Pregnant women and mothers in sub-Saharan Africa are at high risk for perinatal depression, warranting a need to develop culturally tailored interventions to prevent perinatal depression. This paper documents the process of adapting an evidence-based preventive intervention developed in the United States, the Mothers and Babies Course (MBC), to fit the contexts of rural pregnant women and mothers of young children in Kenya and Tanzania using the updated Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). Data from informant interviews and field observations from the planning and implementation phases were used to make adaptations and modifications of the MBC for perinatal women through the eight aspects of FRAME. Follow-up field visits and reflection meetings with case managers and intervention participants indicated that the adapted version of the MBC was well accepted, but fidelity was limited due to various implementation barriers. The FRAME provided an optimal structure to outline the key adaptations and modifications of a preventive intervention intended to maximize engagement, delivery, and outcomes for high-risk perinatal women in rural settings.  Pregnant and postpartum mothers in sub-Saharan Africa, the majority in low-income and middle-income countries (LMICs), are at higher risk for perinatal depression (PD) than women in high-income countries . PD is aThe high prevalence and negative consequences of PD warrants prevention efforts for women in sub-Saharan Africa. However, most research has focused on developing treatments for postpartum depression. Evidence-based psychological interventions documented in the literature to treat PPD in LMICs include cognitive-behavioral therapy (CBT), interpersonal psychotherapy, and problem-solving therapy . To our The limited focus on preventive interventions for PD in sub-Saharan Africa warrants additional research in this area. Yet, efforts to systematically document culturally adapted interventions have been limited , thus stThe MBC was developed as a group intervention to prevent postpartum depression for low-income English- and Spanish-speaking pregnant women at high depression risk in the United States . The MBinternal reality refers to one’s thoughts and values, and the external reality refers to one’s behaviors or interactions with others. The MBC teaches participants to manage their mood—by changing their internal reality (thoughts) and external reality . The MBC also integrates elements of attachment theory, proposing that the quality of a child’s relationship with their primary caregiver during infancy has a sustained effect on that child’s behavior throughout their life [The MBC is based on CBT principles, an evidence-based treatment and preventive intervention for depression for many populations, including women and families ,15. To ieir life .The FRAME is a comprehensive model, developed and updated by Stirman et al., 2019  to documWhen and how in the implementation process the modification was made. This aspect describes the timing of the implementation process of the modification of the intervention; (1) Whether the modification was planned/proactive  or unplanned/reactive. This aspect describes the extent to which the intervention modifications were planned  prior to delivering the intervention, and/or unplanned  during the implementation phase in response to unanticipated challenges (“reactive”);(2) Who determined that the modification should be made. This aspect identifies the person(s) who participated in the decision-making process for the intervention modifications;(3) What is modified. This aspect describes the types of changes that were made to the intervention, which can occur at various levels: content , context (delivery), training, and evaluation, as well as at the implementation and scale-up phases; (4) At what level of delivery the modification is made. This aspect identifies the target group(s) that the intervention was modified for, which has implications for ascertaining the potential effectiveness of intervention delivery;(5) Type or nature of content-level modifications. This aspect describes the specific content-related modifications made within a particular setting  and includes details regarding whether and how “drifts” occur in the process of delivering the intervention;(6) The extent to which the modification is fidelity consistent. This aspect describes the extent to which the modifications made to the intervention were consistent with the core elements that comprised the intervention (“fidelity-consistent” modifications) compared to modifications that are peripheral to the intervention elements (“fidelity-inconsistent” modifications), which can impact the outcomes and applicability to a particular setting;(7) The rationale for the modifications made. This aspect describes the intent or goal and specific reasons why the intervention modifications were made, including the various factors/levels  that inform the adaptation process, and the barriers and facilitators of adopting the intervention at a broader level. (8) We organized and analyzed our data using the updated FRAME. These data were gathered from field observations and informant interviews when the MBC was adapted to perinatal mothers in Kenya and Tanzania from the years of 2016–2018. . We describe below in detail our process for the first two phases of the study, planning and implementation, which form the core intervention modifications for Kenya and Tanzania; In 2016, the planning phase began as a collaboration between the MBC’s cocreator (developer) and the senior technical advisor (STA) for Catholic Relief Services (CRS), an international humanitarian agency working with populations and organizations to promote sustainable and collaborative human development. The STA led the Thrive II project, which aimed to increase the attainment of age-appropriate developmental milestones for children under two years in Kenya, Tanzania, and Malawi. Thrive II utilizes a modified version of the Care Group Model  compriseThe impetus for the MBC to be added to the Thrive II came from results from CRS’ first project, Thrive I, indicating that primary caregivers of children 0–5 reported high levels of anxiety (64%) and depression (61%) . HoweverPlanned intervention modifications. Modifications were made collaboratively between the MBC developer’s knowledge of the MBC in research contexts and CRS staff’s knowledge of what works in their rural settings in Kenya and Tanzania. The MBC was modified in content and training in five ways . First, these modifications considered the sociocultural contexts of the recipients in Thrive II (aspect 5.1). These women live in communal rural areas with few resources, are financially dependent on husbands and their families, and have low literacy levels. The intervention’s name was revised to “The Mothers, Babies, and Young Children (MBYC) Course” given its focus on the first two years of life. Second, the intervention’s format was changed to match the Thrive II project structure and staffing (aspect 5.1). The original MBC materials included participants’ and instructors’ manuals that were delivered weekly for 90 to 120 min per session and booster sessions occurring after the end of the intervention to reinforce materials. The MBYC would be integrated and also take place biweekly to follow to structure of THRIVE II’s ECD interventions. As the original MBC materials were available in 6, 8, or 12 group sessions, CRS staff decided to implement the longest version to maximize learning, because this was a new intervention that focused on mental health. Participants would partake in both ECD and MBYC interventions every two weeks, starting with the MBYC and ending with the ECD sessions with 45 min in each intervention. At the end of the 6 months, women would “graduate” from the MBYC but continue with the remaining ECD course for the last 6 months. The ECD intervention also included a monthly home-visit component led by the CGV, which was also adopted with the MBC. Home visits are an essential part of the ECD intervention in order to check in individually to address barriers to ECD and MBYC practice. Finally, booster sessions were included at 3 and 6 months following the completion of the MBYC to reinforce the main intervention concepts, ensuring that participants are practicing the concepts that they learned in the MBC to manage stress and decrease the risk of PD.Third, the MBYC materials were carefully reviewed by the STA, program managers, and the developer to address literacy and cultural contexts (aspect 4.1). Translations of materials addressed local dialects where the intervention was delivered, including how “depression” and “stress” were expressed within the region. Additionally, there was a mood scale in the original MBC that asked women at the end of each session to rate their mood on a nine-point scale, from one (worst) to nine (best) mood each day within the past week. As some of the women do not know how to read numbers, these numbers were added with faces that depict facial expressions of emotions corresponding to a five-point and seven-point scale . The CGVs, supervised by CHWs, delivered the ECD materials. The CGVs and CHWs were already trained in the ECD materials, participated in Thrive I, had a full caseload, and did not have time to administer another curriculum. Case managers were hired and trained to deliver the MBYC course to maximize the fidelity of the delivery by employing staff who had some mental health background. The intervention developer provided training for the MBC in August 2016 to CRS program staff and partners from Kenya and Tanzania. The training format was modified to fit the needs of CRS staff by expanding the two-day training to five days  to provide a detailed introduction to CBT concepts that were new to attendees and included time to practice these skills in the field.Unplanned Modifications. The first training in August 2016 was well received by attendees and led to additional modifications of the intervention materials (aspect 2). Overall, participants understood the CBT concepts and intervention and appreciated especially the relaxation exercises as a way to manage stress. The field practices suggested that the mothers understood these concepts. However, the participants’ and facilitators’ manuals needed to be further adapted to the needs of the rural African context (aspects 3–5). The attendees recommended removing participant manuals because of low literacy, and it was not common practice in these programs to provide a manual (aspect 3.2). However, CRS staff recommended continued use of thought that it was important for women to be able to monitor their mood scales, leading to several modifications to the materials . First, the mood scales and core contents were included in a small spiral booklet with illustrations that would be easier for the women to carry back and forth to sessions. Second, the mood scale ratings changed from five to seven to represent more variations in the reporting of one’s mood, including suggestions to make the facial expressions more contextually relevant  stayed on with the project post-August training. Thus, two new case managers were hired, who had a teaching or health background. A subsequent 3-day training was conducted for the two new case managers as a new training and as a refresher course for the initial case managers in both countries. The program managers from Tanzania and Kenya provided this refresher training, which is a reactive change to onboard the new staff in the new intervention (aspect 4). The core elements of CBT, reality management, and attachment models that comprise the original MBC were retained and are the main theoretical frameworks for the intervention. The three modules of the intervention  remain similar to the original MBC. New checklists were created to assess the fidelity of the MBC in the group sessions and home visits. Home visits were intended to check in with participants who may not have been able to attend some of the interventions in groups. Since the home visits were only part of the original design in the care-group model in Thrive II, not the original MBC intervention, CHWs needed additional training regarding when to refer participants for additional depression risk assessment.The reasons for modifying the MBC for perinatal mothers living in rural Kenya and Tanzania came from several factors. From a sociopolitical perspective, attention to mental health is limited in rural areas of sub-Saharan Africa, partly due to stigma and to limited resources devoted to mental health . Thus, CN = 756; Tanzania: N = 986) women who participated in Thrive II. Informed consent was obtained from 1742 women to participate in the MBC. On average, each case manager had between 23 to 27 groups, with 7–10 women per group, which occurred from February to July 2017. In February and March 2017, the intervention developer, the two program managers (one per country), and the technical advisor conducted field visits to observe the sessions being implemented by each case manager. Fidelity checklists were used to aid the observations and provide feedback to case managers on their performance. During this time, each case manager conducted 1–4 MBC sessions. Field observations revealed that case managers differed in how they delivered the intervention content. For example, case managers with teaching or program management backgrounds stood to deliver the content to participants who sat in a circle on the ground; whereas case managers with a counseling background generally used communication strategies for behavioral change . These observations led to several modifications thereafter. The implementation phase for the MBC took place from February to July 2017. Three case managers provided the MBC to 1742 (Kenya: Two observations were consistent in the field visits in both countries and led to unplanned changes made to the intervention content following the field visits (aspect 2). First, case managers were all using old materials presented in the first training in August 2016. The flipcharts, take-home messages, and spiral notebooks were created after this training, but these materials were not yet available when the groups started due to budget delays. Second, case managers spent little time integrating the reality-management model with the content that they were teaching participants . This limitation was due in part to time constraints, the lag of time between training and implementation which led to focusing on the more concrete aspects of the intervention, and the lack of integration of the ECD and MBC materials as the content was taught by two different facilitators. Although the MBC content did not vary within the sessions observed, case managers differed in what material they chose to emphasize; therefore, the timing of the various activities differed across the same sessions. For example, relaxation was introduced as a coping skill in session 2. The goals were to introduce and define the concept of relaxation, discuss its benefits, demonstrate a breathing exercise in session, and encourage women to practice relaxation between sessions. However, in some groups, the case managers defined this concept but did not demonstrate it in session yet encouraged women to try this on their own, whereas other case managers completed all tasks as described in the facilitator’s manual. The intervention developer, STA, and program managers met with the case managers in each country to provide feedback on post field visits and suggested modifications for the implementation phase (aspect 3). These modifications focused less on content and more on the process of delivery—contextual modifications to improve the facilitators’ ability to teach the MBC concepts, which were novel in perinatal mental health in the sub-Saharan rural setting (aspects 4 and 5). Finally, case managers should use the post-training materials as they become available. These modifications considered participants’ limited literacy by using flipcharts and more pictures to teach the MBC intervention . The use of older materials in the first few sessions of the MBC limited the fidelity of the intervention delivery. A review of the fidelity rating forms indicated that the supervisors generally rated the case managers as performing very well and adhering to all content within each intervention session. However, these ratings did not always match what the intervention developer, STA, and program managers observed in the field. Lower ratings suggested “bad” performances, and supervisors did not want to provide lower ratings to the case managers. Instead, the STA and intervention developer reframed the lower ratings as an opportunity to assess areas that needed additional review of the intervention content for participants to apply in their lives. Furthermore, due to budgetary constraints and difficulty in hiring additional case managers, the high number of groups that each case manager was responsible for meant that the case managers had to travel far between villages, making it difficult to deliver the material with optimal fidelity. Therefore, the intervention developer provided additional guidance on how to deliver the content and engage the participants to practice within and outside of group sessions to increase fidelity.The intervention developer also provided biweekly remote supervision for the case managers to increase the fidelity of the intervention delivery, including guidance on content and process. Based on the fidelity ratings, case managers reported on activities that were successfully implemented, challenging to facilitate, or lacked group participation. Case managers from both countries mostly participated in these supervision calls together, enabling them to learn from their individual styles of delivering the MBC. Modifications were made in response to the observations made in the field visits. case managers (providers) were encouraged to use the new materials. From an organizational perspective, this meant that CRS needed to devote additional financial resources to the community to get these materials in a timely manner. The goal was to maximize fidelity to the MBC, thereby increasing retention and improving outcomes for perinatal women living in rural settings in Kenya and Tanzania (recipients), who were also receiving ECD concepts aimed at improving the lives of these mothers and their babies in the first two years of life.The purpose of the field visit was to elicit feedback from mothers and case managers regarding their experiences with receiving and implementing the MBC, respectively . Based oIn the reflection meeting with five mothers and CGVs, the recipients reported the intervention as very useful and important to them; the most helpful activities increased their awareness of mood and the impacts of stress and depression on their daily lives and relationships. They also liked relaxation and learning ways to manage their daily stressors and relationships with others. They valued the group support, and some women expressed that this was the first time that they had a group that focused on their own wellbeing. They also liked the incentives  provided at the graduation of the MBC. Regarding challenges, the women mentioned that the case managers were sometimes late getting the session and/or had to rush off after a session to facilitate another session. Women also wanted monetary incentives for their participation in the intervention (which was not part of the Thrive II program). The reflection meeting with the six case managers indicated that they concurred with the mothers’ feedback on the intervention. The case managers appreciated the remote supervision to reinforce the key messages in the session and ways to improve facilitation . The case managers reported having difficulty using old intervention materials, and that the new materials came “too late”. Furthermore, participants had varying levels of comprehension of the intervention due to different literacy levels and/or missing previous sessions. Thus, the time allotted for each session was sometimes not enough, particularly if the concepts were more difficult to understand. Specifically, the materials from the thoughts module were more difficult for case managers to facilitate and for participants to understand. Finally, the contents of the MBC and ECD interventions were presented separately by the case manager and CGV, respectively. As a result, the contents of the two interventions were not coordinated, yet there were some opportunities to integrate these interventions. For example, the ECD curriculum stressed the importance of mothers playing and interacting with the baby to promote positive parenting. As depression can impede this interaction, this would have been an ideal opportunity to reinforce the confluence of these key messages. A final challenge was that the case managers were responsible for a large caseload, which led to difficulties with overscheduling, being on time, and with few opportunities to conduct home visits. The FRAME was used to document the process and the reasons for culturally adapting the MBC to the contexts of perinatal mothers in Kenya and Tanzania. Through a review and analysis of field notes, informant feedback, and multiple collaborations among the intervention developer, program managers, case managers, and participants, the MBC underwent a series of proactive and reactive modifications during its planning and implementation phases. Follow-up field visits and reflection meetings with case managers and intervention participants indicated that the adapted version of the MBC was well accepted; however, fidelity was limited due to various implementation barriers. The adapted MBC was overall feasible and acceptable as an intervention to address mental health for mothers during the critical early childhood period in Kenya and Tanzania. Our work in adapting and modifying the MBC in Kenya and Tanzania is consistent with previous work that has systematically documented the cultural and contextual adaptations of the MBC with different populations  that could be affected by PD. This process involved two days of close review of both the ECD and MBC curricula by the case managers and CRS program staff who were most knowledgeable of these interventions. The intervention developer and STA organized the workgroups to review and identify activities in the ECD curriculum that could be incorporated into the three modules of the MBC. Additionally, given the difficulties with comprehension of thoughts, the next iteration added one more session (three to four sessions) for this module, resulting in 13 sessions. A new version, called the Integrated Mothers and Babies Course (I-MBC), was created and will be used as part of a follow-up project to improve the wellbeing of pregnant women and mothers and children < 2 years old.The second challenge, how to scale up the I-MBC, given the difficulty in recruiting counselors to work in rural areas, was addressed in two ways. First, lessons learned in implementing the MBC indicated that certain activities were more difficult for case managers to deliver with fidelity to participants, including the reality-management model and the cognitive restructuring activities in the thoughts module. The CRS staff and the intervention developer identified these activities, discussed the best ways to deliver them, and provided a role-play scenario for each activity. CRS provided financial resources to a media company to record these activities to serve as “job aids” for future facilitators. Second, CRS staff recommended that future facilitators of the I-MBC include CHWs, a model that is widely used in Africa to address the shortage of mental health specialists via task-shifting . To maxiOur process of cultural and contextual adaptation has limitations, namely that this is a unique process that involves the efforts of multiple stakeholders in two different countries. Although we were successful in documenting this process, our findings may not be applicable to other countries in sub-Saharan Africa, which may have diverse expressions and experiences of PD. We encourage others to follow this process of adaptation and documentation to ensure that the process fits their contexts and settings. Perinatal depression (PD) is a significant public health issue for pregnant women and mothers with young children in sub-Saharan Africa, and interventions are needed to prevent PD in this high-risk group. The FRAME provided a valuable way to document how the MBC, a preventive intervention for PD originally developed for low-income urban women in the U.S., was adapted to fit the contexts of rural pregnant women and mothers of young children in Kenya and Tanzania via integration with an ECD project. This process of adapting, modifying, and implementing the MBC is dynamic, complex, multifaceted, and imperfect with unanticipated challenges along the way, involving multiple stakeholders and their expertise. This process is a worthwhile investment for organizations to make in order to yield successful engagement, delivery, and outcomes for high-risk perinatal populations as we move to scale up and sustainment. This process may help future researchers and providers to document their own process of adaptation and modification of evidence-based interventions to maximize the impact of such interventions in the field to improve the wellbeing and development of mothers and their children.


Fifty-three point four of the participants used herbal medicines to reduce physical complications, 46.6% used them to improve anxiety and stress induced by ostomy, and between 66 and 80% was completely satisfied with the use of various types of complementary medicine. The study results showed that the frequency of complementary medicine use among patients living with a permanent ostomy varied from a few days to several years. Considering the use of complementary medicine by these patients, educational programs, and interventions are necessary to increase the general awareness of ostomy patients about the types of complementary and alternative medicine (CAM) and the effects of these methods.Patients living with a permanent ostomy encounter many physical, psychological, and social challenges due to the loss of function of a part of their body. Today, as the use of alternative therapies increases, some of these patients are seeking complementary medicine to relieve the symptoms and complications of their disease. Therefore, the present study aimed to determine the use of, reasons for, and satisfaction with the complementary medicine among patients living with a permanent ostomy. This descriptive cross-sectional study was conducted on 100 patients living with a permanent ostomy who were referred to ostomy clinics in southeastern Iran. The census method was used for sampling. The research tool included a complementary medicine questionnaire. SPSS-25 was used for data analysis. The results showed that in physical methods, most of the participants used herbal medicines (83%), aromatherapy (79%), vitamin supplements (76%), and diet (66%). In mental methods, most of the participants used prayer/recourse/vow (91%) and music therapy (75%) . People with university education ( Ostomy surgery of the bowl is an operation that can be due to a variety of reasons, such as cancer, trauma, inflammatory bowel disease, and intestinal obstruction, and it is defined as an opening in the abdomen for fecal excretion . The numToday, most patients living with an ostomy are looking for alternative and complementary methods to reduce the disease complications and improve their quality of life –8. WhileBiologic therapies include dietary supplements and herbal medicines; physical therapy includes massage therapy, movement therapy; and energy therapy . AccordiIn addition to suffering from the physical complications of ostomy, Iranian patients suffer from mental and psychological problems, may quit their job, have sexual problems, do not travel and exercise, and cannot conduct religious and doctrinal rituals as well as attend holy places and mosques . In addiThe use of CAM has long been considered, and today, healthcare providers pay more attention to it as one of the therapeutic methods. Meanwhile, studies have emphasized the effective role of providing appropriate information to the community and preventing unnecessary use of CAM , 24. AlsThis cross-sectional descriptive correlational study was performed on patients with ostomy, who referred to two ostomy clinics in southeastern Iran from August 2021 to late October 2021. These clinics are the main referral centers for patients with ostomy. The two centers selected for sampling were governmental, and ostomy patients were referred to these two governmental centers from doctors' offices and hospitals.p=0.05). In this study, patients with ostomy (140 people) referred to two ostomy clinics were selected for sampling. Census sampling was done from the patients who referred to the clinic, and 100 of the 140 people participated in the study. The response rate of the participants was 0.71%. Inclusion criteria were having at least 18 years of age, ability to speak Persian, visual and auditory health, and passing of at least one year from surgery. Exclusion criterion was no response to more than one-third of the questions.The sample size was 100 participants by using the sample size formula . The questionnaire was scored on an 8-point Likert scale ranging from never to every day. In addition, the reasons for adopting complementary medicine were measured using three options: symptom reduction, anxiety reduction, and others. The minimum score was zero, while the maximum was 168, with a higher score indicating higher use of CAM. In addition, 10 items were used in this questionnaire to measure the level of satisfaction with complementary medicine on a five-point Likert scale , with the highest score being 40 and the lowest score being zero for satisfaction of CAM.The new and related scientific books, articles, similar research studies, and websites were used to determine the content of the questionnaire . AccordiSampling began after approval of the proposal, acquisition of the code of ethics, presentation of the letter of introduction to the ostomy clinic, and coordination with the authorities. We tried to refer to the clinic when there was no disruption in the treatment course of these patients, they were in a good mental condition and also when they had enough time to answer questions. The data collection instrument in this study was a questionnaire. The researcher used interviews to complete the questionnaires.t-test and analysis of variance were used to determine the relationship between the demographic information of patients and the mean of the application of various CAMs. Significance level was considered p < 0.05.SPSS-25 was used to analyze data. Frequency, percentage, mean, and standard deviation were used to describe the study variables (the reason and satisfaction with using). Inferential statistics were used to determine the relationship between the variables. Independent The researcher referred to the target medical centers after receiving the code of ethics (IR.KMU.REC.1398.700) from Kerman University of Medical Sciences and a letter of introduction. The researcher obtained informed consent from patients referred to the medical center for rehabilitation, and participants who were illiterate obtained their informed consent through a legally authorized representative and legal guardian. After obtaining permission from the authorities of these centers and providing the necessary explanations about the objectives and method of the study. Patients were included in the study after their doctor confirmed that they were in good health and that they were able to answer the questionnaire items, which were asked in the form of interviews and recorded by the researcher. All methods were performed in accordance with the relevant guidelines and regulations.The mean age of the participants was 54.52 ± 15.94 years. The mean ostomy duration was 3.08 ± 3.46 years. Fifty-six % of the participants were male, while 44% were female. Ninety-eight % of them had a permanent colostomy and 68% had an ostomy due to rectal or colon cancer. All patients had information on how to treat their disease with the use of complementary medicine, and 42% received information from others . The stuThe majority of people used wet cupping, diet, vitamin supplements, leech therapy, and dry cupping to reduce the physical complications of ostomy. Moreover, 53.4% of them used herbal medicines to reduce physical complications, and 46.6% used them to improve anxiety and stress induced by ostomy, while most of the participants used massage to improve anxiety and stress induced by ostomy. None of the participants used mental methods to reduce the physical complications of ostomy. In addition, 26–100% of the participants did not consult any physician regarding the use of complementary medicines. The majority of them consulted with physicians for the use of vitamin supplements (74%) and diets (62%) .Patients living with a permanent ostomy were highly satisfied with the use of complementary medicine in all aspects (access to the method (80%), easy use of the method (78%), safety of the method (75%), noninterference with daily activities (66%), reduction of physical symptoms induced by ostomy (67%), reduction of psychological symptoms due to ostomy (75%), no concerns about drug interaction (67%), feeling better after using the method (80%), inexpensiveness (83%), and time saving (80%)). Therefore, 66–80% of the participants were completely satisfied with the use of various complementary medicine methods .People with elementary education and uneducated ones used fewer methods of complementary medicine than other people, while people with higher incomes used more methods of the complementary medicine. People with a history of addiction used fewer methods of the complementary medicine. Moreover, participants, who obtained their information from other people, used fewer methods of the complementary medicine than other participants .This study aimed to evaluate the use, reasons, and satisfaction with complementary medicine among patients living with a permanent ostomy. According to the study results, the frequency of complementary medicine among patients with a permanent ostomy varies from a few days to several years. The majority of participants used herbal medicines, aromatherapy, vitamin supplements , as well as, prayer/recourse/vows and music therapy  every day or several times a year. Farooqui et al. showed that cancer patients used CAMs, including dietary supplements, natural products, and multivitamins . HoweverAccording to the study results, the majority of participants used a variety of the complementary medicines to reduce physical complications and improve anxiety and stress induced by ostomy. In addition, Duluklu and Çelik in Turkey showed that patients with permanent colostomy used medicinal plants, such as lavender essential oil because they were simple, inexpensive, easy-to-use, and effective in eliminating the offensive odor caused by colostomy . KiwanukAccording to the study results, the majority of people who used a variety of complementary medicine methods were completely satisfied with the use of complementary medicine. Furthermore, Kaur et al. showed that 99.4% of the patients were satisfied with the complementary medicine and felt that it had a positive effect on their health . AccordiThe study results showed that those with higher education and income used more complementary medicine methods than other people. CAMs are not covered by insurance in Iran because people, who earn more money, use CAM more . Jang etThe study results showed that individual whose source of information was the Internet and medical staff, used complementary medicine more than other participants. This finding is consistent with that of previous studies. Ebel et al. in Germany showed that physicians and nurses, print media, and the Internet were the most important sources of information for the use of complementary medicine among cancer patients . The IntThe study results showed that individuals, who did not have a history of addiction, used the complementary medicine more. No relevant studies were found in this regard, but based on the results of a systematic review, the effect of the complementary medicine on addiction has been unclear or negative, so further research is needed in this regard .This study had several limitations. Participants became tired of the large number of questions, so the researcher tried to provide an intimate environment and collect data when patients were in good physical and mental condition. Patients living with an ostomy were inaccessible because of their limited number, so sampling was done in the medical centers affiliated with two universities of medical sciences.The study results showed that the frequency of complementary medicine use among patients with a permanent ostomy varied from a few days to several years, with physical  and mental  methods being the most commonly used methods of complementary medicine. Patients living with an ostomy must increase their knowledge of the types and effects of CAM. On the other hand, nurses and other healthcare providers have more contact with patients, so they can inform patients of the benefits and risks of using CAM. Improving the methods of using complementary medicine can be a cost-effective care approach for patients living with an ostomy.


Pregnancy frequently is associated with emotional conditions such as anxiety and depression. Perinatal depression has an incidence of around 12%. Only recently researcher put the attention on the effects of pre- and postpartum psychopathology on infant neurocognitive development. Neurobiology studies indicate that perinatal maternal depression can significantly affect the structure and function of children’s prefrontal cortex and modulate the development of cognitive abilities from intrauterine life. On the topic, the scientific literature appears ambiguous, reporting mixed results. Some studies have found no significant differences in developmental outcomes between prenatal and postpartum exposure to maternal depression, others have suggested a greater burden of depression in pregnancy than in postpartum, and still others have emphasized the role of chronicity of symptoms rather than the period of onset. Few studies have examined the effects of different developmental trajectories of maternal depression on children’s neurocognitive outcomes. The assessment of maternal health has for years been limited to postpartum depression often neglecting the timing of onset, the intensity of symptoms and their chronicity. These aspects have received less attention than they deserve, especially in relation to the effects on children’s neurocognitive development. The aim of this Perspective was to highlight inconsistencies and gaps that need to be filled in the approach to the study of this problem. Given the wide heterogeneity of data in the current literature, further studies are needed to clarify these interactions. This Perspective provides an overview of current progress, future directions, and a presentation of the authors’ views on the topic. Pregnan2.Even though it was not our goal to conduct a literature review, we tried to provide an overview including reviews, meta-analyses, and recent articles on the subject. We planned two steps in the literature search. First, relevant publications were found by searching the Pubmed electronic databases. The following search strategy was used for the Pubmed database:  AND (child*[Title/Abstract] OR infant*[Title/Abstract])) AND (neurocognit*[Title/Abstract] OR neurodevelopment*[Title/Abstract] OR development[Title/Abstract])) AND (depression[Title/Abstract])). We selected recent literature to identify current advances in the field of interest. Based on a qualitative assessment, the studies considered most useful in highlighting contradictions in the literature data were selected. In the second phase, the snowballing search method was used to track down related works using the bibliography or reference list at the end of the most interesting articles - especially reviews and meta-analyses - found in the first phase of the search.3.Neurocognitive development refers to the full range of mental activities and abilities, including memory, language, learning, problem solving, perception, and higher abilities such as executive functions involving attention and behavioral control, which are important for self-regulation . Specifi4.There are multiple mechanisms that might underlie the interactions mentioned above. First, mothers with depressive symptoms might initiate with greater difficulty a dyadic interaction within which to maintain joint attention with their child. Consistent with other authors, we consider it is possible that these women are more distracted and less attuned to their children’s demands for interaction . Indeed,5.in utero is associated with lower total brain volume and brain gray matter volume in preadolescence  or the presence of stressful events in the past year on the child’s neurocognitive development, not just using them as control variables. In addition, more data should be collected on low and middle developing countries. Further studies should also consider other confounding factors, e.g., maternal IQ, being primipara, gender of the child, sociocultural background of the woman, and the presence of additional ongoing psychological symptomatology. In our idea, chronicity and intensity of maternal depression have greater negative effects on child neurodevelopment than a single depressive episode pre-and/or postpartum. Although a literature review was not within our objectives for this perspective, we tried to include data from a wide range of studies . This allowed us to outline the state of the art on the topic covered in this perspective, as well as to highlight inconsistencies and gaps that need to be filled in the approach to the study of this issue. Systematic reviews and meta-analyses on the topic have shown unclear results, therefore, a continuous evolution of research is needed in order to carry out a more careful analysis of the overall results in the literature. In this perspective, we pointed out that the assessment of maternal health has for years been limited to postpartum depression , often neglecting the timing of its onset, the intensity of symptoms and their chronicity. In our idea, these aspects have received less attention than they deserve, considering the decisive role these factors might play in delineating the impact of maternal depression on childhood neurocognitive development. Certainly, as mentioned above, some aspects are very difficult to assess, thus they are less considered in the literature. However, recent studies have opened this discussion by highlighting the gaps and inconsistencies among the various data available in the literature. These considerations should be integrated in the evaluation and development of screening and treatment activities for the pregnant population, especially considering the actual burden in terms of health and disease development pathways.According to other authors , 42, we 7.Maternal depression represents a public health problem related to serious difficulties for the establishment of a good mother–child relationship. Maternal depression is also capable of directly and indirectly altering infant brain and neurocognitive development. Few prospective studies have examined the effects of perinatal depression on cognitive development with seemingly contradictory results. These inconsistencies may reflect methodological differences, but also the neglect of aspects such as the time of onset of depressive symptoms, their intensity and their duration. Further studies are needed to clarify these interactions. Understanding the prenatal and postpartum mechanisms underlying these relationships, as well as identifying a gestational age of increased vulnerability would help design more appropriate interventions. There is a clear need for clinicians to design early intervention pathways to be implemented already during pregnancy. These could have important clinical implications for mother–child dyads who are candidates for individualized psychological treatment aimed at reducing the impact of maternal psychopathology on child development.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.MS developed the theoretical formalism. All authors contributed to the article and approved the submitted version.This project has been supported by the Department of Health Promotion of the Regione Puglia, Italy.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Italy was among the first countries in the world to experience the devastating consequences of the COVID-19 emergency and suffered its consequences to a devastating scale. Understanding how the country got there in spite of a relatively well-resourced public and private health system in at least part of the country, is imperative to be able to operationalise any lessons learnt for future epidemics in Italy and beyond.Methods: The paper reports the findings from a research scoping exercise conducted in Italy in 2020. We conducted extensive archival research and collected 29 testimonies either in writing or as semi-structured interviews. We sampled purposively with a stratification strategy in mind, specifically aiming to gain testimonies from different social groups, classes, ages, and nature of employment. Our sample also reflects the different experiences between the Northern and Southern regions, a divide that has long been economically and politically salient in the country.Results: Evidence and considerations of epidemiological nature normally guide public health responses to crises. This study supports the idea that socio-economic, cultural and political factors also affect transmission outcomes. We highlight specifically the role that socio-economic and health inequalities play in this respect, through factors such as overcrowded dwellings, lack of alternatives to in-person work, informal work set-ups, pervasive organised crime presence, poorly planned social support and communication strategies.Conclusion: A socio-economic and political lens is needed in addition to an epidemiological one to fully understand the social experiences and implications of public health crises such as the COVID-19 pandemic and to devise effective response measures that are locally relevant and acceptable. Thus insights provided by multi-disciplinary task forces can render policy-making and social support interventions as well as communication strategies more effective. Implications for policy makersNational epidemic preparedness plans were not adequate with respect to both personnel and equipment supplies, but future preparedness should go beyond the simple epidemiological side of transmission. Socio-economic considerations other than age and pre-existing pathology should be used to determine risk profile; these should include consideration of socio-economic and health inequality. Where significant inequalities exist, context-specific measures should be planned to increase local relevance and effectiveness. In the case of Italy, geo-political and economic disparities are particularly important due to implications in terms of work informality, population density, organised crime presence, political disenfranchisement and lack of trust in institutions.  Implications for the public Understanding why and how historical, political, social and economic factors converge to determine the needs of an epidemic management plan is key to helping the population reach a certain level of social cohesion around nationally mandated containment measures. By understanding why measures need to be locally relevant and appropriately communicated to be effective, mediation and social cohesion efforts can be directed towards ensuring cooperation in the identification of the most appropriate forms of social support. An open and constructive communication effort between the public, locally embedded multi-disciplinary task-forces and the government can increase transparency and policy adherence.1 Since then, Italy has taken a special place in the living history of the COVID-19 pandemic and its effects in Europe, as the first European country to experience the devastating consequences of the unfolding emergency. Images of overwhelmed hospitals, military trucks carrying coffins and of the tightly regulated lockdowns announced what was to come across the continent.2 On February 20, 2020, a 38-year old man from Codogno, a small town in the Lombardia region of Italy, was the first in the country to officially test positive for COVID-19.3 or many say from the Fall of 2019.4 It was only in February though that evidence of the sustained spread of the disease emerged, while authorities began introducing a series of emergency lockdown measures first targeting local hotspots and eventually, from 11th March, the national territory.4 Draconian punitive measures were deemed necessary to halt the spread of an epidemic which was rapidly depleting the national health system’s capacity.5 Indeed, already on March 16, 2020, recorded cases had reached 27 980 and Italy was second only to China in terms of cumulative mortality. In the months that followed, the country’s epidemic grew further recording as of March 2021, a year on, a number of total cases and deaths per 100 000 population among the seven and third highest in the world respectively.7 Transmission in the North of Italy had been under way, unnoticed, from at least the beginning of January 2020,12 Italy’s experience with COVID-19 is an important starting point of any reconstruction of the pandemic’s effects on Europe. Understanding how the country got where it did in the Spring of 2020, in spite of a relatively well-resourced public and private health system in at least part of the country, is imperative to be able to operationalise any lessons learnt for future epidemics in Italy and beyond. However, this account is inevitably incomplete if we focus solely on transmission and epidemiological considerations. Indeed, it is increasingly recognised that, when organising outbreak responses, there is a need to also take into account the social, political and economic dimensions of epidemics.14 The COVID-19 pandemic has similarly given rise to a wide range of analyses highlighting the significance of social, political and economic contexts, pointing for example to the impact on transmission of different policy decisions, the relationship between marginalisation and risk of infection and the historical roots of mistrust in epidemic response measures including vaccination.19 This study contributes to this growing literature in the social science of infectious diseases, offering insights on the socio-economic, historical and political factors that contributed to the COVID-19 crisis’ trajectory in its first months in Italy. Through this analysis, we aim not only to bear witness to a collective experience of crisis, but also to note the limitations of epidemiological approaches that do not take into account how localised political economies structure the experiences and consequences of epidemics and their associated interventions. This includes an understanding of how socio-cultural dynamics affect transmission, the circulation of information, and the ability to put in place effective responses. Such dynamics differ across social and geographical contexts because social policies, political economies and historical trajectories have significant effects on different countries and communities’ experiences. During the West African Ebola outbreak, for example, epidemic responders quickly realised the role of local burials practices and caring patterns in the transmission of the virus, and anthropologists supported the design of interventions that took into account social pathways of infection as well as the socio-economic impacts of restrictions.i) to bear witness to the individual and collective experiences in Italy’s first wave of the pandemic, (ii) to support an understanding of the COVID-19 pandemic that takes into account Italy’s particular socio-political context, and (iii) to identify recommendations for future interventions. In what follows, we first present our data and methodology, we then move onto the findings which are divided into thematic areas, each of these is discussed in order to derive social and health policy implications. In this study, we use personal testimonies and semi-structured interviews collected across Italy in the months between February and October 2020 as a starting point to highlight social, economic and political factors that we deem relevant for understanding the impact of the COVID-19 pandemic during Italy’s first wave. We contextualise these testimonies with an analysis of the pandemic’s trajectory, drawing on newspaper articles and a review of official reports. The aim of the article is threefold:  and five in the North . We carried out a total of 13 interviews in southern regions  and collected 16 testimonies from northern regions . The sample was determined by access; with those targeted by requests for interviews or testimonies determined by gatekeeper dynamics and subsequently via snowballing. Those who agreed to participate in interviews and/or provide were included in the final sample. The data used in this article were collected either in the form of semi-structured interviews or written testimonies. We utilised rapid evidence assessment qualitative methodologies, which have been increasingly applied in the context of health emergencies. The interview guides contained questions on respondents’ demographics, personal experience of the pandemic, impact suffered through their employment and living conditions, their opinion of the institutional response and their expectations for the future, including what type of support they had access to or were likely to keep receiving. The semi-structured interviews were collected among 13 respondents, with 15 having been initially approached. Written testimonies were solicited by email, with a short blurb circulated on social media and by email, requesting for the email to be shared with others. The blurb explained our role as researchers and asked for contributions to help us write a report on social experiences affecting people in areas hit by coronavirus, and that we were particularly interested in reflections on personal experiences from healthcare workers (HCWs), socio-economic impacts of lockdown and any challenges associated with COVID-19 regulations. Sixteen respondents sent their written testimonies. We followed an ethical protocol approved by the researchers’ institutions and stored the data safely on University drives after having thoroughly anonymized it. In order to contextualise the data that reflects personal and collective experiences, our thematic analysis of the testimonies and interviews was complemented by extensive archival research. More specifically, we conducted a review of newspaper articles from leading national newspapers and local news as well as official reports from research institutes or organisations.4 As work-related movements are frequent, the disease was quick to spread to all other regions within a matter of weeks. However, while Lombardia, and more in general the North of Italy, have a well-resourced health system and one among the best in the world, the same cannot be said of the rest of the country, where the state of the healthcare system often reflects the decades of divided dual-speed growth experienced by the country.21 The rapid onset of the COVID-19 epidemic in Italy followed a delay in recognising and detecting the spread of the virus in January 2020. This allowed the contagion to progress unchecked for weeks and to grow exponentially in Lombardia.22 Unsurprisingly, many of them were knowingly or unknowingly infected prior to or while travelling. In spite of this, however, many self-isolated upon arrival spontaneously, something which contributed to the first wave of the pandemic broadly sparing Southern Regions the crisis that engulfed the health systems in the North. Indeed, the time lapse before the initial realisation the virus was spreading in the North and fears raised by reverse migration seem to have allowed the Southern regions to prepare themselves and lock down pre-emptively, something which differed markedly with the experience of the following second wave in the autumn of 2020, as we will discuss below. Against this background, the potential for widespread transmission beyond Northern regions was particularly worrying and concerns intensified when the announcement that a lockdown would be enforced in Lombardia and some surrounding areas was leaked to newspapers. The leaked information, in fact, gave thousands of residents, who lived in Northern regions for study or work reasons but whose families were from the South, the time to board trains and buses, literally overnight, directed towards the South.23 According to a number of reports, such difficult decisions had already been implemented in the most affected areas of the North.25 As beds for the hospitalised were not freeing up at pace with new case numbers in Lombardia, private and public bed spaces in intensive care units (ICUs) rapidly filled up as of mid-March 2020 already. Many other regions in Italy only had a fraction of the ICU availability of Lombardia, particularly in the South. The risk was therefore that, if the spread of the disease went unchecked, entire regions could have been completely unable to provide ventilation, resuscitation, and on-going care for critical COVID-19 patients, as well as emergency care for other patients with significant co-morbidities. Such possibility generated controversies around the potential necessity of triage to prioritise intensive care for younger patients or those more likely to recover.26 A later judicial investigation would find public health administrative directors in the province potentially liable for gross misconduct and failure to implement protocols mandated by the World Health Organization (WHO).27 The suspension of funerals as part of the measures to stem transmission meant that morgues were becoming full. In the province of Bergamo, a particularly badly affected area, the death of a mayor was accompanied by the distressing news that burials in Val Seriana were happening “every half hour.”28; shortages which were compounded by a delay on the part of the European Union to intervene in support of the Italian health system.30 Alarmingly, in our discussions with HCWs in Campania and Calabria, it became clear that that family doctors – that is, the primary healthcare providers – were lacking PPE throughout the crucial initial weeks of the pandemic. As Italian family doctors are considered self-employed professionals, there was a delay, or unwillingness according to some, to step up the provision of PPE, while supplies in shops and pharmacies very rapidly depleted: Another risk factor was associated with the nationwide shortage of HCWs and of their personal protective equipment (PPE)We received one single PPE kit for all doctors in the municipal district to share (…) this is because we are considered as self-employed professionals. We tried to buy our own PPE but it is impossible, it has run out virtually everywhere. (…) The government will send them out only when it is too late, I needed protection now and earlier over the past few weeks” . “33 Combined with the fact that most HCWs were initially only encouraged to wear a mask when coming in contact with symptomatic patients, this meant that family doctors and many other categories of HCWs carried out their duties throughout the critical initial phases of the pandemic without any adequate protection. This was particularly concerning as the evidence of widespread asymptomatic transmission had already started to emerge.34 Indeed, Erdem and Lucey reported that Italy was among the countries with the highest HCW mortality rate by population, with the estimate standing at 0.35 per 100 000.34 In hospitals, nurses and doctors were working long shifts and foregoing their annual leave; yet staff shortages were common due to illness or self-isolation, until a controversial governmental decision on ninth March (Decree n.14 9/3/2020), which asked all quarantined HCWs to resume their duties immediately if they did not display symptoms, even if they had had contacts with potentially infectious patients. While such a decree was meant to stem the loss of further precious personnel resources, it unsurprisingly generated bitter protest among HCWs, who were concerned both about their own health and about the risks that hospitals could rapidly transform into clusters of nosocomial transmission.35 In a similar way, shortages of testing kits were the reason why it was established by the Italian authorities that only those admitted as inpatients could get a COVID-19 test. The decision raised concerns that transmission may be further fuelled by undetected infection, precisely at a time when the WHO changed its guidelines to encourage countries to step up testing efforts in an attempt to stem transmission carried by asymptomatic and mild cases.per se became co-morbidity. Italy’s ageing population, with 22% of the population being over 65,36 made the threat from co-morbidities even more serious.37 Outbreak case counts often obscure the broader effects on those suffering from other diseases. As Regions across Italy began suspending all planned procedures and accident & medical clinics of non-urgent nature, only the service of haemato-oncologic patients and other cardiovascular emergencies was guaranteed to free up resources for the COVID-19 emergency. In addition to this, even those with significant and urgent pathologies were often reluctant to attend their medical appointments for fear of contagion. Thus, another main concern beyond the epidemic of COVID-19 38 This, combined with living and working conditions that do not allow for effective social distancing make this part of the population particularly vulnerable. For example, living conditions in some of the urban areas in Southern Italy where our respondents were based, made it almost impossible for social distancing and containment measures mandated by central and regional governments to work. These areas are mostly home to low-income households and have very high levels of population density, with the poorest often co-habiting in a one-room open space. An additional element to consider is that medical conditions, especially those of chronic nature, may be more prevalent among the low-income sections of the population given their impaired or diminished access to adequate healthcare.39 The entrepreneurial community in the industrialised North pushed for continued economic activity, a message that was shared and reinforced by the main Italian Industry Confederation, Confindustria.4 While public and private employers made efforts to facilitate home-working and a government-led ‘digital solidarity’ initiative made available online collaborative working platforms ; the coordinator of a private sector industrial consortium in the northern region of Lombardia noted: In 2020, Italy’s gross domestic product growth rate dropped to -8.8%.those who work on the factory floor can’t do ‘smart working’” . “…41 The ability and willingness of different companies to comply with newly mandated protective measures in order to stay open was far from uniform and a former opposition party leader continued to report complaints from workers, who felt they were being asked to keep on working while not being adequately protected.42 In some cases, these tensions resulted in strikes and contestations. Certain business sectors and worker categories proved to be particularly vulnerable. Italy’s entertainment and tourism sectors – key sectors for the nation’s economy – unsurprisingly took a significant hit, affecting with it from waiters to chefs, from tour guides to owners of bars and restaurants. A category that was also significantly affected was that of freelancers. The self-employed landscape in Italy separates between professionals such as lawyers or accountants – who receive protection from dedicated professional bodies – and freelancers, who work on a largely more causal and less formally protected way.43 There was a gap of weeks before the government announced any support measures, which left many without a source of income but still liable for bills and rent. A series of wide-ranging measures were finally announced in mid-March including the provision of sick pay for people in quarantine, the suspension of taxes and mortgage repayments, the reduction of utility bills for the whole of 2020 and a transfer of 600 euros to the self-employed.44 many lost their jobs before that decree came into place due to reduced overall economic activity, bankruptcies, or because they worked informally, as a hairdresser in Campania explained: Although nation-wide measures were put in place in the summer 2020 to forbid individual firing and redundancies,I was on probation when COVID-19 struck, they wanted to hire me on a formal contract, but this fell through as they cannot afford to pay for a share of my furlough” . “ More complex narratives also emerged where precarious employment compounded issues of co-morbidity and lack of access to healthcare, as in the following testimony by a pastry-maker:I was supposed to undergo surgery on 16th March, but the lockdown meant it got cancelled. I wasn’t able to undergo surgery until the following September. So, for now, I still have not been able to get a job (…) which meant I ended up in long-term unemployment” . “46 following laws such as the Biagi Law of 2003 whose impact on increasing precariousness for younger generations is still the subject of debate.47 The result is that today, in Italy, a significant proportion of people work in the informal or ‘unobserved’ economy, this includes both Italian and migrant workers. Italy’s main statistics agency  calculated in 2016 that the ‘unobserved economy,’ made up of underreported illegal activities like drug trafficking and prostitution and irregular work, amounted to around 12.4% of gross domestic product.48 As in other parts of Europe, work flexibilisation pressures have risen steadily in Italy in the last thirty years,51 but they are tied to requirements of citizenship and residence status. Informality is common in Italy both in the rental and job markets,53 this means that many, citizens and undocumented migrants alike, did not qualify for such social assistance upon losing their jobs as a result of the pandemic. Significant differences are likely to compound over time along the regional dimension, given that Southern regions experience more pervasiveness of informality and that the vulnerability deriving from informal work is higher in these Regions.30 A number of social and income support funds exists to supplement the incomes of those who lose their jobs and/or are unemployed,54 Various initiatives advanced requests for an alternative form of income supplementation that anyone struggling to meet their basic needs due to COVID-19 could apply for, regardless of employment type, citizenship, or residence status. Unfortunately, while it emerged from our interviews that a number of private and public grassroot initiatives were organised including the establishment of food banks, no concrete steps were taken to establish a government-run income supplementation scheme with universal coverage. In May a time-limited emergency fund was approved for households suffering economic difficulties as a result of COVID-19; once again, however, anyone who could not prove their residence status was excluded from the scheme. This fuelled widespread complaints that national support measures had been laid out in a way that favoured Northern regions, while the specific reality of the South had been overlooked, as denounced in the following testimony by a personal trainer in Campania:If the government wants to keep people home due to the pandemic, better forms of support are needed, taking into account differences in territories (…) [in the South] many work informally, if we want logical rules that can be respected by all, they need to be created by politicians who know the local reality” . “ The narrative became particularly powerful as it strengthened an already existing record of exclusion and discrimination between different areas of the country.55 A local NGO coordinator from Campania, explained that, aside from health-related matters, socio-economic concerns were found to be most pressing due to the widespread informality in migrants’ employment arrangements. In addition, employers’ fears of transmission further reduced work opportunities, be it casual odd jobs or permanent jobs as home carers for the elderly. Similar concerns were raised in relation to the migrant population, which was estimated to be in excess of half a million people in Italy in 2020.We receive hundreds of daily calls asking for help (…) as people now think twice before employing someone in their homes, and for many migrants who worked informally it is impossible to justify going out during the lockdown without a contract” . “ The main concern among volunteers and social workers was that many had being going without food for days and would have been at serious survival risk without the network of support that was swiftly established at the grassroot level. Significant anxiety was associated with the repercussions on elderly relatives and their ongoing care needs, as it is apparent in the testimony below by a resident of a town in Liguria:The difficulties are not only felt from an economic but also from a psychological point of view. In spite of having so much free time now that we are in lockdown, I cannot concentrate, let alone relax, as we are forced into a permanent state of anxiety. The media bombard us with distressing messages, fake news are raging on social media and we hear from the windows the constant sound of police cars and their speakers blasting orders to stay home. All the while, I keep thinking of my parents who live alone as they are separated and my grandmother who is in her 90s and is feeling so scared that she hasn’t let me in in a week and she doesn’t even leave the house to dispose of garbage” . “4 A ‘familialistic’ or informal care orientation implies that family members take the primary role and are the main recipient of welfare support in relation to the care of the elderly,57 who often either live at home with younger relatives or rely on their regular visits to get support with first necessities. In turn, grandparents are often the primary providers of childcare. These circumstances are, however, associated to significant implications in terms of transmission dynamics, given that COVID-19 has markedly different risk profiles depending on age. Many of the elderly who lived on their own were indeed left frightened and entirely isolated, as they had to rely on shop-owners to periodically bring some groceries to their house. As mentioned above, Italy has an ageing population among the largest in the world.58 Volatile governments, regular corruption accusations and significant political divisions have contributed to this in recent years. In Italy, trust in institutions has historically been low. A Eurobarometer survey in 2018 showed for example that 66% of the population tended not to trust the government.4 as conveyed by the following response by a physician in Campania: A context of mistrust is relevant for understanding initial concerns around adherence to government regulations. In the first weeks of the emergency, there were for example reports of people escaping quarantines from Northern locked down areas. Rumours also circulated widely on traditional and social media that mischaracterised and underplayed the epidemic comparing it to an ordinary flu; or, in other cases, spread false information leading to panic. While many, especially among the wealthier classes, worried about the broader consequences resulting from the reluctance to comply with regulations on the part of the youth and all those who lacked adequate information or sense of community belonging,The government should frighten [the youth]. We should not make up lies but people will start to comply only when they realise that full-capacity ICUs will soon be reality” . “ A significant challenge for building trust in the national response during the first wave was particularly around the perception of confused, or even contradictory, communication. This, as one of our interlocutors, a communications specialist based in Tuscany, put it, was both in terms of ‘vertical’ communication between different tiers of the institutional hierarchy and external communication from the government to the public. For example, tensions around COVID-19 testing meant municipal health centres were receiving contradictory protocols around whether to do ‘blanket testing’ or test only those who were symptomatic. A second example is the leak of the ordinance relating to the lockdown of a number of northern Regions, as described earlier, due to which the decree was published in full in a major national newspaper before the government announced it. Some of our testimonies also focused on the perception of contradictions in the ordinances not necessarily in terms of lack of information but rather due to too much, at times contradictory, information. Indeed, disagreements among experts and authorities played out quite publicly in Italy, with social media and TV shows rife with debates but a dearth of explanation about the rationales behind specific response measures.I am staying home’),59 the engagement of celebrities in the sharing of public health messaging and community-led musical ‘flash-mobs’ from people’s windows and balconies to strengthen a sense of national solidarity during the lock-down.61 Other information campaigns and social mobilisation efforts have had more success, including the viral hashtag #iorestoacasa 3 the Italian healthcare system rapidly became overwhelmed in various parts of the North of the country. Scarce essential PPE in the critical initial months of the pandemic accompanied HCWs shortages as personnel got ill or quarantined, against a backdrop of spiralling death numbers and rapidly filling morgues. Our findings explored a number of socio-economic and public health dimensions that accompanied the first few months of the rapidly spreading first wave of COVID-19, that is, at a time when the country had been caught unprepared and the government had not yet announced relief measures. These findings therefore reflect a transitory phase, but one that was crucial in determining a host of socio-economic tensions and an initial climate of mistrust in the public health response that had long-lasting consequences. More specifically, we described how, after transmission went unnoticed for at least the whole of January 2020,4 The self-employed status of family doctors was thought to be relevant in explaining such delay in the distribution of PPE. Future outbreaks would need to take into account the transmission implications of leaving unprotected the health-system tier that more closely comes in contact with the community. A number of policy-relevant points emerge: the first is that governance oversight and administrative delays meant family doctors lacked PPE throughout the first few weeks of the outbreak, something which exposed them to unnecessary danger and aggravated community transmission.33 and the newly issued guidelines by the WHO inviting countries to step up testing efforts in an attempt to stem asymptomatic transmission. While widespread supply shortages were at the origin of such decisions, they resulted in heightened risk of spread within the community and the danger that hospitals could transform into clusters of nosocomial transmission.31 Indeed, an inquest into the public health system crisis in the province of Bergamo, the worst affected hotspot in the North, revealed that hospital transmission played a considerable role in the initial phases of the epidemic, at a time when pandemic preparedness plans were outdated by over ten years and had not been timely triggered in spite of formal warnings by the WHO.27 Secondly, a number of early decisions were taken with respect to access to tests and PPE, with tests reserved for inpatients, while self-isolating HCWs were recalled to work if asymptomatic. This was in contrast with both the emerging evidence of widespread asymptomatic transmission63 provides food for thought for alternative self-isolation and treatment arrangements. Thirdly, the Italian experience of the COVID-19 pandemic calls into question the common understanding of vulnerable categories from the point of view of transmission. These categories are normally defined as those with pre-existing pathologies and the elderly, but we argue that location-specific transmission dynamics should guide the identification of socially vulnerable groups, in particular to include in the context of Italy those living in overcrowded conditions such as in low-income neighbourhoods or migrant centres, who face specific challenges in relation to self-isolation. In this respect, the Community Care Centres model established in previous epidemics64 this underscores a parallel emerging need for appropriate guidelines for households engaged in the provision of such care. In particular, as the elderly normally receive support from younger relatives and look after children in the household, a delicate balance needs to be achieved between minimising the psychosocial impacts of isolation and the transmission implications of inter-generational mixing. An important additional point in relation to the analysis of transmission dynamics is the comparative dimension between Northern and Southern Italy and the emerging importance of appropriately timed lockdowns. In fact, evidence emerged that during the first wave, the entrepreneurial community in the industrialised North pushed for continued economic activity, a message that was shared and reinforced by the main Italian Industry Confederation, Confindustria.4 To the contrary, a different production landscape and attitude of authorities towards it, coupled with the time lapse after the identification of widespread transmission in the North, allowed Southern regions enough time to lock down pre-emptively. This was no longer an option in the Autumn of 2020 when community transmission was already much more sustained everywhere across the national territory and the dire consequence of the first lockdown had pushed many in the South to resume their economic activities and occupations. As one of the most at-risk groups from the pandemic, the protection of the elderly proved particularly challenging in the context of the Italian familialistic long-term care orientation. Indeed, the pandemic has greatly increased the need for care, and especially that of the unpaid type Indeed, even though the first wave of the epidemic fell short of causing in southern Regions levels of crisis similar to the North, what hit them most were the socio-economic consequences of the lockdown. The Italian government passed unprecedented legislation to support workers, including those working on precarious contracts and the self-employed. However, on the one hand, this did not happen straight away and some categories of workers were left out, such as factory workers — who were still required to go to work — and irregular workers. For the latter, in particular, the absence of a contract meant either that they could not justify leaving home under the very strict lockdown monitoring by the police or that if work stopped they could not access furlough and social support schemes. Similar dynamics applied to Italian and migrant informal workers alike; yet, in spite of the importance that the informal sector covers in the Italian economy, no concrete institutional steps were taken to establish an income supplementation scheme with universal coverage that effectively took into account the reality of a large chunk of the vulnerable population.53 complaints were raised that the institutional response to the pandemic was skewed towards the interest of the North. This reflects historical patterns of structural regional inequality66 and exacerbates politically-relevant perceptions of it. In this respect, a risk was also identified in the danger of organised crime’s acquisitions of struggling businesses in the wake of the pandemic, as part of widespread exploitation and money laundering operations in the South. However, an effort to stem further infiltration in the productive socio-economic landscape as a consequence of the COVID-19 induced economic crisis appeared missing. As it has been shown that the population in Southern regions is more vulnerable to the precariousness created by informal work,69 While strong community-led mobilisation inspired by solidarity and numerous examples of social cohesion around government-mandated measures appeared in our testimonies, confusing institutional communication still partially undermined trust in the public response to the epidemic, especially in the early stages. Specifically, ineffective vertical communication among institutional levels took place alongside contradictory information circulated externally to the public through a variety of channels, including social media. A lack of concerted effort to harmonise public messages resulted in too much, too vague, information that was difficult to absorb and rationalise. Perceptions of a North-South divide, of structural inequality, and of the State’s absence behind organised crime’s expansion all combine to determine the historically low levels of institutional trust in Italy. In this respect, recent epidemics, including the Ebola outbreaks in West Africa, have highlighted the central role played by trust in the challenges related to the implementation of outbreak response measures.70 In particular, response task forces should consult latest guidance on meaningful community engagement to develop initiatives relevant to the Italian context and that encourage participation not only at the national but also at the local level, by appropriately reflecting and representing local concerns and understandings.71 This is more easily achieved when trusted social networks, for example local social movements, football associations, or parent groups, are identified and engaged. In the context of Italy, it might also mean developing regionally specific communication campaigns to divulge national messages in ways that are locally relevant. Finally, effort should be placed on the identification of latent or explicit social conflicts and marginalised groups so as to develop more targeted messaging. Prior epidemics have shown the importance of clear and coherent community engagement and risk communication in supporting campaigns to increase the acceptability of outbreak response. The importance of all such socio-political dimensions, beyond epidemiological consideration, underscores the need for ensuring that the right stakeholders are sitting at the table when the institutional response to public health emergencies is devised. More specifically, task forces should include competencies from different sectors of society; beyond political representatives. This of course includes scientific and medical professionals, but it should also encompass local community representatives, cultural mediators, communication experts, and social scientists to ensure relevance and viability in local contexts. Bearing in mind the limitations described above and the time-limited nature of the analysis we undertook in this study; further research avenues should concentrate, first of all and in the context of Italy, on comparing if and how the policy response and the socio-economic outcomes differed in the subsequent phases of the epidemic. Furthermore, more work aimed at generating comparative perspectives between instances of successful local participatory governance of epidemics in contexts beyond Italy is needed. This analysis draws evidence from Italy which was the first country in Europe and one of the first in the world to face the COVID-19 pandemic. Italy was also among the worst hit countries in the world in the first phase of the pandemic. The aim was to document social experiences and perspectives through personal testimony as the pandemic was unfolding. In so doing, we have highlighted the importance of considering a host of socio-economic, cultural, and political factors that affect transmission outcomes alongside epidemiological factors. The analysis has sought to offer complementary tools and perspectives from the social sciences realm that can render policy-making more effective in future public health crises in and beyond Italy. We identified a number of policy-relevant dimensions connected to the decisions to delay the protection of family doctors and neglect the emerging evidence on asymptomatic transmission in the early phases of the outbreak response. We further highlighted that socio-economic considerations other than age and pre-existing pathology should be used to determine risk profile. Specifically, where significant inequality exists, context-specific measures should be planned. In the case of Italy, this should particularly take into account geo-political and economic disparities as well as the implications of widespread informality, high population density, and the living conditions among the poorest in relation to self-isolation. Finally, we shed light on how ineffective communication strategies can strengthen pre-existing low levels of trust in institutions and thus hamper the effectiveness of outbreak response measures. In this respect, we suggested future health policy-making should endeavour to review lessons learnt from prior epidemics, as a means to improving the planning of vertical and external communication and its relevance for local contexts so as to increase uptake. In particular, including social scientists alongside medical professionals and politicians in the relevant task forces can help achieve the latter. The study received ethical clearance from both the University of Bath and the University of Westminster. Authors declare that they have no competing interests. SM: literature review, data collection, analysis, and writing up. LE: literature review, data collection, and analysis.