One of the consequences of ineffective governments is that they leave space for unlicensed and unregulated informal providers without formal training to deliver a large proportion of health services. Without institutions that facilitate appropriate health care transactions, patients tend to navigate health care markets from one inappropriate provider to another, receiving sub-optimal care, before they find appropriate providers; all the while incurring personal transaction costs. But the top-down interventions to address this barrier to accessing care are hampered by weak governments, as informal providers are entrenched in communities. To explore the role that communities could play in limiting informal providers, we applied the transaction costs theory of the firm which predicts that economic agents tend to organise production within firms when the costs of coordinating exchange through the market are greater than within a firm. In a realist analysis of qualitative data from Nigeria, we found that community health committees sometimes seek to limit informal providers in a manner that is consistent with the transaction costs theory of the firm. The committees deal not through legal sanction but by subtle influence and persuasion in a slow and faltering process of institutional change, leveraging the authority and resources available within their community, and from governments and NGOs. First, they provide information to reduce the market share controlled by informal providers, and then regulation to keep informal providers at bay while making the formal provider more competitive. When these efforts are ineffective or insufficient, committees are faced with a “make-or-buy” decision. The “make” decision involves coordination to co-produce formal health services and facilitate referrals from informal to formal providers. What sometimes results is a quasi-firm—informal and formal providers are networked in a single but loose production unit. These findings suggest that efforts to limit informal providers should seek to, among other things, augment existing community responses. Informal health care providers are typically unregistered and unregulated entrepreneurs operating in local health care markets without formally recognised health care training, although they may have received some informal training through apprenticeships . One of Informal providers include drug sellers or chemists, traditional healers, traditional birth attendants, and village doctors. Their practice may be herbal or based on modern medicine, and may also be general or specific for procedures such as deliveries or bone-setting . InformaAddressing the presence of and preference for informal health care providers in local health care markets requires effective governance . In 2007On the other hand, support for community-led initiatives has not been considered as a strategy for reducing the presence of and preference for informal providers , 2. CommIn line with the national health policy, each community in Nigeria is expected to have a community health committee . TypicalThe study was conducted between November 2014 and January 2015 in four (out of the 36) states in Nigeria: one in northern Nigeria (Kaduna), two in central Nigeria (Nasarawa and Benue) and one in southern Nigeria (Lagos). The states were chosen for their geographic and ethnic spread. Each of the states has an average of about 20 local government areas. Two local government areas were randomly selected in each state, and from each local government area, two communities were purposively selected, for having a health committee. In all, 16 communities were included in the study. For the in-depth interviews, four categories of study participants were purposively selected based on their availability, on granting informed consent to participate, and on their potential to provide rich, relevant and diverse information: (1) the health worker in charge of the health facility and/or the longest-serving health worker at the facility; (2) the officials of the community health committees, such as the chairman, secretary and treasurer; (3) community members, i.e. individuals in the community who are not members of the health committee, such as religious, women’s and traditional leaders; and (4) primary health care managers employed by the federal, state and local government levels, who provide support for primary health care in the selected communities. However, for the focus group discussions, we included all committee members who were available, had not participated in the in-depth interviews, and gave consent to participate. We excluded potential participants who were less than 18 years old.We developed semi-structured questions and prompts to explore issues affecting the supply and demand of primary health care services in the communities. If the respondents cited issues related to informal health care providers, the study instrument provided scope to probe how and why and efforts to limit the influence of informal health care providers. The questions included: (1) What are the challenges of health service delivery in this community (or communities)? (2) What other health care providers are in the community (or communities) besides the health facility? (3) What do people in this community (or communities) do when someone becomes ill? (4) Who do you (or people in communities) trust for information about health and health care? (5) What would make people in this community (or in communities) who don’t more likely to use the health facility? (6) Who influences people in this community (or in communities) to use or not use particular health services in and how? (7) What are your (or committee members’) reasons for joining the committee? (8) What are your (or committee members’) challenges discharging responsibilities in the committee? (9) What organisations (government and non-government) does the committee (or committees) work with and how? Notably, the part of the questions in brackets were used during interviews with primary health care managers to apply more broadly to the local government area or state where they work.We conducted one focus group discussion with health committee members in each of the 16 communities included in this study. Recruitment for in-depth interviews continued until saturation of themes was achieved. In all, we conducted 130 in-depth interviews: with 25 PHC workers , and with 15 PHC managers working at the local (7), state (4) and federal (4) tiers of government. We also interviewed an average of 1 to 2 officials of each committee (making 29 interviews), 2 to 3 other members of each committee (making 35 interviews) and 1 to 2 people in each community who are not committee members (making 26 interviews). Each interview lasted about 60 min and each group discussion involved 8 to 10 people and lasted about 90 min. Data were collected by eight trained researchers in pairs; one pair in each state over the period of about three months. Researchers with postgraduate degrees in public health were selected for their ability to speak the local languages of their respective study states. They were briefed for the purpose of this study by two of the authors (SA and KO). Researchers and participants met for the first time during the study, but there were prior telephone contacts to schedule data collection. Interviews and discussions were conducted within health facility premises or an open space nearby. Researchers kept notes during the field work and were debriefed by author SA at the end of data collection. When required, the data were translated to English by the researchers who collected the data. The interviews and group discussions were audio-recorded, and subsequently transcribed to aid analysis.In line with the practice of using the small sample case study design to investigate informal institutions , the study was designed as a comparative case study , 35. Eacoutcomes. In the second step, we identified factors related to the community or committee that either enabled or constrained the outcomes (i.e. contexts). The list of outcomes and context expanded as coding proceeded, and they were debated, refined and adjusted between two authors (SA and AC-O). Disagreements in coding and discrepancies in interpretation were decided by consensus among the authors, with insights from the researchers who collected the data, and in consultation with PHC managers in Nigeria.For this realist analysis, we adapted the stepwise approach to realist analysis proposed by Danermark et al , in fourHumans are boundedly rational economic agents . In thisHowever, people care about the health of others and their ability to access health care services. This is described in economic terms as the “caring externalities” of health care markets. In other words, the social benefit of health care exceeds private benefit . TherefoIn the third step, we iteratively reframed the identified outcomes and context within theories in order to aid our understanding of the phenomenon under investigation. We adopted the transaction costs theory of the firm which predicts that economic agents tend to organise production within firms when the costs of coordinating exchange through the market is greater than within a firm . This comechanisms) that led to the outcomes, in line with the findings of an earlier study on how community health committees function in Nigeria [In the fourth step, informed by these theoretical propositions, we sought to identify the reasoning process  referring to communities or PHC managers when the context, mechanism or outcome being reported occurred, was identified or described in that community or by the PHC manager. We used the first letter of each state to denote the state, the letters A and B to denote the two local government areas in each state, and the numbers 1 and 2 to denote the communities in each local government area. A finding from community number 1 in local government A in Benue is marked BA1. When reference is being made to a local government PHC manager, it is to the first letter of the state, and the local government whether A or B; e.g. BA or BB. When reference is being made to a state PHC manager, the letter S is used in combination with the first letter of the state; e.g. BS. When reference is being made to a federal PHC manager, the letter F is used in combination with the first letter of the state in which the federal PHC manager is based; e.g. BF.We obtained information from 223 community health committee members; 64 of whom participated in the interviews and 159 in the discussions. Of the participants who were community health committee members, there were 40 in Lagos, 43 in Benue, 77 in Nasarawa and 63 in Kaduna. Their average age ranged from 43 years in Kaduna to 49 years in Lagos, with overall average age of 46 years. The male to female distribution in Lagos was 1:1, whereas it was 2:1 in Benue, Nasarawa and Kaduna. Lagos had the highest proportion of committee members with tertiary education, with 50% having attained some form of tertiary education. Further, 80% of committee members in Lagos had a dependable income either as business owners or civil servants, compared to between 38% (Benue) and 57% (Nasarawa and Kaduna). In Benue, 62% of committee members were either unemployed or subsistence farmers with no ready cash income, while 43% of committee members in Nasarawa and Kaduna were in this category, but only 18% in Lagos. Based on the interviews, discussions and observations, we identified three categories of events resulting from the actions, decisions and relations of community health committee members which may influence the use of informal health care providers: information, regulation and coordination – see Table The idea of having a community health committee was typically introduced to communities by government PHC managersHowever, committee messaging depends on which provider is the major competition. Where the public sector health facility is the only formal health provider in the community, the emphasis is on the health facility being of better quality than its competition.Functioning in the ‘village square’ mode, the majority of committees meet monthly and spread information about services at the health facility through their family and friends.By spreading information through these channels, committee members and other community members, health facility officers in charge and government PHC managers, report significant increases in the use of the health facility and reduction in the use of informal providers.However, in spite of high costs of participation, some committee members reckon that the benefits they derive from participation outweigh the costsContextual enablers of the information strategy include the autonomy of committees to decide who to invite to meetings and membership.Committees also engage in activities to ensure the responsiveness, quality and credibility of the health facility to which the committee is linked, by monitoring and supervising the health facility and health workers. On the other hand, the committees also seek to keep the activities of informal health care providers within safe limits. Where information has been particularly effective, informal providers self-regulate or exit the local health care market.Functioning in the ‘back-up government’ and ‘general overseers’ modes, committee members ask health facility officers in charge about inappropriate behaviour of health workers,However, committees achieve the outcome of respectful service delivery, appropriate prices and reduced absenteeismUnlike the health facility where there is a recourse to governments as the employer of health workers, it is more challenging to enforce rules governing the supply of health services by informal providers. In this regard, traditional healers and birth attendants enjoy significant advantage: their services are in line with belief systems of many in the community, they offer more flexible payment options, and where they live and work is closer to more people than the health facility.Committees sometimes (as ‘government botherers’) call on government PHC managers to intervene where disagreement and conflict arise when committee members find inappropriate practices as they monitor traditional providers.The challenges limiting the use of formal health care providers are sometimes beyond what the information and regulation strategies can address. In these instances, the committees seek to coordinate referrals from informal to formal health care providers; and they also seek to coordinate resources from within and outside the community to address the challenges of quality and accessibility limiting the use of the health facility to which the committee is linked. Such challenges are identified by committee members by virtue of living in the community, and as ‘village square’ from their discussions during their committee meetingsEnabled by having high income community members on the committee, some of whom are invited on the committee for that purpose,Given their experience and expectation of government failure, committees sometimes lobby governments (as ‘government botherers’) only after they have tried other means of addressing challenges such as raising funds within the community and from NGOs (as ‘back-up government’).Raising funds within the community is enabled by having high income people on the committee,Committees as ‘general overseers’ augment funds raised from the community and NGOs with funds generated from health facility revenue (service charges and medicines). With combined funds from all these sources, committees build or rent accommodation for health workers to reduce absenteeism,When efforts to improve services at the health facility are not enough to sufficiently reduce the use of informal providers, committees seek to establish referral networks with informal providers. Traditional birth attendants are encouraged to refer pregnant women who consult them to deliver at the health facility.In addition, committees seek to more directly connect individuals in the community and the health facility by influencing and supporting health workers to offer home delivery services for pregnant women, especially in Kaduna where preference for traditional birth attendants is partly because they offer home services.The findings from this study reveal that community health committees in Nigeria tend to act as institutional entrepreneurs , 46 in rThese findings are in line with the evidence that, whether for altruistic or self-interested reasons, community groups are able to manage their commonly owned resources . Indeed,To limit the influence of informal providers within the local health care market, the committees provide institutions of economic governance: securing the property rights of people to maximise the benefits of public goods provided by their governments but derived from their resources and taxes; facilitating appropriate health care transactions while discouraging inappropriate transactions; and encouraging collective action to provide public goods including physical and organisational health care infrastructure . There aWith government failure (to provide and oversee PHC) and market failure (due to information asymmetry), community groups become a governance alternative , as theiHowever, there are constraints on the capabilities of committees to limit informal providers. First is a limited sense of legitimacy to make, change, monitor and enforce the rules governing health care in their community. To gain legitimacy within their community, government PHC managers and NGO representatives who establish, mentor and support the committees should encourage the involvement of influential community members, particularly traditional leaders in selecting committee members and in their day to day activities. Second is the need for financial support from governments and NGOs to hold meetings and information campaigns and to implement projects, due to the high fixed costs of producing health care services. But given that extrinsic rewards tends to undermine intrinsic motivation for high-interest tasks, especially when rewards are tangible, expected, and not performance-based , it is iThe perceived cause of an illness  and the absence of universal health coverage account in part for why informal health care providers thrive in may low- and middle-income countries. Informal health providers also thrive partly because many instances of illness are either self-limiting or have a low likelihood of treatment complications, such that seeking care from informal providers can be an effective cost-cutting strategy. However, care-seeking pathways can be elaborate for chronic conditions with specific treatment, raising transaction costs. In a previous study in Nigeria, 67% of patients receiving treatment for tuberculosis had earlier consulted chemists and traditional healers, transaction costs accounted for 24% of the costs of care, and 62% of transaction costs were incurred during the first inappropriate consultation  and ChinIn summary, this study shows that supporting community groups such as the health committees can be an effective policy tool to address the presence of and preference for informal providers in low- and middle-income countries where bottom-up initiatives are important because of the tendency for government weaknesses. In studying and seeking to intervene in such weakly governed health systems, it is therefore important to consider the implications for access to health care of the failure to provide information, regulation and coordination within local health care markets. Indeed, efforts to limit the use of informal providers, whether by governments or NGOs , should take into account the relative costs of intervening at each level of governance  with the benefits of reducing transaction costs in the community. Having an empirical measure of costs  against which to compare the costs of interventions to limit informal health care providers can inform the choice among alternative governance interventions. In addition, considerations of potential interventions should take into account existing community responses, the mechanisms through which the community responses are enacted, the contextual enablers and constraints of such responses, the successes, failures and costs of the responses, and to weigh those costs against the cost of intervening at other levels of governance.


Tobacco cessation training programs to treat tobacco dependence have measureable effects on patients’ smoking. Tobacco consumption in low- and middle-income countries (LMICs) is high and slowly decreasing, but these countries usually lack measures to face the epidemic, including tobacco cessation training programs for health professionals and organizations. Based on a previous online smoking cessation training program for hospital workers in Spain, the Fruitful Study aims to increase smoking cessation knowledge, attitudes, self-confidence, and performance interventions among health care professionals of three Spanish-speaking low- and middle-income Latin American and Caribbean (LAC) countries.The purpose of this paper is to describe the methodology and evaluation strategy of the Fruitful Study intended to adapt, implement, and test the effectiveness of an online, evidence-based tobacco cessation training program addressed to health professionals from Bolivia, Guatemala, and Paraguay.This study will use a mixed-methods design with a pre-post evaluation (quantitative approach) and in-depth interviews and focus groups . The main outcomes will be (1) participants’ attitudes, knowledge, and behaviors before and after the training; and (2) the level of implementation of tobacco control policies within the hospitals before and after the training.To date, adaptation of the materials, study enrollment, and training activities have been completed. During the adaptation, the main mismatches were language background and content adaptation. Several aids were developed to enable students’ training enrollment, including access to computers, support from technicians, and reminders to correctly complete the course. Follow-up data collection is in progress. We have enrolled 281 hospital workers. Results are expected at the beginning of 2017 and will be reported in two follow-up papers: one about the formative evaluation and the other about the summative evaluation.There is a need to learn more about the cultural and content elements that should be modified when an online tobacco cessation training program is adapted to new contexts. Special attention should be given to the personal and material resources that could make the implementation possible. Results from the Fruitful Study may offer a new approach to adapting programs to LMICs in order to offer education solutions with the use of emerging and growing communication technologies.Clinicaltrials.gov NCT02718872; https://clinicaltrials.gov/ct2/show/NCT02718872 (Archived by WebCite at http://www.webcitation.org/6mjihsgE2) Tobacco use remains a global public health concern; annually it causes 6 million preventable deaths . The tobIn the LAC region, smoking rates vary by country, sex, and socio-economic status ,5. In soIn LAC countries smoking consumption among health care professionals is still similar to that of the general population ,14, and Implementation research recommends addressing organizational constraints in order to overcome executive barriers when the cessation messages are delivered such as lack of time, support, and resources ,19. TraiIn the literature, there are several conceptual training models that exhibit significant heterogeneity . For exaUsing previously established programs can save time and money while increasing the likelihood of achieving successful outcomes . In addiAdaptation implies not only to the replication or translation of a program but to the process of adjusting a program to reduce mismatches between its characteristics and the new context in which it is to be implemented. Adapting a tobacco cessation education program should take into account the treatment regulation of each country, the existing guidance and proceedings, and the dynamics of the health organization . Card etWe selected the ongoing Brief Intervention for Smoking Cessation Training Program from the Catalan Institute of Oncology (ICO) as the baseline program and created a partnership between ICO and three hospitals from Bolivia, Paraguay, and Guatemala to first adapt and later disseminate the course. We intend to increase the capacity-building of the implicated organizations that will ultimately initiate a cascade of change within their countries . Our traThe purpose of this paper is to describe the methodology and evaluation strategy of the Fruitful Study research protocol intended to adapt, implement, and test the effectiveness of an online, evidence-based tobacco cessation training program addressed to health professionals from Bolivia, Guatemala, and Paraguay.The primary research goal of the Fruitful Study is to evaluate the impact of an online, evidence-based tobacco cessation training program aimed to increase smoking cessation knowledge, attitudes, self-confidence, and performance interventions among health care professionals of three Spanish-speaking low- and middle-income LAC countries .Our primary hypothesis is the participants in the online tobacco cessation training program will increase their tobacco-related knowledge, attitudes, and behaviors by the 6-month follow-up, as compared to baseline conditions prior to the training. Our secondary hypothesis is that participating hospitals will exhibit greater tobacco control progression, commitment, and implementation of tobacco cessation services.The Fruitful Study is a 2-year mixed-method  study conducted in one hospital in each of the three participant countries .For the quantitative approach, a pre-post design will be used to (1) assess participants’ attitudes, knowledge, and behaviors before and after the training using a questionnaire (Tool 1); and (2) measure the level of implementation of tobacco control policies within the participant hospitals before and after the training using the Self-Audit Questionnaire (SAQ) (Tool 2). For the qualitative approach, focus groups and in-depth interviews of key persons will be used. With this methodology we aim to (1) explore the experience of adapting the training program in each of the participant hospitals; (2) ascertain participants’ experience undertaking the training program; and (3) understand the opportunities and barriers of undertaking online smoking cessation training programs in the participant countries. With the results of the focus groups, the research team aims to identify any difficulties in accessing and completing the course and to make the necessary improvements.The two main participant units from each organization are students and the hospitals themselves. The participant hospitals were selected because they had previously collaborated with the Training Unit of the ICO in training their health professionals in either electronic learning (e-learning) or in-person courses. The selected hospitals and their characteristics are shown in Student participants were all health professionals and paraprofessional staff from the three participant hospitals. All health providers in the selected hospitals, including nurses, doctors, and other health professionals were invited to enroll in the training. Each local coordinator recruited participants from a variety of units and departments over a 6-month period through informative sessions, leaflets, and posters (designed to inform about the training program).The selected original training program was chosen because it was shaped using evidence-based guides, was originally designed for Spanish hospitals , and is addressed to hospital workers. Furthermore, offering the course through an online platform has clear potential to reduce cost and increase training coverage within participant hospitals in less time.The original course was developed in the online platform e-oncologia based on the in-person courses offered during the last 10 years by the Tobacco Control Unit of the ICO. The theoretical framework underpinning the training program is the Stages of Change Model , and theModulesModule 1 describes the tobacco epidemic, tobacco-related morbidity and mortality, second hand smoke, and measures included in the MPOWER strategy to tackle smoking.Module 2 provides orientation on how to assess the smoker, how to assess tobacco dependence and willingness to quit, and evaluate smoker self-efficacy, previous quit attempts, previous relapses, and so on.Module 3 introduces the efficacy of the different levels of attention and treatment orientations  and presents the clinical settings where the intervention is possible . It explains in detail the 5As intervention model.Module 4 explains in detail the different tobacco cessation treatments available . It also provides orientation about the follow-up, strategies to improve the adherence of the treatment, how to identify withdrawal symptoms, how to deal with relapses, and so on.This online training program includes (1) slides; (2) review exercises; (3) cases of 4 patients differing in demographics, diagnostic, stages of change, setting; and (4) problem solving exercises. The training provides several materials including slides, online tutorials with an expert tutor, recommended readings, patient cessation brochures, a therapeutic pocket guideline, and an organizational recommendation model to facilitate the implementation of tobacco cessation services in the hospital setting.The original online course was firstly tested by 10 voluntary participants in Catalonia (Spain). Evaluation of the tobacco cessation program was thereafter tested in the ICO by 150 health professionals. This pilot test proved the acceptability of the training model, the adequacy of its contents, and obtained a high level of satisfaction in the trainees. This training initiative has also been shown to increase the level of implementation of tobacco control in Catalan hospitals (according to the SAQ)  and the Based on literature regarding attrition among online learners , and ourThe adaptation has been done with local partners and other stakeholders. First, a group of professionals with extensive experience in tobacco control in their country were selected for identifying and categorizing mismatches between the original materials and the new context. Experts expressed that the goal and objectives were aligned with the original program model . Since tMismatchesLanguage background and literacy level in some of the terms used:The course was in Spanish from Spain, and the Spanish spoken in Bolivia, Guatemala, and Paraguay differs somewhat with respect to vocabulary, some expressions, and in some cases even in grammar structures.Description of the epidemiology smoking in Model 1:The original version included the situation in Spain, whereas the adapted version included the most updated data in Bolivia, Guatemala, and Paraguay.Tobacco cessation pharmacological treatment in Module 4  and settings where tobacco prevention and cessation services are performed in Spain  were adapted to the current resources in each country.In case studies, the clinical simulations demonstrate the cultural characteristics of each country.Questions and answers of the assessment and evaluation were also changed according to the adapted contents.Several aids were necessary in order to enroll students. Thus, local investigators suggested a double registration method through the online platform consisting of an independent method (first one) by which students generated their own credentials and a second one assisted by a computer technician who created the login credentials and helped them in the usage of platform. The second method was necessary since many students had little or no experience in pursuing online education.This study is expected to last 24 months (from November 2014 to November 2016). Information on the various activities is depicted in the event planning timeline .This paper was written during the 18th month of the study when the post-evaluation data was being gathered. During the training (months 6 to 13), each participant had 1 month to fill in the baseline evaluation, complete the online training, and take the exam. Participants were monitored by local coordinators that acted as champions and encouraged participants to enroll and complete the course. Coordinators set monthly meetings with personnel from the different units and services to increase the number of participants and support those enrolled to complete the course. In addition, during the implementation, coordinators from each hospital offered assistance to students with little or no computer skills. Technical support was mainly used by less educated health professionals  and older workers who were less familiar with the use of computers. They offered their assistance in logging into the online platform, filling out the questionnaires, completing the evaluation, as well as other technical support-related issues. Participants’ progress was monitored in real-time on the Web platform. The project coordinator at the ICO sent biweekly reports of the participants' progress to coordinators, and if necessary personal emails and videos that motivated the students to finish the course and complete the evaluations. Participants accessed the course using their electronic devices  or the ones provided by their hospitals during and after working shifts. The hospitals from Guatemala and Paraguay made a library available with computers to facilitate students’ enrolment before or after their working hours. The hospital from Bolivia provided a computer room in which students had access to the course and the support of a technician during specific hours of the day. Therefore, the participating hospitals facilitated computer and Internet access at the workplace.To design the evaluation we applied the conceptual frame for continuing medical education (CME) conceived by Moore et al  that fosThe formative evaluation will assess the adoption, implementation, and maintenance of the training program. We will measure program coverage, completion rates, fidelity with the training program, usage of the materials, and the satisfaction with the training. We will use qualitative (focus groups and interviews) and quantitative methods to gather this information. The indicators linked to the performance of the program are (2) number of participants; (2) characteristics of the participants ; (3) number of hours dedicated to the training program; (4) program performance and fidelity to the curriculum plan ; (5) service utilization or dosage use of the training ; and (6) opinions, experience, perceptions, and satisfaction with the training course.We will investigate the short and intermediate outcomes by measuring the impact of the smoking cessation training program within the participant hospitals using quantitative methods (pre-post design). This will include the level of implementation of tobacco control policies within the participant hospitals before and after the training by using the SAQ (Q1) and participants’ attitudes, knowledge, and behaviors before and after the training using a questionnaire (Q2).To assess differences in tobacco control polices implemented within the hospitals we will use the European Network of Smoke free Hospitals (ENSH) SAQ . This toTrainers’ attitudes, knowledge, and behaviors will be assessed using a questionnaire composed of 63-items. The website-delivered questionnaire is emailed to the participants at baseline and 3 months after finishing the training. The questionnaire, designed by Sheffer et al , takes 3Each participant country will carry out at least 5 focus groups with hospital workers enrolled and not enrolled in the course. Participants will be volunteers. The focus groups will consist of homogenous working categories to avoid possible reticence of some participants to openly talk in the presence of their supervisors. In each country focus groups will be conducted by external local qualitative researchers that will follow the same protocol.Descriptive statistics will be used for the quantitative indicators. The quantitative variables will be summarized using means and other central tendency measurements, whereas the qualitative data will be summarized by computing their frequencies and percentages. The qualitative indicators gathered by the qualitative methods (focus groups and interviews) will be summarized using the classical content analysis approach (creating codes and chunks of information and the researcher complements the codes with description of this code). Analysis of the data will be validated by informants to increase the reliability of the data .Usual statistics will be used to describe the sample and non-parametric tests will be used for pre-post comparisons for tobacco control policies (measured by Tool 1) and the trainees’ knowledge, attitudes, and behaviors (measured by the Tool 2). In addition, a validity and reliability test of both instruments is planned.Based on literature regarding gains of training ,40, we aWe have enrolled 281 hospital workers . The overall average completion rate is 66.2% (186/281). At the time of submission of this paper, data collection for the post-evaluation was underway. Evaluations will finish in November 2016 and results are expected by the beginning of 2017. Results of this study will be reported in two follow-up papers: one about the formative evaluation and the other about the summative evaluation.We will consider a good level of coverage of the training program if at least 50% of the enrolled health professionals in each hospital conclude the training program. We will measure the engagement of the training program with the focus groups and key informant interviews. We anticipate that hospitals will increase their tobacco control policies by 20% to 30% according to the SAQ. In addition, we anticipate that health professionals’ level of knowledge, attitudes, and perception in tobacco cessation will increase to 30% to 40%.Health professionals and paraprofessional staff from the three countries will be invited to voluntarily participate in the project. We will be able to determine whether the recruitment process used by each coordinator affects both the number of participants recruited and the commitment to start and finish on time. We hypothesize that as they agree to join, they will be highly motivated to pursue the course and we expect many of them to succeed on their own. However, participants may have varying levels of computer skills and Internet usage that could affect their course enrollment and progression. Online training programs also require devices for their use  and a high speed Internet connection. Although Internet services and technological devices are rapidly growing in low-income countries  it may nAccording to a paper by Ng et al  tobacco It is for these reasons that the methods and results of Fruitful Study may offer a new approach to adapt and implement programs to LMICs countries in order to offer education solutions through the use of emerging and growing communication technologies.It is critical to develop distant learning programs to train health workers in tobacco cessation in LMIC where opportunities for continuing education are scant and sometimes not well adapted to the reality of their contexts. This study will show whether it is possible to adapt and implement an online course in developing countries. In addition, we will determine how best to implement effective distant-learning strategies in organizations belonging to LMIC, especially to detect what resources and aids are required to make the training possible in all levels of the workforce. Finally, we will measure whether the training program will increase knowledge, attitudes, and perception in tobacco cessation among participants and will produce changes in tobacco control policies at the organizational level.


Public policymaking is complex and lacks research evidences, particularly in the Eastern Mediterranean Region (EMR). This policy analysis aims to generate insights about the process of hospital accreditation policy making in Iran, to identify factors influencing policymaking and to evaluate utilization of evidence in policy making process.The study examined the policymaking process using Walt and Gilson framework. A qualitative research design was employed. Thirty key informant interviews with policymakers and stakeholders were conducted. In addition hundred and five related documents were reviewed. Data was analyzed using framework analysis.The accreditation program was a decision made at Ministry of Health and Medical Education in Iran. Many healthcare stakeholders were involved and evidence from leading countries was used to guide policy development. Poor hospital managers’ commitment, lack of physicians’ involvement and inadequate resources were the main barriers in policy implementation. Furthermore, there were too many accreditations standards and criteria, surveyors were not well-trained, had little motivation for their work and there was low consistency among them.This study highlighted the complex nature of policymaking cycle and highlighted various factors influencing policy development, implementation and evaluation. An effective accreditation program requires a robust well-governed accreditation body, various stakeholders’ involvement, sufficient resources and sustainable funds, enough human resources, hospital managers’ commitment, and technical assistance to hospitals. The health system of Iran has been improved during the last three decades. At national level, the Ministry of Health and Medical Education (MOHME) is responsible for policy-making, funding, planning, leading, coordinating, and evaluating the healthcare services provided by a variety of public and private healthcare organizations and institutes. This responsibility has been delegated to the Universities of Medical Sciences and Health Services (UMSs) at provincial level. UMSs are also responsible for educating and training human resources needed for delivery of healthcare services .Public and private hospitals provide the secondary and tertiary healthcare services. All hospitals must have a license for operation. Certain structural and procedural standards have to be met to receive such a license. The license has to be renewed every five years. In addition, hospitals have to go through an annual accreditation process to be eligible for providing healthcare services. Besides, un-noticed visits can be done by the health authorities for the aim of continuous quality and safety assessment. The assessment and evaluation are performed by accreditation office at UMSs. At national level, the Office for the Accreditation of Healthcare Institutions is responsible for policy making, planning and leading the national hospital accreditation program. Hospitals are reimbursed on a fee for service base. The hospital tariff is based on its accreditation grade. The higher the hospital grade, the higher the tariffs it charges patients .The first hospital evaluation system in Iran was established in 1962. Limited number of structural standards was used for hospital evaluation. In 1997, more structural and procedural standards were added to the hospital evaluation checklists and several specialized surveyors have been recruited to assess diverse areas of the hospitals’ activities. Finally, in 2012, the hospital evaluation system was upgraded to the hospital accreditation system .Hospital accreditation is “a systematic external evaluation of a hospital’s structures, processes and results (outputs/ outcome) by an independent professional accreditation body using pre-established optimum standards” . The objHistorically, the American College of Surgeons firstly developed accreditation standards for surgical training in 1917 which later led to the establishment of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1951 . During Accreditation helps improve hospitals’ systems, processes, operational effectiveness and outcomes ,8. It prHealth policy includes plans, and actions for achieving health care goals through defining a vision for the future, establishing goals, objectives and targets, setting priorities and specifying different groups’ roles . Policy This study focusing on policy analysis of hospital accreditation in Iran aims to generate in-depth insights on the process of policy making, to identify factors influencing policymaking, to assess the extent that evidence is used, to examine the impact of hospital accreditation policies and to reflect on lessons learned for informing future public policymaking. Such a study provides insights for structuring the decision-making process.This qualitative study explored the “Iranian Hospital Accreditation (IHA)” policy making process using Walt and Gilson triangle framework .Walt and Gilson (1994) developed a policy analysis triangle framework incorporating context, actors, process and content concepts specifically for healthcare sector. The triangle framework allows the analysis of the contextual factors such as social, economic, and political factors that influence the policy, the process by which the policy was initiated, formulated, developed, implemented and evaluated, the objectives of the policy and the actors involved in the policy making .Furthermore, Kingdon’s (1984) Multiple Streams Framework (MSF) was used to analyze further the policymaking process of the national hospital accreditation in Iran. Kingdon using the multiple-streams theory in agenda setting argues that the public policy process has a random character, with problems, policies and politics flowing along in independent streams. A “policy window” opens only when these three independent streams converge, propelling governments to act. The problems stream contains the broad problems facing societies. The policy stream refers to the set of policy alternatives that researchers and other stakeholders propose to address problems. The politics stream consists of political transitions, national mood, elections, or pressure from interest groups .Thirty face to face semi-structured interviews were conducted between April and September 2015. A purposeful sampling method was used . InterviIn addition, related documents were reviewed and analyzed to explore the role of evidence in the policy making process and to validate the information obtained from interviews. Hundred and five documents were obtained dating from 1985 to 2015 including official letters, legislations, law decrees, directives, reports and minutes of meetings of Ministry of health. The review of documents was conducted by a reviewer and checked by a second reviewer. The document review was guided by a protocol adapted from Hanney et al. .Since 1997, all Iranian hospitals were evaluated annually using a checklist covering more structural standards in fifteen domains including management, medical staff, nursing staff, administrative and support staff, safety equipment, medical equipment, non-medical equipment, medical records, education and research, religious and humane values, patients satisfaction, hospital committees, sanitation, physical structure and some limited quality indicators. Less attention was paid to procedural and outcome standards in such a mandatory program.On-site surveys were conducted by a team of 3–10 surveyors each focusing on specific domains of the standards. The Accident and Emergency (A&E) department of the hospital was evaluated first. If the A&E department achieved lower score than the rest of the hospital’s departments and wards, the grade of the A&E department was declared as the hospital grade. A range of five evaluation grades including excellent, one, two, three, and non-standard were applied. The tariff of hospitals was linked to their evaluation grade. Thus, there was an incentive for hospital managers to improve hospital performance, so, they could charge patients a higher tariff. For those hospitals that achieved grade non-standard, they have been given a time of three months to improve their performance and solve the problems identified during the evaluation process.more studies on patients’ rights are conducted. The health system should be more accountable for the safety and quality of healthcare services provided at hospitals. The aim of introducing accreditation was to enhance the hospital’s responsiveness. The hospital evaluation system was not very effective at that time”.The development of the hospitals’ accreditation policy was mainly due to the failure of the hospital evaluation system in providing a clear comprehensive and valid picture of hospitals’ performance specially regarding to the quality and safety of services. Hospitals that achieved higher grades had still problems with the quality and safety and patients were not satisfied with them. The overall awareness of the people about quality and safety had increased as so as their expectation. A senior official at health insurance organization said: “There was a pressing need to upgrade hospital standards and include more comprehensive structural, procedural and outcome standards. Some hospitals voluntarily used the industrial ISO and EFQM models for self-assessment and even applied for their certifications. The fast growing recognition of hospital accreditation worldwide particularly in the EMRO region’s countries such as Egypt, Lebanon and Jordan encouraged some Iranian hospitals to apply for international accreditation programs such as Accreditation Canada International. As the accreditation model was specifically developed for the health sector, it was decided to use an accreditation model for the country. Thus, the authorities at ministry of health considered developing a national accreditation model for Iranian hospitals and a few researches have been conducted on hospital accreditation models of US, France, Lebanon and Egypt.The existence of a structure for hospital evaluation system at MOHME and UMSs and familiarity of hospital managers and employees with the evaluation system facilitated the execution of the accreditation program.The objectives of initiating an accreditation program were to use more comprehensive structural, procedural and outcome standards to enhance the quality and safety of hospital services, to respond better to the clients’ needs, to improve hospitals’ key performance indicators, to reduce costs, to improve clients’ satisfaction and to develop health tourism.Reviewing the accreditation standards of some pioneer countries such as USA and France, as well as some Middle Eastern countries such as Egypt and Lebanon and holding some focus group discussion meetings with evaluation and accreditation experts helped adopt, develop and adapt accreditation standards for Iranian hospitals. Departmental approach was used to develop hospital accreditation standards. Overall 8104 criteria were used for the accreditation of 37 hospital departments and wards. After the first round of national hospital accreditation survey in 2013, some changes have been applied to the content of the standards based on the comments received from the hospital managers and employees and surveyors. As a result, some criteria were merged together and 2157 criteria for accreditation of 36 departments of the hospital were included in the accreditation program. These standards mainly focused on structures and processes rather than outcomes.The accreditation program was a decision made at the MOHME. Some people who were acquainted with the hospital accreditation program and had good relationship with the authorities at the hospital evaluation department of MOHME had critical role in initiating the program there. Then, some hospital accreditation consultants were invited to help develop the standards and running the program. The concept of hospital accreditation, its differences with the previous evaluation system and its goals were explained to the other departments of the ministry of health to get their support. Insurance companies well accepted the program as they assume the accreditation program could improve the quality and safety of hospital services better than the old evaluation system. They believed that the results of the accreditation program could be more reliable as it uses comprehensive set of standards.Nevertheless, there was some resistance mainly from the private hospitals. They got used to the previous evaluation system and they found the number of the standards and criteria as the main barrier to implement them. They found it difficult to coordinate hospital resources to implement 8104 accreditation criteria. The Office for the Accreditation of Healthcare Institutions (OAHI) finalized the first draft of the standards and piloted it in eight hospitals and as a result the standards were modified using the comments received. Then, the standards were announced to all hospitals including private hospitals. Consequently the resistance was gradually decreased.Too much emphasize on the structural standards, lack of procedural and outcome standards, the reports of medical errors and lack of public satisfaction of the quality of hospital services were among the main problems of the hospital evaluation system (problem stream). The political stream had been created as the authorities at the MOHME demanded a change in the hospital evaluation system to reduce public dissatisfaction. The quality and safety of hospital services was a priority for top managers at MOHME. Hospitals were asked to apply measures to improve the quality and safety of their services. Therefore, the hospital evaluation system should be changed to embed quality and safety standards.One alternative to solve the problem was considering other evaluation models such as ISO and EFQM. However, the success of the accreditation model worldwide and its healthcare characteristics urged the authorities to consider it as an applicable solution for solving the problem. Accordingly, a comparative study of several countries’ accreditation program began to help choosing a hospital accreditation model for Iran.Some officials suggested that an accreditation council comprising of representatives from government regulatory agencies, professional organizations, practitioners, and the public should be created to govern the accreditation program. The idea was not accepted. It was assumed that as the program is new, including many parties in the governing body of the accreditation program make it complicated and as a result the resistance would be increased. It was decided to make the program mandatory and to be carried out annually by the MOHME with the cooperation of UMSs. Subsequently, the accreditation policy window has been opened and set the hospital accreditation program in the agenda.The hospital accreditation standards were formulated in six phases. In phase one, a study of the hospital accreditation programs and standards of US (JCI), France, Egypt and Lebanon was conducted in 2007. In the second phase, the necessary local standards were added to the list of standards. In the third phase of the project, a departmental model was used for the hospital standards and the first draft of the standards was prepared. In the fourth phase, a poll was conducted and different symposiums were held on the first draft of the standards to know the opinions of different groups of experts. Standards were piloted in eight hospitals in the fifth phase to pinpoint the probable problems. In other word, the performance of these hospitals was evaluated using the new set of hospital accreditation standards. Finally, in the sixth phase, after holding a number of meetings with the representatives from various departments of MOHME, UMSs and academic associations, the final copy of the accreditation standards were formulated and communicated to hospitals for implementation. The entire process of standards development, obtaining feedback, pilot testing, refinement, and final printing took three years.The cascading training for implementing hospital standards was organized to be conveyed from the OAHI to UMSs and then to the hospitals. The first accreditation survey was done in 2012. There were no specific criteria for appointing surveyors. More than 700 surveyors were chosen from the curative affairs department of UMSs and trained. An on-site survey team consisted of about 20–25 surveyors who were chosen from UMSs staff in some specific fields . At least one physician and a nurse were included in the team. The full accreditation surveys involved an intensive process of reviewing documents and conducting site tours, observations, and staff and patient interviews. Trained surveyors performed the surveys. The surveyors submitted the hospitals’ scores on the devices prepared for them through the portal of ministry of health. The formal report of the hospitals’ scores and grades were sent to the UMSs to communicate to the hospitals. Hospital grades were Excellent, One plus, One, Two, Three and non-accredited. Almost 71.4 percent of hospitals achieved grade one and over.The implementation of the accreditation program and standards was with some difficulties. Insufficient personnel to implement the standards were the main challenge of the hospitals. Poor hospital management and leadership commitment, lack of time, and lack of physicians’ involvement were also inhibiting proper implementation of the accreditation standards. Some problems with the contents of the standards and criteria were also mentioned by the interviewees such as too many standards, insufficient outcome standards, ambiguity of standards and criteria, imbalance of the standards of various departments of the hospital, and the scale of scoring. Lack of coordination between the accreditation program and other programs in the Ministry of Health also caused problems for hospitals. As a result, hospitals had to apply many standards posed by various departments of the ministry of health.The personnel are still unaware of the goals of the [accreditation] program. There are not enough personnel in nursing and para-clinical wards and there is no possibility to recruit more staff. Personnel are under pressure which in turn lowers the quality of services”.Furthermore, surveyors were not well-trained and had little motivation for their work. The surveyors had to do their routine duties in UMSs in addition to the hospital surveys. They were overloaded and less motivated. As a result, there was a lack of reliability in the accreditation process. Surveyors emphasized more on the documentations during the first round of the accreditation survey. This put more financial burden on the hospitals to prepare the documents and took too much time of staff specially the nursing personnel. Lack of a national hospital policies and procedures forced hospitals to prepare all those policies and procedures themselves which took too much of the time of hospital personnel. One hospital manager commented: “The second round of the accreditation program was carried out in 2014 during which the number of standards and criteria were reduced and the surveyors received new trainings. Reducing the number of standards and criteria and putting more emphasis on the process of implementing the standards rather than documentation solved some of the previous mentioned problems. However, some problems such as standards ambiguity, imbalanced distribution of the standards and the scale of scoring were remained unsolved. Hospitals’ managers and staff complained also about the differences in the surveyors’ opinions. Therefore, two clinical and administrative senior surveyors from other provinces accompanied the surveyors team and took the lead in the second round of hospital accreditation. After the second round of the accreditation survey a five category scale of excellent, one, two, three and non-accredited were used for grading hospitals.Unfortunately, there is a lot to do for the outcome indicators. Hospitals should learn to measure the indicators. Until then, they will only work on the procedural indicators”.Some measures were taken at the MOHME to evaluate the process of the accreditation program. For instance, the education and training programs of UMSs for hospitals on accreditation, and the process of hospital accreditation upon the request of the hospitals were evaluated by OHOA. Hospitals that achieved the excellent grade were reassessed. Hospitals’ managers and staff and surveyors could raise their concerns on accreditation through OAHI website. UMSs were also asked to send their concerns and suggestions to OAHI. After the second accreditation survey in 2015, the opinions of all hospital managers on accreditation standards, methods, implementation and effects were solicited through a national survey. Five hundred and forty seven hospitals participated in the survey. However, there was no attempt to evaluate the outcome of the hospital accreditation due to the difficulties in measuring and collecting hospital key performance indicators. One senior official from the Ministry of Health indicated: “The hospital accreditation policy in Iran was well-intentioned aiming to enhance the quality and safety of services provided in Iranian hospitals due to the shortcomings of previous hospital evaluation system. Lack of procedural and outcome standards were the main problems of the hospital evaluation system. There was a pressing need to upgrade the hospital evaluation system and optimize the standards and include more quality and safety standards. Many healthcare stakeholders were involved in the hospital accreditation policy making process and evidence from the leading countries was used to guide policy development. However, benchmarking just a few countries’ hospital accreditation programs could not provide enough evidence for developing a comprehensive set of standards. As a result, the hospital standards and criteria in Iran were not inclusive and less attention was paid to the outcome standards. Furthermore, frequently quick revision of accreditation standards caused many problems for hospitals.The hospital accreditation program did not achieve the intended benefits due to the shortcomings in policy implementation. Insufficient resources and information to implement accreditation standards in hospitals were the main barriers in policy implementation. Furthermore, surveyors were not well-trained, had little motivation for their work and didn’t use the same approach in hospital evaluation and accreditation.Overall, the responsibility of hospital accreditation in Iran is laid in the hands of OAHI at the ministry of health. In other word, a governmental institute governs hospital accreditation program in the country. About 80 percent of Iranian hospitals are owned by the government. Thus, if the accreditation body’s structure and governance is not independent, there is a chance of having biased results. Smits and colleagues 2014) believe that low and middle income countries lack the financial capacity and resources to set up independent free-standing accreditation bodies. As a result, the accreditation bodies in these countries are governmental . To be m believe Worldwide different approaches are used for administration of the hospital accreditation program. For instance, the accreditation body in countries such as Lebanon, Italy, Scotland, England and France, is a governmental institute. In contrast, in the United States and Canada, private independent agencies manage the accreditation program . In MalaIran hospital accreditation program faced some challenges regarding to the content of the standards and the way those standards have been implemented , 4. Too World Health Organization (WHO) has mentioned some challenges for hospital accreditation in Eastern Mediterranean such as giving a precise value or numerical score to findings, having standards for a few hospital units rather than all hospital services, lack of an inter-institutional and independent national commission on hospital accreditation, multiple accreditation entities, competing among each other, and setting different standards, priorities and fees, and confusing licensing with accreditation, misperception of the role of surveyors .The Iranian hospital accreditation is in its infancy. We cannot expect the same results of well-established accreditation programs like what we see in US, Canada and Australia which have an experience of 65, 57 and 42 years . Thus, tSome policy options are proposed for improving the implementation of hospital accreditation program. International Society for Quality in Healthcare (ISQua) has some basic requirement for the healthcare accreditation programs including the accreditation body, standards and surveyors training, which can be used for benchmarking and improving the Iranian hospital accreditation program . TherefoThe structural, contextual and procedural changes involved in the accreditation put too much stress on hospital managers and employees. Stress creates physical and mental problems for employees and negatively affect their quality of life  and perfHospital surveyors should be selected and recruited based on specific and obvious job description and person specification and should pass a comprehensive training course to be eligible for the surveys. Training surveyors helps reduce the inconsistencies among them during the accreditation process . CapableThis study highlighted the complex nature of policymaking cycle and various factors influencing policy development, implementation, and evaluation. The underlying philosophy of the hospital accreditation as a strategy for quality and safety improvement was not fully congruent with the Iranian context. Hospital managers treated the accreditation as the final goal instead of a means to achieve service quality. An effective accreditation program requires a robust well-governed accreditation body, sufficient and sustainable funds, enough human resources, management commitment, education and training, and technical assistance to hospitals. Various stake-holders’ involvement should be encouraged in the governance of the accreditation program. Appropriate surveyors should be selected and trained professionally to ensure inter-rater reliability among them. On time, feedback about the accreditation survey and ongoing technical assistance should be provided for hospitals on standards implementation.Ethical issues  have been completely observed by the authors.


Vehicular Ad hoc NETworks (VANETs) are widely recognized to be instrumental in realizing such concept, by enabling appealing safety and infotainment services. Such networks come with their own set of challenges, which range from managing high node mobility to securing data and user privacy. The Software Defined Networking (SDN) paradigm has been identified as a suitable solution for dealing with the dynamic network environment, the increased number of connected devices, and the heterogeneity of applications. While some preliminary investigations have been already conducted to check the applicability of the SDN paradigm to VANETs, and its presumed benefits for managing resources and mobility, it is still unclear what impact SDN will have on security and privacy. Security is a relevant issue in VANETs, because of the impact that threats can have on drivers’ behavior and quality of life. This paper opens a discussion on the security threats that future SDN-enabled VANETs will have to face, and investigates how SDN could be beneficial in building new countermeasures. The analysis is conducted in real use cases , which are expected to be among the vehicular applications that will most benefit from introducing an SDN architecture.The demand for safe and secure journeys over roads and highways has been growing at a tremendous pace over recent decades. At the same time, the smart city paradigm has emerged to improve citizens’ quality of life by developing the  The integration of Information and Communication Technology (ICT) into a strategic approach to sustainability, citizen well-being, and economic development, has led to the concept of the smart city . In otheNowadays, particular interest in smart cities is focused on smart mobility, which includes enhancing traffic conditions, travel efficiency, vehicle safety, and drivers’/passengers’ comfort while on the road. Citizens want to connect to the Internet everywhere on the road, subscribe to a variety of services, and get real-time information about traffic and facilities . These services are mainly provided by vehicular applications which must be able to cope with the high mobility of the network environment and consequently with the unreliable connectivity, both in Vehicle-to-Vehicle V2V) and Vehicle-to-Infrastructure (V2I) communication. Road Side Units (RSUs) are usually located only at a few critical intersection points with short radio communication ranges. Therefore, connectivity is intermittent: it is often broken and subsequently re-established in a different location [V and VehConsequently, communication networks must be designed using a totally new approach, devising a new network paradigm that will be structured to minimize the impact of disconnections caused by vehicle mobility and improve reliability of communication in Vehicular Ad hoc NETworks (VANETs), fostering the development of smart mobility. The Software Defined Networking (SDN) paradigm  is a suiSome aspects of the benefits offered by SDN to VANETs have been investigated in the literature ,8,9,10, A detailed survey of studies conducted by the research community for enabling SDN in VANETs is provided. While the applicability of SDN in vehicular networks has been discussed in several works, such a comprehensive overview with in-depth technical explanations is unprecedented.The awareness of the impact that SDN could have on security when applying such a paradigm in smart cities is raised for the first time.The introduction of a clear vision of the novel security countermeasures that SDN could build against some traditional attacks in VANETs, is totally novel and unprecedented.Finally, the applicability of the study in four concrete use cases shows the feasibility of the proposed solutions that are destined to be successfully implemented in future smart cities.The core contribution of this paper can thus be summarized as follows:The present article is organized as follows: In this section, we first outline the main features of the SDN paradigm. Then, we analyze how this programmable approach applied to networking can be useful in easing the management of VANETs in future smart cities and providing Quality of Service (QoS) support for different types of service. By providing and overview of the few solutions already suggested in the literature, we highlight the advantages offered by SDN, which make it a good candidate for coping with smart city issues and especially for meeting the requirements of vehicular applications.The Software Defined Networking  paradigmInitially designed for wired networks, the SDN paradigm has also been widely recognized as an attractive and promising approach to improving wireless and mobile networks . These cAn SDN-enabled VANET has the advantage of dynamically adapting to topology changes by reconfiguring data forwarding rules in the network . In thisMost of the infotainment applications in future VANETs will require the exchange large multimedia files. SDN has the potential to improve the management of content delivery  and in pSDN can also improve and reduce the number of broadcast messages exchanged in VANETs, with the consequent advantage of efficiently using network resources through collision reduction. Liu et al. use this capability in defining an SDN architecture for GeoBroadcast in VANETs . NormallAs highlighted in this section, the SDN paradigm can introduce several advantages when applied to VANETs, but we are still far from a seamless integration of SDN in the vehicular environment due to many challenges to be faced, most of them inherited from its mobile nature.Smart cities enhance the performance of urban services through tight integration of several sectors using ICT. Each sector can have its own requirements for internal and external communication over the network. Modern networks allow multiple tenants to share an infrastructure and offer the capability of allocating resources to each tenant according to communication requirements. However, these requirements can change in real time, depending on events occurring in the city; thus it may be necessary to dynamically scale the amount of network resources allocated to tenants. This section presents several use cases are presented, where SDN can be instrumental in managing the network infrastructure to meet the requirements of the applications.One of the most well-known smart city applications is the smart parking system, already available in several real deployments ,19. The The addition of an SDN controller to the infrastructure can aid the dissemination of parking availability in a given area through V2I/V2V communications or using communications between peers, as achieved with the Floating Content approach ,22,23,24Smart parking is prone to several security threats, and in particular to hardware attacks, which can compromise the physical devices  or their communication interfaces (through jammers). The addition of an SDN controller in the parking system can be particularly beneficial in detecting such attacks. Usually, monitoring applications can be characterized  and hencclimate departure in [One of the main goals of smart cities is to improve energy efficiency and reduce greenhouse gases emissions, to delay the climate change  that isrture in ,28,29, trture in .EVs are considered to be the future active elements of smart grids, the technology that integrates information and power networks to efficiently distribute electrical energy. The original smart grid concept was devised to manage the distributed and intermittent production of electrical energy from renewable sources. In such a scheme, EVs will be able to dynamically improve the storage capacity of the power network in two ways: by absorbing unexpected generation peaks from renewable sources, and by injecting electricity back to the grid, acting as a short-term or emergency power supply . EVs wilfree-riding). On the EV side of EVI, malicious software can bring about minor issues, like the incorrect display of indicators such as fuel gauge and tachometer, up to more serious malfunctions in the safety system, such as taking control of the vehicle throttle and brakes. Furthermore, since EVs take part in V2V communications, the smart grid of EVs inherits the security vulnerabilities of VANETs. The combination of EVI with smart grids is intrinsically complex and prone to security issues at several levels as discussed in Increasing the freedom for communication across the EVI increases the number of possible security threats that can arise, for example, malware can be carried by compromised vehicles and infect EVSEs, which in turn will infect more EVs. This can obviously not only have a negative impact on service availability and security, but also on secondary aspects like the robustness of the market system, in which users might unduly benefit from services without paying . Consequently, this chain requires a central entity to manage the selection of an appropriate platoon leader and to establish its action profile, such as its acceleration and deceleration pattern, according to the city conditions. Since a smart city consists of complex transportation systems that are tightly connected, a central entity, namely the RSUC, might have coarse-grained control over multiple platoons and support each platoon leader, be responsible for intra-platoon issues, and wisely instruct follower vehicles .In other words, the central controller can instruct the elements in the data plane  with appropriate rules for acceleration/deceleration, merging/splitting and changing lane according to real-time traffic conditions and unexpected events in the smart city. For instance, by using signaling messages exchanged over cellular (LTE) or wireless links (Wi-Fi or IEEE 802.11p), the RSUC can collect information on platoon status and abnormal vehicle behavior. On the dissemination side, the RSUC can instruct the leader on how to set specific parameters  to ensure better network utilization and a safer journey. Such data messages convey information about distance and speed, for example, and are transmitted over IEEE 802.11p as beacon messages and WAVE Service Advertisement (WSA). The centralized orchestration provided by the RSUC allows the traveling distance over which the platoon stays intact to be maximized and therefore allows its lifetime to be extended. In addition, the presence of a centralized controller plays a major role in keeping the platoon secure and robust against cyber-attacks. For instance, the RSUC can support the platoon leader in a fast and efficient manner in detecting jamming and replay attacks as well as attacks targeting the management protocol. This latter is responsible for the splitting, merging, leaving and lane changing maneuvers. These threats are investigated in depth in In large cities, the management of emergency situations that require the mobilization of the emergency services  becomes a difficult task when combined with traffic management systems. A quick reaction in such circumstances improves emergency management effectiveness and reduces its impact to the normal operation of the vehicular and transportation infrastructure. For example, emergency events occurring in the transport system may request the communication network to allocate additional communication channels or generally an increased amount of resources, in order to manage the event efficiently. A tight coordination of data network, traffic management systems and emergency services requires an adaptation of network data flows to raise the priority of actions that will affect the immediate handling of the emergency, such as quick traffic light actuation, deviation of traffic flows, and reservation of parking spots. More generally, the communication requirements between Emergency Services and traffic management systems in smart cities can range from best-effort to real-time depending on the type of information being exchanged and the urgency of the communication. Rather than statically over-provisioning resources to satisfy the possible needs of different types of communication, the SDN paradigm allows the flow of information between actors to be dynamically controlled in a proactive or reactive manner. This offers the ability to proactively provide a minimum amount of resources to these services and reactively scale according to changes in application needs.SDN can help to disseminate emergency messages about an event that has occurred in the network by orchestrating Floating Content replication ,22,23. WIf the accident requires prompt action from the rescue service, for example when peoples’ lives are threatened, the SDN controller can rely on the infrastructure and ask RSUs to contact the first aid service via cellular networks, announce the event to surrounding vehicles, and broadcast IEEE 802.11p messages on the service channel as summarized in The synergy between the centralized (infrastructure-based) and the distributed (FC-based) solutions can provide a quick local traffic redirection and a fast notification of the critical accident to the emergency vehicle, which will benefit of clear roads in the neighborhood of the event.Furthermore, SDN can also help to mitigate some typical security breaches in the Emergency Service scenario, such as the Sink Hole Attack and the DDoS attack, by enforcing a trust scheme, as described in detail in http://securingsmartcities.org/), which aims to find workable solutions to make our cities cyber-safe. Security is of foremost importance in smart cities since business opportunities are strongly dependent on regulation concerning privacy and trust in the technology. To increase market demand for new emerging applications, citizens should be confident that data exchanges are secure, private, and that their personal information is kept confidential. In this section, we first review the classical security and privacy issues in VANETs. Then, in order to estimate the security threats that SDN could introduce when applied in the vehicular domain, we study the vulnerabilities of SDN from a security perspective.The awareness that smart cities are exposed to several cybersecurity challenges is rapidly increasing, as shown by the creation of the global Securing Smart Cities initiative , which can be dangerous if an emergency situation occurs. Thus, each vehicle should be able to establish the reliability of the received message, based for example, on the reputation of the sender vehicle.To be cyber-safe, VANETs should meet the classical security requirements: Authenticity, Availability, Confidentiality, Data Integrity, and Non-Repudiation. The large scale of the network, the high mobility of the nodes, the uncertainty of their relative geographic positions, the intermittent connectivity between the nodes, and the unreliable channel conditions, make it difficult to satisfy these requisites . There aprivacy risk, given that the TA will be aware at any time of each user’s specific location. An analysis of the security techniques that can secure VANETs while preserving privacy is presented in [Authentication represents the first step towards securing VANETs: all RSUs and vehicles in the network should register and get certificates from a Trusted Authority (TA). Before sending a message, each vehicle should first digitally sign the message. By checking the signature, the receiver can verify the integrity of the message, as well the identity of the sender. Despite these advantages, authentication poses a ented in . Severalented in . Trust sDespite the numerous and different methods proposed so far in the literature, VANETs cannot yet be considered cyber-safe, and there is still a need to design new approaches that can preserve user privacy, while protecting VANETs from attacks.The adaptation of SDN in smart cities will offer authorities the opportunity to run and upgrade different applications in a scalable manner, as they appear, without being concerned about network and hardware complexity. Despite the foreseen tangible benefits of SDN in improving resource allocation and network management  is used to prevent malicious users from jeopardizing the network. Handling these myriad security mechanisms in a cooperative manner is not trivial. Here, the role of the controller is vital: with its global view of the network, it is able to deploy a huge set of security policies while avoiding overlap and conflict between them, and optimizing network resources. The global awareness of the controller drastically reduces the complexity of security policy deployment and optimizes overall network performance.SDN’s abstraction from the underlying hardware resources can also be helpful in improving security. In fact, diverse security mechanisms, such as multi-access technologies, wire sniffers, firewalls, etc. , can be Finally, SDN allows per-flow-based granular security management to be implemented. In SDN, all packets belonging to same flow are handled by the same service policy at the data layer. Therefore, if some flows are identified as suspicious, it is possible to efficiently label and isolate them; forwarding devices will not be burdened with handling packets coming from these labeled flows. This section focuses on security benefits introduced by the application of SDN in VANETs. For each use case we describe in detail how SDN, with its programmability and monitoring features, can help in building new countermeasures against classical attacks in vehicular networks.Smart parking relies on the communication between intelligent sensors, deployed at each parking spot, and the gateway, using wireless technologies such as Zigbee, LoRa and Wi-Fi. These networks expose a large number of vulnerabilities and are subject to a wide range of attacks. We detail two types of attacks: jamming and eavesdropping, which target service availability and data confidentiality/privacy respectively.Given the broadcast nature of wireless communication, an outsider attacker can jam the network by using a transmitter more powerful than those embedded in sensors, as shown in As stated in For example, Software Malware. In fact, an EV could intentionally (or not) carry any sort of malicious software, which first infects the EVSE it is connected to, from there it may potentially spread the worm to other EVs or even worse, to the entire smart grid. The key to protecting the EVI from this type of attack is to strengthen the security of access points to the fixed infrastructure (EVSEs), at both protocol and physical level. Notably, the IEC 61851 protocol [In the EVI, vehicles (mobile nodes) and the Smart Grid (fixed network) are frequently in contact, exchanging data and energy through specific interfaces that are particularly vulnerable to attackers. The safety of Vehicle to Grid (V2G) communications has been already studied in the literature . Howeverprotocol , which pEVSE_1, provided to the EV at time EVs can also be subjected to Masquerade Attacks , which impair the reliability of the whole system. The dynamic of the attack is illustrated in Given the important role played by the platoon leader, one of the primary tasks of the central controller (RSUC) should be the careful selection of the trusted leader. To this end, Hu et al.  propose Besides privacy issues, several security attacks can be initiated in a CACC-enabled platoon, either by external  or internal attackers (vehicles belonging to the platoon itself). Beacons messages normally used for intra-platoon communication, between the leader and the followers, are vulnerable to such malicious or misbehaving attackers. In the following section we describe how SDN could offer mechanisms for detecting and thwarting attacks from such malicious users. The analysis is conducted in the two distinct modes of platoon operation: the normal traveling and the platoon management maneuvers.I denotes the Platoon id and j denotes the id of the vehicle inside the platoon) will trigger a slowing down action or a speeding up action to increase or decrease respectively the intra-platoon distance. To do this, the platoon leader relies on beaconing to exchange crucial parameters for a longitudinal control [In this mode, the platoon is a stream of vehicles traveling on a straight highway. The platoon leader  control . PositioReplay attack:nonce numbers to uniquely identify each communication, preventing the malicious node from impersonating future communications inside the platoon. As shown in The malicious user captures and replays a previously generated beacon at a later time or in other parts of the platoon. The replayed beacon includes expired information not relevant to the current situation of the platoon. For example, the platoon leader Jamming attack:The attacker can be either a stationary or a moving jammer. Given the nature of the mobility of the platoon, it is rational to have a moving jammer that tracks the considered platoon and causes regular interference. The high level of interference coupled with the continuous aspect of this attacks makes it a thorny problem. As depicted in During its journey, the platoon structure can undergo changes leading to it is becoming bigger or smaller stream of vehicles. The platoon management protocols handle three basic maneuvers: merge, split and lane change. Each maneuver is coordinated by exchanging a sequence of micro-commands . In thisThe platoon management protocol is based on a coordination approach. The leader initiates the desired maneuver and followers either obey or send requests to the leader. to him. In addition, the configuration data required for coordination  is stored by the leader and not divulged to followers. The latter dynamically join and leave the platoon. However, some attacks can affect the smoothness of these maneuvers. We highlight how an inside attacker can impede two main maneuvers (merge and splitting).Merge maneuver:Merge combines two successive platoons in the same lane to form one single platoon. As shown in Splitting maneuver:A split maneuver divides a platoon into two successive ones in the same lane when, for example, platoon size exceeds the predefined maximum size. It can be initiated by a follower in order to become a free vehicle, or by a leader to make a space for a lane change. In As highlighted in this section, SDN promises to dramatically simplify platoon management maneuvers and enable sophisticated countermeasures to overcome malicious users’ threats.Emergency services are also heavily impacted by the introduction of the SDN paradigm in VANETs. Emergency notification is a life-critical VANET service that has particularly demanding criteria for security, which SDN can strengthen. In an emergency, SDN can modify the amount of network resources allocated for that VANET portion and reroute the emergency flow towards the rescue service in an efficient and secure manner, coordinating data encryption and making sure that messages are delivered correctly. An attacker who compromises the SDN-enabled VANET, can reroute emergency requests preventing them from reaching needed rescue teams or alerting teams when they are not required so impairing the reliability and availability of the service.In traditional, distributed VANETs, a malicious vehicle can instruct a subset of nearby vehicles to send all their traffic through the attacker’s interface. SDN can provide an efficient strategy against this kind of attack, known in the literature as a Sink Hole attack. When a vehicle must act as a V2V intermediate node for communication, either towards infrastructure or another vehicle in the area, a trust-based authorization scheme, coordinated by the SDN controller, can be devised. In particular, the intermediate node must ask the SDN controller for authorization to act as a data relay, after the controller has computed its reputation in the opinion of the community. A generic vehicle that needs to send data to another peer must ask the SDN controller whether the recipient is dependable or not; this is determined by collecting feedback about it from the experience of community members. For example, a positive feedback can be provided from the members of the community when a certain vehicle forwards the traffic according to the rules of the protocol, while a negative feedback can be provided when the vehicle acts like a sink hole, gaining the right to act as a intermediate forwarding node but actually behaving like a Man-in-the-Middle. All the traffic, including emergency alerts will be routed through the malicious vehicle that, having full control of the information exchange, can decide to drop all the requests for help coming from an area, as shown in zombie vehicles), a particular case of Distributed Denial of Service (DDoS) applied to VANETs can occur. When the coordinating malicious vehicle (botmaster) triggers its infected vehicles subset (botnet), each infected node can start to originate fake emergency requests to overload the rescue team, thereby compromising the availability of the road safety service. In this case, SDN can identify the sources of the malicious traffic and then instruct the data plane (RSUs and vehicles) to drop the packets of those flows. In this way, the malicious network traffic is dropped directly at the routing device closest to the zombie vehicle. Furthermore, an SDN-based reputation management scheme for vehicles could be useful in identifying malicious users and exclude them from the network, using a shared consensus algorithm that is resilient to malicious collectives and does not present single points of failure [If a malicious user takes control of a subset of vehicles that have been infected by malware  are widely accepted as a cornerstone for enabling safety, traffic and infotainment applications for drivers, passengers, and pedestrians in the smart city. Indeed, these highly-mobile networks are expected to contribute to road safety by providing pertinent information to drivers on potential threats within their surroundings. However, a VANET is not a benign environment, owing to its vast operating area and the underlying technologies used to deliver critical information. The wireless transmission of data using V2I and V2V communications makes it easily and constantly accessible to malicious users. Undoubtedly, in smart cities, security is fundamental to ensure a high level of availability and the integrity of services vital to citizens. While the complexity of smart cities is steadily increasing and evolving, traditional security measures and network management tools cannot practically cope with the explosively growing number of vehicles and the plethora of forwarding rules updates. To counter this thorny issue, Software Defined Networking (SDN) is proposed as an efficient paradigm that offers agility and flexibility to deal with the surge of vehicles and accommodate heterogeneous running applications. The first part of our paper provided an overview of SDN and the underlying architectures in VANETs, giving a special attention to new emerging applications in VANETs such as smart parking, platooning and electric vehicles. Our purpose was to investigate how these new applications can be orchestrated and managed by SDN. However, the new way of operating communication networks within SDN poses security and privacy challenges that must be solved so smart cities can be successful and accepted by citizens. To this end, we provided a comprehensive review of threat vectors in both VANETs and SDNs. For instance, platoon leader, electric vehicles and electric vehicle infrastructure could be the target of malicious users intent on wrecking vital services in a smart city. This investigation was particularly useful in understanding how SDN can overcome the weaknesses and vulnerabilities of current VANET architectures. Starting from this point, we provided some insights into the primary improvements required by SDN in the targeted use cases of VANETs. The intelligence of the SDN controller can detect improper behavior of electric vehicles or platoon members. Consequently, it can isolate these malicious nodes and reduce the resources allocated to them. Furthermore, the programmability of SDN allows security policies to be upgraded as the smart city evolves.To the best of our knowledge, our paper is the first study that tackles the issues and new countermeasures introduced by SDN in SDN-enabled VANETs. However, there is a long path ahead of us before we can ensure a benign VANET environment where drivers and passengers can make their journeys without being compromised. We urge governments, standardization bodies and research institutions, along with car manufacturers to plan at all levels for making SDN a future security solution in our smart cities.


This article traces what recent research and primary sources tell us about psychotherapy in Communist Europe, and how it survived both underground and above the surface. In particular, I will elaborate on the psychotherapeutic techniques that were popular across the different countries and language cultures of the Soviet sphere, with a particular focus upon the Cold War period. This article examines the literature on the mixed fortunes of psychoanalysis and group therapies in the region. More specifically, it focuses upon the therapeutic modalities such as work therapy, suggestion and rational therapy, which gained particular popularity in the Communist countries of Central and Eastern Europe. The latter two approaches had striking similarities with parallel developments in behavioural and cognitive therapies in the West. In part, this was because clinicians on both sides of the ‘iron curtain’ drew upon shared European traditions from the late nineteenth and early twentieth centuries. Nevertheless, this article argues that in the Soviet sphere, those promoting these approaches appropriated socialist thought as a source of inspiration and justification, or at the very least, as a convenient political shield. What happened to psychotherapy behind the so-called Iron Curtain? Some commentators have assumed that it was almost non-existent in the Soviet sphere, only to emerge as a significant force in society after the fall of the Berlin Wall Rose, . Others Detski Dom) experiment in Moscow, a therapeutic residential institution for children led by the psychoanalytic educationalist Vera Schmidt. With many attendees from among the children of the Party elite, including Stalin’s own son, the Children’s House pioneered psychoanalytic child rearing practices with involvement from Sabina Spielrein and Alexander Luria . Investigations had, for example, demonstrated that it was the very meaning of the word, rather than its sound, which produced an effect upon the body Shvarts, . For exaIn East Germany, at the university polyclinic in Jena, similar ‘autogenic relaxation’ techniques were also pioneered by two internal medicine specialists, Gerhard Klumbies and Helmuth Kleinsorge, who had taken over the psychotherapeutic clinic after the war due to staff shortages. Instead of looking back to Russian and French research, they drew upon the work of Jena’s own Johannes Schultz and local German psychosomatic traditions from the pre-war period. The clinic became a centre for both experimentation and training: it hosted workshops for the instruction of physicians and therapists from across the Eastern bloc countries, and some from the West Geyer, . The JenIn 1960, the Russian psychotherapist Miassischev claimed that there were two main approaches to therapy in the Soviet world: ‘suggestion and persuasion. They differ mainly in the purpose of the activating words. Sometimes they are contrasted as the irrational and the rational’  and a special issue of History of the Human Sciences on ‘Psychotherapy in Historical Perspective’ (April 2017).