Food memory has been determinant in the survival of social groups, the causes of its activation are varied  and it is transmitted from generation to generation. These interactions have given rise to an ethnic food heritage that responds to cultural processes and territorial specificities. It is in this logic that this study is proposed, which aims to explore the dynamics between food, memory, and identity of two ethnic groups in the state of Puebla in Mexico in a context of health disruption. The experience of these two groups shows how food identity and memory is particularly strategic in the face of adversity, as is currently the case with the COVID-19 pandemic.The online version contains supplementary material available at 10.1186/s42779-022-00123-w. This study proposes to explore the dynamics between food, memory and identity of two ethnic groups in the Puebla state in Mexico in a context of health disruption. Food shortages were present before and after the prehispanic period , and theThe indigenous treatment of the nascent food systems incorporated a strong influence of their worldview, allowing for new processes of experimentation and learning in the context of the existing plant biodiversity of the new world , this foFood bioculture is extensive and more complex than is widely believed , 13 globMexico is part of this reality; in its territories, we find 11 linguistic families in 68 ethnic groups. This fact shows a cultural richness that places this country as one of the ten most linguistically diverse nations in the world . In thissee Fig. The phytogenetic resources of the Sierra Norte de Puebla region share an origin with Mesoamerica, constituting 15.4% of the species of the world food system  (This provides the region and its people with an ethnic food heritage that includes a diversity of diets and edible plants (known in the region as quelites); through this study, we will present some of these diets, their preparation and plants used. This diversity of edible plants is distributed in indigenous territories through a network of local markets that constitute the phytogenetic bank of indigenous peoples , 21, 22,Food has been a human need since humans appeared on Earth. The ways in which humans eat have been mediated by their cultural identity and the territory in which they live. It is to be expected that each social group will have food and eating habits that are differentiated by the specificities of their territories .Food habits determine the frequency and intensity of consumption of certain foods and flavours, but also the configuration of these habits can be shaped by adverse events at the micro-, meso- or macro-level . Ethnic The appropriation of this ethnic food legacy has rested in recent centuries on the memory of indigenous people. The memory of the human species is genetic, linguistic, and cognitive , 31, andHumans persist in a variety of ecological environments, displaying an enormous diversity of behaviours , 34. ThiGlobally, biocultural memory is represented by a “hard-core” of indigenous peoples numbering 476 million people , 36, 37.According to Karim-Aly  knowledgThe construction of an ethnic food knowledge has been made possible by the connections between culture and nature in a context of changes and mobilizations that indigenous people have historically capitalized on in a food bioculture , 41–43. The prehispanic and colonial history of indigenous people in Mexico has not been static but dynamic, trade routes or food shortage events are recorded facts , 45, 46.In other ethnic regions of the world, we can identity these logics in the context of changes and mobilizations that make biocultural heritage possible, for example, the indigenous Warao, who have inhabited the Orinoco Delta in Venezuela for more than 2,000 years . On the Biocultural food memory reveals the different interrelationships that a social group has with nature in the process of configuring its diet. The need to feed themselves has led indigenous groups since time immemorial to explore, learn about and experiment with nature, and these processes have provided them with extensive ancestral knowledge of the flora of the territories they have dominated.But when we talk about food memory, we also evoke sensations and consider memories as an inseparable part of time . This waXanthosoma robustum), a wild plant that was used by indigenous nahua elders in the Sierra Norte de Puebla in Mexico and has now been rescued from nahua memory to cope with the COVID-19 pandemic as a food security strategy in the face of virus containment measures.The characteristics of an ethnic diet are based on the worldview of the indigenous group, thus indigenous people have been able to identity plants for different uses in correlation with their needs. The indigenous groups memory records with each plant are kept by individual elders of the group and transferred from generation to generation through oral tradition. One example is Mafafa . There are other species that are not traded in local markets, these are exchanged by the indigenous people. All edible plants are consumed fresh; the forms of preparation are varied and include rudimentary methods of transformation to increase their digestibility and palatability, as well as to eliminate toxic substances.A small region such as the Sierra Norte de Puebla has 182 species of edible plants, which are collectively used and distributed through local markets in the municipalities that make up the region , 67. AccMost edible plants come from the indigenous food system, i.e. from home gardens, family plots or milpas . Many species are wild, and others are cultivated, but their use and management imply a process of humanization. The ancestral knowledge that the indigenous people of the Sierra Norte de Puebla have is a strategic advantage; for example, the management of the COVID-19 pandemic in the region has forced the indigenous people to make use of their edible plants that provide food of nutritional value. Disruptions in the local economy have dynamized the ethnic diet in the region; the changes combine economy and health, although they obtain a complementary economic income from sales in the local market, the consumption of their plants provides the healthy diet necessary to combat the pandemic.The COVID-19 pandemic has taken humanity by surprise, the rapid spread of the virus has left several sectors of the economy  in shock , 69. As COVID-19 threatens global food security, especially in developing countries . The curThe indigenous food systems of the Sierra Norte de Puebla are based on a socioecological reality that has been historically constructed since ancestral times. According to Guzman , this meThese food systems have historically been differentiated from the non-indigenous population, although they are increasingly integrated and altered by the latter . The recIn the two indigenous societies, the totonac and nahua, the role of women was relevant, the testimonies collected during the fieldwork show that the management of food knowledge covers most of the phases, i.e. identification and management of edible plants, recipes, different forms of preparation and transmissibility of knowledge. According to Ardren , in the According to archaeological evidence and ethnohistory, ritual foods were difficult to prepare, as they required specialized training or ingredients that men did not possess, the author suggests that women who held knowledge of such aspects of cooking were highly valued individuals –77.The study was geographically located in the Sierra Norte de Puebla, which is made up of two of seven regions of the Puebla state in Mexico; administratively, it is home to 63 of the 217 municipalities. It is a region that has been in dispute for more than a millennium due to its natural resources .This region is part of the physiographic province of the Sierra Madre Oriental, its relief is mountainous, and its altitudinal gradient is between 200 and 2000 m above sea level, which gives the region a varied climate. Its territories reflect the traces of human interventions, showing a mosaic of landscapes ranging from primary vegetation, maize plots, coffee plantations, pastures, and home gardens . AccordiThe study was conducted in nine municipalities of the Sierra Norte de Puebla, considering the following ethnic groups: totonac and nahua. Figure The fieldwork was conducted in November 2020 and May 2021, the study was based on a qualitative approach, using the semi-structured interview as a research technique. According to , semi-stThis technique makes it possible to take into account the feelings, expressions, views, belief systems, values and traditions of the individual or group. The interviewer is able to follow thematic trajectories in the conversation that can deviate from the guide when deemed appropriate to re-learn the reality .The interviews were carried out with heads of families with the following distribution: five families from nahua group settled in the municipalities of Hueytamalco, San Juan Ahuacatlan and Zoquiapan. In the totonac group, there were a total of eight families settled in the municipalities of Olintla, Hueytlalpan, Jopala, Caxhuacan, Huehuetla and Tepango de Rodriguez. A total of 13 heads of households were interviewed, of which eight were women between the ages of 40–80 years and five were men between the ages of 30–60 years. The dynamics of the interviews consisted of bringing the whole family together and the head of the family developed the topic through trigger questions with the support of other family members, establishing a reflective conversation around the history of their traditional foods, beliefs, values, food traditions and how the COVID-19 pandemic influenced the majority of foods that are derived primarily from wild plants.As an important aspect during the interviews, the biocultural enquiry was unveiled by the heads of families through the oral tradition that has been passed down through generations in each ethnic group, rescuing from memory the ancestral food customs. One example was the first conquest suffered by the totonac ethnic group in prehispanic by the mexica who, due to their wars, required a constant supply of food, something that the totonac territories were able to provide.The origin of the totonac ethnic group is uncertain , with thhttp://pares.mcu.es/ParesBusquedas20/catalogo/show/304154?nm). This strategy allowed the totonac a constant supply of food in temporal terms and under a variety of climates, the advantages described above were the cause of the mexica conquest.The territories of totonac influence are mostly highly biodiverse, with irregular topography and a variable climate. These characteristics allowed for the development of adaptation strategies, for example, the use of natural resources through the different ecological levels of the Sierras (Puebla and Veracruz) . This showed the close relationship that has been forged between the cultures of each ethnic group and nature. In a biocultural context, the heads of households aged between 70 and 80 told stories about edible plants and their usefulness when they were children and how their parents taught them this knowledge orally, which was remembered when the COVID-19 pandemic began (see Table The heads of households were mostly women 61%) with ages between 40 and 80 years old, the women showed their knowledge about traditional foods, their ways of preparation and their relationship with their system of beliefs, values, and traditions  of the COVID-19 pandemic implemented in the region. Table Sechium edule) or Xmala maklhtutkun (totonac name), which have added sesame seeds (Sesamum indicum) and tomato (Solanum lycopersicum) to their preparation.The totonac and nahua indigenous groups of the Sierra Norte de Puebla are historical occupants of the region and have built up ancestral knowledge of its food dynamics. Table see Fig. Another example where the added of external cultural elements is observed is the traditional food “Tamal de frijol” or “Pulak´la” (totonac name). It is prepared with beans, chayote leaves, chili, sesame seeds, banana leaves, and maize-dough/maize-tortilla see Fig. . This foMs. Avélina says that long ago in her community, because of poverty, they had to make maize-tortillas work. The way they made them work better was by mixing the nixtamal dough with green plantain dough. He told us that on one occasion his community suffered a strong storm that affected the crops, the river grew and took away most of the houses due to the landslides. Most of the neighbouring communities were cut off. Unable to get food for their consumption, they had to apply the method of making banana-tortillas. “...Now with the COVID-19 pandemic, once again we are forced to have more food because of the sanitary measures we must not leave our house...” .Ms. María mentions that when she was little her mother fed them a variety of quelites and that the cinco-quelites (Makuil kilit) were part of her almost daily diet, she liked to eat them a lot because her mother cooked them in different ways, at that time, in order for the ladies to fry their food, they used lard (oil substitute) because there was no bottled oil yet. However, the most common way to prepare it was just to boil it because butter was somewhat complicated to acquire and due to its economic condition, it was more viable to consume it in the same way it had been done before. He also talks about how with everything that is happening now regarding the pandemic, it would be feasible for the new generations to opt for consuming the quelites, especially Makuil kilit because it is very healthy, very tasty and can also be accompanied by some sauce in a molcajete and that like the quelite, its ingredients are obtained in the field or in the garden Many plants still persist in the memory of indigenous people, as evidenced by the fact that they have been rescued from ethnic memory to be put at the service of indigenous people affected by the COVID-19 pandemic. The testimonies of the totonac and nahua indigenous people show this dynamic and its importance.Musa acuminata Colla x M. balbisiana Colla), beans (Phaseolus vulgaris) and tatanchichi (Vasconcellea pubescens). In the case of edible plants, nine species were identified, which have also been reported in the literature as useful plants lost importance in the diet of some indigenous groups over the years but remained in their biocultural memory. With the arrival of the COVID-19 pandemic and the ancestral knowledge about these plants, the totonac and nahua chose to rescue them for consumption. The edible plants identified are Malla Capen (Macuna pruriens), Xakg Xanan Stapu (Flower of the species: P. vulgaris), Chayote (S. edule), Makuil kilit (Cyclantera dissecta), Quelite de pisis (Alocasia plumbea), Potro ma´anta (Dioscorea bulbifera), Kilhxtik (Tinantia erecta), Tapixnuna Xkutna (Begonia spp.), and Mafafa (X. robustum).The interviews made it possible to identity three important traditional foods, which with the appearance of COVID-19 intensified their consumption, these being banana  were reported in the municipality of Caxhuacan, here the totonac make use of the leaves of Mafafa and a plant called Agrio, the leaves are put in hot water, when cooked they are mixed with Chili and sesame seeds, then ground to form a paste or cream. The paste is then combined with maize-tortilla  of the COVID-19 pandemic became visible. From a broader perspective, the deployment of this ancestral knowledge aligns with the current debate on mainstreaming sustainable food systems , 95 and Araceae, Begoniaceae, Cucurbitaceae, Commelinaceae, Caricaceae, Dioscoreaceae, Fabaceae, and Musaceae (see supplementary data 1). The families of edible plants in the region are numerous, but only those that the indigenous people listed as having been rescued or intensified for consumption are mentioned.The indigenous people remembered the edible plants for their qualities and took advantage of the opportunity offered by the COVID-19 pandemic due to the sanitary measures established  to rescue them. The families identified were: Mr. Bonifacio and Ms. Carmen spoke to us about the food importance of the Mafafa. They commented that in rural areas it was already beginning to be noticed that quelites were being replaced with canned and packaged products, but with this pandemic, people are returning to quelites as food for all, especially Mafafa or Paxnikaka (totonac name). This plant was again a very common food for the grandfather and other people of this town, because of the pandemic, the grandfather cannot go out to the markets often to buy food because of the virus that is present, so the grandfather returned to the life of before, consuming plants that are found in the mountains. The most outstanding edible plant was the Paxnikaka, which is very easy to prepare and does not have many ingredients, but the food is very tasty .The sweet potatoes (Potro ma'anta) are eaten; here, they are not poisonous if they are not cooked well any problem even there are children or older people who eat it raw, we cook it in the fire tastes more tasty. They are eaten in two ways, the first is boiled with water, is accompanied by bananas or chayotes. The second consists of toasting them on the fire with firewood. There are people who prepare it in atole , they boil them and then they take off the husk, squeeze them, add boiled water and sugar with this is the atole .The importance given to edible plants by indigenous women and men has become more relevant today due to the spatial mobility restrictions caused by COVID-19. The testimonies of the indigenous totonac show this reality.The analysis explored the dynamic of food, memory, and identity of two ethnic groups in the Sierra Norte de Puebla. The topics addressed based on the methodological approach employed in the study were presented in the context of the COVID-19 pandemic. The fact that the pandemic was a disruptive element in the local economy of the ethnic groups interviewed led to the rescue of foods and edible plants for reuse. The literature reports at least 182 species of edible plants with high nutritional value that exist in the region. It was found that the totonac and nahua ethnic groups of the Sierra Norte de Puebla region in Mexico revalue three foods and nine edible plants.The foods and plants identified have a food use, although some species of the same family may be found to have different uses . In the region, the whole plant is edible  and cooking methods may vary according to the qualities of the plant. The study supports the strategic importance of food memory for the totonac and nahua ethnic groups and shows the potential of food heritage for the rescue of plant species that have historically been part of their ethnic diet. Tracing ethnic foods is a revalorization strategy capable of transforming the way of conceiving consumption and food security in the face of the COVID-19 pandemic. From a broad perspective, it constitutes an alternative to conventional food systems that under a capitalist production model, promote food poverty in vulnerable territories.The study showed the food, memories, and identity of only two ethnic groups in the region. The region has 63 municipalities where seven ethnic groups live, including the two ethnic groups under study. This suggests that food dynamics in the context of the COVID-19 pandemic may have a higher level of complexity. A research agenda oriented to deepen this type of study would contribute to the design of public policies in the field of mitigating food insecurity in Mexico as well as in other regions of the world.Additional file 1. Some families of the species of importance to the totonac and nahua ethnic group in the Sierra Norte de Puebla.Additional file 2. Degree of importance of the answers given by the heads of households. Note: Categories of importance: Under = 1; Medium = 2; High = 3; Very high = 4.


Workforce resilience in pharmacy is required to ensure the practice, education, and administrative systems remain viable and sustainable over time and when facing challenges. Whether it is addressing burnout of pharmacists or students, or the structure and policies/procedures of employment and professional organizations, working to increase resilience across all individuals and sectors is essential to relieve pressure and promote better well-being, especially during the recent pandemic. The purpose of this article is to describe the development of a community of practice global group focused on development of resilience within the pharmacy workforce that is inclusive of students, pharmacy interns/preregistration and registered pharmacists. The steering group meets monthly and has representation of 24 members across eight countries. Members meet to discuss pertinent issues they are facing in practice, as well as to share and progress ideas on education, research, and practice initiatives. To date, members have collectively implemented resilience training in pharmacy education, researched burnout and resilience in both students and pharmacists, and facilitated international collaborations both within and outside core group members. Future activities will focus on strengthening the community of practice in order to harness the power of the collective. There are increasing calls to investigate and develop workforce resilience across the health system as a priority, especially in light of COVID-19 ,3. StudeUniversity students consistently report experiencing higher levels of mental distress compared to the general population . StudiesResilience is at the core of the WHO European policy framework for health and well- being—Health 2020—and the United Nations Sustainable Development Goals . The WHOThe concept of a global resilience team (GRiT) started in September 2019 following delivery of a workshop on ‘Developing Resilience in Undergraduate Pharmacy Students’ at the International 10th Biennial Monash Pharmacy Education Symposium 2019. A call for expressions of interest to contribute was offered at the end of the workshop. During the first meeting, representation, aims, purpose, governance and terms of reference were discussed. The Chair and steering committee evolved over the next 2–3 months. A global community of practice was formed, and the purpose of GRiT was defined as a forum to learn, share ideas and to provide a support network to those interested in developing a greater understanding of resilience in the profession. The group was intended to provide a platform for people to collaborate on a range of initiatives, projects and research studies in the field of resilience and to share their findings. Specific areas of interest included resilience in undergraduate students, pharmacy interns/preregistration students, postgraduate pharmacists, preceptors and educators. Pharmacy interns or preregistration pharmacists are pharmacy graduates who are completing a period of supervised practice before being eligible to apply for general registration.The decision was made that 2 types of membership were to be included—steering group members and general group members. The steering group consists of 24 members working collaboratively. Eligibility for membership was agreed to be via invitation and decided by the group at the monthly meetings. The overall responsibility of the steering group was to provide support, oversight and strategic direction for GRiT. General members are interested individuals, who can be invited to join the meetings to present work or seek advice from GRiT. The decision was made to keep the steering group small initially with global representation, to enable GRiT to become established and a strategic plan formulated. Inviting general members to present has added depth to discussions. As GRiT evolves and develops, we expect changes to be made to the governance and structure of the membership.GRiT meets monthly via a video conferencing platform. Meetings have an agenda and minutes are prepared and distributed by the Chair or a designated steering group member in advance. Meeting are structured with inclusion of an informal presentation by a steering group or general group member of proposed initiatives or actual work being undertaken. Meetings include an opportunity for open dialogue and discussion to share ideas/knowledge and seek advice on proposed or ongoing initiatives between group members.To date, the global community of practice GRiT has met every month since September 2019. The Chair is supported by a steering group, composing 23 members from the following countries USA, Canada, UK , Ireland, Bahrain, Qatar, Australia and New Zealand.Communities of practice develop through a range of activities, as such the community should be dynamic, allowing participation and learning on the part of everyone . Such acCommunity of practice activities are described in more detail below together with several achievements of GRiT and GRiT members.Involvement with GRiT created the inspiration to embed the notion of resilience and the development of resilience skills into the undergraduate programs at the Faculty of Pharmacy and Pharmaceutical Sciences (FPPS), Monash University. The recently redesigned educational programs had a strong emphasis on skill development and including resilience and grit as core competencies was seen as important. In 2019/2020, two interventions were implemented and described below.First year skills coachingThe skills coaching program at FPPS enables students to focus on their skill development. Eight core skills underpinning the pharmacy program are: problem solving, oral communication, written communication, empathy, reflective practice, integrity, teamwork, and inquiry. Students are asked to reflect on their experience and development. Skills coaches provide feedback on the reflections and from there the student identifies specific actions to work on.Small groups of students (10–12) regularly meet with a dedicated skills coach. At each meeting, the skills coach facilitates a discussion and/or introduces an activity to the students. In 2019, resilience was included as one of the topics in the first-year skills coaching program. Students were asked to define resilience, then asked to consider some of the ways in which their resilience had been impacted, and to consider strategies to improve their resilience. In both 2019 and 2020, it was observed by facilitators that the topic of resilience generated meaningful discussion between the students and between students and skills coaches.Fourth year students’ workshopAt the beginning of 2020, a tailor-made two-hour resilience workshop for fourth year students was designed and implemented. Prior to this class, the notion of resilience had not been presented to this cohort of students. Given that the students would be graduating soon, it was deemed necessary to start the conversation to ensure students were aware of how to build on their existing resilience prior to entering the workforce as professionals.http://www.resilienceagenda.com, accessed on 8 June 2021) to reinforce the concepts discussed over the entire year. Anecdotally, there was a lot of energy in the room and the feedback from the class was overwhelmingly positive.The workshop included a mix of individual and team-based activities centered on defining resiliency, evaluating previous and existing resiliency, and developing a resiliency plan. The workshop was supported with a resilience diary . Webinar topics addressed a range of issues such as resilience, burnout and stress management as well as topical clinical issues. Sixteen webinars were hosted between April and December 2020, with a total of 5465 registrants (average of 342 per webinar). Recordings of the webinars were available for viewing on the IIOP website afterwards with an average of 215 views per webinar (Range 35–733). Rich insights have been gained from the webinar discussions and feedback from participants. As a result, new approaches to supporting CPD are emerging within the IIOP to meet the evolving needs of practitioners.The Irish Institute of Pharmacy (IIOP) supports and quality assures continuing professional development (CPD) activities on behalf of the Pharmacy Regulator, the Pharmaceutical Society of Ireland (PSI). Self-management and workplace-management are included in the Core Competency Framework for Irish pharmacists . The IIOA needs analysis was undertaken by the IIOP’s COVID-Hub Mental Health working group in October 2020, to better understand the topic of stress management amongst pharmacists. This provided further insights into pharmacist’s experiences and perceptions of stress, and the types of interventions required to enhance resilience. The IIOP is engaging with members of the GRiT collaborative to explore new approaches to support pharmacists’ continuing professional development in this area. In addition, CPD resources for practitioners will be the focus of the first funded projects within GRiT, which will assist in raising the importance of resilience for practicing pharmacists.Involvement in GRiT provided the idea and motivation to conduct research in the area of burnout and resilience among the pharmacy workforce in Qatar. Burnout is a psychological syndrome characterized by three dimensions: emotional exhaustion, depersonalization, and decreased feeling of personal accomplishment . BurnoutUsing shared learning from the GRiT membership, a study to explore pharmacy student and faculty member resilience across schools and colleges of pharmacy in the Eastern Mediterranean Region (EMR) was initiated. The EMR is one of the WHO’s six regions and has a population of approximately 679 million people. Whilst the EMR shares some similarities, including a common language in parts and a comparable cultural milieu, it is a highly nuanced and dynamic region, both politically and socio economically. Up until recently, studies on resilience in higher education have found dominance in Western-based research, with limited focus on countries within the EMR . ResearcThe EMR’s resilience in pharmacy education study aims to investigate factors affecting resilience among pharmacy students and faculty members and has received ethics approval from University College London, in the United Kingdom. At the time of writing, the study was in the data collection phase, using the Connor–Davidson Resilience Scale 25 (CD-RISC-25)©. It is anticipated that the study results will provide evidence-based recommendations to inform all stakeholders in pharmacy higher education institutions in the EMR of mechanisms and systems needed to enhance resilience and general-wellness of students and academics. Moreover, fostering resilience has been positively attributed to academic engagement and achievement and contributes to student mental health and well-being. Therefore, understanding the magnitude and associated factors of resilience amongst pharmacy students and faculty members in the EMR, would be helpful to university administrators and policymakers in the region.In the UK, GRiT steering group members from three universities  are collaborating on research focusing on pharmacy student and pharmacist resilience, well-being and burnout. In 2019, the Academic resilience scale (ARS-30) and the Warwick–Edinburgh Mental Well-Being Scale (WEMWBS) were completed by all Master of Pharmacy (MPharm) students across the three institutions. A total of 1161 undergraduate pharmacy students completed the measures, with low resilience and well-being scores correlated. Within each university, these findings have supported implementation of student self-management and well-being programs.In June 2020, a longitudinal cross-sectional online survey was distributed via social media to explore UK pharmacists’ response to the COVID-19 pandemic. The online survey consisted of four validated scales: Connor–Davidson Resilience Scale (CD-RISC 10), Oldenburg Burnout Inventory (OBI), Short Warwick–Edinburgh Mental Well-Being Scale (SWEMWB0) and the Recovery Experiences Questionnaire (REQ). In addition, open questions were asked regarding work challenges, positive changes to working practice, and most useful support at work, alongside participant demographic data. A total of 202 questionnaires were completed, with representation from all patient-facing sectors of pharmacy practice (primary and secondary care). Well-being, resilience, burnout and recovery scores were all found to be lower than population norms. Key themes identified included changes in working practice, emotional and physical responses, inter- and intra-professional working, organizational tensions, staffing and work–life balance. A second round of data collection was undertaken in October 2020, with analysis ongoing.Establishing a smaller regional working group within GRiT has proven to be a successful and supportive collaboration of like-minded researchers, with progress and outputs reported back to GRiT within the monthly meetings.The pharmacy internship year is demanding, with requirements to complete a required number of practice hours, an Internship Training program as well as undertaking the registration examinations, which are in two parts—a written and an oral exam. COVID-19 placed additional significant stress on the 2020 cohort of interns due to disruptions to their supervised hours and their ability to undertake face-to-face examinations due to strict lockdown requirements in the first wave  and second wave (in Victoria).The Australian Pharmacy Council (APC), the accreditation authority for pharmacy education and training, and the Pharmacy Board of Australia, the regulator for pharmacists, recognized the potential impact of COVID-19 on pharmacy interns, and worked together to modify practice hour requirements, timing, length and delivery mode of the examinations. The APC Intern Written Examination, previously a 3 h computer-based exam, was modified to a 2 h examination and was offered through either remote online proctored or test center examination and delivered later in the intern year. The oral examination was conducted by video conference. These actions reduced the regulatory burden on interns, gave them more time to prepare and were implemented with extensive consultation and communication to ensure all interns were informed of the options that would suit them best. Two-thirds of interns elected to sit the October 2020 written examination in test centers, and one-third by remote proctoring. There were no significant differences in the outcomes across these groups. A survey of all candidates’ post-exam showed that 40% of those who chose online delivery did so due to safety concerns or travel restrictions during COVID-19. The result of a collaborative approach by the accreditor and regulator resulted in no delay to the 2020 interns being able to register, thus reducing the stress and anxiety for both the interns and the broader pharmacy workforce.Several GRiT members working within Australian Hospitals identified the need to investigate the resilience of employees during the COVID-19 pandemic. The Royal Brisbane and Women’s Hospital  together with Monash Health  pharmacy departments, in collaboration with psychologists and statisticians, developed a multisite study to investigate Pharmacy Workforce Resilience during the COVID-19 pandemic. The study received full ethics and governance approval at both sites and was seen as a priority area for research in the respective organizations. The study was a prospective longitudinal study involving survey and semi-structured interview techniques. Questions were developed that related to participant resilience, coping strategies, recovery experiences and burnout. The survey was designed to be administered to participants three times during the COVID-19 pandemic. The first survey was delivered in July 2020 and the final survey in December 2020. The results are currently being analyzed but, as a result of participant comments in the surveys and semi structured interviews, a commitment has been made in both pharmacy departments to develop resilience training and education material for the pharmacy workforce.The motivated academics, practitioners, and regulators who are involved in GRiT benefit considerably from the opportunity to network and share promising practices. However, they recognized that the group’s full potential is limited by lack of funding and other support necessary to undertake high-quality research and implement cutting-edge programming to support resilience across the profession. While there is general recognition of the importance of professional resilience in most jurisdictions, there is limited funding available for research and development work. Where funding is available it is most often targeted to other, larger professions such as medicine or nursing. The broad networks of GRiT members resulted in opportunities to meet with potential funders, primarily from the pharmaceutical industry. While GRiT is neither a formal organization nor a structured group, its culture is collectivist, inclusive, and collaborative in orientation. The group selected three senior members to represent GRiT at meetings with potential funders. To ensure collective objectives were clearly presented and adequately represented, a written funding proposal was developed and circulated to all GRiT members for feedback and commentary. A collective decision was made that funding requests should focus on creating a sustainable infrastructure for the group’s on-going viability and support resilience researchers and practitioners in their work directly related to pharmacy practice. The value of a global collaborative representing different sectors of the profession, with a culture of collective decision making and willingness to openly share findings and resources, was seen as a significant asset. A key learning from this process has been the limitations associated with the informal nature of GRiT. Funders must have certainty and accountability from recipients that funding will be used appropriately. Despite these barriers, GRiT has been successful in attracting funding to support the development of CPD material for the pharmacy profession in resilience training and education, and welcomes the opportunity to collaborate with any organizations interested in progressing the resilience agenda within pharmacy.GRiT has developed a community of practice by bringing together like-minded people, interested and passionate about raising awareness for resilience development and training within the pharmacy profession. It has facilitated the embedding of the concept of resilience into undergraduate and postgraduate curricula. GRiT is currently an informal group of individuals who participate voluntarily in their own time. We decided, soon after formation, that the group would function well as a community of practice. Communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly. It is recognized that a community of practice generally has three characteristics: the domain, the community and the practice .GRiT is not simply a network of people, but rather has an identity defined by a shared domain of interest about resilience within the pharmacy profession. The group has a defined global membership that meet regularly via video conference. The group does not necessarily see themselves as experts in the field but rather are committed to developing knowledge and skills in the area.GRiT meetings occur every month and have standing agenda items that allow individuals to provide updates on their work, and to seek support and advice for progressing their ideas. Information is freely shared, and the terms of reference for the group require that information is not shared outside the group unless permission is sought beforehand. GRiT members regularly learn from each other, motivate each other and collaborate when the opportunity arises.GRiT members are all practitioners coming from all aspects of the pharmacy profession. We have pharmacy undergraduate and postgraduate educators, practicing hospital and community pharmacists, pharmacist regulators and pharmacist leaders. We have developed and continue to gather resources, experiences, and tools that are openly shared by the group.GRiT has faced some challenges over their first 18 months. Organizing suitable and socially acceptable times to meet across nine time zones has been a challenge. This is further complicated by day light saving changes occurring in some countries at different times. It is accepted that not all members can join a meeting every month owing to the times zones. Equity has been established by altering times every other month to suit western and eastern hemispheres. However, to maintain some consistency, the meetings occur during the last week of every month. This approach has been successful and received positive feedback from the group. Another challenge faced by GRiT was that posed by submitting the necessary ethics applications to local Human Research Ethics Committees to undertake research studies. Different processes and procedures exist to obtain ethical approval in different countries, making it challenging for the group to work on a single project. It is an aspiration of the group to collaborate at some stage on a single project and the group continues to learn and problem solve, how to navigate the necessary ethics procedures to enable this to happen.GRiT continues to grow and develop, and future activities will focus on strengthening the community of practice. In addition to providing an intentional time and space for discussions on resilience, GRiT will continue to provide a medium for exploring resilience through various lenses. The shared commitment of the group allows for discourse to push boundaries and challenge the ways in which we explore the intersection of resilience with other factors, particularly when it comes to health equity and racial justice. As such, the group intends to explore resilience not just as a one-dimensional understanding, but one that accounts for the privilege and accountability, or lack thereof, in recognizing resilience as a multidimensional social process. The group proposes to strengthen strategic plans and coordination in order to harness the power of the collective. GRiT will continue to share knowledge and skills within the community of practice but also to the wider pharmacy profession using a variety of platforms. In addition, the group aims to continue to be innovative, creating new knowledge and ideas for resilience development and training. In the longer-term direction of the group will be developed to address strategic and emergent requirements in the area of developing resilience across pharmacy.This community of practice demonstrates what can be achieved when like-minded practitioners come together with a common interest and passion. Despite the challenges faced by the global nature of the group, GRiT continues to grow and develop for the purpose of learning, support and collaboration. This enables research in resilience and the development of material to enhance resilience training and development at all levels of the pharmacy spectrum, from development in health professionals to developing and delivering evidence-based programs to undergraduate and postgraduate students.


Forensic Flexible Assertive Community Treatment (ForFACT) is used as a specialized form of outpatient intensive treatment. This outreaching type of treatment is aimed at patients with severe and long lasting psychiatric problems that are at risk of engaging in criminal behavior. In addition, these patients often suffer from addiction and experience problems in different areas of their life . The aim of this exploratory study was to gain more insight into the characteristics of the ForFACT patient population. More knowledge about these patients may enhance the effectiveness of ForFACT and therefore (further) reduce the risk of recidivism. Data on 132 ForFACT patients were gathered by studying electronic patient records, criminal records, and by conducting semi-structured interviews with practitioners and patients. Additionally, as part of a cognitive screening, two screening instruments were conducted to gain insight into intelligence and possible mild cognitive impairments. This article gives a broad description of the ForFACT patient population, including demographic data and context variables, diagnostics, recidivism risk and offense history, and aspects related to care. Furthermore, several recommendations are given to further improve ForFACT. Based on the results it can be concluded that the ForFACT patient population shows a high degree of diversity in complex care needs and responsivity issues. Therefore, this article highlights the necessity for ForFACT to collaborate with other mental health institutions, as well as probation officers, and forensic or criminal justice institutions. Moreover, it is important to continually check the inclusion and exclusion criteria when admitting patients to ForFACT, and to examine whether ForFACT is still the most adequate care for patients or if they need to be referred. In addition, the results emphasize the importance of cognitive screening for forensic outpatients. Finally, this study zooms in on the interface between forensic psychiatric care and general mental health care.In the Netherlands,  In the last 60 years, the focus of psychiatric care in Western countries transitioned from conventional institutional settings to community-based services Novella, . This prflexible ACT integration into the community for justice-involved individuals with mental illness seems to be difficult   model offending) when defining and implementing treatment. The responsivity principle says that the type of treatment should be tailored to the learning style, motivation, and capacities of a patient.Since the primary goal of FACT is to prevent criminal behavior, the FACT method corresponds to the Several studies looked into the question whether FACT is an effective type of treatment for forensic psychiatric patients. In contrast to ACT, FACT has indeed proven to be effective in preventing arrest and incarceration    should be indicated, and as a consequence some patients can get “stuck” between the two systems  needs, and issues concerning responsivity. Offering an appropriate type of care to forensic patients, in line with the RNR model, is of great importance to decrease the risk of criminal behavior and individual suffering, as well as to secure societal safety. Information was gathered about patients who received treatment within a Dutch ForFACT facility. Based on the results, several recommendations are given to further improve ForFACT.This research study took place at a Dutch outpatient mental health care facility: Kairos (part of the Pompefoundation). Kairos offers treatment to forensic psychiatric patients and consists of three outpatient clinics and two ForFACT teams (in the region Arnhem and Tiel in the Netherlands). Both teams have been screened for model fidelity by the CCAF, the Dutch Certification Centre for ACT and FACT teams, by using the ForFACT scale  offenses for which they received criminal charges. In the Netherlands, there is a policy stating that ForFACT may also treat patients who are expected to show an elevated risk of criminal behavior if no forensic treatment would be offered, for instance for patients with serious socially disruptive behavior. Thus, the Dutch ForFACT teams partly operate in a preventive manner, since patients can also be referred to ForFACT without a current conviction . A combination of social exclusion, expulsion from regular treatment, complex psychopathology, limited social network or a strong criminal network often lead to these people relapsing within criminality, or committing a crime for the first time. This subgroup of patients is treated without a decision of the court. Moreover, ForFACT patients often suffer from addiction, mild cognitive impairments and experience problems in different areas of their life .veiligheidshuizen.” Depending on the needs of the patient, this communication platform also includes, for instance, probation officers, community police officers, and the Dutch Custodial Institutions Agency.People are excluded from treatment at Kairos ForFACT when they are younger than 18 years old, do not have a correspondence address, or do not have health insurance . Furthermore, if patients refuse to give permission to ForFACT to request treatment information from other/past mental health care facilities or judicial reports, they will also be excluded. In case of extreme addiction or psychotic problems, a patient can be treated in collaboration  with other mental health care institutions . Lastly, ForFACT coordinates treatment together with other forensic services, mental health services and municipalities within a communication platform, the so called Dutch “Based on their own caseload, the ForFACT practitioners determined which patients were eligible to participate in the study. Patients were excluded from participation if they were in detention or in  crisis. In total, 223 ForFACT patients were approached for participation in this research study. Eventually, 132 patients agreed to participate, of which 18 patients limited their permission to only study his/her electronic patient record and criminal record. Demographic information about the study sample can be found in the result section.An extensive study of the electronic patient records of the 132 participating patients was conducted. More specifically, information was gathered from the intake interview report, treatment plan, diagnostics, and medication files. Information about patient characteristics that was considered relevant for this study, but could not always be retrieved from the electronic patient records, was acquired by interviewing the ForFACT practitioners and patients. Based on information that was found in the electronic patient records, a timeline was created in Microsoft Word for each patient that participated in the interviews. Since ForFACT patients are often characterized by a long history of (forensic) care, this timeline represented the history of care . The timeline contained previous treatments before ForFACT, over a time span of 10 years. This time span was chosen because of the availability of information in the electronic patient records, and because 10 years was considered to be a reasonable time frame for patients to be able to recall events from their memory during the interview.By studying the electronic patient records, data were gathered concerning recidivism risk at the moment of the intake procedure from 111 ForFACT patients. The Dutch FORE  is used by ForFACT as a risk assessment tool/instrument during the intake procedure and subsequently every 6 months  was shown to the patients on printed-paper. Patients were asked about their history of care over the past 10 years: the type of care, the date, duration and the overall satisfaction with the received treatment . The answers the patients gave to the interview questions were added to the printed timeline.To gain insight into the cognitive vulnerabilities of the ForFACT sample, two screening instruments were conducted. One instrument was the Dutch version (8.1) of the Montreal Cognitive Assessment (MoCA), which is a validated screening instrument for mild cognitive impairments (MCI) . For purposes of this research, official criminal records of the participating ForFACT patients were requested. These criminal records were used to make a timeline for each patient with their offense history, from the moment study was conducted until 10 years back in time. These timelines contained information about the date, type, and number of criminal offenses.In the Netherlands it is possible, under certain conditions and by following the privacy laws, to request official criminal records at the judicial information service  and a substantial agreement concerning the categorization of treatment goals .The information that was gathered from the electronic patient records, criminal records, and the interviews was scored. During intensive meetings among the researchers and before any data-analyses were conducted, the variables were categorized. The information gathered from the electronic patient records, criminal records and interviews was used as a starting point for categorization (to make sure categories were in line with the available data in the electronic patient records). For “psychiatric diagnosis,” the Diagnostic and Statistical Manual of Mental Disorders  classification system was used   was conducted to test the difference in the number of convictions between patients with a very low to moderate risk of reoffending and a high to very high risk of reoffending. Furthermore, the Spearman correlation coefficient was calculated to measure the relationship between the current number of diagnoses and the number of treatments received in the past, and to measure the association between the sum scores on the MoCA and the sum scores on the SCIL. Some variables contained missing data, for these variables the total sample size was <132. These variables were financial debt (n = 128), financial guardianship (n = 28), medication (n = 131), MoCA (n = 112), SCIL (n = 108), and FORE (n = 111). The deviations regarding the total sample size for these variables are also mentioned in the result section.Patient data were pseudonymized, meaning that names were replaced with research codes. Data preparation and data-analysis were performed using IMB SPSS (25th version). Due to the exploratory nature of this research study, the data analysis mostly consisted of data exploration through descriptive statistics. However, to gain more insight into the associations and relationships between variables, additional analyses were conducted . The association between recidivism risk and the number of convictions was measured by calculating the Spearman's correlation coefficient. To find out about the difference between the mean scores of patients on dynamic risk factors and static risk factors, a Paired Sample M = 40.3, SD = 11.3) and the majority of patients was male (88%). Approximately one-fourth of the patients (26%) had a non-Dutch cultural background, meaning that the patient or his/her parents were not born in the Netherlands. When looking at employment rates, 61% of the patients was unemployed, 24% had a paid job, 8% of the patients was unfit for work, and 7% did voluntary work, had sheltered employment, or was studying. Furthermore, 32% of the patients had no further education after primary school. Regarding the financial situation of the participants: 63% of the patients had financial debt (n = 128) and 53% of the patients had a type of financial guardianship (n = 128) . Finally, 35% of the patients were in a romantic relationship and almost half of the patients had one or more children (46%).The ForFACT patients included in the study were 18 to 72 years old .The most frequent primary diagnoses were impulse-control disorder (31%), personality disorder (30%), and schizophrenia and other psychotic disorders (17%) see . BesidesThe ForFACT practitioners indicated that 70% of the patients experienced problems related to substance abuse during ForFACT, of which 61% met the criteria for a DSM substance-related disorder. With regard to the type of substances, 38% of the patients experienced problems related to the use of cannabis, 33% to alcohol, and 15% to cocaine. In addition, 83% of the patients experienced addiction problems in the past 10 years (before ForFACT).n = 131), of which 16% did not show medication adherence. Most patients received antipsychotics (46%) followed by sleeping pills or sedatives (39%) (n = 131). Nearly one out of 10 patients (9%) had a high risk of suicidality. Besides psychological problems, 57% of the participating patients had medical/somatic problems, of which 27% suffered from a chronic disability , 25% had “other” disabilities , and 12% had a movement disability .Use of medication was found in 76% of the patients (n = 112). Which means that these patients had an indication for the presence of mild cognitive impairments (MCI). Furthermore, 67% of the patients had a sum score of 20 or lower on the SCIL (n = 108). These patients presumably had an intellectual disability. There was a strong positive correlation between the sum scores of patients on the MoCA and the SCIL . More than half of the patients (54%) had a sum score below the cut-off score on the MoCA as well as on the SCIL. Another indication for MCI or intellectual disability might be language proficiency. The ForFACT practitioners indicated that almost one-third (31%) of the patients had an insufficient to moderate Dutch language proficiency. Meaning that they, in general, did not have sufficient Dutch reading, writing, and listening skills.With regard to the cognitive screening, 63% of the participating ForFACT patients had a sum score of 25 or lower on the MoCA (n = 111). In addition, on average, ForFACT patients scored relatively low on dynamic risk factors  compared to static risk factors , . The clinical estimation of the recidivism risk of the participating ForFACT patients (during the intake procedure), based on the FORE, was as follows: 6% had a very low risk, 26% had a low risk, 26% had a moderate risk, 34% had a high risk, and 7% had a very high risk to reoffend . There was a weak significant association between the clinical estimation of the risk to reoffend on the FORE and the number of convictions in the past 10 years . On average, the subgroup of patients with a high to very high risk to reoffend had more convictions in the past 10 years  than the subgroup of patients with a very low to moderate risk to reoffend  . Of the participating ForFACT patients, 5% had no criminal record, meaning they had no previous convictions, dismissed cases, mistrials, or acquittals in their past. In addition, 13% of the patients had no convictions, dismissed cases, mistrials, or acquittals in the past 10 years. However, these patients did have a criminal record and could have had one or more convictions before this time period (though these data were not included in the current study). On average, patients with a criminal record had 12 convictions  in the past 10 years , followed by a probation officer (35%), a general mental health care facility (12%), and a forensic mental health care facility (6%). More than one-third of the patients (34%) already had a previous referral to Kairos (ForFACT or outpatient clinic). The participating patients could have received ForFACT with (40%) or without (60%) a decision of the court.M = 17.4, SD = 12.8). Some patients received treatment for 3 years or longer (8%).Most ForFACT patients received treatment in their own living environment (63%). The other patients saw their ForFACT practitioner at the outpatient clinic (19%) or received a combination of treatment at home and at the outpatient clinic (19%). On average, patients were receiving ForFACT for 17 months, at the moment the electronic patient records were studied . A few patients (3%) had no previous treatment. There was a weak significant association between the number of diagnoses of a patient and the number of previous treatments (before ForFACT) . Taken all together, patients indicated that they had an equal amount of positive, negative as well as neutral (neither positive nor negative) experiences with their received care in the past.When looking at the type of care patients received in the past 10 years, before they were referred to ForFACT, more than half of the participating patients (52%) had a type of housing assistance in the past. In addition, 79% received outpatient treatment and 51% of the patients received inpatient care. On average, patients had 4 types of treatments in the past 10 years (before they were referred to ForFACT)  needs, and responsivity. Data were collected from 132 patients who received treatment from a Dutch ForFACT team. The results will largely be discussed by means of the three principles of the RNR model: risk, need, and responsivity  offenses before this time period, followed by a long period of incarceration (during which no new crimes were committed). In addition, it is likely that several patients have not officially been convicted but have committed offenses without them being reported to the police . Lastly, some patients without a criminal record might show a (high) risk of potential criminal behavior.These results raise the question whether patients with a low recidivism risk and/or no criminal record should receive ForFACT, or whether they should be treated by a regular flexible ACT team. Within the Dutch treatment context, patients can, under specific conditions, be referred to ForFACT without an order of the court . ForFACT may experience pressure from general mental health facilities to accept non-forensic patients who have no previous or recent convictions, but who display aggressive/disruptive behavior . Moreover, ForFACT experiences problems when referring patients with a reduced recidivism risk to less intensive/outreaching types of care, because these services are not keen on accepting patients with forensic features and aggression/impulsivity problems. This could explain why patients with a low risk to reoffend and/or no criminal record do receive ForFACT. Another possible explanation could be that these patients are admitted to ForFACT, not because of a current high risk of reoffending, but because of complex  psychiatric needs, combined with severe responsivity issues. Apparently, there is a need for a specialized service like ForFACT, with forensic expertise, to treat these types of patients.According to the RNR model, forensic psychiatric care should focus on the needs of patients in order to be effective. The results related to diagnostics indicate that the needs of ForFACT patients vary and are highly complex. ForFACT patients suffer from multiple psychiatric disorders, of which the most common primary diagnoses are impulse-control disorders or personality disorders. Impulsivity seems to be an important distinctive characteristic of this patient population. Patients with impulse-control disorders and personality disorders may not be easily referred to flexible ACT teams, but are referred to ForFACT instead, because of their aggression/impulsivity, imminent criminal behavior and nuisance. When patients receive medication for their psychological problems, medication adherence seems to be a problem. In addition, several patients show a high risk of suicide and more than half of the ForFACT patients experience medical/somatic problems. Furthermore, the great majority of ForFACT patients experience addiction problems during ForFACT and/or have experienced problems with addiction in the past. In order for ForFACT to be effective, according to the RNR model, these various complex care needs should be assessed and addressed [especially if they influence/are related to (re)offending].An issue underlining the complexity of the needs of ForFACT patients is that, in most cases, the self-expressed health care needs of patients during the intake procedure, and the treatment goals formulated by practitioners do not correspond. Some patients find it difficult to formulate and communicate their care needs, for instance, because of a limited understanding of their (psychiatric) problems, a lack of self-reflection, and/or diminished cognitive functioning. Improving the correspondence between the practitioner's treatment goals and the patient's needs expressed at the beginning of treatment is of importance for treatment motivation, treatment effectiveness and the patient's recovery. Determining the care needs of ForFACT patients seems to be far from easy. This might also be reflected in their complex history of care. The great majority of patients received multiple types of (unsuccessful) treatment in the past, before they are referred to ForFACT.Besides as an expression of the heterogeneous and not easy to influence needs of ForFACT patients, this history of care is also related to another RNR principle: responsivity. There are numerous responsivity issues within this specific population that might influence treatment effectiveness. In this study, we zoomed in on a few of these issues. For instance, approximately one out of five patients show limited motivation and commitment for treatment. Especially such a group of patients may benefit from an outreaching type of care, which is a distinct feature of ForFACT. Another issue concerning responsivity is highlighted by the results of the cognitive screening. These results indicate that the majority of patients were qualified for further diagnostic research because of a (strong) suspicion of MCI or an intellectual disability. Insight into the intellectual and cognitive level of functioning of patients is of great importance for tailoring care and achieving treatment goals. Cognitive problems and intellectual disabilities may be associated and possibly interact with psychopathology, impulsivity and limited inhibition. ForFACT practitioners need to adjust the way they approach a patient to the patient's level of cognitive functioning. In addition, the level of cognitive functioning of patients may determine which type of collaboration is needed with other mental health services specialized in care for patients with intellectual disabilities, to provide the best type of treatment and continuity of care for these patients.Even though this research study has been prepared and conducted thoroughly, some limitations should be mentioned. First, 41% of the approached ForFACT patients declined to participate. Although such percentages are far from unusual when conducting research within a forensic psychiatric population, this research project misses data on a  important group of ForFACT patients. Unfortunately, there is no information available about the characteristics of these patients because of privacy issues. Secondly, the information that was gathered from the interviews is subjective to the patient's ability to remember events from the past and should be interpreted carefully. Some patients indicated they could not remember exact dates, years, locations or types of treatment. Additionally, the sum scores of patients on the screening instruments is a contemporary snapshot of cognitive abilities and might be under the influence of external factors . Furthermore, the administered instruments are designed for screening, not for determining a diagnosis, and there are no specific norms or cut-off scores available for the ForFACT patient population. With regard to the FORE, the estimation of the recidivism risk might not be completely accurate. During the course of treatment, practitioners will get to know a patient and his/her circumstances better, which will probably also improve the accuracy of a FORE score. In addition, this study examined only two ForFACT teams. It may be possible that ForFACT teams across the Netherlands vary depending on the region , specific local situations/policies leading to potential differences in whom they treat and how they treat them. Finally, in order to cope with the amount of collected data in this study, categories were formed for the variables. There is always a small margin of error when categorizing variables. However, the inter-rater reliability for the categorized variables was studied and found to be substantial enough to proceed.Besides the mentioned limitations, this study is one of the first studies that extensively looked into the characteristics of the ForFACT patient population. Based on the results it can be concluded that many patients adhere to the ForFACT criteria: they show a (high) risk of (re)offending, have clear forensic care needs and display critical responsivity issues. However, it seems there is also a group of ForFACT patients who do not show a high risk of reoffending and have no criminal record. Initially, these patients do not appear to have specific criminogenic needs for forensic treatment. However, it seems as if they are in need of care within the scope of ForFACT because of their complex psychiatric care needs, aggression, disruptive behavior and responsivity issues , which are often too complex for a regular flexible ACT team. This is in line with Kusters et al.  who founBesides providing care for patients with criminal charges, ForFACT seems to operate on the interface between forensic mental health care and general mental health care by also providing care for a group of patients with complex needs and responsivity issues (according to the RNR model), but without a high risk of (re)offending. This group is at risk of receiving no treatment at all or being referred to different settings, as professionals struggle to find the correct approach for the complex needs and responsivity issues of these patients. For this group of patients, ForFACT acts in a preventive manner by focusing on treating the needs of these patients in order to prevent actual offending. Furthermore, it seems as if regular flexible ACT teams are not able to fully respond to the responsivity problems and these patients are therefore often referred to ForFACT . The decision within the Netherlands to let ForFACT also treat patients with a risk of criminal behavior, but no current conviction, may raise questions about whether this is the most effective method. One could argue that, for the time being, these patients do receive treatment and are therefore not stuck between mental health care and forensic psychiatric care. Still, it is very important to continually check inclusion and exclusion criteria when admitting patients to ForFACT, and to check whether ForFACT or regular flexible ACT is the best-indicated type of care. A distinct feature of ForFACT is its ability to provide continuity of care by (temporarily) intensifying or de-intensifying treatment. It is important to prevent patients from receiving unnecessary prolonged treatment by continually monitoring the possibilities of patients to be referred to a less intensive/outreaching type of care. In line with Cuddeback et al. , ForFACTDue to responsivity issues, it can take a long time before a solid therapeutic relationship is build. The outcomes of this study therefore emphasize the importance of ForFACT teams to include practitioners with sufficient experience and skills within the forensic psychiatric field. This recommendation is in line with Cuddeback et al. . In addiThanks to this study, more knowledge is available about the ForFACT patient population. However, the results provided by this study raise additional research questions, for instance, regarding the upscaling and downscaling of treatment. Future research could focus on multiple single case studies to test the effects of the ability of ForFACT to (temporarily) (de)intensify treatment. It would also be interesting to compare the patient characteristics of the ForFACT population and the regular flexible ACT population, and to zoom in on the group of patients who experience problems within the interface of forensic care and general mental health care. Furthermore, more knowledge is needed about the type and severity of the disruptive behavior and possible associated risks, needs and responsivity issues, which causes patients to be referred to ForFACT. Future research could look into discharge and referral processes between different types of (forensic) mental health care facilities in order to improve these processes, and to make sure patients receive the most appropriate type of care.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by The Internal Scientific Committee of the Pompefoundation. The patients/participants provided their written informed consent to participate in this study.MS and FS performed the data collection and organized the dataset, by supervision of MV and BB. MS performed the statistical analyses en wrote the first draft of the manuscript. All authors contributed to the conception and design of the study, manuscript revision, read, and approved the submitted version.This study was funded by Koers en Kansen voor de sanctie-uitvoering, a program set out by the Dutch ministry of Justice and Security, and the Pompefoundation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The COVID-19 pandemic is straining health systems and disrupting the delivery of health care services, in particular, for older adults and people with chronic conditions, who are particularly vulnerable to COVID-19 infection.The aim of this project was to support primary health care provision with a digital health platform that will allow primary care physicians and nurses to remotely manage the care of patients with chronic diseases or COVID-19 infections.For the rapid design and implementation of a digital platform to support primary health care services, we followed the Design Science implementation framework: (1) problem identification and motivation, (2) definition of the objectives aligned with goal-oriented care, (3) artefact design and development based on Scrum, (4) solution demonstration, (5) evaluation, and (6) communication.The digital platform was developed for the specific objectives of the project and successfully piloted in 3 primary health care centers in the Lisbon Health Region. Health professionals (n=53) were able to remotely manage their first patients safely and thoroughly, with high degrees of satisfaction.Although still in the first steps of implementation, its positive uptake, by both health care providers and patients, is a promising result. There were several limitations including the low number of participating health care units. Further research is planned to deploy the platform to many more primary health care centers and evaluate the impact on patient’s health related outcomes. Since the first case of COVID-19 was diagnosed in Wuhan, China in October 2019, the virus quickly spread around the world to become a global pandemic and a public health emergency, as declared by the World Health Organization in March 2020 [Portugal has also been severely affected by this pandemic, with 420,629 confirmed COVID-19 infections and 6972 deaths by the end of 2020 ,4; howevIt has been observed that older adults and those with underlying health conditions are at increased risk of contracting COVID-19 and have an increasingly rapid and severe progression, often leading to death . MoreoveAnother cause for concern associated with this pandemic is the severe and widespread disruption of prevention and treatment services for populations affected by chronic conditions. This was reflected in a survey conducted by the World Health Organization , involviSeveral studies ,10 have All these issues have led to a renewed focus on telehealth, as a means of providing care to both patients with COVID-19 infections and those requiring other routine clinical services without increasing the risk of potential exposure for patients, clinicians, and staff ,13.In this context, we sought to design a web-based digital platform to support primary health care services during the COVID-19 pandemic, by facilitating web-based consultations between primary health care teams and their patients, to guarantee appropriate care, promote adherence to treatment, provide counseling and psychological support.We aim to share our efforts and experiences in creating a digital health service during a public health emergency . This project resulted from a collaboration between academia and health professionals and allowed for the timely deployment (within 3 months) of an innovative digital platform to improved access to health care during lockdown.We designed, created, and implemented a digital platform with specific features in the shortest possible time under difficult circumstances imposed by the pandemic situation using the pace established by Scrum and in a close collaboration with the Primary Health Care professionals who would be using the platform.We followed the Design Science Research Methodology ,15, whicEach step—problem definition, defining the objectives, and design and development, demonstration, evaluation and communication—was performed as a research task.A set of interviews with general practitioners, nurses, and clinical secretaries helped identify both the critical chronic care processes  and the major communication problems between chronic patients and health care professionals , and moreover, in the pandemic, how to access to chronic patients at home.The aim of this activity was to identify the digital care services required by the patients when they interact with their primary health care providers, specifically during lockdown due to the pandemic. This helped to inform the functionalities that the health professionals felt were lacking in care, supported by functionalities that were intended to mimic the work processes of the goal-oriented care methodology for primary health care provision . Goal-orThe design and development of the digital platform was based on the goal-oriented care methodology for primary health care provision  and on aThe platform was then applied in practice engaging the 3 family health units’ professionals for 4 weeks. This allowed us to test online medical and nursing teleconsultations as well as disease monitoring through patient-shared health data.Data from the demonstration were collected. The platform utility was then evaluated based on the teleconsultations effectiveness and patient’s adherence to care, as well as major bottlenecks in users’ experiences. The evaluation also provided more information about the usefulness of the digital service and identified missing features for implementation in the next design cycle. This step will be fully completed after 12 months of the deployment of the platform.This activity aims to disseminate the project’s results. This activity will be performed throughout the duration of the research project. It includes webinars, oral communications, papers published in conference proceedings within the fields of study and papers to be published in peer reviewed journals.The project received Ethics approval from the Lisbon Health Region Ethics Commission, and in accordance with international security (ISO 27001) and privacy  standards.In Portugal, primary health care is largely provided by a publicly funded National Health Service System. Regional Health Authorities ensure access through primary care through primary care trusts. These trusts coordinate different types of primary care practices  and support units  to around 150,000 to 400,000 citizens. Primary care is provided by smaller practices , generally composed of teams of 15 to 30 health care providers, with 6 to 11 family physicians, an equal number of family nurses, and a smaller number of administrative staff and trainees. These practices serve a fixed list of around 15,000 citizens .There is a mandatory use of electronic health records and electronic prescription; however, the use of videoconferencing is not widespread, mostly because health care units do not have the proper technical equipment for teleconsultations .Unidade de Saúde Familiar in Portuguese) in the Lisbon Health Region. A USF is an operating unit of primary health care centers with functional and technical autonomy, where patients are closely managed and monitored by a group of primary health care professionals, thus representing an ideal site for our pilot project.The primary health care digital platform was piloted during the month of July 2020, in 3 family health units , located in a suburban area of Greater Lisbon. At the end of 2019, there were 15,011 registered users and the team consisted of 20 professionals: 8 doctors, 7 nurses, and 5 clinical secretaries. The USF also included family medicine residents and assistant nurses and specialists, as well as technical assistants. USF das Conchas is also a model A family health unit, located in Lisbon. There were 13,750 registered patients, 8 doctors, 7 nurses, and 5 clinical secretaries. USF Ribeirinha is a model A family health unit, located south of Lisbon, on the south bank of river Tagus. There were 14,962 registered patients, 9 physicians (and 10 residents), 8 nurses, and 6 clinical secretaries.The pilot project included 3 USFs that were purposely selected. These health care units were selected for their previous participation in innovative projects addressing the organization of primary health care digital services and their strategic location in a region with a high population density and with a high number of COVID-19 infections and because of the high prevalence of chronic conditions in registered patients.The new digital service was co-designed  involving patients and health care providers.This research included populations that were vulnerable to the COVID-19 infection, namely older adults and those affected by chronic conditions as recommended by health authorities . ParticiWe included physicians and nurses in these 3 practices who were willing to participate in the study. All the teams were led by their USF coordinator. Regular team work meetings  were organized with providers to explain and test the digital platform and, in which, we received their feedback and suggestions.The digital platform was developed based on an existing system from previous eHealth research projects conducted by members of the research team, namely ePharmaCare  and HAITDesign Science Research Methodology was used to adapt the platform to the specific objective of the project—namely to allow primary health care physicians and nurses to monitor patients with chronic diseases and those with COVID-19 infections under quarantine -23—by thIn terms of architecture, the primary health care digital platform  is a web-based app with 3 relational databases using PostgreSQL. There is a staging database to enable proper testing before production, a production database to collect USF data, and a research database, with anonymized data from the production database. The platform was also integrated with Zoom (Zoom Inc) to allow for teleconsultations.We expected that the digital platform would work as a chronic disease management portal, where health care professionals, patients, and caretakers could manage patients’ chronic conditions. It was built to allow both synchronous (consultation videoconferences) and asynchronous communication .The digital platform promotes and facilitates communication, by including integrated views of the patient’s demographic information, chronic conditions, medication, exams, and personal goals—inspired by goal-oriented care  and dispThe platform presents a set of functionalities that allow scheduling and management of consultations using telephone  or via digital videoconferencing using Zoom. Teleconsultation scheduling requires only 3 clicks . The platform is also a decision-support system, displaying alerts if patient inputs are out of the specified range upon automonitoring  and for drug interactions. The platform also manages and informs patients regarding COVID-19 infection and safety measures. All patient-related health information is processed in a secure manner in accordance with General Data Protection Regulation rules.Universidade Nova de Lisboa (with the coordination), including also researchers from 3 other institutions, namely Instituto Superior Técnico and Universidade Lusófona in Portugal and the Geneva University Hospitals in Switzerland.The project was proposed and implemented by a multidisciplinary team of 9 researchers, mainly from The research team comprised 3 physicians , 1 nurse and PhD student, 1 professor of community pharmacy, 1 expert in health communication and PhD student, 1 professor of information systems, 1 expert in digital platforms and PhD student, and 1 professor of health information systems as the team leader (and leader of ePharmaCare ).Part of the team was focused on the development of the digital platform and on direct contact with the family health units (tests and discussions), while the other part of the team provided problem-solving expertise .The project started in May 2020 and by the beginning of July 2020 the platform had been fully deployed (within 9 weeks) and delivered to the 3 family health unit coordinators. We provided 2 tablets (with cameras for teleconsultations) to each USF. A kick-off session was organized with each USF to facilitate the adoption of the platform and address any questions. Every USF performed their first consultation with a real patient during this meeting (the patients were contacted beforehand).The research problem had been previously defined and the project had identified that there were barriers to communication with chronic patients, such as patients’ lack of mobility and lack of information between the consultations .To define and validate the objectives of a solution , focus groups in each of the 3 USFs were organized, and a set of functionalities were specified for integration into the digital platform. All the functionalities that were proposed were validated in the Scrum meetings.The Scrum meetings took place every week  and were supported by Trello to manage the information about the sprints. The meetings started with analyzing the previous week’s sprint, validating the activities that were accomplished as planned, discussing feedback from end-users, and defining a new delivery date for the activities that were, for any reason, not finished as expected. In the second part of the meeting, a new sprint that took into the project timetable into consideration, including who was responsible for each activity, was defined.Next, the process of designing the new digital platform was developed in collaboration with the physicians, nurses, and clinical secretaries of the 3 USFs. Often the physicians of our team would help clarify requirements for a functionality, and the digital platform team would analyze how it could be implemented. In every Scrum meeting, validated functionalities were assigned to a timeframe, to be developed and integrated into the platform. Nonvalidated functionalities were transferred to staging, for future consideration. After the first set of meetings, it was decided that the platform would include 5 priority features.This feature allows appointment to be easily booked for teleconsultations. Prior to the appointment, a message is sent to both physicians and patients with the schedule and the unique link to the teleconsultation. It also included a SOAP  free-text structure, as demanded in primary health care settings . If partThis feature allows monitoring of patients’ biochemical and physiologic data as well as prescribed medicines, with several graphic displays available to facilitate interpretation and follow-up. This data can be uploaded by the patient (at home or after examination at the community pharmacy) or by the physician (at the consultation).This feature allows patients to upload daily or regular physiologic and biochemical data that can be later visualized by physicians or the patients themselves. Patients can also ask questions and share information with the health professionals via a chat system, in addition to receiving information sent by the health professionals.The platform has new smart components, including algorithms that allow a set of alerts to improve physicians’ and nurses’ responses to a potential negative evolution in patients’ data. As an example, all physiological and biochemical indicators have healthy limits included in the system, and whenever the indicator is outside these limits, or whenever this indicator is n-times outside the predetermined normal interval defined by the physician, it issues an alert.Using the Portuguese medicine database webservices provided by the National Authority for Medicines and Health Products (INFARMED), we included a module for therapeutic management. This module allows professionals or patients, to input the name of their medication  and dosage to yield a therapeutic profile. A feature of this profile is to automatically calculate the end date for each medication package prescribed, assisting with medicine management and therapeutic adherence issues. This feature, alongside the participation of a specialist pharmacist, will allow for different types of medication reviews and enhanced pharmaceutical care. This last function was inherited from the ePharmaCare project.The demonstration took place after a meeting with USF teams in July 2020. There was a positive uptake by health care providers and patients in a truly short term. As of December 31, 2020, there were 53 health care providers (37 physicians and 16 nurses) from 3 USFs engaged and using this platform to follow 35 patients .In order to provide the first evaluation of the digital care provided, during the sequential meetings and first tests, we observed, listened, and recorded health care providers talking about their experiences and difficulties while using the platform.At 3 kick-off meetings with USFs (in the beginning of July), the physicians and nurses showed marked enthusiasm. In all occasions, they immediately took the new tablets with the system and started using them without almost any help from the research team.Interestingly, in the first presentation of the digital platform by the researchers, during which physicians were told that they could define functionalities that they needed to be added to the platform, 1 physician enquired whether they could really ask for additional functionalities for the system.Jardim dos Plátanos, a retired lawyer of 83 years of age (who provided written consent), acknowledged the reception of the email with the log-in and password. Soon after, he managed to initiate the teleconsultation easily, without any help from the physician.We observed that the first patient at USF A physician, during her first consultation and while talking with the patient, managed to effortlessly book another appointment  and requested that the patient enter his weight and arterial pressure every week in the platform. The patient said he would try.Several physicians and nurses pointed-out the user-friendliness of the digital platform, and the reduced number of clicks necessary to perform the basic functions .In 1 USF, the 2 physicians mentioned that the platform could also be used to follow pregnant women, since the protocols are well-known, and it would reduce their COVID-19 infection risk .It was observed that each USF’s team preferentially used different functionalities of the platform that were in line with the work and organizational processes of each site. Indeed, while 1 USF preferred to use the platform mostly for teleconsultation, another used it more for the recording and monitoring of patient data and another to focus on engaging more digitally literate patients. Understanding this behavior could be a possible focus for a future study.Ribeirinha, a clinical secretary was called to help tackle this barrier.Several physicians mentioned difficulty getting the tablet (often kept in a lockable drawer) when they were busy with consultations in order to perform teleconsultations. At USF Conchas was naturally skeptical at the beginning, but soon after using the platform, he accepted the challenge and assumed the leadership of using the system in his USF. In the meantime, we had a meeting at this USF with the National eHealth Institute, where this coordinator played an important role in promoting the value of the platform.The USF coordinator at An important measure of some difficulties was the slow rate of adding new patients. This was, the health professionals said, in part, limited by the holiday season and related absences of many health care providers and patients. Logistic difficulties due to COVID-19 were also a barrier.Important features of the digital platform that had not been possible before were the ability to contact and see the patients  and to make appointments with reminders for upcoming teleconsultations. We were told that several patients had already started entering their own data onto the platform.Regarding dissemination, in addition to an oral communication presented to a special COVID-19 session , a pressThe main objectives of this rapid implementation project were attained: a digital platform was designed, implemented, and demonstrated in 3 different USFs, with several health care providers already using it to manage a set of their patients remotely .The rapid implementation  was focused on the development of the platform, with main organizational implications, such as communication with patients and the number of interactions .Tablets were chosen for 4 reasons: camera, easy access to the internet, inexpensive, and easy to use. They can be used by different physicians and nurses throughout the day and provided the capabilities for performing both teleconsultations and monitoring. The results thus far have provided valuable proof-of-concept feedback and proved that health care professionals in the USFs could provide remote consultations to their patients during the COVID-19 pandemic using our digital health service.We observed that health care providers were able to safely communicate with and prescribe appropriate treatment to their patients, as well as inform them about the COVID-19 related protective measures and answer any other queries they might have . Yet, we did not have the opportunity to assess patients either on quarantine or in isolation as, at the time of implementation, the rate of COVID-19 infected patients was still relatively low in Portugal (approximately 0.8% ), and thThere are similar projects that are currently being developed in countries all over the world, such as in Canada ,2, the UAlthough we have not completed the evaluation of our service, there is increasing evidence that clinical consultations conducted through a video link tend to be associated with high satisfaction among patients and staff, with no difference in disease progression and lower costs compared with traditional clinic-based care . In factNevertheless, there is still a lack of national and local guidelines regarding the remote management of patients using digital health solutions, and urgent research is required in this field. Our research efforts may contribute, albeit indirectly, to solving this problem. Other risks of using this type of platform include the possibility of misdiagnoses, equipment malfunction, and privacy breaches . Other iOther researchers have also highlighted the importance of implementing digital solutions without further fragmenting the existing landscape of care . This reThis digital platform will also be a valuable source for epidemiological data. We are also currently discussing different functionalities that can be used for research purposes . The project team was recently contacted by a set of health care centers inquiring how to be included in the study, and by African Portuguese-speaking country partners, as they have shown interest in this platform for advancing universal coverage in their countries.Although still in the first steps of project dissemination, we are seeing promising results with a positive acceptance by health care providers and patients. The primary health care units now have a digital platform for following and monitoring chronic patients, which can be use in the eventuality of subsequent waves of COVID-19 infections or during the flu season.This study had several limitations. Most notably, the results may not be generalizable, as only 3 health units participated in the study, and it was developed under the restrictions of COVID-19 pandemic . Further research is required to evaluate the impact on patient health-related outcomes. We believe that this platform could be scaled-up to many more primary health care centers in Portugal.