The Haitian population within the US represents the largest diaspora outside of Haiti, with most Haitians residing in major urban communities. Despite clear differences in health outcomes specific to Haitians, the community has traditionally been aggregated into the general Black population. To address specific health disparities, this workshop was designed to distinguish and elaborate on the health care problems affecting Haitians.We created an interactive 60-minute workshop including a PowerPoint presentation, two case presentations, and a 5-minute informational video to bring awareness of the historical perspectives impacting Haitian/Haitian American health, access to care, and health care disparities to providers. Knowledge was assessed by pre- and postworkshop evaluation forms. The module was aimed at health care professional learners.Seventy-four people with diverse ethnoracial identities, including medical students, residents, academic faculty, physicians, nonmedical graduate students, and health care staff and administrators, attended three workshops. All learning objectives were met, with pre- and postworkshop data indicating a statistically significant increase in participants’ reported confidence. Workshop attendees commented positively on the group discussion component, the workshop's interactive nature, the opportunity to apply taught knowledge to case presentations, and the historical context provided.As the number of Haitian immigrants continues to rise throughout US urban communities, providers must increase their culture competency in training and delivery to improve care for a major population. This module can help better prepare health care providers and trainees to offer competent care to Haitian/Haitian American patients. Much of the literature on the Haitian population has been focused on the health conditions prevalent in Haiti, such as HIV/AIDS, and, most recently, the impact of the 2010 earthquake.6 Studies on these health conditions within the Haitian community have demonstrated disparities in health outcomes compared to the Black population.7 Studies on cervical cancer, for example, have shown that Haitian immigrants are less likely to receive cervical cancer screening, are more likely to be diagnosed with cervical cancer at a higher stage, and have higher mortality rates compared to Black Americans.9The Haitian population represents the second-largest Black foreign-born population in the United States.10 While public health and health care institutions have navigated pathways towards mitigating the social and structural determinants of health to improve health outcomes, health care professionals have historically focused on cultural competency to care for diverse populations.11 Cultural competency aims to provide clinicians with the skill to manage cultural differences and knowledge of how culture can influence health. Cultural humility, which we believe to be a superior practice when working with diverse communities, prioritizes a lifelong commitment to self-evaluation and focuses on the patient-provider power imbalance and community partnership.12 There has been growing focus on integrating the social and structural determinants of health into health care education. Structural competency has been suggested as a framework to best prepare students and those in training on the social and structural determinants of health.12 Structural competency is defined as “the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political and economic structures.”14Racial and ethnic disparities are long-standing and have been recorded since population health statistics began being reported. As an institution, public health has recognized that these disparities are not a result of biology or individual factors, but rather of the social determinants of health and the structural inequities that cause them.15 The addition of immigrant status adds another layer of barriers, such as those related to language, insurance access, and legal status.16 In addition, the Haitian immigrant population has a unique history and culture that influence not only everyday lives but the perception of health as well. Lastly, the Haitian community is one that has been subject to stigma and bias that persist today.The social and structural determinants of health that cause racial and ethnic health disparities are historically rooted but continue to be perpetuated through persistent inequities. Haitian immigrants are most likely to reside in urban communities that have been historically disadvantaged and are themselves subject to the same barriers. In New York City, New York, for example, the single largest Haitian immigrant population is in Brooklyn, where community assessments have estimated that 23% of deaths could have been averted based on the economic profile of the district.18 These cities are also home to a significant number of academic medical institutions. New York City, for example, has eight medical school campuses and is home to the second-highest Haitian population in the United States. Academic medical centers and public health groups have also had a presence in Haiti dating back decades. Haiti, which has been described as the “nongovernmental organization (NGO) nation,” has a significant number of American medical and public health professionals who have worked in Haiti and continue to do so.19 Despite the long history of US-Haiti relations and the significant US presence in Haiti, to date there has not been a medical curriculum dedicated to Haitian health and the barriers that contribute to Haitian health disparities.The three largest Haitian populations within the United States are in Miami, Florida; New York City, New York; and Boston, Massachusetts.MedEdPORTAL is an excellent resource for educators to find curricula on how to best integrate racial disparities and social determinants of health into medical education.13 As we work to navigate this path within our institutions, we must appreciate that marginalized communities are not monolithic. There remains an importance in understanding the uniqueness of the communities we serve. These distinctions are important in understanding the unique barriers of a given community and enabling the development and implementation of effective interventions. Such community enclaves have a unique history and culture that contribute to their determinants of health. As previously developed curricula geared towards Indigenous and Puerto Rican communities have demonstrated, centering on and understanding the values of a given community are important.21 The coauthors of this module felt that it was important to highlight the disparities present within the Haitian community using similar methodology. While the methodology that traditional cultural competency utilizes has limitations, there remains value in understanding the historical and cultural aspects of a given community in addition to its barriers to care. Culturally responsive care is essential in achieving health equity. A systematic review of the impact of cultural competence training has demonstrated not only improved knowledge, attitudes, and skills of health professionals but also improved patient satisfaction.2324 In the first step, our problem identification and general needs assessment entailed a review of current literature and speaking with community leaders on Haitian health care. For step 2, we reviewed prior MedEdPORTAL publications to understand how culture-specific content has been included in medical school curricula. Medical students and faculty were engaged from the beginning to provide constant direction for the development and implementation of this module. In step 3, we established our objectives and goals in accordance with the collaboration of our coauthors and the literature review. In step 4, our educational strategies consisted of an interactive PowerPoint presentation, case presentations, and a video highlighting the trauma experienced by Haitians. Each component included a reflection, problem-solving, understanding, and sharing of perspectives in an interactive group environment. In step 5, workshop implementation was presented during Black History Month (February 2020) for medical students, residents, physicians, faculty, and health care staff members at three different medical schools in urban and suburban New York. In step 6, evaluation and feedback were captured through pre- and postworkshop surveys completed by participants.This workshop teaches practitioners how to utilize the Kern six-step curriculum model for structure, implementation, and assessment.The aim of this workshop is to prepare participants to better care for the Haitian community. The unique history of Haiti and its relations with the United States is highlighted to show how that history contributes to federal policies, as well as stigma and bias that persist today. One does not need to be of Haitian background to facilitate this workshop. The module is designed for medical students, residents, institutional faculty, and physicians but is also appropriate for health care professionals, especially those who serve a Haitian population or travel to Haiti for work. This workshop offers an interactive curriculum presented through an equity lens and from the viewpoint of the Haitian community.t tests to compare pre- and postassessment answers and a qualitative analysis based on the module's learning objectives to analyze open-ended questions.This in-person workshop was written and modified by experts specializing in Haitian cultural research, health care disparities, and/or academic medicine. The primary team comprised six Haitian-identified individuals, all of them having experience working with Haitian communities in the United States and/or Haiti. The team consisted of two obstetrics and gynecology physicians, a family medicine physician, two graduate students, and an executive director of a global mental health organization. Christina Pardo facilitated and implemented the workshop at three medical schools in the state of New York . This workshop was offered at each of the above institutions as a part of their programming for Black History Month in February 2020. This educational study, which included students and residents, received institutional review board (IRB) approval at the sites of implementation . Data from the IRB-approved sites were interpreted using descriptive statistics paired to learner This 60-minute workshop was created to increase the understanding of Haitian health care disparities and to fill a knowledge gap regarding cultural competency with Haitian and Haitian American patients. The targeted audience for this workshop included medical students, residents, and physicians but could also include other health care professionals and trainees. A fellow, faculty member, or administrator with robust experience in the social and structural determinants of health and/or a specific understanding of Haitian/Haitian American health issues would be the recommended facilitator. A facilitator without this experience should not be dissuaded from presenting this workshop. Rather, appropriate preparation and self-guided learning could prepare the facilitator to effectively present the material. Three primary educational approaches were featured: (1) a collaborative didactic PowerPoint presentation, (2) a video discussing trauma-informed care regarding Haitian patients, and (3) case-based discussion in small- and large-group formats highlighting common health problems and associated risk factors for Haitian patients.The facilitator began with a didactic presentation  laying oThe following is an extensive description of the resources utilized to conduct the workshop successfully.An overview of the workshop was outlined in a 45-slide PowerPoint. The presentation highlighted the core foundational concepts of the workshop, including key information about the social, historical, and structural determinants of health; a comprehensive analysis of Haitian health care disparities and health outcomes; and an overview of Haitian access to health care and policies/interventions affecting Haitians and Haitian Americans. Embedded within the PowerPoint presentation were the cases and a link to the Trauma in the Haitian Context video.This document presented instructions on how to conduct the presentation and explanations of how to talk about each PowerPoint slide in detail. Facilitators who do not identify as Haitian/Haitian American and/or lack knowledge about Haitian culture, history, and/or values are recommended to follow the guide strictly and use the provided resources to better explain important concepts.The video highlighted different levels of trauma experienced by Haitian or Haitian American patients. It is included here as These cases were developed to further elaborate on and discuss common health issues of and barriers to accessing quality care faced by Haitian and Haitian American patients. The case presentations were displayed on slides 40 and 41.Participants were asked to fill out a pre- and postworkshop questionnaire. The primary questions collected demographic information and assessed participants’ competency levels regarding Haitian culture, Haitian/Haitian American history, and health care disparities affecting Haitian patients aligned with the workshop objectives.Demographic questions were included on the preworkshop survey. Two open-ended short answer questions were asked on the postworkshop assessment: “What did you like about this workshop?” and “What suggestions do you have to improve this workshop?” Each participant was given approximately 5 minutes to complete the pre- and postworkshop evaluations.The review of the PowerPoint, facilitator guide, video of trauma in the Haitian context, and case presentations took approximately 3 hours. We recommend that no more than two cofacilitators lead the workshop. Any additional facilitators should spend extra time in advance discussing the breakdown of slides between presenters by phone or face to face.Materials needed included writing utensils, audiovisual equipment to display the PowerPoint presentation, computer with video and audio, printed copies of the case presentations, and printed copies of the pre- and postworkshop assessment forms.n = 74) were a diverse sample by gender and by race and ethnicity: 36 (49%) identified as female, 29 (39%) as White, seven (10%) as Hispanic/Latino, 20 (27%) as African American/Black, and 14 (19%) as Asian. There were 39 medical students, 18 academic faculty members/staff, seven medical residents, and two nonmedical graduate students.The number of participants per session ranged from nine to 47. Seventy-four (100%) participants responded to the preassessment questionnaire, and 64 (86%) completed the postassessment. The three workshops’ respondents . For all four objectives, the preworkshop median was 1, and the postworkshop median was 3. Through use of the Mann-Whitney U test, it can be concluded that the respondents’ confidence for each objective was statistically significantly higher after the workshop than before (p < .001).Respondents’ reported confidence in their ability to achieve each of the four stated learning objectives was greater after the workshop. Confidence was rated on a 0–4 scale , relevant historical context, and interactive cases that incorporated learning objectives into practical patient examples.We arranged participants’ responses by each learning objective for the questions “What did you like about this workshop?” and “What suggestions do you have to improve this workshop?” Remarks on the workshop were generally positive, with some recommendations for improvement. Specific positive comments, as related to each of the learning objectives, are provided below.•○“I enjoyed learning about the history of Haiti which gives a cultural context to the Haitian patients we see.”○“It was beautifully designed. Very engaging and I learned a lot! Feeling the love for the Haitian community from Haiti to Brooklyn.”Objective 1: Describe the history of Haiti and Haitians within the United States.•○“I enjoyed the cases; they were a good way to really look at the disparities in practice.”○“Excellent, clear, concise description of the history of Haiti and the environmental political factors contributing to the health disparities. Cases tied directly back to the content of the slides.”Objective 2: Compare and contrast health issues and disparities of Haitians residing in Haiti and the United States.•○“I love the integration of policy, history, and health. It gives me a better understanding of Haitian health.”Objective 3: Explain how at least two implemented policies have affected Haitians’ and Haitian Americans’ health outcomes.•○“Different/various approaches to understanding the background of Haitian patients.”○“Workshop was very informative and highlighted every aspect in improving care for Haitian patients.”Objective 4: Describe at least two health care access problems faced by Haitians in the United States and/or Haiti.Responses for “What did you like about this workshop?” included the following:In answer to the question “What suggestions do you have to improve this workshop?”, several respondents requested additional time, making comments such as “more time to go over the great information,” and suggested placing key information on busy slides in bold text and providing slides to participants ahead of the workshop for prereview. Most importantly, respondents suggested the addition of real Haitian-identified patients who could share their health conditions and issues in relation to the US and Haitian health care system.Because the Haitian population in the United States is the largest outside of Haiti, this workshop was designed to educate diverse health care trainees and professionals about the historical, political, and social factors that contribute to Haitian health. Trainees and health professionals gain a structural competency for the Haitian community that will enable them to provide the best care for the Haitian patient. The workshop helps to address the lack of material related to Haitian health care disparities and helps to fill a knowledge gap regarding cultural awareness of Haitian and Haitian American patients. Notably, the workshop is presented applying methods that center on cultural values, history, governmental policies, and a current portrayal of Haitian patients. Accordingly, the learning objectives are for participants to comprehend the history of Haiti and Haitian identity within the United States, compare and contrast health issues and disparities of Haitians residing in Haiti and the United States, explain how policies have impacted the health outcomes of Haitians in Haiti and/or the United States, and describe health care access problems faced by Haitians in Haiti and/or the United States. A comparison of Haitian and Haitian American communities recognizes the migratory patterns that exist within Haitian families and the complexity in ensuring quality care.Based on the quantitative and qualitative feedback responses, the objectives were overwhelmingly met. In general, the presentation was very well received, and there were statistically significant increases in participant knowledge. Additionally, improvements were made to the workshop based on the suggestions shared in the evaluations.Ideally, our workshop is designed for a small to midsize audience of fewer than 40 individuals. The suggested audience size has been selected to ensure active participation and group reflection with discussion. We have found and believe that a smaller audience promotes a more energetic and engaging environment for discourse. In addition, facilitators should also consider a lecture hall layout to promote intimate small-group discussions and participant interactions. However, recognizing that many medical school classes are larger in number, the facilitator can promote an interactive environment by situating students in small groups to discuss cases before calling the whole group together to participate in a discussion.A number of qualities made this workshop effective. First, most participants shared that the case activity was an interactive way to open conversation around the intersection of culture, health, and history. Some thought the hypothetical case scenarios made the content more engaging, while others said applying cultural context to practical examples made the presentation more informative. Second, participants appreciated the video interview that discussed the scales of trauma, which provided additional visuals that helped establish a deeper understanding of cultural familiarity. Additionally, most participants noted that they valued the presentation's organization, delivery, and relevance to a familiar patient population.There were also opportunities for improvement. For presentation structure, the most common recommendation was to reduce the amount of information on the individual slides. To address this, we restructured slides that were content heavy. Some participants desired more content on the current care of Haitian and Haitian American patients. Other participants desired us to incorporate live interaction with Haitian patients who could exemplify a real-world health care experience. The ability to do this is of course limited and requires an ongoing trusting relationship with the Haitian community. If a facilitator of this presentation does in fact have such a relationship, then we encourage the inclusion of a willing participant to provide the patient perspective. However, we do not believe one is necessary to meet the objectives of the module. Additionally, other participants requested best practices for providers to become more culturally competent for their Haitian patients. While we understand this desire, the aim should not be to master the Haitian culture but rather to achieve a baseline understanding that incorporates the ideals of cultural humility. There is no one lecture that would provide all cultural norms of a given community, nor do we need to master all norms to provide culturally sensitive care.In summary, this workshop addresses a need for curricula dedicated to the Haitian community, which represents a significant portion of the Black immigrant community. Although the workshop focuses on the Haitian community, the methodology of understanding a community through structural and social determinants of health with the addition of cultural and historical perspectives is one that should be utilized for any community being served. Vulnerable, marginalized, and minoritized communities are not monolithic, and understanding the unique contributions and barriers to care of each is important.We created an interactive workshop to investigate the intersection of history, culture, policy, and the social determinants of health. Medical students and health care practitioners are influenced by the effects of history and politics, often in ways many might not understand. These effects of history and politics are present in discourse about policy reform, ahistorical maligning of immigrant and Black communities, and the downstream activities of providing care to the most vulnerable communities. Our workshop integrates individual and community aspects with societal factors using vignettes. The discussion and solutions are framed to address all levels from the individual to the institutional to the community. Students and practitioners can draw from their own experiences and interests to address how best to care for the Haitian community using any one individual level or through a multipronged approach. Our students and practitioners are left with a foundational knowledge of not only how to best interact with diverse communities with cultural humility but also how to evaluate different communities and patients in order to understand the internal and external forces that impact health.During the development of this module, special care was taken to create a multidisciplinary work group. All members of the work group are of Haitian heritage and have worked with or for the Haitian community in the United States and/or Haiti. This allowed us to integrate both experiential and evidence-based perspectives on how best to care for the Haitian patient and community. The work group members’ knowledge and experience relating both to Haitian heritages and to health care students and professionals in the United States allowed for the development of a module that can be facilitated in diverse settings.Through participant feedback from the postworkshop survey, we were able to identify strong characteristics of the presentation and implement changes to improve the delivery and comprehension of the presented information. Many participants shared their appreciation of the presentation's interactive nature along with the relevant content and illustrations. Additionally, participants appreciated the applicability of the case presentations as examples of current issues experienced by Haitian patients in medical centers. Providing hypothetical experiences encouraged participants to apply the information presented throughout the module to real issues. Given the dynamic nature of health care, facilitators can also consider sharing their own professional experiences in caring for patients who identify as Haitian. Facilitators’ comments should align with the objectives of this module. This will allow participants to understand the relevance and importance of cultural competence in modern medicine and as a caregiver when new issues arise.There were some limitations present in the design of this module. Though the presentation was well received, it is imperative to note that it provided a single session with self-assessment surveys and multiple-choice questions given immediately before and after the presentation. No assessment of change in behavior or attitude was done. Change in attendees’ competency in Haitian-identified patients’ health care issues may not be sustained and would need to be reevaluated in the future. For example, further follow-up in assessing maintained competency could occur after 6 months. Additionally, it is important to account for the impact of the changing political landscape and its impact on Haitian and Haitian American health care with regard to immigration status, access and availability to care, and government intervention impacting the community. As health care continues to evolve, newly developed perspectives, including stereotypes and bias, may arise that could influence the delivery of care. For that reason, reviewing up-to-date information before implementing the module is crucial to ensuring an accurate present outlook on Haitian and Haitian American health.Racial and ethnic considerations including health policy, barriers to care, and bias disproportionately affect underserved populations; thus, a diverse, well-informed physician workforce is required. This would offer the knowledge to address components on all levels from the individual to the institutional and community through both practice and policy. This workshop enables participants to introduce these topics and encourages them to proactively become involved in one or more levels of intervention.Presentation.pptxFacilitator Guide.docxVideo Trauma in the Haitian Context.mp4Case Presentations.docxPre- and Postworkshop Evaluation Form.docxAll appendices are peer reviewed as integral parts of the Original Publication.


R2 model was 0.484, meaning the level of religiosity had a substantial impression on healthy and lasting marital commitment. According to the final outline of the model factors associated with building religious support factors (β = 0.491), the marital commitment had a better and healthier impact. The goodness-of-fit of the measurement of the conceptual model showed a value of 0.51, which indicated that the theoretical model had sufficient consistency and rationality, and accurately fitted the data. Such an advanced statistical model is missing from the previous literature. The study results provide helpful insight to elucidate the social dynamics of marital commitment. The findings designate that religious practices strengthen and promote nuptial commitment. The study is novel in the context of religiosity impact on martial commitment with a cultural background of Pakistan. The generalizability of the study does not apply to the entire population or other regions. Future studies can investigate other religious variables to explore further research findings. The findings are helpful for decision-makers and policymakers to concentrate on marital issues and challenges confronted by couples worldwide.Religious studies are a vital branch of social science that seeks to explain the beliefs of human society and deals with the practices and beliefs of individuals. This distinctive study focuses on such influential aspects of a healthy life, which could play a vital role in the marital quality and matrimonial commitment of individuals. The study principally focused on inspecting the role of religiosity in healthy marital commitment among individuals. It is a distinctive and central value in regulating a healthy social life. This research designed a conceptual model for assessing marital commitment, and the study model comprised two primary variables. The study received datasets through a survey questionnaire based on participants from five private and public sectors. The research study conducted an empirical analysis to test the proposed conceptual framework. The findings exhibited that the value of the  Several researchers have recently assessed the connection between religion and marital commitment in many areas of family studies. In general, previous studies have shown that people with the highest level of religiosity had lower levels of marital commitment and an improved quality of life in modern societies, as well as a global cultural influence; and these factors are essential for people, as they have social impacts that directly affect daily lives of people. Communities with better living conditions have improved living standards and social welfare among married women  or church and perform religious obligations, such as religious rituals and pilgrimages, typically show a lower rate of divorce and enjoy a stable married life  technique to test the conceptual design model. Thus, considering the objective of this study, the researcher used the theory of commitment to give the research direction. Commitment is a fundamental notion used to understand the continuation of human relationships in Pakistani society. Behavioral and social scientists have also developed various theories on the marital commitment of people in the past several years. George Levinger conducted studies, introduced the commitment theory, and mainly focused on understanding and separating the processes involved in maintaining relationships . See Scholars widely employ the partial least squares-structural equation modeling (PLS-SEM) tool, which is a broader multivariable evaluation method for calculating the structural equation's variance-based models, particularly in social science  for categorical data at a 5% alpha value (error of 5%). The study has drawn the desired sample by incorporating the formula of Cochran at 95% confidence level with a 5% error margin, which was in accordance with selection inclusion criteria  of endogenous latent variables, which is essential for measuring an internal structural model. Other convenient methods for assessing an inner structural model are the path coefficient and t-statistics value, effect size (f2), goodness of fit, and predicted relevance of the model (Q2).The study applied the following method to gauge the structural model outcomes: noticing the prediction skills of the model and the relationship between the structures. The main way to measure an inner structural model is by the coefficient of determination   indicates the degree of the effect of the latent exogenous structure on the latent endogenous structures. According to Cohen , the effQ2) by Stone Geisser for assessing the quality of the proposed model and the relevance of the model forecast. This model helps in computing the quality of the study model through the blindfolding method .This study applied the predictive relevance of the model - to strengthen marital commitment among married couples in Pakistan. Sociologists and anthropologists try to explain the critical significance of religious sociology and it focuses on the ways people live in society. Pakistani society thrives because of the consequences of theology, as 97% of its people are Muslims, and almost 2.5% are Christians. Therefore, the study results are helpful for decision-makers and policymakers in Pakistan, and the study findings provide valuable insights for other regions worldwide. The study focused on individual religious practices, beliefs, and societal manners, and how these factors influence the marital commitment of married people in Pakistan. The previous research findings have shown that Abrahamic religions (Islam and Christianity) share various identical values and similarities Agius, .The branches of Abraham's religion promote and educate people to strengthen traditional family ties, advise people to get merry rather than cohabitate and keep marital relationships instead of non-marital births .This study proposes another essential research direction for prospective studies to explore the role of spirituality and religiosity in global crises, such as the coronavirus disease 2019 (COVID-19) pandemic Abbas, . Future Despite numerous studies on marital satisfaction  marital commitment. The results also demonstrated that religious rituals are of great importance in predicting marital commitment . Finally, the terms and conditions of marriage were significantly positively related to marital commitment . The hypotheses of this study were thus supported.This study concluded that religious alignment has a profound influence on people and that it enhances religious commitment among couples by improving their awareness and determination to devote themselves to their families. The results showed that 173 (34.1%) individuals professed themselves very religious and that their marital commitment was firm because of their religious beliefs. In contrast, 255 respondents showed themselves to be religious and considered religion to be their priority. This result suggests that 428 respondents (84.3%) were very religious or religious, which indicates that Pakistani society has a strong link with religion and individuals are directly impacted by it. In contrast, 51 (10%) of the respondents declared that they were not religious, 23 (4.5%) couples did not practice any religious rituals, and 6 (1.2%) remained neutral in their beliefs. The findings also showed that religious beliefs were significantly able to predict (β = 0.764, Previous studies examined whether belief in the God of people could help them by providing security, control, help, and advice. Married couples declare and recognize that they consider God in their lives, which gives them a more substantial marital commitment. This study demonstrated that religious people avoid improper extramarital relations, and their religious beliefs make them devoted to staying with their spouse only. In general, religiosity is the most influential factor that affects marital commitment between couples, helping to maintain their relationship. It is a source of family stability and ultimately ensures family satisfaction between couples. Therefore, the religiosity level of individuals is critical. Marriage is the first stage in the formation of a family, and religious people see it as a holy and divine notion recommended by God. People are drawn to marriage as a way to sustain their family center. Religious education also helps maintain marital commitments. It can be combined with religious education, focusing on beliefs to strengthen the religious-oriented practices of individuals and to increase the participation of couples in religious and social ritual meetings. This will promote marital relationships and develop marital satisfaction among couples, thus improving marital relationships. All of the influencing factors in this study, such as religiosity, beliefs, rituals, age differences, and marriage conditions, are essential for married couples. Still, religiosity is the most important and plays a significant role in maintaining married life among religious-minded couples.This study focused on Muslim married couples from merely five selected cities in Pakistan, so the findings are not applicable to other regions and populations. Hence, further research studies should include substantial variability across diverse faiths to study marriage commitment and satisfaction among couples. The specific size of the sample cannot be considered as representing the whole of Pakistan. In addition, the research design did not allow causality to be deduced. A complete and inclusive evaluation of the respondents may overcome the deficiencies of the proposed survey. A qualitative research method or mixed research method is also recommended for future research. The authors eventually used just two aspects of religiousness, religious commitment and religious beliefs, during the execution of this study. Based on existing reviews, there are many other factors of religiosity that merit further investigation. Using a larger sample size to study other religiosity factors could provide more reliable results that could define the roles of these factors in marital commitment and ensuring a happy life among couples based in Pakistan.Regarding limitations, this study also faced certain limitations related to the milieu of cultural and social norms and values of Pakistan, which have existed for a 1,000 years. Therefore, a fundamental limitation associated with this study was the strong influence of so-called religious scholars. This was a significant barrier to collecting survey data from female respondents, as such religious scholars influence them. These scholars strongly believe that women should not interact with men other than family members. The impact of this on rural inhabitants was considerably higher. Even male respondents were unwilling or hesitant to respond, which led to the exclusion of rural residents from this study during the pilot test. This study maintained the secrecy of the respondents and did not release any information that could reveal who the respondents were; individuals could even refrain from discussing their specific internal context.The results showed that the responses did not necessarily reflect the respondents accurately. Some participants tried to present themselves as more religious than they were, while most of the respondents behaved well when responding to the survey. Further significant limitations related to this survey include the self-report tools used to complete this study.Finally, the study findings suggest that family therapists, family counselors, and married and experienced couples can play a pivotal or causative role in society by raising awareness of and commitment to marital satisfaction and high-quality relationships. This is possible through educating and encouraging other married people to maintain their marriages. They can inform others about the harmful results of divorce and its effects on families and children. On the other hand, marital commitment and marital satisfaction among married people can be improved/enriched through additional efficient and coherent measures based on the features of religious beliefs or thoughts by certain strategies that would support generalization and merit further study. Since there is insufficient research in the previous literature, various methods should be adopted to evaluate several maintenance strategies used by people who have had successful marriages.Concerning the future aspects of such research studies, only few measures are essential for the evaluation. The validity of questions, any bias in the selection process, and desired research tools are crucial for absolute reliability. Therefore, these issues need proper consideration, and researchers need to solve the research problems before conducting their study. While it appears problematic, it still offers new opportunities. This will allow potential readers to gain a broader understanding of building a satisfied and devoted marital bond. Religiosity is an incentive for marital commitment and has a significant impact on married couples when they share common religious bonds and beliefs. Therefore, the results of this study suggest that religiosity features will be useful predictors for future studies. Additional studies could explore the relationship between religiosity, attachment style, and marital satisfaction given cultural values of Pakistani society.The empirical data of this study is available upon the request from the corresponding authors.JAman conceptualized the idea, contributed to study design and analysis, and completed the entire article, which included Introduction, Literature, Discussion, and Conclusion, and edited the original manuscript before submission. JAbbas conceptualized the idea, contributed to the study design, and wrote and edited the full manuscript, which included, Abstract, Introduction, Literature, Methods, Discussion, and Conclusion, and edited the original manuscript before submission. UL contributed actively to revise the manuscript to address the reviewer comments and reviewed and approved the final edited version of this research study. GS approved the final edited version and supervised this research study. All the authors contributed to this study and provided their consent to publish this study.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.


This study investigated the current design circumstances of an office as well as employees’ perceptions of the office environment in relation to their perceived health, drawing on sense of coherence theory . Previous studies have related the physical office environment to employee health. However, most studies have focused on alleviating negative effects, while health-promoting potential, including employee sense of coherence, has been overlooked. This study adopted a mixed method case study approach, combining semi-structured interviews with employees, structured observations, and analysis of architectural drawings. The results indicated that employees’ perceptions did not always align with the ideas behind the architectural design and that employees understood the environment differently. The study also highlighted the interrelations (and contradictions) among the different components of sense of coherence. The findings imply that organizations may need to prioritize which components of coherence should be supported most by the office environment. It also suggests that case-specific design aspects should play a more central role in studying and conceptualizing healthy office design and that design solutions should be continuously modified during the use phase, while ensuring employees’ participation. The study concluded that an ‘ideal’ office environment should not be the goal. Instead, office design should provide an environment in which employees are able to cope with challenges in comprehensible, manageable and meaningful ways. How can we plan, design, and manage healthy office environments? Studies show that the physical office environment influences employees’ health. However, most studies have focused on identifying risk factors for health (pathogenic aspects) ,2,3,4. MFlexible office concepts, such as activity-based and combi offices, are intended to support flexible ways of working. In these office concepts, workstations are combined with back-up spaces, such as quiet rooms for concentrated work, phone booths for calls, meeting spaces for collaborations, to support work activities . The maiStudies suggest that architectural design features such as lighting, layout, furniture, acoustics, privacy and the process of relocation/modifications have an impact on how employees experience their new offices ,16,17,18RQ1: What are the current office design circumstances?RQ2: In what way(s) do employees’ perceptions of the office environment relate to their SOC?Given that the case-specific design aspects play a key role in how employees experience office environments, qualitative and in-depth research approaches appear particularly relevant to (i) further understanding of architectural design features that are important to employee SOC; (ii) creating a more accurate evidence base for comparison; and (iii) planning, designing and maintaining healthy office environments. In addition, qualitative studies on the effects of office use on employee health are scarce . Based oThis paper adopts the conceptualization of health proposed by Huber et al. : ‘the abA resourceful  working environment helps employees build up a SOC which leads to greater work engagement . HoweverThis paper builds upon Forooraghi et al. , who appComprehensibility in the office context relates to the features that make the environment structured, predictable, and explicable.Wayfinding refers to attributes of the environment facilitating or hindering easy orientation.Understanding the function of the space refers to attributes of the environment that communicate the function of a space.Behavioral rules refer to attributes of the environment and/or agreements between employees and organizations indicating expected behavior in the physical environment.Information sharing refers to attributes of the environment as well as organizational procedures in which practical information about relocation and/or office maintenance is clearly communicated.Manageability in the office environment relates to the features that enable access and control over resources needed to cope with the challenges of the environment.Control over the environment refers to attributes of the office facilitating or hindering control over perceived stimuli.Access to resources refers to attributes of the environment facilitating or hindering access to preferred/needed technical equipment, furniture, and storage space.Participation and involvement refer to change processes facilitating or hindering building user involvement.Life management refers to amenities that facilitate or hinder employees in balancing the pressure of work life.Meaningfulness in the office environment relates to features that evoke meanings in the environment.Nature references refer to attributes that enable access to the elements of the natural environment.Social connections and support refer to attributes of the environment facilitating or hindering social interactions and feelings of community.Personalization and sense of ownership refer to attributes of the environment facilitating or hindering building users asserting meaning to space through identity expression.A mixed-method case study approach was adopted to investigate the current office design circumstances as well as employees’ perceptions of the office environment in relation to their SOC. Data collection involved semi-structured interviews with employees, structured observations, architectural drawings, and secondary documentations. This methodology followed a convergent-parallel design; i.e., data were collected by different methods in parallel, were analyzed separately, and then the findings were compared, contrasted and integrated , as dispThe qualitative research approach was chosen for an in-depth study of the subjective nature of individuals’ SOC . The quaThe case concerns a university department that relocated from cell offices into a renovated combi office in August 2017. The relocation was combined with an organizational merger bringing together 10 different divisions of employees into one department. Three out of ten divisions had their offices in the same building prior to renovation, and the rest came from other buildings on the campus.The study focuses on the staff areas on the third, fourth (offices and back-up spaces) and fifth (only staff lunchrooms and meeting spaces) floors . The buiThe office interior was modified two years post-relocation by the facility management: (i) A quiet room with couches was turned into a shared office room due to a lack of workstations, (ii) a windowless meeting room was turned into a printing room, following complaints about lack of printers, (iii) translucent curtains were added to office rooms facing the staircases to enhance visual seclusion, and (iv) couches in the lunchroom were moved to other breakout areas on fourth floor and replaced with dining tables and chairs.All university employees of the department were invited via email and posters on site to participate in the study. Forty-one employees volunteered to participate in the interviews . The parData were collected in September 2019, two years post-relocation, through individual semi-structured interviews, structured observations, and review of architectural drawings and secondary documents, such as a building guidebook.The interviews averaged an hour, and they were audio recorded. The questions were designed to enable the interviewees to share their insights on how they experienced the office environment, their activities and preferences . A card-The observations in the office were structured observations; i.e., a systematic plan with a predefined route was used, and employees were aware of the observer. A total of 18 rounds were conducted by the first author. Each predefined route included walking around all the workstations, back-up spaces and breakout areas, with the observer taking structured field notes and drawing annotations as well as pictures. The field notes indicated, for example, the workstations and back-up spaces in use, the number of employees per space, the available facilities and equipment, flows of people between spaces, and whether different spaces were organized and orderly. The rounds were scheduled according to the availability of the observer, avoiding events that were not part of the daily routine of employees and caused abnormal occupancy rates, such as a monthly department meeting. The observations were conducted over two weeks and across four intervals , with the aim to cover the equivalent of a regular Monday to Friday working week.Secondary documentation included an office in-house guide with plans and behavioral guidelines. Such documentation was collected from the university’s internal website, which is accessible to all employees. The architectural drawings, i.e., floor plans, were provided by the facility management and were updated by the first author to be used for observation rounds and further analysis.The data analysis consisted of multiple iterative stages, including content analysis of the interviews, descriptive analysis of the observation rounds, and floor plan analysis of the building material.The interviews were transcribed and coded using NVivo 12. An abductive approach was adopted to analyze the content; combing an inductive and deductive approach, defined as ‘creative inferential process’. That is using empirical data and theoretical prepositions in a dialogical process for analyzing qualitative data . The firFurthermore, data from the observations were analyzed to support and complement the findings from the interviews. This involved reviewing and summarizing observation field notes and occupancy data. Occupancy was calculated for office rooms based on the percentage of workstations occupied with respect to the maximum number of workstations. Utilization was calculated for back-up spaces based on the percentage of the total number of 18 observation rounds that the spaces were observed in use.The architectural drawings and secondary documents were analyzed from a design perspective to support and complement the findings. That is, the employees’ perceptions were contrasted with observation data, architectural drawings, secondary data, and pictures of the office to understand the underlying reasons for these perceptions. For instance, exposure to visual stimuli was mentioned as a negative feature by the majority. The level of transparency observed in drawings and observations confirmed that the extensive use of glass partitions led to a high level of exposure to visual stimuli. Another example is that when interviewees referred to behavioral rules, the in-house book was analyzed to determine what type of information the organization had communicated about expected behavior in shared office rooms and back-up spaces.The triangulation of multiple data sources followed a parallel convergent design, in which the data from different data sources were analyzed independently and brought together during the interpretation .Approval was obtained from the head of the department to carry out the study. Prior to being interviewed, all participants were informed verbally and in writing about the purpose of the study, that their participation was voluntary, that they could end their participation at any time, and that they could choose not to answer any questions. They were also informed that the personal information would be known only by the research team and would be protected according to the General Data Protection Regulation. Informed consent was obtained when the participants agreed to complete the survey.The findings are presented in three sections that reflect the SOC components  and their subthemes, according to the SOC framework by Forooraghi et al. . All secThe perceptions of the office environment show that comprehensibility was associated with wayfinding, understanding the function of the space, and behavioral rules, as presented in .As mentioned, wayfinding refers to attributes of the environment facilitating or hindering easy orientation.Design setting: The observation and floor plans show the symmetrical layout, and the deficiency of distinct design features, i.e., landmarks, in addition to the use of identical and repetitive furniture and colors in all corridors and corners, could lead to navigation challenges, especially for those who were not familiar with the building . That saPerceptions: The interviews indicated that wayfinding had varied influences on how employees comprehended the layout of the office. One-third of the interviewees (13/41) reported that the orientation in the building became intuitive after becoming used to the labeling system and the layout. Nevertheless, others (12/41) found wayfinding difficult due to the monotonous look and the square layout .Understanding the function of the environment refers to the attributes of the environment that communicate the function of the space.Design setting: Most spaces had signs outside and inside of the door indicating the room number and its intended use. Exceptions were the phone booths, which had signage/labels on the window . The abiPerceptions: The different functions mentioned by the interviewees included offices, meeting rooms, phone booths, and quiet rooms. The interviewees expressed alternative activities in these spaces. For instance, spaces labeled phone booths were found to be suitable for engaging in concentrated work with minimal distraction and signaling unavailability to colleagues . Quiet rBehavioral rules refer to attributes of the environment and/or agreements between employees and organizations indicating expected behavior in the physical environment.show consideration and respectbe clean and tidy—leave common areas as you would want to find themenjoy the shared space but please leave private furniture, textiles and plants at homemaintain peace and quiet—it is important to keep your voice down and avoid talking across the roomwhen necessary, use a meeting room or other suitable space for lengthy discussionsuse headphones when listening to music, the radio and so onshow consideration in the use of perfumes or other scentsif somebody’s behavior disturbs you, do say so—but try to give constructive feedback.Design setting: An in-house guidebook was given to employees upon their relocation to the new office in August 2017. The guidebook provided information about the new premises and office etiquette. However, the book was not updated after the office modifications were implemented in August 2019. The book was mentioned only once in the interviews. According to the guidebook, employees should comply with the following guidelines:Nevertheless, the expected level of cleanliness and individual responsibilities were not clearly communicated. Instead, employees were asked to keep the common areas ‘as you would want to find them’.Perceptions: Almost all interviewees reported that they did not have any agreements on how to behave in the office rooms, regardless of the type of office . More thInformation sharing refers to attributes of the environment as well as organizational procedures in which practical information about relocation and/or office maintenance is clearly communicated.Design setting: The phone numbers of maintenance service were provided at the door of every room, providing access to information. However, it was not communicated whether a problem report was already being processed.Perceptions: The office was perceived as less comprehensible by a minority of interviewees (8/41) due to ambiguous facility management strategies/processes. Some interviewees reported that the maintenance service was unresponsive to problem reports, especially concerning the automated shades.The findings show that the office environment influenced manageability through control over the environment, participation and involvement, access to resources and life management amenities, as presented in Control over the environment refers to attributes of the office facilitating or hindering one’s control over perceiving visual and acoustic stimuli.Design setting: The office offered limited personal control over the environment. The climate system was centrally regulated. Additionally, the shades were entirely automated with a sensor that reacted to the amount of daylight outside, at one floor at the same time, with the consequence that the rooms with less daylight became even darker. The extensive use of glass partitions in all office and back-up spaces increased the level of transparency . That saPerceptions: In general, most interviewees perceived limited possibilities to control their environment, i.e., temperature, automated shades, and visual and acoustic stimuli, which reduced office manageability. Temperature was regarded as too low, with no possibility of influence by two-thirds of interviewees (28/41). Over half of the interviewees (22/41) were dissatisfied with the automated shades due to them malfunctioning and offering limited access to daylight. A lack of control over visual stimuli was experienced by 25/41 interviewees, and only four interviewees appreciated the increased spatial transparency. One-third of interviewees (14/41) were satisfied with visual privacy, all of whom had almost secluded workstations. A similar pattern was observed for half of the interviewees (20/41) perceiving a lack of control over acoustic stimuli, and thus the office environment was perceived less manageable.Access to resources refers to attributes of the environment facilitating or hindering access to preferred/needed technical equipment, furniture, and storage space.Design setting: All employees had access to resources, including a uniformly sized personal storage cupboard, shelves, a height-adjustable desk, an adjustable office chair and a docking station in the office rooms. Meeting rooms were equipped either with or without a whiteboard, display screen, video projector and webcam. Flex rooms had cupboards with one screen per desk .Perceptions: The majority of interviewees (31/41) found their needed resources to be available and accessible. High-quality and adjustable furniture, adequate storage space and good IT equipment were found to be important to manage one’s work. An appreciable minority (10/41) experienced a lack of storage space, difficulties working with equipment and a lack of IT support and training.Participation and involvement refer to change processes facilitating or hindering building user involvement.Design setting: In an interview, the change coordinator confirmed that staff participation in the design process was limited to choosing between some predefined solutions provided by the architects. The change process was communicated through a newsletter and organization internal platform.Perceptions: While only a few interviewees (7/41) perceived the opportunity for participation in pre- and/or post-relocation change processes, 16/41 interviewees did not perceive the possibility. The interviewees found the opportunities more formal than practical in that the final solutions were predetermined and that employees’ input was not considered. Overall, the perceived limited involvement in the change processes reduced the sense of empowerment and manageability. This also reduced meaningfulness by creating a sense that the employees’ opinions were underappreciated.Life management refers to amenities that facilitate or hinder employees in balancing the pressure of work life.Design setting: The observations and floor plans showed that facilities such as a resting room, changing rooms and bicycle storage were provided. Accessible changing rooms with cupboards and showers were located in the basement, one for female staff and one for male staff, and the bicycle storage was located in the basement of the building next door. However, no bicycle rack was provided in the storage, decreasing the security of the room. The resting room was located on the 3rd floor with a solid curtain on both sides, being the only room in the building that offered complete isolation.Perceptions: The majority of the interviewees (35/41) perceived high decision latitude for choosing where and when to work due to the organization’s trust-based culture. The freedom to be in control of one’s own work schedule helped manage work-life balance. Nearly a quarter of interviewees reported a lack of access to proper biking facilities such as showers, changing rooms, and enclosed bicycle storage. Only a minority of interviewees (5/41) reported using the resting room on the third floor for relaxation and stress recovery.Meaningfulness in the office environment was associated with nature references, the social environment, personalization, and a sense of ownership .Nature references refer to attributes that enable visual or physical access to the elements of the natural environment.Design setting: All office rooms had windows with outdoor views. However, the northern and western façades faced the campus area and a hill, while the eastern façade faced a concrete wall, and parts of the northern façade faced a brick wall. The central atrium with a glass roof provided daylight and sky views, in addition to the interior balconies simulating an outdoor space . The souPerceptions: Half of the interviewees (20/41) found the views from office windows and balconies inspiring and meaningful, while nearly the other half reported unpleasant views on a concrete and brick wall. Nature references such as greenery and plants in the office interior were perceived as insufficient by 26/41 interviewees. One-third of interviewees (13/41) appreciated the amount of daylight. However, the automated shades limited access to daylight for another third, making the office less meaningful.Social connections and support refer to attributes facilitating or hindering social interactions and a sense of community in the office.Design setting: The shared office rooms , as well as a high level of transparency between the office, back-up spaces and the corridor, increased visibility due to the use of glass partitions and thus increased access to colleagues. The two large breakout areas on the third floor accommodated larger groups of people than those on the fourth floor, which had a maximum of six persons . The lunPerceptions: Over half of the interviewees (23/41) perceived increased access to colleagues and preferred face-to-face interactions for quick exchange of information. The majority of interviewees (36/41) also appreciated the diverse, proximate meeting rooms and breakout areas, which facilitated meetings and breaks with colleagues and hence improved meaningfulness. In particular, the balconies were among the most popular spaces in the breakout areas, offering a bright, relaxing environment for the majority of the interviewees (31/41). Conversely, 12/41 interviewees experienced a lack of sense of community due to difficulties in locating colleagues. This eventually led to feelings of isolation and thereby office environment was perceived less meaningfulness. Some interviewees (5/41) found limited student access to staff areas beneficial to managing one’s privacy. However, others (9/41) perceived a subsequent increase in the hierarchy between students and teachers.Personalization and aesthetics refer to attributes of the environment facilitating or hindering building users from adding personal/professional items to their work environments.Design setting: The colors used in the office interior were mostly neutral  and earthy . Some parts of the office floors were cluttered with books, folders, models and moving boxes , often wPerceptions: Almost half of the interviewees (20/41) appreciated the minimalistic and neutral look. Nevertheless, 16/41 found the aesthetic design of the office too ‘sterile’ and ‘impersonal’, which reduced office meaningfulness . Over onThis study investigated the current office design circumstances and employees’ perceptions of the office environment in relation to their SOC. The overall goal was to contribute to the understanding of interrelations between the office design, the perceived office environment and employees’ SOC. The findings about the office environment are discussed in relation to SOC. Additionally, methodological concerns and practical implications are addressed.The findings indicate that employees had a different conception of place than intended by the designer. That is, the potential of the office environment, such as biking facilities, was not perceived by the employees, reflecting low office comprehensibility. This could be due to a lack of communication with employees concerning the facilities provided. In contrast, the employees found potential in the office environment, which led to deviation from intended use. These acts have been conceptualized as the ‘misuse’ of architecture and as one of the reasons why flexible office concepts do not work as intended . BabapouThe study shows that the components of SOC are interrelated. For instance, transparency and openness increased opportunities for interaction and were associated with positive meanings. However, this also led to difficulties in managing acoustic and visual distractions. This finding aligns with previous associations between open office environments and increased noise and lack of privacy . Hence, Another interrelation is exemplified by personalization and subsequent feelings of confusion for employees. While employees were discouraged from adding personal items to the environment to assert meaning, some found the rules ambiguous (comprehensibility). Nevertheless, personalization of space is used as a means of making sense of the environment and giving meaning to the workspace ,44.The study highlights the relation between the (use of the) office environment and facility management in terms of behavioral rules, lack of training, and a maintenance system experienced as inconsistent with the follow-ups. The importance of clear behavioral rules for successful implementations ,45 as weThe adopted qualitative case study approach fits the contextual nature of architectural design and health  and is cA key strength of the study approach was its objective design perspective in combination with the perceptions of employees. Given the variety of layouts, sizes, implementation processes, etc., flexible offices should be studied with attention to their design differences in order to capture diverse experiences. The study provided insight on the case-specific design aspect which contributes to the development of a sound evidence base. This enables more accurate comparisons between different cases and helps to map positive and negative design aspects in flexible office environments. The study also provides in-depth insights regarding a range of aspects, from risk factors for health (pathogenic aspects) to health-promoting potential of office environments , in response to previous calls for positive approaches toward health) ,2,3,4. INotably, the involvement of design professionals as participants may have resulted in negative bias since design professionals might be more critical about space . HoweverFrom a salutogenic perspective, previous research has shown that when people are healthy, they demonstrate a theoretical surplus of coping resources . NeverthThis study focused on the salutogenic factors of the office environment outlined in the SOC framework. The findings showed that when these factors fit employees’ needs and preferences, they become resources to cope with challenging conditions. Nevertheless, the same factors can become deficits, when they are suboptimal, hindering employees’ SOC.The negative perceptions regarding various aspects of the office environment highlight suboptimal design features with regard to employees’ SOC. The following modifications are based on authors’ interpretations and concern continual enhancements in the office environment that may improve SOC through, for instance, the introduction and communication of expected behaviors, the addition of meaningful items to the office environment, and increased control by adding space-level control over stimuli .The findings showed that not all potential of the office environment was perceived by the employees. Additionally, the ways that employees appropriated the office environment were not planned by the designers. The study also highlighted interrelations between the SOC components. Low levels of office comprehensibility caused by a lack of behavioral rules, information about existing facilities, and facility management/maintenance subsequently led to reduced manageability and meaningfulness. Discouragement of personalization and a subsequent feeling of confusion for employees limited comprehensibility and meaningfulness. Moreover, the facilitated access to colleagues, which was perceived as meaningful, led to more distractions and reduced manageability. The study noted that spatial transparency and openness did not prevent feelings of isolation among some employees and that more interaction is not always better for SOC. This finding implies that organizations may need to prioritize which components of SOC should be supported most by the office environment. Furthermore, it suggests that case-specific design aspects should play a more central role in studying and conceptualizing healthy office design and that design solutions should be continuously modified during the use phase, while ensuring employees’ participation.As outlined in the introduction, a question of interest to organizations and practitioners is how office environments should be planned, designed, and managed to support or enhance health. This question cannot be suitably addressed when the specificity of design is overlooked. Furthermore, the study notes that an ‘ideal’ office environment should not be the goal. Instead, office design should provide an environment in which employees are able to cope with challenges in comprehensible, manageable and meaningful ways.


Total or partial vulvo-vaginectomy or vaginectomy are not routinely surgery due to the complexity of the techniques and because they are considered radical treatments. Furthermore, in literature, there is a paucity of information regarding these techniques and the extent of the reproductive tract resection is not always clearly defined, as the same technique is often named in a different way by different authors, confusing the reader. The aim of this article is to review and describe five surgical procedures on the basis of the correct identification of the anatomical areas: partial vaginectomy, complete vaginectomy, partial vestibule-vaginectomy, vulvo-vestibule-vaginectomy and vulvo-vestibulectomy. For each technique, indications and possible intraoperative and perioperative complications are mentioned. Moreover, authors’ clinical experience in 33 dogs presenting genitourinary lesions not amenable to local resection via simple episiotomy and outcomes are described.Total or partial vulvo-vaginectomy or vaginectomy are not routinely performed due to the complexity of the techniques and because they are considered radical treatments. Little information can be found in the literature, as the same technique is often named in a different way by different authors, confusing the reader. Therefore, the aim of this essay is to describe five different surgical techniques: partial vaginectomy, complete vaginectomy, partial vestibule-vaginectomy, vulvo-vestibule-vaginectomy and vulvo-vestibulectomy. All techniques are described on the basis of the correct identification of the anatomical nomenclature related to structures involved in surgery, in order to give a more precise and unambiguous description and execution of surgical techniques. Moreover, possible intraoperative and perioperative complications and the authors’ clinical experience in 33 dogs are described. All techniques are well tolerated and could be curative in case of benign or malignant tumours that have not yet metastasized and palliative in other cases. Moreover, they are also useful for therapeutic purposes for chronic vaginitis, severe vaginal cysts or congenital abnormalities. It is our opinion that having five different available techniques to approach vaginal disease is useful to perform the best surgery according to the clinical findings, patient’s characteristics, technique invasiveness and whether it is palliative or not. Many diseases, such as benign or malignant neoplasia, vaginitis, vaginal prolapse and congenital abnormalities, could affect the copulatory organs  in the dog and most of them could be age-related . For theUnfortunately, in literature there is little information regarding the surgical techniques performed on the copulatory organs. In particular, the extent of the reproductive tract resection is not always clearly defined, as the same technique is often named in a different way by different authors, confusing the reader.In the authors’ opinion, a correct anatomical nomenclature related to structures involved in surgery could lead to a more precise and unambiguous description and execution of surgical techniques.Therefore, our purpose is to give a more specific and specialized point of view, starting from the Nomina Anatomica Veterinaria (N.A.V.) to describe in detail five different surgical techniques available for the female reproductive system of the dog.N.A.V. subdivides the female reproductive system in Organa genitalia feminina  and Partes genitales femininae externae  . The vagOn the basis of the correct identification of the anatomical areas, five surgical techniques can be described: partial vaginectomy, complete vaginectomy, partial vestibule-vaginectomy, vulvo-vestibule-vaginectomy and vulvo-vestibulectomy .Partial vaginectomy involves the removal of a variable tract of the vagina, always including the cervix. All vaginal tissue, from the cervix to the hymen, are removed in complete vaginectomy. A partial vestibule-vaginectomy is similar to the complete vaginectomy, but a variable part of the vestibule is involved: in this case, a urethrostomy performed in the segment of the vestibule tissue left in situ is mandatory. In a vulvo-vestibule-vaginectomy, all the copulatory organs  are removed and a perineal urethrostomy has to be performed. In a vulvo-vestibulectomy, the externa genitalia and a variable vestibular length is removed: the urethral tubercle is not involved . Except The objective of this study is to describe, in function of the N.A.V. organs’ description, these five different surgical approaches to the bitch reproductive system as performed by the authors. Since the literature provides scarce and ambiguous explanation about these kinds of techniques, another purpose is to offer to practitioners an exhaustive description in order to provide a repeatable, safe and tolerable surgical procedure. For each technique, indication and possible intraoperative and perioperative complications are mentioned. Moreover, authors’ clinical experiences in 33 female dogs presenting genitourinary lesions not amenable to local resection via simple episiotomy and outcomes are described.In the next paragraph, partial vaginectomy, complete vaginectomy, partial vestibule-vaginectomy, vulvo-vestibule-vaginectomy and vulvo-vestibulectomy, as performed by the authors, will be described. All information described below is summarized in Partial vaginectomy (PV) is requested when the first third of the vagina is involved in a pathological process. The main indication for a partial vaginectomy is the treatment of benign or malignant neoplasia, chronic cranial vaginitis unresponsive to medical or surgical treatment such as urethropexy, or cervix trauma occurred during parturition. In the case of malignant tumour, PV is recommended if there is no local dissemination or distant metastases. It could also be performed as a palliative procedure for advanced malignancies when the owner does not allow other surgical procedures, the tumour pushes organs such as rectum or bladder, or in elderly patients. Chronic cranial vaginitis could be consequent to congenital malformation of the vagina and vestibule that cause an urinary reflux or to an abnormal outflow of urine or urine stagnation in the vagina caused by topographic abnormalities of the genital tract following sterilization at a very young age .PV is performed via an abdominal approach with the patient in dorsal recumbency. A ventral midline incision from the umbilicus to the pubis is performed. In intact or ovariectomized dogs the surgical procedure is completed in two steps: in the first step, routine ovariohysterectomy (OVH) or hysterectomy are performed and the bladder is retroflexed to expose the vagina .In the second step, the cranial vagina is resected. The rectogenital and vesicogenital pouch are carefully dissected via blunt and sharp dissection with the purpose to allow the complete isolation of the vagina. The dissection must be performed very close to the vagina in order to prevent inadvertent trauma to the ureters, and to preserve the innervation of the bladder and urethra. Vascular supply  that runs laterally the cranial part of the vagina are ligated close to the vagina and close to the rectogenital and vesicogenital pouch. The vagina is then cranially pulled to allow the resection as caudally as possible. The vaginal stump is sutured with single, introflexing detached sutures. The abdominal wall is then closed as routine.PV performed via abdominal approach presents minimal complications, but the surgeon must be careful when working between the two ureters at the base of the broad ligament lateral the uterus body and vagina: in overweight or obese dogs, the ureters could be difficult to recognize. Urethra must be recognized and not damaged as well as vaginal vascularization to avoid postsurgical complications. The use of a urinary catheter makes it easier to recognize the urethra. Moreover, in some cases, it could be necessary to resect the vagina more caudally, depending on the extension of the lesion: in this case it could be necessary to tie the vaginal artery and vein. These vessels must be ligated as close as possible to the vagina in order to avoid unintentionally tiding of bladder and urethra vascularization.However, depending on the breed, the patient state of nutrition, neoplasia location or topographic position of the vagina, it could be necessary to break through the vesicogenital pouch that divided the peritoneal cavity from the retroperitoneal one in order to allow the complete resection of the organ involved. Moreover, the uterine and vaginal artery  on the lateral wall of the vagina, the pelvic plexus  located on both side of the cervix and pudendal nerve that runs along the dorsal edge of the internal pudendal artery must be identified and preserved. It must be emphasized that in PV, due to the pubic bone, a complete visualization of the structures in this area could not be always possible, thus palpation could help their identification.Intraoperative complications are haemorrhage, urethral damage (such as rupture or stretching) and lesion of the rectum, bladder or clitoris’ corpora cavernosa consequent to a damage of the pelvic plexus. In the post-operative period, it is sometimes possible to detect urethral spasms that could led to transitory urinary retention more frequently than urinary incontinence. Intra- and post-operative complication could be avoided or minimized if the surgery is properly performed as described and all steps are carefully executed.Complete vaginectomy (CV) is indicated when benign or malign tumours, chronic vaginitis or neoformations involving the entire vagina and a PV cannot be performed.First of all, ovariohysterectomy (OVH) or hysterectomy via abdominal approach are performed in intact and ovariectomized dogs. If the dog has previously undergone ovariohysterectomy, before CV is performed, it may be necessary to solve possible adhesions between the vaginal stump, the bladder and the rectogenital and vesicogenital pouch.CV is performed via a perineal approach with the dog in sternal recumbency. The perineal skin, from the base of the tail to the vulvar lips and laterally to the mid-thigh region, are shaved. A pursue-string suture is placed in the anus and a sterile Foley catheter is inserted in the urethra. Immediately after surgery, the pursue-string suture is removed. A midline incision between anus and the dorsal commissure of the labia of the vulva  is made. Tissue and muscle  are carefully dissected via blunt and sharp dissection in order to allow the complete isolation of the vagina. Vascular supply to the vagina  is ligated as close as possible to the organ in order to prevent damage to the other vessel or nerve that could be found in this anatomical region. The isolated vagina is then retroflexed and retracted caudally. Attention must be paid to the urinary meatus, which must not be removed or damaged during the resection of the vagina: the urethra and its junction with the vaginal floor are identified via the urinary catheter and the vagina is resected just cranially in order to left enough tissue to perform an introflexing detached suture. That allowed the complete asportation of the vagina and hymen without involving the urinary meatus. The subcutaneous and cutaneous tissue are closed with attention to ureters, urethra, vessel and pelvic plexus which must not be involved in the suture. Intra- and post-operative complication are similar to those described for PV.Partial vestibule-vaginectomy (PVV) is recommended as treatment for benign or malignant neoplasia, chronic cranial vaginitis unresponsive to medical or surgical treatment, congenital and acquired malformation like stenosis, cyst or paramesonephric residues, vaginal diseases near to the hymen or in the proximal third of the vestibule.Ovariohysterectomy (OVH) or hysterectomy via abdominal approach are previously performed in intact and ovariectomized dog.PVV could be performed by perivaginal approach with the dog in sternal recumbency. The surgery procedure is the same as previously described for CV, but the resection of the organ includes, besides the vagina, a variable part of the vestibule depending on the extension of the lesion.During this procedure the urethra is identified via the urinary catheter, dissected free via blunt dissection and resected at its junction with the vestibula floor. After the resection of the vagina and vestibule, dead spaces are closed by reopposing adjacent soft tissue structures. In order to perform the urethrostomy, an episiotomy is needed to expose the floor of the remaining vestibule. An incision on the midline of the vestibule floor is then performed, the spatulate cut end of the urethra is exteriorized through the small stab incision and the urethral mucosa is sutured to the vestibule mucosa with a 4-0 absorbable monofilament glycomer simple interrupted suture. As the urethrostomy is completed, the episiotomy incision will be closed with a simple continuous pattern with a braided polyglycolic acid absorbable suture in three layers: vestibula mucosa, muscles and subcutaneous tissue and lastly the skin.Intra- and peri-operative complication are the same as described for the other surgeries. A Foley catheter must be left in situ for a couple of days to allow complete healing of the urethrostomy.Vulvo-vestibulo-vaginectomy (VVV) is indicated for benign large or multiple neoplasia involving the vagina, vulva and vestibule, malignant neoplasia, chronical vaginitis and vestibulitis.VVV could be performed by a mixed approach  or caudal approach alone: a perineal urethrostomy is always required.The mixed approach is mandatory in intact or ovariectomized dog and in all cases with suspected abdominal adhesion. The surgical procedure is completed in two steps: an abdominal approach for ovariohysterectomy (OVH) or hysterectomy and a caudal approach for the resection of the vagina, vulva and vestibule. The surgical field is prepared as described for the perineal approach for the CV procedure.Subsequently to OVH or hysterectomy, the bladder is retroflexed to expose the vagina and associated structures. The surgical procedure is the same as described in the PV. In the second step, the patient is placed in sternal recumbency to expose the perineal region. An elliptical incision around the vulvar margin is made, followed by the clitoral artery isolation and ligation in order to prevent emorrhagia. The caudal vagina and vestibule are freed via blunt dissection from the surrounding tissue and ischiocavernosus, ischiourethralis, the superficial branch of the external sphincter ani muscle and constrictor vestibuli muscles are resected, in order to allow a complete dissection . The vagIn caudal approach all the vagina, vestibule and vulva are completely isolated from the surrounding tissue and resected as described above. The vaginal artery must be ligated as deeply as possible.In both caudal and mixed approach, the urethra must be managed with caution to prevent damage to the distal tract and must be freed from the muscular component to correctly perform the urethrostomy. If the vessel of vaginal and clitoral are not correctly identified and ligated, a haemorrhage may occur.Vulvo-vestibulectomy (VV) is indicated for benign clitoral neoformation, malignant not infiltrated neoplasia, vulvo-vestibular traumatic or congenital lesions such as labial aplasia or vulvar stenosis.The patient must be prepared as described for the caudal approach of the CV. An elliptical incision around the vulva is performed, followed by the clitoral artery isolation and ligation. Vulva and vestibule are dissected via blunt and sharp dissection from the surrounding tissue and the ischiocavernosus, ischiourethralis and superficial branch of the external sphincter ani muscles are resected in order to allow vestibula resection just caudally of the urinary meatus. Subsequentially, a restriction of the remnant part of the vestibula diameter, the stump of the genital tract will be pulled caudally and inclined in order to prevent an incorrect urinary out flow or vaginal urinary stagnation: the vestibule mucosa is then sutured to the skin with simple interrupted suture.The technique does not require particular attention, except to avoid injuring urethra and urinary meatus.The medical records of thirty-three female dogs that underwent PV, CV, PVV, VVV or VV from 2008 to 2021 were reviewed. Age, breed, medical history, clinical findings, preoperative diagnostics, post operative management, complications occurred during the surgery and in the postoperative period, and histological diagnoses were recorded.In all cases where a vaginal mass was suspected, diagnosis has been made on the basis of history and clinical evaluation that include vaginal and rectal palpation: in some cases, biopsy or fine-needle cytology of the mass were performed. Ultrasonography of the reproduction tract , biochemical and haematologic profiles, abdominal ultrasound examination  and thoracic radiographic  for cancer staging (when necessary), vaginal cytology was performed in all bitches.®, Ati PETS, Bologna, Italy) or 0.005 mg/kg dexmedetomidina  and 0.2 mg/kg metadone , general anaesthesia was induced by administration of 2–4 mg/kg propofol  intravenously. Anaesthesia was maintained with 1.5–2% isoflurane  in oxygen.In each bitch, after a premedication with an intramuscular injection of 0.01–0.02 mg/kg acepromazina  and the mean age was 9.39 years sd 2.96 . Breeds represented included mongrel (12), Beagle (1), Boxer (3), Labrador (2), Yorkshire Terrier (2), Cavalier King Charles (1), Cirneco dell’Etna (1), Dalmatia (1), English Bulldog (1), English Setter (1) English Cocker Spaniel (1), French Bulldog (1), German Shepherd (1), Golden Retriever (1), Irish Setter (1), Maremman Shepherd (1), Pointer (1) and Siberian Husky (1). Signalment data of the patients are reported in At presentation, as reported in Dog 26 arrived to our clinic for an uroperitoneum originated from a vaginal rupture following surgical closure of the urinary meatus following the surgical removal of a vaginal mass.The surgical technique was planned in function of the clinical examination, abdominal ultrasonography, vaginoscopy and/or vaginography performed and the direct intraoperative visualization of the neoplasia and/or cytological/biopsy preoperative evaluation.Thirty dogs underwent surgery for removal of a vaginal or vulvar neoformation, two for a fluid filled vagina, and one for a fluid filled vagina associated to a chronic vaginitis. PV was performed in 14 dogs, CV in one dog, PVV with a vestibule urethrostomy in two dogs, vulvo-vestibule-vaginectomy with a perineal urethrotomy in seven dogs and VV in nine dogs. Ovariohysterectomy was performed in all intact dogs that underwent PV or CV and VVV. In two dogs who had undergone, respectively, PVV and PV and were previously neutered by ovariectomy, hysterectomy was performed.Surgery was successfully achieved and well tolerated in all dogs.®, Formevet, Milano, Italy) and 2–4 mg/kg carprofen  or 1 mg/kg robenacoxib  once a day for 3 days to reduce inflammation and edema. Amoxycillin/clavulanic acid  at 12.5 mg/kg twice a day for 10 days was administered as prophylaxis.An urinary catheter was left in place for 24–48 h in VV and up to 7 days in VVV or PVV; a petroleum jelly was applied to the perineum to prevent urine scalding at least for 10 days. An Elizabethan collar was used until the removal of the suture. Pain was managed with the administration of 2–4 mg/kg tramadol every 8–12 h  was hospitalization longer. In dog 12, who underwent vulvo-vestibule-vaginectomy and ovariohysterectomy because of neoformations in cranial vagina and in the vulva, the surgery was quite long and a severe haemorragia was observed, requiring a longer recovery due to pain management and blood transfusion. In dog 26, the longer hospitalization was according to clinical alteration referred to the uroperitoneum presented before surgery. In all cases, except for two (dog 1 and 12), the short-term outcome of 7 days was without complications. No micturition or defecation problems were observed, nor ureters or bladder anomalies were ultrasonographically detected in post-operative stage. In dog 1, as a large skin excision lateral the urethrostomy area was necessary, the healing process led to a deviation of the urethrostomy site and a consequent deviation of the urine jet was observed.The postoperative management of dog 26 was without complication, even if in this case surgery was a palliative cure, as metastases were observed at the presentation.Twenty-eight samples were analysed via histopathology; in five cases, the owners refused the histological examination. Vaginal neoplasia (25/28), an intramural cyst (2/28) and a fluid filled vagina with a severe chronic purulent ulcerative vaginitis (1/28) were diagnosed. The results of the histological or cytological examination, performed during the preoperative evaluation, has been confirmed by the histopathological examination done after surgery excepted for dog 33 where the cytological examination was in doubt because the poor cellularity. The results of the histopathological examination are shown in Aim of this article was to describe five different surgical techniques to correct diseases affecting the vaginal, vestibular and vulvar tract in the bitch. To date, the literature reports only four surgical techniques involving this reproductive tract: the authors instead differentiate five techniques depending on the portion that has to be removed and gave instructions to plan the best and less demolishing intervention in agreement with the disease, the age and the physical condition of the patient. Of the five surgical techniques we have described, in the literature, no cases of vulvo-vestibulectomy  are reported. The surgical techniques depicted in this essay are classified in function of the anatomical female reproductive tract involved in the surgery as illustrated in The main problem we had to face, related to surgical techniques described in the literature, is linked to the nomenclature, to not very detailed description of different approaches in the literature, and to the indications relating to the sections of the apparatus that have to be removed. Due to these unclear aspects, it was not easy to understand what type of intervention was performed in the literature and correctly compare the techniques and the results obtained.Surgical textbooks , reviewsAs regards demographic aspect, our data are in line with what has been found in the literature: adult bitches (average age 9 years), mainly whole dogs with neoplastic concurrent diseases ,12,13,15In our cases, 13 of the 25 tumours analysed histologically were malignant, and 12 were benign. This result seems to be in contrast with data concerning the incidence of vaginal tumours in the literature as it was reported that benign tumours show a higher incidence than malignant tumours ,17,18: oThe 5 techniques described were well tolerated by the patients and a complete recovery and hospitalization was observed within 24–48 h in accordance with what is described in the literature ,14,15. PIn the post-operative period (short term outcome 7 days), we did not find any complications affecting the urinary tract and colon/rectum. Two cases of transient urinary incontinence (case 1 and 6) which resolved spontaneously in a couple of days were observed  and oneThe minor post-operative complications observed in our cases are in agreement with what is described in the literature ,14,16,19Ogden et al.  and NeliSome authors consider these very specialized and very invasive/radical surgical techniques and therefore advise against them ,4, whileAlthough CT scans were not performed, as the owners did not consent, it is the authors’ opinion that performing advanced diagnostic tests may be useful in order to better establish the margins of the lesion and the degree of the infiltration: however, in all 33 cases described in the article , surgery was 100% resolutive and the margins decided on the basis of the preoperative and intraoperative diagnostics were sufficient. In reality, among 44 cases described in the articles mentioned, only 12 cases underwent preoperative CT (1 case of  and 11 oIt is our opinion that having five different available techniques to approach vaginal neoplasms depending on their size, location and nature is useful in order to perform the best surgery according to the patient characteristics, technique invasiveness and whether it is palliative or not, as sometimes we had to improve only the quality of life, so it may be appropriate to choose a technique rather than another less invasive and destructive one.Moreover, in our opinion and experience, the possibility to perform an urethrostomy at the vestibular level instead of percutaneous urethrostomy presented several advantages in order to protect the urinary tract from infections or trauma. Finally, nowadays even in veterinary field, the importance of aesthetic factors must be considered, for example, when we leave the vulva.The main limitation of our study is related to the kind of surgical techniques described, which are rarely needed and performed in practice. Therefore, due to the number of patients, it was not possible to perform an adequate statistical analysis or identify particular predispositions within the study population.Another limitation is represented by the difficulty to compare our data with those previously published, as the literature reports little information and an ambiguous description of these surgical techniques.We described in detail five different surgical techniques available for the female copulatory organs related to a correct anatomical nomenclature. All techniques here described results well tolerated by the patient. In the authors’ opinion, the possibility to choose between five different techniques according to the portion of the female reproductive tract that has to be removed and the possibility to plan the best and less demolishing intervention in agreement with the disease, the age and the physical condition of the patient are important points.