the extrapolated critical risk estimates were based on exposures well-below the concentration range of the collected exposure data.Virji et al.  investigGiven the varied approaches that have been taken in assessing the human health risk of exposure to diacetyl, it is certainly of interest to consider whether the availability of new exposure and health data in real-world settings may reduce uncertainties and inform assumptions.As noted above, a primary source of divergence between published final, proposed, candidate or recommended OELs for α-diketones stems from the decision to use animal or human data in conducting quantitative risk assessments. When available, the use of high-quality human data is preferable to animal toxicological data in conducting quantitative human health risk assessments. One of the main arguments raised against using observational epidemiologic data in conducting quantitative risk assessments is uncertainties determining causality based on concomitant exposures to other respiratory hazards or other confounding variables, both recognized and unrecognized. However, there is a compelling argument for the use of human data in the derivation of an OEL for diacetyl given the strong and consistent association between diacetyl exposure and adverse respiratory outcomes in epidemiological investigations. In addition, these associations are supported by animal toxicological studies demonstrating a clear dose-response relationship between diacetyl and respiratory morbidity.1) or the ratio between FEV1 and forced vital capacity (FEV1/FVC) and average or cumulative exposure in their analysis precludes a direct comparison with the analysis presented in the NIOSH criteria document .Virji et al.  demonstrQuantitative risk assessments for diacetyl have generally assumed that the adverse respiratory effects of exposure to diacetyl are driven by cumulative exposures over a working lifetime. Although NIOSH also recommended short-term exposure limits at levels 5 times the REL to protect against toxicity from 15-min peak exposures, the criteria document highlights the need to better characterize peak exposures, generally defined as brief or intermittent exposures to high concentrations, that may be relevant to human health risk  reportedTo date, the epidemiologic evidence of associations between diacetyl and respiratory morbidity has largely come from occupational exposures to flavoring additives, while associations between 2,3-pentanedione and respiratory outcomes have not previously been evaluated in epidemiologic investigations. In the studies included as part of this research topic on exposures and respiratory health in coffee workers , exposur1 below the 5th percentile . Workers exposed for less than working lifetime are predicted to be at lower risk. One difficulty in conducting occupational epidemiology is when exposure concentrations are near the REL , many workers would need to be studied for a very long time to quantitatively describe the risks, which is rarely feasible; therefore, studies with higher exposures are often used to estimate risks. However, when additional epidemiology studies describe dose-rate effects, such as decrements in lung function associated with peak exposures, this information can be used to expand our understanding of the mechanism of toxicity and can provide some insights into what types of exposures may be critical for workers' health. These considerations would similarly inform other quantitative risk assessments based on cumulative exposures to diacetyl.In evaluating how this information might inform quantitative risk assessment of chronic low exposures, it is illustrative to examine the potential impact on the NIOSH risk assessment. In the NIOSH quantitative risk assessment for diacetyl, the risk to an individual worker exposed to the REL over the entirety of their working life is estimated to be 1 in 1,000 for developing an exposure-induced decrement in lung function as defined as an FEVThere will undoubtedly be differences of opinion in the extent to which this information can or should be used to quantify and/or interpret the risks of exposure to diacetyl and 2,3-pentanedione. In our view, the relatively small sample size with concentrations that are limited to the lower range of exposures may prove inadequate to support a full quantitative risk assessment. Further, the presence of both diacetyl and 2,3-pentanedione exposures makes it difficult to combine this dataset with the human data upon which the NIOSH and SCOEL assessments are based, which included only diacetyl exposure. Nonetheless, the insights gained from this research should be of use to occupational health professionals in evaluating and managing risks from exposure to diacetyl and 2,3-pentanedione, alone or in combination, in coffee processing facilities.The original contributions presented in the study are included in the article, and further inquiries can be directed to the corresponding author.DJ proposed the concept and wrote the first draft. CW summarized details of published risk assessments for diacetyl. DJ, CW, and JC-G contributed to defining the scope of the work and designing the article. JC-G summarized key findings from recent investigations of exposures and respiratory endpoints among workers in coffee roasting and packaging facilities. All authors contributed to manuscript revision and review and approved the final submitted version.This work was supported by the National Institute for Occupational Safety and Health (NIOSH).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.


This study constructs a formation model of customer well-being (CWB) in customer experience with joy and customer satisfaction as mediating factors linking three critical factors—convenience, performance and relationship of customer experience with CWB. By collecting data from customers of retailing, the model was empirically tested. The results show that the three critical factors all have positive effects on CWB. Meanwhile, service performance has a direct effect on CWB. Joy plays a key role in the formation of CWB mediating the relationship between the three critical factors and CWB. This study is the first in the literature to explore CWB from the perspective of customer experience with joy as an antecedent of CWB. It provides important implications for managers to enhance customer experience and CWB in the service setting. It also helps managers to pay attention to the role of customer joy in customer experience and make full use of it. Over the past two decades, the importance of well-being has been widely recognized . Many stCustomers experience management, and understanding the role of the customer experience at each stage of the journey is critical for retailers and manufacturers to survive and thrive . Some seSince the customer experience of a service involves many touchpoints and various factors within them, a one-off study of all these factors is impossible. Therefore, some scholars focus on the key factors in customer experience and explore their impact on customer experience. For example, Although there are few studies in the literature focusing on the impact of the critical factors in customer experience on CWB, some scholars have noticed this problem and carried out relevant studies. For example, Moreover, joy plays an important role in consumption situations  because The above-mentioned deficiencies in literature make it urgent to explore the impact of customer experience on CWB as well as the role of joy and customer satisfaction in the forming of CWB. Therefore, the purpose of this study is settled to explore CWB in the service setting from the customer experience perspective. Specifically, this study will complete two tasks: (1) To investigate the influence of the critical factors on CWB; (2) to explore the mediating role of joy and customer satisfaction on the relationship between customer experience and CWB. The research questions are:What impact do the critical factors in customer experience of service have on CWB?How does this impact emerge?What is the role of joy and customer satisfaction in the effects of the critical factors on CWB?To achieve this study’s purpose, we choose convenience, performance and relationship as the three critical factors of the customer experience because they well reflect the convenience of service acquisition, the accuracy of service benefit transmission and the value of service relationship in the customer journey, respectively. This study clarifies the effect routes of the three critical factors in the customer experience on CWB, treats joy as another important antecedent of CWB besides customer satisfaction. The conclusion of this study enriches the theories of customer experience and CWB, and reminds service marketing managers that CWB can be effectively promoted by improving the role of some critical factors in the customer experience. The conclusions of this study also remind managers to take advantage of joy that emerges in the customer experience journey to improve CWB.The second part of this paper reviews the relevant literature and proposes hypotheses to be tested on this basis. The third part focuses on empirical research design and data collection. The fourth part reports the empirical analysis, the results and the discussion on these results. Finally, the paper reaches its conclusion, summarizes its theoretical and practical value as well as the shortcomings of this research and future research directions.Well-being is the eternal pursuit of human beings. The bottom-up spillover theory holds that specific experiences influence overall life through sublife areas such as family leisure and work . BecauseTouchpoints occur along the customer journey in services . CustomeSome researchers believe that there are three key factors influencing consumers’ shopping experience in the context of technological innovation: channel selection, value dimensions related to convenience and enjoyment, and social interaction . Some otConvenience, service performance and the relationship between customer and firm are all important factors influencing the customer experience. Convenience is an important topic in consumer behavior . It is rService convenience refers to the savings in time and effort perceived by customers when purchasing and using services . It affeH1: Convenience of a service has a positive effect on CWB.Service performance refers to employees’ behaviors of serving and helping . It invoService performance reflects the transmission level of service benefits. It brings benefits to customers and helps improve their quality of life. Therefore, it may have a favorable impact on CWB. The conclusions of some studies seem to support this. For example, H2: Service performance has a positive effect on CWB.Customer relationships do not just exist; they have to be obtained . They arIt is found that the relationship intention and behavior of firms are largely reflected by frontline service personnel, and creating a good relationship between customers and service personnel has a positive impact on the relationship between customers and firms . And gooH3: Relationship between the customer and the firm has a positive effect on CWB.Customer satisfaction and CWB are two different but closely related concepts . The forCWB is often referred to as happiness, and many people even use happiness directly to represent CWB , in thisAlthough there is no much research in the literature on the relationship between joy and CWB, the past few decades have witnessed many studies on shopping hedonic values e.g., , shoppinH4: Customer satisfaction has a positive effect on CWB.H5: Joy has a positive effect on CWB.From the perspective of the customer experience of the service, the convenience of the service provides the desired service layout for users. For example, the clarity of layouts, the presence of signage , landmarA good convenience of service facilitates information processing with reduced ambiguity and promotes goal attainment. Therefore, positive responses have more chances to occur , includiThe convenience of service not only makes customers feel less obstacles to obtain service benefits, but also more controllable feelings of service activities. The higher the customers’ perceived control over the service, the more likely the customers are to view the shopping experience as enjoyable . ConversH6: Convenience has a positive effect on customer satisfaction.H7: Convenience has a positive effect on joy.Service performance in service process includes the factor of social interaction with customers. Social interaction is an important factor affecting customers’ shopping experience . ServiceIn the service context, service performance includes physical and mental labor, as well as emotional labor . Some scH8: Performance has a positive effect on customer satisfaction.H9: Performance has a positive effect on joy.Compared to the purchase of goods, services are more uncertain  because For customers, at the end of the customer journey, they may develop a deeper connection with the service provider after consumption  through The understanding of customer relationships has been greatly enriched in relationship marketing theory and the focus of customer experience has been broadened to include the emotions and perceptions associated with the experience . In custH10: Relationships have a positive effect on customer satisfaction.H11: Relationships have a positive effect on joy.Based on the above reasoning, the three critical factors - convenience, service performance and relationship may have a positive impact on customer satisfaction and joy, which in turn has a positive impact on CWB. Therefore, they are likely to have an indirect positive influence on CWB through customer satisfaction and joy.Convenience improves customer satisfaction , enhanceH12: Customer satisfaction (a) and joy (b) positively mediate the effect of convenience on CWB.H13: Customer satisfaction (a) and joy (b) positively mediate the effect of service performance on CWB.H14: Customer satisfaction (a) and joy (b) positively mediate the effect of relationship on CWB . Exogenous and endogenous variables were analyzed. Six factors were identified, corresponding to the six factors of the study design. The factor loading of all questions was above 0.7, meeting the test requirements . By calculating Cronbach’s alpha, the reliability of the constructs was assessed, resulting in an acceptable level of reliability , to avoid CMB, both procedural and statistical methods may be applied to control for the possible existence of CMB . First, In this study, on the basis of EFA, LISREL 8.7 was used to perform confirmatory factor analysis on the adjusted questions and factors. The composite reliability (CR) values and the Cronbach’s alpha values are commonly used to test the reliability of the constructs. In this study, they were used to test the reliability of the constructs. The Cronbach’s alpha values of the constructs in the main data exceeded the threshold value of 0.70, demonstrating strong indicator reliability . The CR The standardized loadings of the indicators were more than the threshold value of 0.60 . All aveX2 = 176.70, df = 121, X2/df = 2.446 (The global goodness of fit of structural equations and the path coefficients between latent variables was tested through LISREL 8.7. The results of goodness of fit analysis of structural model indicated that the final model has an acceptable fit to the data. The fit statistics were:  = 2.446 ; CFI = 0 = 2.446 . All of  = 2.446 . This inThe results of structural model analysis show that neither convenience nor relationship shows direct influence on CWB. That is, H1 and H3 are not supported by data. However, service performance has a direct positive impact on CWB. That is, H2 is supported by data. Both customer satisfaction and joy have a positive and significant impact on CWB. That is, H4 and H5 are supported. Convenience, performance and relationships all have a positive and significant influence on customer satisfaction and joy, supporting H6, H7, H8, H9, H10 and H11. The detail results of the final model are listed in Mediation analysis explores whether the relationship between independent variables and dependent variables is direct or indirect . In thisMediation is supported when the indirect effect is significant and the confidence interval is not zero . The resThe data analysis results show that the three critical factors in customer experience have a positive and significant influence on customer satisfaction and joy, and thus, H6–H11 are verified. The results of the study also show that the effects on CWB are varied among the three critical factors. Among them, performance has the strongest impact on CWB. It even has a direct impact on CWB, that is, H2 is verified. This result is similar to that of This result bears some similarity to The results of this study also support the research conclusions of The results of this study show that the three critical factors - convenience, performance and relationship in customer experience all have a significant impact on CWB. Among them, performance has a direct and indirect impact on CWB, while convenience and relationship have impact on CWB through customer satisfaction and joy. Among convenience, performance and relationship, performance has the strongest influence on CWB.Based on these results, we conclude that the customer experience of service has a significant impact on CWB. This is fully reflected in the impact of the three critical factors of customer experience on CWB. These effects can be mediated by customer satisfaction and joy. Performance even has a direct impact on CWB.Both enhancing the service experience and improving well-being through transformative service are service research priorities called for by the transformative service research . The perThe customer journey of experience includes many different touchpoints , which hIn the research of CWB, according to the spillover theory, scholars often regard customer satisfaction of a specific consumption as an important source of CWB, or even take it as the only source e.g., , which iThe results of our research show that convenience, performance and relationship, which are the three critical factors in the stages of customer journey, have important effects on CWB. This conclusion reminds service theory researchers and managers to some extent that the three service factors are important for customer perceptions, especially the performance factor. Thus, trying hard to raise service quality in relation to these three factors at the varied touchpoints is necessary for service firms to enhance CWB. The conclusion of this study also implies that strengthening customer experience management is an important way to improve CWB.Joy plays an important mediating role in this relationship, which has not been noted in previous CWB studies. Customer satisfaction with specific services also has an important impact on CWB, which proves the spillover effect of customer satisfaction with specific services on CWB. Hence, the managers of service firms may take different measures to satisfy customers’ needs based on their perceptions of the touchpoints at different stages to enhance CWB and ultimately cultivate loyal customers.The results of this study should remind service firm managers that there exists a dual pathway from service touchpoints to CWB. Managers should not only satisfy customers but also motivate them to experience joy to achieve CWB. In some marketing practices, managers set the service environment to be ‘sad’ and ‘depressed’ to provide so-called psychological comfort to customers who experience failure and trauma in life. For example, some ‘sad tea shops’ selling soft drinks make their environment look sad. These managers take it for granted that their way of doing business helps meet the needs of psychologically injured customers. Based on the conclusions of this study, the appropriateness of their approach seems need to be reconsidered. In practice, although such service shops are located near densely populated market centers, they are still light. One of the important reasons may be that there is a serious deviation in their understanding of the intermediary variables between the marketing factors of service touchpoints and CWB.The results of this study show that the joy triggered by active participation in consumption activities can more effectively promote CWB, while the temporary joy brought by a lottery or being lucky and coming out ahead may not have this effect. Therefore, encouraging customers to actively participate in services and to experience services might bring positive emotional experiences to customers and promote an improvement in their CWB in the whole consumption field.Although this research explored the effect of the three critical factors in the stages of customer experience journey on CWB in the service context, the data were collected only in Chongqing city, China. Whether the results are applicable to other cultural contexts remains unknown. Future research on the three factors of the stages of customer journey may be carried out in other cultural contexts. Regarding CWB, the effects of other factors of the stages of customer journey also need to be explored in different service contexts, and more related marketing strategies and tactics need to be explored to promote customer assets, especially CWB.In this study, joy is taken as and verified to be one of the two antecedents of CWB. Hence, our research constructs a new model of dual paths to CWB. However, in this research, joy refers to “real joy,” while the other dimension of joy, “magic joy,” is not mentioned. Does magic joy influence CWB, and if so, how? This question is left for future research. In life well-being theory, affects include not only positive affects but also the absence of negative affects. What will the outcome be if all these affects are included in the model of CWB in the service context? In future research, more efforts are needed to address these issues.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.CX: conceptualization, methodology, software, investigation, formal analysis, writing—original draft, and writing—review and editing. JJ: data curation, writing—original draft. XG: resources, supervision, writing—review and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background and Objectives: During pregnancy, women undergo various physiological and anatomical changes that are accentuated as the pregnancy progresses, but return to their previous state a few weeks/months after the pregnancy. However, a targeted therapeutic approach is needed. Most of the time, during this period, these changes precipitate the appearance of pain, musculoskeletal pain being the most common. Pregnant women should avoid treating musculoskeletal pain with medication and should choose alternative and complementary methods. Exercise along with rest is the basis for treating chronic musculoskeletal pain. Side effects of physical therapy are rare and, in addition, it is not contraindicated in pregnant women. The benefits of this type of treatment in combating pain far outweigh the risks, being an easy way to improve quality of life. The objective of this article is to discuss the management of musculoskeletal pain during pregnancy, to identify the main musculoskeletal pain encountered in pregnant women along with drug treatment, and to expose the beneficial effects of alternative and complementary methods in combating pain. Materials and Methods: A literature search was conducted using medical databases, including PubMed, Google Scholar, and ScienceDirect, using the keywords “changes of pregnancy”, “musculoskeletal pain”, “pregnancy pain”, “pain management”, “pharmacological approach”, “alternative and complementary treatment” and specific sites. Information was collected from studies whose target population included pregnant women who complained of musculoskeletal pain during the 9 months of pregnancy; pregnant women with other pathologies that could increase their pain were not included in this review. Results: The articles related to the most common non-obstetric musculoskeletal pain in pregnancy along with pharmacological treatment options and alternative and complementary methods for musculoskeletal pain management during pregnancy were selected. Conclusions: The results were used to guide information towards the safest methods of therapy but also to raise awareness of the treatment criteria in order to compare the effectiveness of existing methods. Treatment must consider the implications for the mother and fetus, optimizing non-pharmacological therapeutic options. During pregnancy, a woman’s body undergoes various changes, both physiological and anatomical, necessary to meet the increased metabolic needs in order to support the growing fetus, for its harmonious development and also to prepare the body for birth ,2. It haA proper diet is important at any time of life, especially during pregnancy. The diet of the pregnant woman must provide nutrients and energy to support both the normal requirements of the mother and the needs of the developing fetus. The recommended diet for pregnant women does not differ much from the diet of an adult, necessarily comprising a healthy, balanced and varied diet. For pregnant women, it is recommended to use foods rich in minerals and vitamins, especially iron, vitamin D and folate . AdditioNew detailed clinical trials are currently needed regarding the treatment of the most common pain in pregnancy, adapted to current times with socio-economic or dietary modifications; a treatment that must be correlated with physiological and anatomical changes that normally occur in pregnant women. In the foreground should be non-pharmacological treatment; physiotherapy being a method more easily accepted by pregnant women. This paper provides a comprehensive look at the physiological and anatomical changes in pregnancy, the main musculoskeletal problems and the treatment that can be addressed, pharmacological treatment and especially non-pharmacological treatment, based on alternative and complementary methods.Regarding the cardiovascular system, during pregnancy heart rate can increase by up to 60% with the highest values registered from week 20 until birth. Cardiac output is required to increase and to maintain normal blood pressure. Initially, the increase in cardiac output is achieved by an increase in stroke volume, followed at the end of the third trimester by an increase in heart rhythm . The higDuring pregnancy, in the gastrointestinal tract, gastric motility is most affected. High levels of hormones, especially progesterone, cause smooth muscle relaxation and decreased bowel motility, thus prolonging gastric emptying time, leading to constipation . Likewis2) and alveolar (PAO2) pressure but also a decrease in the partial pressure of arterial carbon dioxide (PaCO2). The decrease in PaCO2 produces an increased gradient of carbon dioxide (CO2) between mother and fetus, helping to deliver oxygen to the fetus and eliminate CO2. Elevated progesterone levels create this gradient, with progesterone being a respiratory stimulant that sensitizes CO2 receptors [2 as well as decreased total lung capacity and increased VM. Thus, most often in the third trimester, the pregnant woman may experience a feeling of shortness of breath [Respiratory changes also occur in pregnant women. The diaphragm rises by about 2 cm, which leads to a 5% decrease in lung capacity. The current volume increases by up to 40% leading to a decrease in the expiratory reserve volume by 20% and an increase in ventilation per minute (VM). The increase in VM determines an increase in the level of arterial  and thyroxine (T4) by about 50%, while free T3 and T4 levels remain constant or slightly altered. It also increases the production of hormones by the adrenal glands. Low blood pressure and vascular resistance stimulate the renin–angiotensin–aldosterone system, resulting in an up to 10-fold increase in aldosterone at the end of the third trimester of pregnancy. Moreover, there is an increase in the level of cortisol and adrenocorticotropic hormone, a corticosteroid-binding globulin, which leads to a state of hypercortisol. On the other hand, the high levels of estradiol in pregnancy result in an increase in prolactin that induces growth in the pituitary gland ,20.Over time, it has been observed that many physiological and anatomical changes occur in pregnant women that can affect the essential organs, but the most common are those at the musculoskeletal level. Weight gain, the enlargement of the uterus with a shift in the center of gravity and hormonal and vascular changes cause a number of musculoskeletal problems. Changing the center of gravity causes lumbar lordosis with the flexion of the neck and the drooping of the shoulders ,25.Mechanical pressure, elevated progesterone and relaxin levels increase joint laxity and prepare a woman’s body for childbirth. Additionally, in pregnant women, fluid retention causes the compression of soft tissues. All these changes that occur make the pregnant woman susceptible to musculoskeletal disorders. Most pregnant women complain of musculoskeletal disorders, and some of them show signs of disability. The majority conditions have been described as spinal pain, pain in the upper and lower extremities, peripheral neuropathy and muscle cramps. In addition, carpal tunnel syndrome, which results from compression of the median nerve, is quite common in pregnant women ,20,26. MThese musculoskeletal disorders cause disabilities and loss of work capacity in pregnant women . Pain duNext, some aspects of the main imaging investigations for the diagnosis of musculoskeletal disorders will be presented.X-rays are among the oldest types of imaging available, which use electromagnetic waves to produce an image. Bone lesions can be highlighted by radiography, but in order to diagnose muscle disorders more advanced imaging explorations are needed. The possibility that an X-ray taken during pregnancy will produce serious effects on the fetus is very small. However, the risk of affecting the child depends on the amount of radiation exposure and its gestational age. Thus, the exposure to high doses of radiation in the first two weeks after conception can cause a miscarriage; exposure up to eight weeks can increase the risk of congenital malformations; and up to week 16, high doses of radiation can lead to intellectual disability. The dose of a single exposure to radiation is far lesser than the doses associated with these risks. Another method of diagnosing musculoskeletal disorders is computed tomography (CT), which investigates bone and muscle injuries. This method offers a more detailed examination of body compared to radiography. It is not proven that the fetus is affected by the amount of radiation used in CT. However, its use on the abdomen or pelvic area is to be avoided in order to exclude any risk of developing cancer in childhood. If the examination of both the mother and the fetus is necessary, other imaging tests, such as ultrasound or magnetic resonance imaging (MRI), are used. Ultrasound uses sound waves to photograph the inside of the body. Ultrasound captures images of soft tissues, muscles and ligaments and can also diagnose musculoskeletal conditions along with MRI. Ultrasound can easily detect the signs of inflammation at the muscle and joint level. This imaging method is the most used for pregnant women, but if the images obtained do not provide a clear answer, an MRI examination can be resorted to. MRI is a method that uses radio waves and magnetic fields to capture images of the inside of the body. MRI can capture images of the body’s soft tissues, even muscles, unlike X-ray imaging. In addition, MRI can capture joint injuries, such as torn ligaments or cartilage. There are no proven adverse effects due to the MRI either in the pregnant woman nor in the fetus, and is a frequently used method today ,29.The main musculoskeletal pains encountered during pregnancy can be classified into lumbar, pelvic and joint pain.Lower back pain occurs in about half of pregnant women and is considered a normal pain during pregnancy . A higheIn addition, lower back pain encountered at night during pregnancy may be due to venous engorgement in the pelvis. The growing uterus presses on the vena cava and combined with fluid retention in pregnancy causes venous congestion and hypoxia in the lumbar spine . Some woThe most affected musculoskeletal structures during pregnancy and postpartum are the pubic symphysis and the sacroiliac joints. Most of the time it is difficult to establish the exact cause of the pain based only on the anamnesis, and detailed imaging investigations are required. Non-inflammatory causes of back pain, such as mechanical stress on the pelvic area caused by pregnancy, can cause subchondral bone marrow edema that cannot be differentiated from axial spondyloarthritis .Bone marrow edema (BME) is a condition encountered in radiology described as a nonspecific lesion pattern, characterized by a change in marrow signal intensity at the level of the femoral head suggesting marrow infiltration through interstitial edema. Many aspects can lead to bone marrow changes, especially at the level of the sacroiliac joints, it is not yet clear whether postpartum bone marrow changes, which are mechanically induced, are different from inflammatory sacroiliitis seen on MRI. From an imaging point of view, spondyloarthropathy is characterized by BME around the sacroiliac joint (sacroiliitis) and structural changes, such as the fatty replacement of the bone marrow at the sites of inflammation, subchondral erosions and sclerosis .The scientific team led by Agten compared the MRI results of the sacroiliac joints subjected to mechanical stress due to pregnancy with those of a group of women known to have spondyloarthritis to make the differential diagnosis. It was found that mechanical pressure on the joints can lead to bone marrow edema, only inflammatory changes being present, while in the group with spondyloarthritis, structural changes and erosions were also evident. Thus, these findings may provide guidance to differentiate mechanically- and hormonally-induced bone marrow changes and inflammatory sacroiliitis .Pelvic pain is described by pregnant women as a burning sensation, stabbing in the sacral area or as pain in the pubic symphysis. This pain may radiate to the groin or posterior thigh. The first symptoms appear during week 18 and reach a maximum intensity in week 36 . Pelvic Furthermore, it has been shown that high body mass index, multiparity, mental stress, physical exhaustion and smoking are factors that can accelerate the onset of pelvic pain in pregnancy .Lumbar disc herniation is considered the most common pathology of the spine in pregnant women; however, the condition is very rare in pregnant women compared to pelvic pain, with an estimated occurrence of 1 in 10,000 women. In recent years, an increase in the average age of women who become pregnant has been observed, a consideration that may increase the incidence of lumbar disc herniation among pregnant women. The most frequent symptoms were represented by radicular pain, along with the weakness of the muscles innervated by the root of a spinal nerve, the reduced sensation in the sensory distribution of a spinal nerve but also urinary incontinence. According to data from the literature, no more than 15% of patients suffering from this disorder develop severe neurological deficits. In terms of therapeutic management, it has been observed that the majority of lumbar disc herniation sufferers do not require surgery .Pregnant women may experience joint pain, which often raises the suspicion of inflammatory diseases, such as rheumatoid arthritis or systemic lupus erythematosus. However, the development of new-onset inflammatory arthritis is rare during pregnancy, and there is evidence that pregnancy protects against new-onset rheumatoid arthritis . Soft tiAnother common condition is carpal tunnel syndrome, which occurs in the third trimester of pregnancy and affects the wrist. Due to water retention during pregnancy, the median nerve is subject to high compression. The symptoms are characterized by pain, paresthesia and tingling in the distribution area of the median nerve, which intensify after repeated movements and during the night . Carpal The treatment of musculoskeletal pain should include a structured approach, combining non-pharmacological and pharmacological options, while surgery is only desired in extreme situations, such as for acute disc herniation . For theLiposolubility, molecular weight, maternal metabolism speed and the binding to plasma proteins are the main parameters on which the presence of drugs in the fetal and placental circulation depends. Most therapeutic agents reach the placental circulation to a greater or lesser extent, with the exception of large molecules, such as insulin and heparin. The stage with the highest teratogenic risk is the one between weeks 4 and 10 during the development of the organs. After this period, the action of drugs that cross the placental barrier can reduce the amount of amniotic fluid, can delay the birth of the fetus or can trigger certain pathologies . A propoIn the late 1970s, the Food and Drug Administration (FDA) implemented a cataloging system that assesses the potential risks of pregnancy-administered drugs. This system, based on scientific evidence, has classified drugs into five broad categories . HoweverParacetamol is the most widely used analgesic in pregnancy. It has an analgesic potency similar to aspirin, being considered an effective and safe therapeutic agent at standard therapeutic doses throughout pregnancy. Acetaminophen is the main active substance used by pregnant women to combat mild to moderate pain and fever, due to its painkiller and antipyretic effects . There aMoreover, regarding the effects observed at the genital level following prenatal paracetamol exposure, possible neurological side effects have been identified. Observational studies have reported several associations between the occurrence of neurological disorders and the administration of acetaminophen during pregnancy, disorders such as autism ,81,82, aThe activity of NSAIDs  on the fetus is mediated by inhibiting the production of prostaglandins, which stimulate blood circulation in the organs. The effects of nonsteroidal anti-inflammatory drugs on the fetus differ depending on the period of pregnancy in which the mother used them . In geneAccording to the FDA classification, codeine and most opioid compounds are in category C with potentially toxic to the fetus. The main compounds in this class are morphine-like agonists , meperidine-like agonists, and synthetic opioid compounds (tramadol). A study of 563 pregnant women showed that mothers’ exposure to codeine a in the In the case of pregnant women undergoing chronic opioid treatment, it is recommended that the lowest dose be used or, if possible, that the therapeutic agent be discontinued gradually, initially being replaced with the methadone of buprenorphine, to prevent withdrawal symptoms . It has Capsaicin and lidocaine in the form of topical treatment can be used to treat lower back pain. Topical lidocaine 5% inhibits fast sodium channels in neuronal membranes, stopping nociceptive activity potentials. While capsaicin acts as an agonist for the transient receptor potential vanilloid subtype 1 (TRPV1) channel at the level of nociceptors. Their adverse effects generally consist of localized erythema and skin rash .According to the FDA, patches with 5% lidocaine are classified in category B regarding the potential risk following administration to pregnant women. There are no studies on the human species that affirm the safety of the drug, but in studies on rats, the transdermal application of lidocaine in a dose of 30 mg/kg did not produce adverse reactions in the fetus. In the Collaborative Perinatal Project, in the 293 children born to mothers exposed to lidocaine in the first trimester of pregnancy, no increase in the frequency of congenital anomalies was observed. The safety of topical capsaicin during pregnancy or breastfeeding has not been established in humans. Animal studies have not shown fetal teratogenicity in the development of the fetus, and knowing that small amounts are absorbed through the skin, it is not considered to cause adverse reactions in humans .Exercise and rest are the basis for treating chronic musculoskeletal pain. The main goals of physical activity are to regain strength, endurance, flexibility and, especially, to reduce chronic pain by modulating the biochemical processes in the body . The sidNon-invasive therapy is most often preferred over drug treatment, and surgery is not considered an option during pregnancy. Specialists in this field use several treatment techniques for pregnancy-associated lower back pain, including passive treatments, such as rest, but especially active treatments, such as exercise .The effects of exercise during pregnancy and postpartum have been evaluated in several randomized controlled trials ,124,125.In another study, water gymnastics proved effective. Specifically, performing exercises in the water once a week in the second half of pregnancy has significantly reduced back and back pain, with no risk of urinary or vaginal infections following this therapy. Therefore, the reduction of back pain has also reduced the need for medical leave because of this .Massage therapy and chiropractic care are effective treatment options for pregnant women suffering from lower back and pelvic pain. Regarding side effects, very few were reported, not affecting the baby, lumbar spine or pelvis ,131.With the development of pregnancy, especially in the third trimester, the center of gravity of the pregnant woman moves to the anterior and there is an increase in lumbar lordosis, which has the effect of hyperactivity of the pelvic muscles and the hypermobility of the joints. In this case, a chiropractor can intervene to help the pregnant woman reduce the mechanical pain, and even giving advice about special pillows can significantly reduce these problems in the pregnant woman. In addition, high pressure is exerted on the lower limbs, requiring proper footwear, orthoses or massage to provide the necessary comfort . MassageAnother method of treatment for the removal of musculoskeletal pain in pregnant women is the use of the pelvic girdle.Randomized clinical trials have shown that using this method in women with pelvic girdle pain reduced their disability and pain intensity compared to women who only exercised or received general treatment information .Another randomized study in women with symphyseal pain showed that wearing a stiff belt decreased pain in all patients, as well as in the group of those who exercised, but the combination of the two methods did not show an improvement in reducing pain intensity . MoreoveAcupuncture is another technique for treating pain. Studies in this direction have shown that needle therapy used in pregnant women has significantly reduced pain and increased function ,140,141.Exercise and manual therapy should be the main treatment methods for relieving pelvic and lower back pain during pregnancy. However, if these techniques are not enough or are limited due to pregnancy, electrotherapy can be used . TENS (tLikewise, TENS can be used to reduce pain during labor, it has been shown to be a safe technique for both mother and newborn .Exercise is recommended for pregnant women to limit weight gain but also to maintain cardiovascular function and to prevent chronic diseases. Exercises on land or in the water, as well as manual therapy, acupuncture and electrotherapy, have been shown to be beneficial in combating muscle pain during pregnancy, as presented. Furthermore, exercise has beneficial effects on other levels. Significant weight gain during pregnancy increases the risk of many pathologies, from gestational diabetes to pregnancy-induced hypertension. Thus, it has been found that frequent exercise during pregnancy reduces the risk of obesity and the association with a healthy diet is the best method of weight control . AnotherHowever, one aspect that should not be overlooked is the psychological impact of physiotherapy. Clinical studies have concluded that exercise is an ameliorating factor in pregnancy and postpartum depression, improving the quality of life and the perception of pain and general health ,154,155.Many women experience musculoskeletal problems during pregnancy, which often limit their daily activities, so therapeutic intervention is needed to prevent or combat pain. The information collected showed that alternative and complementary methods decrease the intensity of pain and in addition help to improve musculoskeletal function. Although there is clear evidence of the effectiveness of exercise therapy in combating lower back and pelvic pain in pregnancy, it is not possible to specify exactly what kind of exercises are suitable for each pregnant woman, the exercises being different in the studies. To be able to compare the effectiveness of existing therapies, it is necessary to select groups according to the same set of criteria. Further studies are needed to strengthen the effectiveness of physical activity, as well as more robust data on the effectiveness of electrotherapy and craniosacral and osteopathic therapy, as data are limited in this direction. An optimal level of intensity of physical activities must be established to maintain the safety of the woman and the fetus, and more detailed studies are required to determine the relationship between the type of exercise, its dose, intensity, and desired response of preventing or treating a problem.