Background: Recent health system shocks such as the Ebola outbreak of 2014–2016 and the global financial crisis of 2008 have generated global health interest in the concept of resilience. The concept is however not new, and has been applied to other sectors for a longer period of time. We conducted a review of empirical literature from both the health and other sectors to synthesize evidence on organizational resilience.Methods: We systematically searched for literature in PubMed, Econlit, EBSCOHOST databases, google, and Google Scholar and manually searched the reference lists of selected papers. We identified 34 papers that met our inclusion criteria. We analysed data from the selected papers by thematic review.Results: Resilience was generally taken to mean a system’s ability to continue to meet its objectives in the face of challenges. The concepts of resilience that were used in the selected papers emphasized not just a system’s capacity to withstand shocks, but also to adapt and transform. The resilience of organizations was influenced by the following factors: Material resources, preparedness and planning, information management, collateral pathways and redundancy, governance processes, leadership practices, organizational culture, human capital, social networks and collaboration.Conclusion: A common theme across the selected papers is the recognition of resilience as an emergent property of complex adaptive systems. Resilience is both a function of planning for and preparing for future crisis (planned resilience), and adapting to chronic stresses and acute shocks (adaptive resilience). Beyond resilience to acute shocks, the resilience of health systems to routine and chronic stress (everyday resilience) is also key. Health system software is as, if not more important, as its hardware in nurturing health system resilience. This includes the 2008 global economic crisis7 The concept was subsequently applied to the ecological sciences where it was used to refer to an ecosystem’s ability to absorb shocks while maintaining function.9 This early conceptualization of resilience as a system’s ability to bounce back from a disturbance has been called engineering resilience as it was based on a “machine” view of systems, with simple cause and effect dynamics. However, subsequent applications of resilience, especially to social systems, recognized the complex adaptive nature of systems. This recognition prompted a view of resilience as involving the adaptation and transformation of systems though the emergence of new structures such as policies, processes and organizational culture that enable organizations to continue to perform their functions in the face of challenges.11However, despite its relatively recent entrance into the global health debates, the concept has been applied in other sectors for a longer period of time. The concept originated from the physical sciences, where it refers to a physical system’s capacity to return to its original form after a disturbance.12 Yet understanding what makes systems resilient in the real world is critical to thinking about developing strategies for strengthening their resilience. We reviewed empirical literature with the aim of exploring how resilience was conceptualized, identifying the factors that influence organizational resilience and how they could be nurtured. Organizational resilience has been defined as ‘the maintenance of positive adjustment under challenging conditions such that the organization emerges from those conditions strengthened and more resourceful.’13 Because empirical literature on resilience is scarce, and because the health sector has a very short history of engaging with the concept, we deliberately broadened our review to include literature from both the health and other sectors. This is, to our knowledge, the first review of empirical literature on resilience undertaken to support health systems thinking, and it makes the following contributions. First, the evidence synthesized enriches debates on health system resilience by drawing on experiences from other sectors, so allowing for cross-pollination of ideas. Second, the evidence on factors that influence organizational resilience can inform the development of interventions for strengthening health system resilience, and developing frameworks for monitoring the impact of these interventions.Despite the growing interest in the concept of resilience, there is scarce evidence on how to generate or strengthen resilience in health systems or in other sectors. The resilience literature is predominantly conceptual, focusing on concepts and principles.We searched literature in December 2016 in PubMed, Econlit, EBSCOHOST databases, google, and Google scholar. We used the following keywords to search for literature: ‘Resilience’ and ‘organization*’ or ‘organization’ or ‘institution’ or ‘system.’ We manually searched the reference lists of selected papers for relevant papers. We did not use any time restrictions in our search but included studies up to the time of the literature search . We used the following inclusion criteria to select papers to be included in the review: (1) papers published in the English language, (2) papers that reported empirical research on organizational resilience rather than theoretical/conceptual papers. Empirical research is based on observed and measured phenomena and derives knowledge from actual experience rather than from theory or belief, and (3) papers that reported studies that focused on organizational resilience, rather than the resilience of individuals. In this step, we first screened study abstracts and then obtained full-text formats for studies deemed relevant. Two authors independently reviewed all abstracts and full-text formats.The first step in the literature search resulted in a total of 24 984 papers. Of the 24 984 articles, 24 708 articles were excluded after a review of abstracts because they were not empirical papers, and/or focused on individual rather than organizational resilience. Eight more articles were excluded for being duplicates. An assessment of the full-text formats of the remaining 268 papers resulted in a further 234 exclusions. A total of 34 studies were finally included in the review . Figure 22 applied an a priori framework to quantitatively assess the resilience of general insurance organisations in Jordan to multiple everyday challenges of competition, loss of customers, financial losses and political instability, while Hassall et al23 examined the perspectives of practitioners from multiple industries  in Australia on organizational resilience to unspecified acute shocks. On the other hand, Achour and Price14 explored the healthcare resilience strategies of healthcare organizations in the United Kingdom to econoLembani mic challenges, while et al28 examined the mechanisms that influence the resilience of the Ivory Coast health system to disruptions caused by a civil war.48 The quality appraisal results are outlined in We used the Critical Appraisal Skills Programme (CASP) tool, which uses a check-list approach with screening questions, to assess the adequacy, trustworthiness and relevance of the evidence reported in the articles.A large number of selected papers scored poorly on explicating (1) the approach used to select study participants, (2) the relationship between the researchers and participants, and (3) measures taken to ensure the study adhered to research ethics standards. However, our observation what that this was largely because of difference in style and practice of science writing in health and other sectors. While papers from the health sector were structured in the common tradition of health/medical science  with each section providing significant detail, papers from other sectors were more heterogeneous in structure, and focused more on discussing findings, and less on explicating methods. We therefore interpreted the differences in quality score as difference in style and writing practice rather than necessarily difference in quality. As a result, we opted to include all the selected papers, as excluding some on the basis of the quality score would likely preferentially exclude papers from other sectors and we judged all papers as offering valuable insights for the review.49 This entailed the following steps: (1) familiarizing with the data by reading through the selected papers, (2) generating a coding framework, (3) reading through the selected papers and coding the contents based on the coding framework (4) charting the coded data, and analyzing by constructing themes from these emergent ideas and concepts in an interpretive stage where findings from the selected papers were integrated into coherent themes. Coding was done in NVIVO version 10 software.We conducted a thematic review of the selected papers.24 who examine the tension between continuity and change and how they affect the resilience of socio-ecological systems to environmental changes in South Africa and Uzbekistan, adopt Folke’s9 definition of resilience as a system’s capacity to absorb disturbances, while learning from them and reorganizing. While resilience engineering is grounded on a machine-like view of systems, with simple cause and effect relationships, organizational resilience that is conceptualized as the ability of an organization to absorb, adapt, and transform in the face of challenges is grounded on the view of systems as complex and adaptive.50Across the selected papers, resilience was generally taken to mean a system’s ability to continue to perform and meet its objectives in the face of challenges. There is a general consensus around the notion that organizational resilience is achieved by a combination of absorbing the challenges faced, and changing by adapting and transforming so as to continue to thrive in the face of challenges. This is in contrast to the early notion of resilience as simply bouncing back from shock (resilience engineering). For instance, Herrfahrdt-Paehle and Pahl-Wostl,45 who explore the link between work engagement and the resilience of infrastructure organizations  to earthquakes in New Zealand, distinguish between two dimensions of resilience; planned resilience, and adaptive resilience. Organizations exhibit planned resilience when they employ pre-existing plans to avoid or minimize the effect of a crisis. These include business continuity and risk management plans that outline pre-disaster activities required to keep organizations running during and after a period of disruptions such as natural  and man-made disasters .45 Adaptive resilience emerges during the post-disaster  period as new capacities are developed by organizations by responding to emergent situations.34 Walker et al45 emphasize that while planned resilience is important, adaptive resilience is more influential since it is more sustainable and effective in the context of uncertainty about what the future could bring.Walker et al,31 insecurity,29 economic crisis,19 unspecified natural and/manmade disasters,46 and rapid policy reforms.35 Only 2 papers focused on the resilience of health systems to chronic, everyday challenges. Challenges are described as chronic if they persistent and recurrent over long periods of time. Lembani et al29 examined the resilience of the health system of South African provinces faced with chronic health system dysfunction and politicization. Felland et al21 examined the resilience of local healthcare safety nets to chronic economic pressures and budget cuts in the United States of America. Among the papers that examined resilience outside the health sector, there appears to be a focus on both acute shocks, such as earthquakes,45 environmental disasters,37 and other natural disasters,20 and multiple everyday challenges such as competition, financial difficulties, punitive laws, and climate change.24 It appears that the notion of resilience to chronic, everyday challenges has been embraced more by other sectors, compared to the health sector.A majority of the papers (9/12) that examined the resilience of health systems focused on acute, often catastrophic shocks to the system. Shocks are classified as acute if they are sudden in occurrence and transient in nature. These included disease outbreaks,39 When material resources are used strategically, organizations can overcome disruption. Financial resources are also considered necessary to mobilize other needed resources during crisis. For example, Pal et al39 observed that resource constraints, specifically material, ﬁnancial, and technological, impaired the resilience of small and middle enterprises to economic crisis in Sweden. McManus et al32 examined factors that influence the resilience of 10 case study organizations  to acute shocks  in New Zealand and found that an organizations’ financial position was a key ingredient to its resilience.The availability of resources is considered a key enabler of organizational resilience.32 For example, hospitals in the United Kingdom developed and tested business continuity and risk management plans to ensure the continued functioning of core services throughout natural (such as floods) and man-made (such as terrorist attacks) disasters.14 McManus et al32 found that the degree to which organizations planned for continued supply of essential goods and services in times of a crisis contributed to the resilience of 10 case study organizations  in New Zealand. One of the strategies used by organizations to prepare for crises or disasters is by going through scenario exercises (pseudo-crisis situations). Lapao et al27 observes that health systems in Lusophone African countries, faced with the uncertain future of a disease outbreak, should, among others, prioritize the training of health professionals to seriously prepare them through scenario drills.Resilience to acute shocks, rather than everyday challenges, is enhanced by adequate planning.44 For example, Ager et al15 found that the flow of information between the security services and state ministry of health strengthened health system resilience to the Boko Haram insurgency in Nigeria. Lapao et al27 found that a clear flow of information was necessary to allow a quick and correct response to the Ebola disease outbreak in Lusophone African countries. Information was seen as a key ingredient to how timely and adequately organizations adapted to challenges. According to Stephenson et al,44 knowledge management involves ensuring that strategies, organizational goals and achievements are effectively communicated across the organization. Further, organizations should proactively monitor what is happening in their environment. This could be achieved by activities such as evaluation of competitors, market research, and political and regulatory awareness.44 A key utility of effective information management and use was in enhancing the situation awareness of organizations. Situation awareness refers to an organization’s perception and understanding of its environment.33 Situation awareness is characterized by an increased understanding of the factors that trigger crisis, minimum operating requirements, availability of internal and external resources. Organizations can identify the early warning signals that precede a crisis by monitoring internal and external environments. Reflecting on the experience of the Ebola disease outbreak in Lusophone African countries, Lapao et al27 recommend the need for effective information and epidemiological surveillance systems that monitor and report on the status of the system and provide real time early warning of impending health threats.Organizational resilience is widely identified as being dependent on how information is managed and used.46 According to Lembani et al28 collateral pathways refer to the availability of alternative routes to achieve a desired goal. For instance, in Ivory Coast, the civil unrest following the disputed presidential election of 2010 disrupted healthcare service provision. The local health system achieved resilience by adopting a number of collateral pathways. For instance, non-physicians were allowed to prescribe medicines, and medicines were sourced externally through the United Nations (UN) system.28 In the United States, one of the strategies employed to improve the resilience of the health safety net programme, in the face of federal budget cuts, was to increase focus on insured patients in order to generate revenues that help cross-subsidize uncompensated care.21 Collateral pathways enhance resilience by providing for alternative courses of action; when a system experiences disruption or challenges on one pathway, an alternative pathway is utilized to achieve the same goal. This characteristic draws from the feature of systems as complex adaptive systems (CAS).51 Related to the notion of collateral pathways is redundancy. Redundancy is the inclusion of extra components or resources that are not strictly necessary to functioning, in case of failure in other components or resources. Sheffi and Rice41 examined the resilience of the transport sector to supply chain disruptions caused by acute manmade and natural shocks and found that organizations were more resilient when they kept additional resources in reserve (over and above the required levels) to be used in case of an emergency.Ensuring that organizations have multiple, alternative courses of action also bestows resilience.44 Governance is used here to mean the rules and processes that guide operations and affairs of organizations.52 A number of governance practices are identified as critical for organizational resilience. The first is decentralization; resilient organizations adopted a form of governance characterized by distributed control, rather than top down hierarchy, under central control.44 This allowed systems to be more responsive to changes in the environment by empowering local actors and provided the necessary flexibility that facilitated timely responses to everyday challenges and in times of crisis.44 For example, when the healthcare system in Ivory Coast was disrupted by civil war, the fact that drug management and distribution had been decentralized from the federal to the state level made it much easier to transport drugs to and from the local drug store whenever transport routes were secure.15 This allowed for reduced disruption of drug supply during the civil war. A shift from a centralized and top-down decision making system, to a decentralized system with bottom-up decision making that was characterized by local and regional initiatives was shown to contribute to the resilience of the California water management system to chronic economic, political, and environmental challenges in the United States of America.18 Another governance practice that distinguished resilient from non-resilient organizations was non-linear planning. For example, the federal and state laws required the California program of water management in the United States to plan in a linear, stepwise fashion; defining problems, identifying possible interventions, and refining them into implementable actions. This approach was linear in the sense that it did not allow for feedback loops between different stages  or the simultaneous considerations of problems and solutions. This approach was however found to compromise the resilience of the water management system to everyday environmental, economic, and political challenges, and was instead replaced by a non-linear approach that was evolving, open-ended, iterative, and characterized by feedback loops between stages, and learning by trial and error.18 Non-linear planning is compatible with CAS which are typically characterized by non-linear dynamics. Resilient organizations also practiced deliberative democracy, rather than representative democracy.44 Deliberative democracy differs from representative democracy in that deliberation, not mere voting, is the basis of decision making. Decision making by deliberative democratic principles empowered actors and built trust, motivation and commitment.44 Related to deliberative democracy, organizations that embraced transparency in their processes and decisions, especially during turbulent times were found to be more resilient.24 Another governance feature that influences the resilience of organizations to both acute and everyday challenges is the degree of coordination between different functions and parts of the organization.33 McKenzie et al31 examined the resilience of the Nigerian health system to a disease outbreak such as Ebola, and found that the fragmentation of the health sector, characterized by lack of coordination between the delivery of services, management of human resources, and health financing, was the most significant threat to resilience because it resulted in duplication of efforts, wastage and impaired coordination during crisis. McManus et al33 found that organizations (10 case study organizations drawn from varied sectors) whose functions and parts operated in an uncoordinated and “silo” fashion where less resilient to manmade and natural disasters, compared to organizations that had coordinated systems. Integrating delivery systems enhances coordination, effectiveness and efficiency as well as eliminating constraints, managerial uncertainty and wastage of resources.33Governance practices are also shown to influence the resilience of organizations to both acute and everyday challenges, in both health and other sectors.45 For example, Seville et al42 examined the resilience of road infrastructure organizations to earthquakes in New Zealand and found that while some organizations had comprehensive risk management and business continuity plans, resilience depended not only on how well these plans were applied, but also on the leadership capacity of the organizations. In South Africa, health facilities that had dedicated leaders were found to be more resilient to everyday challenges  compared to health facilities whose leaders were not dedicated.29 One of the important roles of leaders was creating a clear and shared vision.33 A shared vision provided a point of focus and stimulated agency among staff during challenges and crises. McManus et al32 found that leadership practices characterized by visibility, and availability contributed to the resilience of organizations to acute natural and manmade shocks in New Zealand. Leadership in resilient organizations was characterized by inclusive decision making.39 Leaders ensured that relevant stakeholders were included and contributed to decision making. This nurtured the resilience of organizations to both everyday challenges, and acute shocks by building trust, empowering, motivating and creating commitment among staff and other stakeholders. For example, Pal et al39 examined the resilience of textile firms in Sweden to economic crisis and found that firms that had transparent and inclusive leaders were more resilient compared to those that had less transparent, non-inclusive leaders. A distinction was also made between leadership practices that were not aligned to the complex adaptive nature of systems, and those that were aligned. Booher and Innes18 found that the resilience of water management organizations to everyday environmental, economic and political challenges was improved when managers exercised complex leadership: rather than being controlling and directive, the leaders were mediators and facilitators of the actions of organization actors, and influenced conditions to guide interactions.The importance of leadership practices to the resilience of organizations is a recurrent theme across the selected papers in both the health and other sectors, and for both acute, and everyday challenges.45 The ability of leaders and other staff to view challenges from an opportunistic perspective is important for resilience.45 Resilient organizations consider challenges as learning opportunities, and used these experiences to develop capabilities that improve their resilience.45 For example, Oluwasoye and Ugonna37 found that the resilience of multinational oil corporations to environmental disasters  in Nigeria was weakened by a tendency towards denial of problems and potential risks. They observe that improving the organisational resilience of these organizations will entail, among others, the willingness for organization’s leaders to own the problems and seek to learn from the experiences.37 Sawalha22 found that an organizational culture characterised by lack of organisational learning from past experiences weakened the resilience of insurance companies to everyday challenges  in Jordan. Second, resilient organizations support creativity and innovation.44 Mafabi et al30 examined the resilience of 51 public corporations in Uganda to unspecified acute shocks and observed that when organizations have a creative climate, staff are motivated to generate new ideas, which strengthen organisational resilience. Staff in organizations with a poor creative climate were guarded and closed, and reluctant to offer innovative and creative ideas because they would be disregarded. A creative climate is thought to be imperative for providing a conducive environment for organizational adaptation and transformation in the face of challenges.44 Resilient organizations nurtured creativity by providing time and resources for experimentation, rewarded innovation, tolerance for failure, and an atmosphere in which employees felt safe to share new ideas.44Two cultural practices are identified as key to organizational resilience. First is the organizations attitude towards everyday and acute challenges.45 For instance, Ager et al15 found that the resilience of the healthcare system in Yobe state, Nigeria, in the face of Boko Haram terrorism insurgency was enhanced by staff commitment and motivation, that was characterized by acceptance of challenging working shift arrangements and taking of additional responsibilities through informal task shifting. In Ivory Coast, the continuity of service delivery of the HIV program was made possible by the commitment and motivation of health workers, who continued to come to work despite delays in salaries, and security concerns.28 One ways of ensuring that staff are motivated and committed is prioritizing staff wellbeing.45 Walker et al45 found that the resilience of infrastructure organizations  to earthquakes in New Zealand was enhanced in those organizations where the wellbeing of staff was prioritized. This was achieved by creating a positive social environment where staff were free to express emotions and share information, providing staff with resources that were adequate to match their work demand, actively listening, monitoring, and addressing changing staff stresses, and flexibility around staff-needs.45 Employee engagement was reduced when managers lacked emotional intelligence. Macey and Schneider53 define work engagement as a fulfilling, positive, work-related state of mind that is characterized by dedication and vigor. In organizations that had a high level of employee engagement, staff dedication and commitment made them to focus on the needs of the organization despite the existence of a crisis.45All the selected papers recognize the important role that human resources play in the resilience of organizations to everyday challenges and acute shocks. Having an adequate number of human resources and the requisite skills was highlighted as a critical contributor to resilience. However, beyond numbers and skills, ensuring that staff are adequately motivated and fully committed to organizational goals was highlighted as more important.43 For example, during the civil war in Ivory Coast, the resilience of the HIV service delivery program was enhanced by the relationship between healthcare facilities that allowed them to share drugs with those running out of stock.28 The resilience of the California water management system to everyday environmental, economic, and political challenges was enhanced by the networked nature of its agencies and a culture of collaboration among them.18 Social networks offer avenues for increased mobilization and transfer of knowledge, dissemination of innovations, thus increasing the overall resilience of systems.54 Collaboration among organizations in a networked environment also expands resources that can be drawn on, ability to learn, and its capacity to respond.45 Andrew et al16 examined the resilience of public (government agencies), private  and non-governmental organizations (temples and community groups) to floods in Thailand and found that organizations that strategically collaborate with others are able to mobilize additional resources that are crucial for emergency response. The study found that organizations in urban and sub-urban areas were less resilient compared to those in rural areas because urban settings were more fragmented and hence had less social support and cohesion compared to rural ones, making them more vulnerable to disruptions.16How well organizations establish and leverage their networks determines the extent to which they are resilient to everyday challenges and acute shocks.56 CAS are characterized by self - organization and emergence.57 Self-organization occurs when system components mutually adjust their configurations in response to environmental signals.58 Self-organization of the system leads to emergence, the appearance of unpredictable outcomes such as new structures, and patterns of behaviour.59 Complex interactions between system components provide multiple paths for action and enable organizations to adapt to multiple environmental changes.57 The attributes of resilient organizations that we identified in this literature review, including the use of collateral pathways, governance practices that promote flexibility, nurturing of social networks and collaborations neatly map onto the view of resilience as an emergent property of CAS. Further, complex leadership practices that foster productive emergence rather than prescriptive control recognize the CAS nature of systems. Leaders who recognize complexity seek to forge connections and networks among system agents because they appreciate the value of social networks to organizational resilience.61 They seek to create organizational environments that incentivize the emergence of positive adaptations, rather than prescribe solutions.61 They see the system whole rather than as isolated components.61 Given that health systems are CAS, these attributes of CAS should be recognized and nurtured to promote the resilience of health systems.Drawing from our review, we make several observations that are relevant to nurturing the resilience of health systems. First, a recurrent theme across resilient literature is the recognition of systems and organizations as CAS. A CAS framework is predominantly used to understand and examine organizational resilience. This resonates with conceptual literature that views resilience as an emergent property of systems. CAS are composed of multiple interconnected components whose interaction is dynamic and non-linear.Second, empirical literature recognizes that resilience is both a function of planning for and preparing for future crisis (planned resilience), and adapting to change and disruptions (adaptive resilience). It is however recognized that planning alone is not sufficient, and that organizations must focus on developing a capacity to adapt to changing environments. While planning might help mitigate the effect of acute shocks to the health system, whether or not the health system is able to maintain core functions of delivering quality healthcare services in an efficient and equitable way also depends on how well it adjusts to the post crisis phase. Investing in structures and processes that promote the adaptive capacity of health systems is therefore important. Further, resilience to everyday challenges cannot be achieved by risk management and organizational continuity plans because such plans are often aimed at isolated events that are transient and have clear boundaries. Everyday challenges are unpredictable, multiple, and have fuzzy boundaries in the sense that they are interconnected in complex ways. To overcome these challenges, health systems will need to adapt in creative and innovative ways, and transform to new and improved forms of operations.62 In the same way that organizations outside the health sector recognize and strategize on how to nurture resilience to chronic, everyday challenges, health systems also need to focus on nurturing what Gilson et al62 call “everyday resilience.” This is crucial not only because everyday resilience has an inherent value, but also because it has an instrumental value in promoting the resilience of organizations to acute shocks.33 This can be explained by the finding from our review that everyday resilience, and resilience to acute shocks share attributes.Third, while the empirical literature from other sectors has embraced not only the notion of resilience to acute shocks, but also resilience to chronic or everyday challenges, it appears that the health sector is largely focused on acute shocks. This is perhaps understandable given that the resilience debate in the health sector has been inspired by the occurrence of acute shocks, most notably the 2014-2016 Ebola outbreak. However, general experience of health systems, especially in low- and middle-income countries, highlights the fact that health systems also face chronic everyday challenges such as dysfunctional policies, chronic underfunding, limited human resource capacity, and high levels of disease burden.A fourth lesson to draw from this literature review is that organizational software is at least, if not more, important than organisational hardware, in nurturing health system resilience. While the hardware of material resources are key ingredients for health system resilience, soft aspects of the system such as adequate planning, governance practices, leadership practices, organizational culture, staff motivation and commitment are much more important in and of themselves, and also in ensuring that the hardware is adequately mobilized for resilience. For instance, our review found that social networks and collaboration (system software) were crucial in mobilizing material resources (system hardware) that was necessary for resilience.To our knowledge, this is the first review of empirical studies that focuses on organizational resilience, and includes literature from the health sector. Understanding the attributes of resilient systems and strategies that can be employed to nurture resilience will be useful in informing global health efforts to strengthen health systems. Further studies should focus on testing the attributes identified by this review in the health sector, as well as identifying other factors that characterize resilient health systems. For the concept to offer insights that are useful in improving health systems performance, it is imperative that sufficient evidence about how organizations and systems experience, and deal with, both chronic stresses and acute shocks is generated. The concepts and principles that have dominated much of resilience literature will need to be tested in the real world of health systems. In such work, frameworks should be developed that focus not only on resilience to sudden shocks, but also resilience to everyday challenges. Moreover, methods that appreciate the CAS nature of systems, such as system dynamic modeling, should be applied and explored.Edwine Barasa, Rahab Mbau, and Lucy Gilson are members of the Consortium for Resilient and Responsive Health Systems (RESYST). This document is an output from a project funded by the UK Aid from the UK Department for International Development (DFID) for the benefit of developing countries. However, the views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them. Edwine W. Barasa is supported by a Wellcome Trust Training Fellowship (#107527). The funders had no role in the writing of this paper or in the decision to submit for publication. This work is published with the permission of the Director of KEMRI.Not applicable.Authors declare that they have no competing interests.EB and LG conceptualized the review; EB and RM conducted the literature search and selection. EB and RM conducted the data extraction. EB conducted the analysis, and synthesis. EB developed the first draft of the paper. All authors contributed to subsequent and final drafts.1Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya. 2Nuffield Department of Medicine, University of Oxford, Oxford, UK. 3School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. 4Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.


Entamoeba histolytica is the causative agent of amebiasis in humans and is responsible for 100,000 deaths annually, making it the third leading cause of death due to a protozoan parasite. Pathogenesis appears to result from the potent cytotoxic activity of the parasite, which kills host cells within minutes. Although the mechanism is unknown, it is well established to be contact-dependent. The life cycle of the parasite alternates with two forms: the resistant cyst and the invasive trophozoite. The adhesive interactions between the parasite and surface glycoconjugates of host cells, as well as those lining the epithelia, are determinants for invasion of human tissues, for its cytotoxic activity, and finally for the outcome of the disease. In this review we present an overview of the information available on the amebic lectins and adhesins that are responsible of those adhesive interactions and we also refer to their effect on the host immune response. Finally, we present some concluding remarks and perspectives in the field. Entamoeba histolytica is one of the most potent cytotoxic parasites known. Due to its ability to destroy human tissues, Schaudinn in 1903 coined the term histolytica. E. histolytica is the causal agent of amebiasis, which is primarily a disease of underdeveloped countries and is estimated to cause 100,000 deaths each year. According to the WHO, amebiasis is the third leading cause of death due to a parasitic disease  methionine-labeled trophozoites were separated from the culture medium (conditioned medium) by centrifugation and solubilized with octylglucoside. The detergent-solubilized amebas and conditioned medium were separately submitted to different affinity chromatography columns coupled to: galactose, Mab H8-5, and ASOR (the most potent inhibitor of amebic adherence), and the electrophoretic analysis showed that the eluted fraction of all three columns, treated with β-mercaptoethanol, consisted of a protein with a molecular weight of 170 kDa. In the case of the eluate of the ASOR column there were also some faint bands of 26 and 30 kDa. There were no differences between the lectin obtained from the solubilized trophozoites or the conditioned medium. By western blot the lectin was recognized by three monoclonal antibodies that inhibited the adherence of the ameba to the CHO cells [In 1986, Ravdin and collaborators [ in 1987  reportedet al. in 1998 [Giardia lamblia, due to the presence of CXXC and CXC sequences [Following its purification, a structural analysis was performed which revealed a glycosylated molecule with a molecular weight in non-reducing conditions of 260 kDa and a pI of 6.2 . The tre in 1998  and is a in 1998 , and itsequences . It is iet al. [2) and increased intracellular calcium levels are involved in this process; these findings clearly suggest the activation of a signaling pathway.The role of different domains of the H subunit in amebic adherence has been analyzed with the use of monoclonal antibodies raised against various antigenically and functionally distinct epitopes on the heavy subunit . The majet al.  have shoIn addition to its role in adherence, the Gal/GalNAc lectin has been implicated in amebic cytotoxicity to different target cells. This has been demonstrated with the apposition of amebic and target cell membranes which does not lead to cytotoxicity when the amebic lectin is inhibited with galactose  or N-acetylgalactosamine   or if th19BSA in a way inhibitable by NAcGal. However, Pillai et al. [The neutralization by monoclonal antibodies of different epitopes in the heavy subunit allowed the determination that all of them are found in the cysteine-rich region (amino acids 482–1138). The antibodies that blocked or increased the sugar-binding capacity were mapped between residues 428–818 , and thei et al.  found thE. histolytica through the hepatic parenchyma [On the other hand, using stable transfectants of the virulent strain in which the expression of the 35 kDa subunit was inhibited by antisense RNA it was shown that the absence of the L subunit strongly inhibited their cytopathic and cytotoxic activity as well as their ability to induce the formation of liver lesions in hamsters ,43. Thesrenchyma ,45.in vitro studies, demonstrating the transfer of the lectin from the surface of trophozoites to enterocytes and hepatocytes in culture [in vivo models such as experimental liver abscess in hamsters or intestinal amebiasis in mice [E. histolytica and found that it encodes only one rhomboid protein (termed EhROM1) with the residue requirements for proteolytic activity. EhROM1 displayed the atypical mode of substrate specificity, analogous to the rhomboid of Plasmodium falciparum (PfROM4), the specific substrate for EhROM1 resulted to be the Gal/GalNAc lectin, as demonstrated by cotransfection of EhROM1 and the heavy subunit of Gal/GalNAc in COS cells. In E. histolytica trophozoites, EhROM1 changed localization to vesicles during phagocytosis and to the posterior cap structure during surface receptor shedding, in both cases colocalizing with the Gal/GalNAc lectin. These findings implicate EhROM1 in immune evasion.The effects elicited by the Gal/GalNAc lectin in the adherence and citotoxicity of trophozoites are clearly a result of its surface localization. Nevertheless, several  culture  and othe in mice ,48 have  in mice  investiget al., who showed that the presence of sialic acid in colorectal mucins correlates with the susceptibility to E. histolytica infection in different mouse strains [In vitro, the Gal/GalNAc lectin has been shown to induce IL-2 and IFN-ɣ in T cells, eliciting a TH1 response [H1 cytokine production [The participation of this lectin in the adherence of trophozoites to mucin oligosaccharides  is a rel strains . Also, i strains ,53,54,55 strains . Also, i strains . In vitrresponse . The preresponse . Interesoduction .Braga and coworkers showed its implication in host evasion mechanisms in 1992  through E histolytica infection [E. histolytica, and has been tested in different experimental animal models of amebiasis [With respect to humoral immune response, it has been shown that IgG and IgA against the lectin can be detected in patients with amebiasis ,65,66. Onfection ,68,69,70mebiasis ,73,74,75E. histolytica molecules that have been specifically ascribed as adhesins or lectins; notwithstanding other molecules that have been implicated in the adhesion process. Although the precise mechanism of cytotoxicity has not been fully defined, it is well established that after adherence, host proteins become dephosphorylated and host intracellular calcium increases [So far we have restricted our review to those ncreases . Very rencreases . WhateveSeveral studies have suggested that the Gal/GalNAc lectin is capable of activating signal pathways as a result of contact, to this respect, only the group of Galván-Moroyoqui and Meza  clearly Something that draws attention is the fact that there are multiple genes encoding each of the three subunits of the Gal/GalNAc lectin complex; so that multiple combinations can be made to constitute de heterodimer in association to the intermediate subunit. Slight differences in the sequences of the subunits of the lectin complex embedded at the surface of the ameba may account for differences in some functions and might be responsible for virulence or avirulence and finally define the outcome of the disease. Biochemical studies of the Gal/GalNAc lectin complex are needed to understand how it works, and could be applied to other parasites and to other pathologies.


Neglecting occupational safety and health (OSH) can have adverse and even deadly consequences. While OSH is important in any nation, the issue is particularly concerning in developing countries, including ones in the Caribbean. The purpose of this study, which was carried out in 2012 and 2013, was to examine the reasons for an apparent fundamental lack of awareness of OSH in the Caribbean. We conducted a descriptive study, in which a questionnaire was administered, via telephone, to key policy-making representatives from six English-speaking Caribbean nations, in order to assess the current OSH environment in their countries. We also did a situational analysis of current OSH regulations and legislation within the six countries. We found that that some of the countries’ OSH laws are out of date or are limited to a certain type of industry. We also found that there is very little documentation on research on exposure to and risks from hazards and on psychological and reproductive health as related to OSH. It is recommended that these Caribbean countries both increase national OSH awareness and strengthen enforcement of OSH regulations. Additionally, further assistance and a more coordinated effort from intergovernmental bodies could help build and fortify OSH systems in the Caribbean. There is a direct link between occupational safety and health (OSH) issues and national security, the local economy, the environment, and overall health , 2. SincUnfortunately, the exact causes behind the neglect of OSH policies and laws remains largely unknown in developing countries, including in the Caribbean. There are an estimated 283 million workers in total in the countries of Latin America and the Caribbean (LAC). Occupational fatalities in LAC nations are significantly higher than in the United States of America, at 0.135 and 0.005 per 1 000 workers, respectively. Despite this high toll in the LAC nations, OSH issues receive little or no attention , as well as Caribbean academicians, health professionals, and politicians. These experts were recruited from professional networking meetings in the Caribbean and selected specifically because they are recognized experts within the field of occupational health and safety within the Caribbean. A survey was chosen instead of in-depth interviews because we wanted to gather more standardized data in order to make comparisons between countries.We also conducted a situational analysis of current OSH regulations and legislation within the six Caribbean countries in order to assess safety and health conditions, employer responsibilities, OSH governing bodies, and compliance and enforcement of laws. Those OSH regulations and legislation were collected from the CARIBLEX database of the International Labor Organization (ILO) and from the Caribbean countries’ official government websites. We also investigated which of the countries had ratified the ILO’s C155 - Occupational Safety and Health Convention, 1981 (No. 155), which provides a framework for a safety and health culture at work  have been working on integrating labor law in the Caribbean region and drafting a model labor law for occupational safety and health and the working environment . It is iOSH principles are highlighted in various ILO conventions and in recommendations adopted by the International Labour Conference. Besides C155, also particularly important is C161 - Occupational Health Services Convention, 1985 (No. 161) . RatifyiExcept for Grenada, which already ratified C155, the interviewees highlighted the importance of approving C155. However, no legitimate reason was given for not doing so. Policymakers may be reluctant to ratify such conventions because ratification might negatively affect international trade and labor relations (These six Caribbean countries need to strengthen OSH standards by instituting a better OSH framework, creating more effective regulations and laws, and coordinating more closely among ministries. These systems should also ensure that all government agencies are sharing information on OSH concerns. Improved communication on OSH issues among all governmental agencies is critical for developing better OSH administration systems.In addition, more effective collaboration with international agencies is needed , 33. TheMore training and education  is essenSome interviewees said that there are current efforts to educate the general public about OSH laws and guidelines by means of seminars and other forms of information dissemination. Such efforts can provide a basic understanding of laws, personal rights, and ways of preventing OSH risks, while also encouraging the reporting of incidents.We only interviewed officials in the six Caribbean English-speaking countries, so the findings are not generalizable to the entire Caribbean region. The findings are also subject to information bias. For instance, the accuracy of information provided by informants depends on their knowledge and interpretation of OSH standards.The authors attempted to minimize such bias by selecting informants who are experts in the OSH field. Additionally, the authors independently reviewed relevant OSH regulations and legislation for the six countries.The findings reflect the state of OSH regulations and legislation at the time this study was conducted. In retrospect, an investigation more tailored to the individual countries might produce a better response and understanding of the major challenges in the region. However, enough information was obtained from the questionnaire and situational assessment to gain a better grasp of the OSH regulations and legislation of each of the six English-speaking Caribbean countries.To our knowledge, this study is the first to investigate the seeming lack of OSH regulations and legislation in the Caribbean. The interviews added knowledge and gave a broad outlook on the OSH issues in the six Caribbean countries. In general, these nations have a complex OSH regulation problem that requires a holistic approach. The primary area of concern in regards to OSH regulations and legislation was inefficiency at the national level. Many legislators of the six countries were still unaware of the importance of OSH issues, and that OSH extends far beyond protecting employees in the workplace. In reality, OSH is a matter of national security, as OSH issues may affect the environment, the economy, and the overall health and well-being of the general population. Legislators and policymakers have to realize the importance of OSH and develop strong, effective legislation and regulations in order to produce sustainable solutions. It is essential that these countries tailor the legislation based on the unique aspects of their own needs and priorities.The authors thank all the persons who played a role in this research.None.RPSP/PAJPH or PAHO.Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the


Nurse prescribing of medicines is increasing worldwide, but there is limited research in Europe. The objective of this study was to analyse which countries in Europe have adopted laws on nurse prescribing.Cross-country comparative analysis of reforms on nurse prescribing, based on an expert survey (TaskShift2Nurses Survey) and an OECD study. Country experts provided country-specific information, which was complemented with the peer-reviewed and grey literature. The analysis was based on policy and thematic analyses.In Europe, as of 2019, a total of 13 countries have adopted laws on nurse prescribing, of which 12 apply nationwide ) and one regionally, to the Canton Vaud (Switzerland). Eight countries adopted laws since 2010. The extent of prescribing rights ranged from nearly all medicines within nurses’ specialisations  to a limited set of medicines . All countries have regulatory and minimum educational requirements in place to ensure patient safety; the majority require some form of physician oversight.The role of nurses has expanded in Europe over the last decade, as demonstrated by the adoption of new laws on prescribing rights. The right to prescribe medications has for long been reserved to the medical profession only. This situation has changed, with an increasing number of countries worldwide having introduced reforms to authorise nurses to prescribe certain medications –6. The UNurse prescribing refers to the official right granted to nurses to prescribe certain medications , 15. TheAn international survey in ten high-income countries  showed that the educational and legal conditions varied across countries . Among hIn Europe, the United Kingdom (UK) has a long experience with nurse prescribing , where tThe purpose of this study was to analyse which countries in Europe have introduced nurse prescribing reforms, the extent of prescribing and regulations in place. Covering all countries belonging to the EU’s single market is of relevance for its free movement principle across borders which also applies to health professionals. For the nursing profession, the first-level education as professional nurse is automatically recognised, yet no nurse specialisations are covered under the EU regulation , 31.The study was based on an expert survey to identify which countries in Europe have implemented reforms on nurse prescribing of medicines and, in those countries with reforms, an analysis of the extent of prescribing authority, regulatory and oversight requirements.An expert survey was conducted in 39 countries (TaskShift2Nurses Study) in 2015 covering all EU Member States and countries belonging to the EU’s single market, plus Australia, Canada, New Zealand and the US. A total of 93 country experts participated (response rate 85.3%). The sampling was based on two interrelated strategies: snowballing and network strategies to counteract the weaknesses associated with snowballing alone, which has been associated with selection bias or too homogeneous groups [Of those countries identified with reforms on nurse prescribing, an in-depth analysis of laws and policy documents was performed as part of an Organisation for Economic Cooperation and Development (OECD) study. Country experts were contacted in 2016 for the purpose of the OECD study on nurses in advanced roles of which prescribing of medicines was one example . A totalIn addition, a literature search was conducted with a search of the peer-reviewed  and grey literature . Search terms covered a set of terms combined with Boolean operators on nurses , prescribing (prescri*) and the names of the 28 EU countries plus Norway and Switzerland.The analysis was based on thematic analyses of the laws, policy documents and other grey material, focussing on the content of the laws, by-laws and the educational and regulatory requirements if stipulated in other legal documents. The analyses were structured according to the groups of nurses authorised to prescribe, by medicines used for the prevention or treatment of major conditions to assess the extent of prescribing, differentiating between initial prescribing (IP) and continued prescribing (CP) only. Finally, additional requirements were analysed by country and groups of nurses, including mandatory registration requirements (e.g. in a registry), levels of physician oversight and other oversight requirements. The analysis was performed by the author using standardised word tables based on the survey responses, complemented with information from the laws and legal documents and fed back to the country experts as part of the 2019 round where experts were requested to provide updates of the information or confirm that the information was up to date.As of 2019, 13 countries in Europe have laws on nurse prescribing in place, which apply nationwide in 12 countries  and in one region in Switzerland in the Canton Vaud  have authorised specific groups of nurses to prescribe certain medications. All have adopted laws to officially grant nurses prescribing rights, in some cases followed by the adoption of decrees to define under which conditions nurses are allowed prescribe, for what medications and the regulatory requirements.The countries vary considerably in the groups of nurses that are authorised to prescribe and their educational requirements: a first group consists of countries in which the prescribing skills and competencies are part of the nurses’ education, e.g. Master’s or Bachelor’s degrees or specific nurse specialisations. Hence, the prescribing skills and competencies are directly integrated in these curricula, e.g. ANP Master nurses in Cyprus, Nurse Specialists with APN degree in the Netherlands, Public Health Nurses in Norway, nurses with Master’s and Bachelor’s degree in Poland, family nurses in Estonia; and nurses with a Bachelor’s degree in Spain. Since courses on pharmacology and pharmacotherapy are routinely part of these curricula, it was only in a few cases possible to single out how many European Credit Transfer Systems (ECTS) points are allocated specifically on skills and competencies related to the prescribing of medicines. For instance, in Cyprus, the curriculum of APN Master-level nurses comprises advanced pharmacology and pharmacotherapy of approx. six ECTS. In Denmark, prescribing is taught as part of a 30 ECTS “cluster” on medical treatment and therapy. In the Netherlands, RNs with a specialisation in diabetes and RNs with a specialisation of lung care are required to have a minimum of 2.5 ECTS on prescribing in their curriculum .additional educational courses which lead to a title as nurse prescriber or similar. The countries are Finland, Ireland and the UK. The UK has introduced two models of prescribing, independent and supplementary prescribers. Ireland and Finland have established one role. Educational requirements vary, they range between typically 30 to 45 UK credits in the UK, 20 to 40 ECTS in Ireland and mandatory 45 ECTS in Finland. In 2019, the UK Nursing and Midwifery Council has published new standards for the post-registration programmes which apply since September 2019 [Second, some countries have set up a separate educational pathway specifically on nurse prescribing, hence, ber 2019 .France and the Swiss Canton Vaud are in the process of implementing the 2017 laws on nurse prescribing, pending the agreement of formularies and other minimum requirements as a prerequisite for nurses to officially being authorised to prescribe medicines.Table Three of the 13 countries have granted full or nearly full prescribing rights to a specific group of nurses. The countries are Ireland (nurse prescribers), the Netherlands  and the UK (independent nurse prescribers). These groups of nurses are by law allowed to prescribe any medicine within their specialty. In the UK and Ireland, the extent of prescribing was expanded gradually over time. In the UK, the law was changed in 2006 authorising independent prescribers full access to the British National Formulary granting the same prescribing rights as for physicians, and subsequently in 2012 to cover certain controlled drugs . In IrelIn the remainder countries, the extent of prescribing is limited, either in the number of medicines that nurses are by law allowed to prescribe or in the type of prescribing, allowing primarily or exclusively continued prescribing. In the Netherlands , Norway , Poland (Master level) and Sweden (Bachelor level), nurses are authorised to initially prescribe certain medicines from a limited set of medicines Table . In the A mix of initial and continued prescribing exists in Finland and Spain; it includes initial prescriptions of vaccines and contraceptives in Finland and Spain and follow-up medications for highly prevalent chronic and acute conditions. In Denmark (Bachelor), Estonia (family nurse), Poland (Bachelor) and the UK (supplementary prescribers), nurses are authorised to perform continued prescribing, according to patient management plans and in a delegated model.No information on the details of prescribing rights was identified for Cyprus, France and the Canton Vaud (Switzerland). In Cyprus, there is no information provided in the 2012 law on what medicines the Master APN nurses are allowed to prescribe. The law states that medicines from a list can be prescribed by nurses, but with no further information. In France and Vaud, due to the adoption of the laws in 2017, developments are ongoing to specify which medications nurses will be able to prescribe.All countries have defined regulatory requirements as a pre-condition for nurses to prescribe medications Table . The reaThis study shows that in Europe, certain groups of nurses are officially authorised to prescribe medications in 13 countries . The majority of the reforms have been introduced over the past decade. Since 2010 alone, eight of the 13 countries newly introduced nurse prescribing . Hence, nurse prescribing has been a recent development in several countries in Europe. The extent of prescribing rights varies considerably, with three countries  granting certain groups of nurses  almost full prescribing authority within their specialty. In the other countries, the number of medications is restricted, defined in a formulary or can be prescribed only after an initial prescription has been made by a physician. All countries have regulated the conditions under which nurses are allowed to prescribe; the majority require additional registration in the prescribing function, some form of physician oversight and other measures to ensure patient safety.The study faces several limitations. First, it has exclusively focused on nurse prescribing; however, some of the countries have also introduced prescribing for other non-medical professions, such as midwives or pharmacists. Second, while the article provides an overview of the groups of nurses and extent of prescribing rights, the exact types and doses of medicines were not covered in-depth and should be investigated in future research. Third, information on educational requirements for nurse prescribing was difficult to obtain, particularly for countries where nurse prescribing is integrated in basic or advanced educational programmes.The findings are largely consistent with previous research , 3, 4 anThe findings of this study show that there are high variations in the educational requirements, ranging from Bachelor level  to Master level degrees . There was no obvious link between the extent of prescribing rights and the length and level of training across the countries. In the three countries with almost full prescribing rights, educational requirements also varied. In the Netherlands, nurse specialists are required to hold a Master’s degree (120 ECTS) as a prerequisite to prescribe medicines. In Ireland and the UK, the competencies are taught in prescriber courses that are approved by the competent authorities, but the length varies and a Master’s degree is not required. There is a paucity of research linking the educational requirements with prescribing practices, the quality of prescribing and patient outcomes. While previous research has analysed the association of higher nurse education  with improved patient outcomes and mortality , 49, no The reforms introducing nurse prescribing in 13 countries span different health systems, educational systems and geographic locations across Europe, including predominantly social health insurance  and Beveridge models . The reasons of introducing these reforms and new laws have not been systematically investigated across countries. Previous research suggests several potential drivers, including increasing patient needs and volume, higher education of nurses, higher workloads among physicians, inefficient division of work and high costs, among others . Other rOne driver often referred to in Europe is the higher education of nurses in line with the Bologna cycle , 51, 52.In three of the 13 countries, the implementation of the laws is ongoing, pending the adoption of regulatory decrees and capacity building in education. France and the Canton Vaud have in common that the laws have been recently adopted in 2017. In Cyprus, the year of adoption was 2012. In Cyprus, there is no evidence of nurse prescribing officially taking place in practice, as no individual request has been made to authorise prescribing rights.The fact that to date 13 countries belonging to the EU’s single market grant certain groups of nurses prescribing rights demonstrates that further cross-country research is required from an EU perspective. Research should focus on commonalities and differences in prescribers’ education across Europe, country variations in prescribing practices as well as the extent of prescribing rights and outcomes on specific patient groups. Moreover, with the increase in health professional mobility across Europe, including nurses, a timely monitoring of nurses with prescribing rights is warranted as to avoid skills mismatches when moving borders –57.A total of 13 countries in Europe have laws on nurse prescribing in place, of which the majority adopted laws over the past decade, suggesting a recent trend expanding the roles of nurses in these countries. The extent of prescribing rights varies considerably, with three countries granting full prescribing rights, whereas the majority of countries have restricted prescribing rights, particularly those with recent reforms. From an EU perspective, future cross-country research is required to monitor the education, prescribing practices and mobility patterns of nurses with prescribing qualifications.


This study investigated to what extent multimodal data can be used to detect mistakes during Cardiopulmonary Resuscitation (CPR) training. We complemented the Laerdal QCPR ResusciAnne manikin with the Multimodal Tutor for CPR, a multi-sensor system consisting of a Microsoft Kinect for tracking body position and a Myo armband for collecting electromyogram information. We collected multimodal data from 11 medical students, each of them performing two sessions of two-minute chest compressions (CCs). We gathered in total 5254 CCs that were all labelled according to five performance indicators, corresponding to common CPR training mistakes. Three out of five indicators, CC rate, CC depth and CC release, were assessed automatically by the ReusciAnne manikin. The remaining two, related to arms and body position, were annotated manually by the research team. We trained five neural networks for classifying each of the five indicators. The results of the experiment show that multimodal data can provide accurate mistake detection as compared to the ResusciAnne manikin baseline. We also show that the Multimodal Tutor for CPR can detect additional CPR training mistakes such as the correct use of arms and body weight. Thus far, these mistakes were identified only by human instructors. Finally, to investigate user feedback in the future implementations of the Multimodal Tutor for CPR, we conducted a questionnaire to collect valuable feedback aspects of CPR training. Mastering practical skills is a requirement in several professions and working domains. For example, working in construction requires to learn how to use a circular saw; nursing requires learning how to draw blood samples from patients; and repairing clothes requires being able to sew. Practical skill training, also known as psychomotor learning, entails the acquisition of an apprenticeship learning model . TypicalThe shortfall of human feedback can be addressed with the employment of Intelligent Tutoring Systems (ITSs), automated computer programs designed to automatically detect learners mistakes and generate personalised adaptive feedback, without requiring the intervention of a human instructor. Although the concept of ITS dates back to decades ago , ITS inIn the past few years, the multimodal interaction approach has become increasingly popular also in the learning science and learning analytics research communities. This increase of popularity is witnessed by the rising interest in Multimodal Learning Analytics (MMLA) ,10. MMLAmultimodal tutoring systems in psychomotor learning scenarios. To do so, we selected cardiopulmonary resuscitation (CPR) training as representative learning task and developed an Intelligent Tutor for CPR using multimodal data . This study validated the mistake detection system of the Multimodal Tutor for CPR, a multi-sensor, intelligent tutoring system to train CPR using the ResusciAnne manikins.In this study, we built upon the approach proposed by the MMLA community and further investigated how it can be applied for automatic mistake detection, which, in turn, can be the base for automatic feedback generation for Validation). The second objective was to explore how the Multimodal Tutor for CPR could detect mistakes that are not tracked by the ResusciAnne and are typically only detected by human instructors .The first objective of this study was validating the Multimodal Tutor for CPR according to common performance indicators as implemented in the ResusciAnne manikin. Thus, we used the manikin data as baseline measurements to compare the accuracy of the Multimodal Tutor for CPR to broadly established measures .CPR is a highly relevant skill, which everyone should learn not only medical experts.Cardiopulmonary resuscitation (CPR) is a life-saving technique which is given to someone who is in cardiac arrest. CPR is useful in many emergencies, including a heart attack, near drowning or in the case of stopped heartbeat or breathing. In the present study, we selected CPR as a representative task for the following reasons:The cases of cardiopulmonary arrest are, unfortunately, widespread. The more people are trained to do CPR, the higher the chance of saving lives. For this reason, CPR is currently compulsory in several types of professions, and CPR training is becoming standard practice in several public settings such as schools or public workplaces.Among the criteria for proper CPR, some indicators, such as correct CC rate, CC depth or CC depth, are more common and tracked automatically by CPR training tools such as the ResusciAnne manikins. Other CPR performance indicators are neglected to down-scale the simulation environment. For this reason, they need to be corrected by human instructors. Examples of these indicators are the use of the body weight or the locking of the arms while doing the CCs. Commercial CPR manikins such as the ResusciAnne manikin do not report on these two indicators, which creates a feedback gap for the learner and higher responsibility for the course instructors.The intelligent tutoring system is a computer program working as “instructor in the box”, meaning that it can provide learners with direct and custom instruction or feedback, without requiring intervention from a human teacher. Traditional ITSs were mostly designed within desktop interfaces for academic education subjects such as geometry and algebra e.g., ,18), and, and18])In the medical field, some examples of ITS can be found in the literature. The Cardiac Tutor  is an ITOnly a few examples of ITS use multimodal interfaces. D’Mello et al.  enhancedmultimodal data, we refer to learner’s motoric movements, physiological responses, information of the learning context, environment and activity. Combining data from multiple modalities allows obtaining a more accurate representation of the learning process . Th. Th36]. Meaningful Learning Task introducing a new data format (MLT session file) for data storing and exchange. The MLT session comes as a compressed folder including: (1) one or multiple time-synchronised sensor recordings; amd (2) one video/audio of the recorded performance. The sensor recordings were serialised into JSON and have the following properties: an applicationId, an applicationName and a list of frames. The frames have a timestamp and a key-value dictionary of sensor attributes and their corresponding values. In the Multimodal Tutor for CPR, each two-minute CPR session was recorded into a separate MLT session file and stored locally. Each session was 17 Mb and contained initially two JSON files, one for the Myo, one for the Kinect and one MP4 file with the video recording. The example of Myo and Kinect is presented in table view in The LearningHub uses the concept of The CPR annotations were later synchronised with the sessions using the Visual Inspection Tool (VIT) . VIT allA screenshot of the VIT used for the Multimodal Tutor for CPR is given in The classification scheme used for the performance indicators summarised in The 22 annotated datasets were loaded into a Python script using Numpy and Pandas, two data manipulation libraries widely used for statistical analysis. These libraries allow the user to define custom data frames with custom time-indexes ideal for time-series and perform various kinds of vectorised operations. The Python script implemented the following routine. It created a list of all the available sessions, and then iterated and processed each session singularly. The results of the processing are stacked up into a single data frame.end with start. As the session implement relative timing, where The script processes first the annotation file, in order to have all the intervals  into a single data frame n elements, We proceeded to mask N is the number of intervals, S is the size chosen for the resampling, and Q is the number of attributes. The issue with this was that time series in Long Short Term Memory networks (LSTM) [For machine learning, we opted for using Keras, an open source neural network library written in Python. We used the Keras implementation of the s (LSTM) , a type classRate, classDepth, and classRelease. Then, we split the dataset in 66.6% training and 33.4% test using random shuffling of the training samples. Then, the data were fed into the LSTM neural network with two layers:LSTM input layer of size dense layer sized as unique values of the target class (either 2 or 3).We first scaled the tensor’s values in a range between 0 and 1. Then, the following sub-routine was applied three times for each target class In The dataset transformed into a tensor of shape The annotation data retrieved from the ResusciAnne manikin are summarised in classRate and classDepth, the target variables with three possible class-values, it is interesting to acknowledge that each participant shifted almost always in two classes out of three. Participants tended to make only one type of mistake for a particular target, or, in other words, either they were too fast or too slow, but not a combination of both. The performance of a single participant is therefore not representative for the full span of possible mistakes that may occur during training. A more even distribution of mistakes can only be achieved when collecting data from multiple participants.We report the individual performance of each participant in the three plots in classRate, this epoch is around the 24th iteration, for classDepth around the 19th, and for classRelease around the 2nd.In classRate, the binary class indicating if the CCs were executed at the right rate and speed, followed by classDepth, indicating the correct depth of the compression, and classRelease, indicating the correct release of the CC. To achieve better accuracy, lower loss function and less premature overfitting, we would need to have more training data.Nonetheless, in classRate is the best-classified target. A plausible explanation is that the depth-camera sensors, as well as the accelerometer embedded in the Myo, can track temporal-related features such as the acceleration in doing the compression. It is essential to point out that all three models shared the same set of 41 features, all CCs were re-sampled into eight bins and we did not take the actual duration of each CC as additional feature. The reason classRelease and classDepth do not perform as well as classRate could stem from the fact that the compression and the release are movements of few centimetres and the threshold of correctness is thin to measure, even for a human observer.With an accuracy of 86.5%, The confusion matrices in armsLocked) and failing to use entire body weight (bodyWeight), we used an additional dataset consisting of five sessions with one participant mimicking the two mistakes. The reason we opted for this solution was because all participants in the initial data collection showed very good CPR technique and did not commit these two types of errors.For the two additional CPR training mistakes of arms not correctly locked , then real-time visualisations, dashboards at the end and haptic vibrations or augmented reality visuals.Finally, we asked the participants to rate their CPR performance with a grade from 1 to 10. The results in With the results presented in Validation). With the approach described in RQ1 focused on the validation of the Multimodal Tutor for CPR and the collected multimodal data against the standardised ResusciAnne manikin measurements . We specifically focused on locked arms and body position mistakes to be detected by the Multimodal Tutor for CPR. To answer this question, we trained our model on additional CPR session where the two training mistakes, bodyWeight and armsLocked, were mimicked. We achieved an accuracy score of 93% for armsLocked and 97% for bodyWeight. Based on this high accuracy, we can answer RQ2 positively: the Multimodal Tutor for CPR was able to detect additional CPR training mistakes beyond the mistake detection of the standard ResusciAnne manikin. As with the previous research question, a limitation of our approach is that the set-up must remain unchanged.RQ2 focused on the classification of training mistakes that so far can only be detected by the human instructors and not by the ResusciAnne manikin  as well as for retrospective human feedback .With the MMLA Pipeline for collecting multimodal data from various sensors (see Among the findings to our research questions, we can also report that the sors see  and our


A traditional and ethical principle recognizes a country’s primary general welfare responsibility to the young and the old. However, the middle, adult, age group cannot and should not be disregarded. The current dental component of the National Health Insurance Law (NHIL), in Israel, only includes children and the elderly. The present commentary focuses on the large group of adults, age 19–74, which are currently excluded.The cumulative incidence of disease increases over the lifetime of a person. We believe that a NHIL commitment with a major age gap in coverage is unacceptable. The recent manuscript, published by Natapov et al., in this journal, has documented the overall dental health of the older Israeli population, with emphasis on nutritional aspects. This contribution to the literature is commendable. However, we aim to follow in the steps of the Alma Ata Declaration and Ottawa Charter of the World Health Organization (WHO) and to clarify that the government’s responsibility should cover all residents regardless of their age. In addition, a dental health epidemiological data base, currently nonexistent for adults, is called for. The National Health Insurance Law (NHIL) of 1995 [A recent addendum to the NHIL now includes 16–18 year olds, thus covering all children, ages 0–18. Elderly people, over 75 years of age, are now expected to be granted basic oral health care services in the near future.Representatives of the Israel Health Ministry  have published a manuscript describing the dental status, visits, functional ability and dietary intake of the elderly in Israel.  The artiThe World Health Organization (WHO) Alma Atta Declaration of 1978 describes the essential value of “Health for All” . The WHOWe do not challenge the special right of treating the young and the old. The vast majority of health and disease including oral health is a life course continuum. It commences and originates among the younger age groups. The elderly have unique needs, related often to low socio-economic status and prolonged chronic complications of pre-existing pathologies –7. We haOral diseases are chronic, debilitating, cumulative and increasingly severe with age . This esFor example, periodontal (gum) disease usually evolves after inferior oral hygiene and development of dental caries (cavities). It emanates from a sweet diet among other factors . Both ofThe epidemiological literature has clearly demonstrated a strong association between dental and general health . This inOriginally, the Israeli NHIL was based upon the principle of health for all, but it did not include any dental health component until 2010. Then, the addition focused on younger age groups, and not on the entire population .Unfortunately, a large-scale survey focusing on middle aged adults’ dental status and needs has never been conducted in Israel. This reflects the inadequate attention to the adult age group, concerning dental health.While the early age groups can be regarded as of paramount importance, ages 18–75 years, the ages that account for the majority of the population, cannot be ignored. This middle age group contributes the major work and financial contribution to the strength, stability and growth of the economy. Younger adults, experiencing inferior dental care, often due to problems of high costs and inaccessibility, very likely will be faced with complications of edentulousness . This, in turn, will place an even heavier weight on the health care system.The bulk of dental care is delivered to adults. This includes a significant price tab that includes issues of work hours lost, adequate supply of dentists, hygienists and dental technicians, and a significant influence on quality of life.An obvious question is what the price tag of our proposal would be. In any location, governments are faced with a budget priority dilemma. Israel is a small country with a wide range of national security and welfare needs. The government shareholders are obligated to justify each and every extra cost.The present commentary has not calculated the extra cost of covering middle aged dental needs. Although in the past, changes in the dental health package have been based solely on political and social considerations, since we believe that it is important to provide dental coverage and care to the entire adult population, we also believe it is important to evaluate the implications, including economic implications, of doing so and would urge the government with its responsibility for the overall health of the population to do this.The basic rationale and philosophy of the Israeli NHIL does not mention any age limitations. Dentistry has always been the exception to the rule, however the present age gap from 19 to 74 cannot be justified on a scientific, epidemiologic, health, or ethical basis.