The WHO and UNICEF recommend home visits to improve health outcomes for mothers and newborns. We evaluated the effect of home visits by community volunteers during pregnancy and postpartum on breast-feeding practices, women’s knowledge about benefits, beliefs and myths of breast-feeding, obstetric and neonatal warning signs, preparation for childbirth and initial care for newborns, and diarrhoea and respiratory diseases in children.Community quasi-experimental design. We estimated difference-in-difference models with fixed effects at the community level weighted by propensity score and investigated implementation barriers through focus groups and semi-structured interviews.Poor rural communities in Mexico; 48 intervention and 29 control.Baseline and follow-up information were reported from two independent cross-sectional samples of women with babies aged between 6 and 18 months .v. control group but were not statistically significant.The intervention increased reports of exclusive breast-feeding in the first 6 months by 24·4 percentage points (pp) , mothers’ knowledge of obstetric warning signs by 23·4 pp  and neonatal warning signs by 26·2 pp  compared to the control group. A non-linear dose–response relation with the number of home visits was found. Diarrhoea and respiratory diseases among children decreased in the intervention Home visits should be implemented as a complementary strategy to the provision of prenatal and postnatal care in rural communities due to their potential positive effects on the health of mothers and their children. In Mexico, between 1990 and 2018, the neonatal mortality rate declined from 22 to 8 deaths per 1000 live births, being higher in entities with a higher level of marginalisation. The main causes of neonatal deaths are due to diseases or difficulties in pregnancy, childbirth or the first month after birth, while poor breast-feeding practices explain 27 % of infant deaths in the country. According to the National Health and Nutrition Survey (ENSANUT), the prevalence of exclusive breast-feeding among children less than 6 months doubled from 14·4 % in 2012 to 28·6 % in 2018 nationally and from 18·5 to 37·4 % in rural dwellings. However, these figures are still below the WHO recommendations, the Global Nutrition Targets 2025 and the recommendations of the National Academy of Medicine and expert groups in Mexico.Worldwide, about 2·4 million newborn babies died during the first month of life in 2019, over a third of neonatal deaths occurred in the first day and three-quarters of deaths occurred in the first week after birth, 47·9 % of pregnant women in rural areas do not receive adequate prenatal care. This includes receiving a medical consultation during the first trimester of pregnancy, four or more consultations during pregnancy and at least seven of the eight recommended procedures during medical consultations according to Mexican official guidelines.Although receiving antenatal care during pregnancy reduces the risk of neonatal mortality in low- and middle-income countries, increase coverage of care, and improve breast-feeding practices and the ability of mothers to identify early warning signs in their newborn, increasing their probability of survival–17. The WHO and UNICEF recommend that home visits should be made to mothers during pregnancy and the postpartum period in order to improve health outcomes for mothers and newborns. Community health workers are associated with improved health among the most vulnerable population in Mexico, but there is little empirical evidence about their importance as health promotion agents, so documentation and evaluation of their actions is necessary to support scale-up.It has been estimated that home visits by community health workers that are complementary to postnatal care in health facilities could prevent between 30 % and 60 % of child deaths in high-mortality settings, which was implemented in poor rural communities in Mexico as a pilot study of home visits by community volunteers (CV) during pregnancy and the first week after postpartum.Therefore, the objective of this study was to estimate the effect of the intervention ‘Caring for the Newborn and the Mother at Home’We used a cluster quasi-experimental design with an intervention and control group at the community level and studied two independent cross-sectional samples of women with children between 6 and 18 months. We evaluated the reported breast-feeding practices, recognition of warning signs and symptoms for the newborn and the mother during pregnancy and the first week after birth, knowledge about the benefits, beliefs and myths of breast-feeding, preparation for childbirth and initial care newborns should receive, and reporting diarrhoea and respiratory diseases in children. Also, qualitative research was employed to investigate possible implementation barriers of the intervention through focus groups with CV conducting home visits and semi-structured interviews with field work supervisors and doctors., and being located within 2 h of the municipal head. Similarly, 29 control communities in three municipalities  were selected for their similar proximity and sociodemographic characteristics to the intervention communities. The number of communities in the intervention and control groups were selected to reach a sample size of 300 women. Fewer control communities were necessary to achieve the same sample size since these communities had, on average, more inhabitants.The intervention ‘Caring for the Newborn and the Mother at Home’ was implemented by the UNICEF and World Vision, a non-profit organisation, from October 2016 to November 2017 in 48 communities in 4 municipalities  located in the Sierra de Zongolica, a mountainous region in the central zone of the State of Veracruz. These communities were selected by World Vision and the Social Security Mexican Institute (IMSS) for being indigenous, having higher than average rates of maternal and neonatal morbidity, having a dispersed population, high and very high levels of marginalisation. As part of standard care in these communities, women and children received medical attention in the Rural Medical Units (UMR by its Spanish acronym) and Rural Hospitals from IMSS-PROSPERA, where the CV usually identify and refer pregnant and postpartum women and their newborns to the UMR, follow up on their prenatal care, and carry out some home visits to identify risk factors.All intervention and control communities were part of the ‘PROSPERA’ Social Inclusion Program, which consisted of cash transfers to poor woman conditional to children attending school, health visits for women and their children, and bimonthly health, nutrition and hygiene counselling for women. Since in Mexico many women do not return immediately to their homes after delivery, the intervention was modified and consisted of two home visits to pregnant women and three home visits in the first week after delivery, regardless of their place of birth . Also, there were two additional home visits for babies with low birth weight and those who had been referred to a UMR due to illness.The WHO/UNICEF original intervention recommends two home visits during pregnancy and three home visits during postpartum; one visit at the day of birth, one visit at the third day and the last visit at the seventh day, and two additional visits for low birth weight babies and the intervention has been implemented and validated in other countries,23. All materials were translated into Spanish and some messages were adapted to the Mexican context and validated through the practices carried out by the CV during training. Topics promoted during home visits by CV are described in Fig. The original materials were developed by the WHO/UNICEF for personnel trainingThe home visits were made by 31 CV, mostly women that were health volunteers belonging to the IMSS-PROSPERA programme. Doctors from the UMR selected CV who were outstanding for their commitment and provided a list of those who would participate in the training. A doctor in the UMR was also trained to follow up on the project implementation, so the CV would consider training as an official topic. The training was provided by the UNICEF, World Vision and IMSS-PROSPERA in two workshops of 5 d each and three reinforcement workshops. After training, CV were invited to implement the intervention in their local UMR and in the areas where the UMR provides coverage. Health personnel of the UMR detected pregnant women in the communities of study and refer them to the CV. World Vision supervised the implementation of the study and the number of home visits realised by each CV, and during the project’s implementation there was an exchange of experiences with field supervisors, to reinforce concepts and clarify doubts.In addition to being volunteers in this study, the CV participated in the IMSS-PROSPERA programme or supported health centres in their localities in other activities, such as supporting preventive health talks, identifying women and children for the application of vaccines, and inviting and following up women for their monthly appointments, for which they did receive a symbolic payment, usually $26 dollars bimonthly, but was not part of this study’s intervention.The study has a cluster quasi-experimental with a repeated cross-sectional design, since outcomes were not measured on the same women and children before and after the intervention. Two independent cross-sectional samples of women with children between 6 and 18 months of age at baseline and follow-up in the study communities were assessed. Because the outcomes of interest  could not be measured in the same dyad at baseline and follow-up (at baseline the baby had not been born), the sample of dyads were different in both rounds, although there could be some women surveyed at baseline who had been pregnant and included in the follow-up sample.Exposure to home visits during pregnancy and postpartum was analysed by intention to treat, which implied that women who lived in the intervention communities were analysed as part of the intervention group and women in control communities as part of the control group.Eleven interviewers from the Superior Technological Institute of Zongolica, all Nahua speakers, were trained in a 5-d workshop held by the supervisors and the research team. The survey questionnaire was pretested by interviewers during the training before being applied. Women were surveyed face to face and interviewers filled out the survey with the responses. Most of the interviews were conducted in UMR, but the remoteness of some communities to their health centre caused some women not to attend and interviews had to be rescheduled at their home or in public places.Baseline information was collected from August to December 2016 in control and intervention communities, from all mothers with children between 6 and 18 months of age that agreed to participate. Home visits were implemented from October 2016 to November 2017 with pregnant women living in the intervention communities. After 1 year of implementation and a waiting period of 6 months for children in the follow-up sample to be the same age as the children in the baseline round, information was collected between May and June 2018 in control and intervention communities. At follow-up, a baby that was born at the beginning of the intervention was 18 months old, while a baby born at the end of the intervention period was 6 months old.To gather additional data, in order to investigate possible barriers to the proper implementation of the intervention, two focus groups were set up, each consisting of six CV in charge of conducting the home visits. Also, three semi-structured interviews were conducted with field work supervisors and the IMSS-PROSPERA doctors.. Mothers were asked if they ever breastfed their child, did early breast-feeding, and the duration  of any type of breast-feeding, if the child was still being breastfed and if the child received any liquid or solid food  before 6 months of age. These liquids and foods are included in the ENSANUT questionnaire to assess breast-feeding practices in Mexico.Due to the study design, breast-feeding practices in the first 6 months of life were assessed by recall and not by status quo from the previous day, considering the number of children that breastfed during the first 6 months and did not receive any other liquid or food before this age. Predominant breast-feeding was constructed similarly, considering if the child received breast milk along with any other non-nutritive liquids such as water or tea.The indicator of exclusive breast-feeding was constructed as recommended by WHOIn addition, information was collected on the women’s knowledge of obstetric and neonatal warning signs in the postpartum period, knowledge about the benefits and myths of breast-feeding and preparation for childbirth, and knowledge about the initial care newborns should receive. Also, we collected information on reports of diarrhoea and respiratory disease in children in the last 2 weeks. A description of indicators is presented in Table .A total sample size of 300 dyads in each group would have enabled us to estimate, with a statistical power of 80 %, a minimum detectable difference between treatment groups of 8·7 percentage points (pp) in the report of breast-feeding practices, and between 7·4–12·3 pp in the mother’s knowledge of warning signs, beliefs and myths about breast-feeding and initial care of the newbornWe estimated proportions for categorical variables, and means and standard deviations for continuous variables for the main characteristics at the community, household and individual level in baseline and follow-up rounds, for both intervention and control groups. adjusted for individual characteristics (child’s sex and age and mother’s age), household characteristics , community characteristics  and each outcome of interest at baseline.We assessed the probability (propensity score) for each woman of being in the intervention communities through a probit modelThe analysed outcome variables were (a) breast-feeding practices, (b) knowledge about benefits, beliefs and myths of breast-feeding, (c) knowledge of the warning signs of the mother and the newborn in the postpartum period, (d) knowledge about preparation for childbirth and the initial care for newborns and (e) diarrhoea and respiratory infections in children Table ..We estimated the effect of the intervention on the outcomes through a difference-in-difference model, which compared the difference between follow-up and baseline outcomes in the intervention communities with the difference between follow-up and baseline outcomes in the control communities, using a linear regression with fixed effects at the community level, and weighted by the inverse of the propensity score, and further adjusted for individual, household and community characteristics described aboveAdditionally, we performed a dose–response sensitivity analysis to assess the association between the reported number of home visits during prenatal and postpartum period  and main outcomes.P-value < 0·05. All statistical analyses were performed in Stata software version 14·2.For all models, we estimated the average marginal effects and reported the intervention effect as percentage point (pp) difference in the outcomes of interest, between intervention and control groups. Differences were statistically significant when . The analysis was made from the transcripts through speech coding and the categories of analysis focused on the intervention experience, the quality of the intervention, barriers and facilitators for the development of the strategy’s activities, needs of CV and suggestions for programme improvement. No specific programme was used for the analysis.Regarding the qualitative analysis, the interviews and focus groups were carried out by two previously trained experts. The results were transcribed and their content analysed by an expert in qualitative analysis, using a phenomenology description of the CV’s discourseA1).We collected information from 1198 women with children 6–18 months of age  and analysed information of 1171 dyads with complete information on variables of interest .In the control group, a higher proportion of communities had a very high marginalisation index in comparison to the intervention group, and there were differences at the individual and household level between groups, both at baseline and follow-up Table . After wThe percentage of women in the intervention group that reported at least one home visit by CV during pregnancy increased from 31·9 % in baseline to 73·9 % in follow-up, while in the control group, home visits (standard care) increased from 23·7 to 29·3 %. Women in the intervention group that reported at least one visit during postpartum increased from 18·2 to 66·3 %, very similar to the 67 % reported of supervisors, while in the control group home visits (standard care) increased from 14·8 to 18·4 % in the same period. No home visits were referred by 22 % of women in the intervention group, which could be explained due to some barriers in the implementation, described later in this section.The prevalence of exclusive breast-feeding reported for the first 6 months of life increased by 24·4 pp  and the prevalence of predominant breast-feeding reported increased by 20·6 pp  in the intervention v. the control group (p < 0·001) . The percentage of women that mentioned at least one benefit of breast-feeding decreased in the control group (Table A1). In addition, the percentage of women who thought that babies under 6 months should be fed with ‘atole, broths, jelly, soup, fruits and vegetables’ fell in the intervention group compared to the control group (P < 0·001) .The knowledge about the benefits of breast-feeding increased 6·7 pp  in the intervention up Table . The belP < 0·001) (Table P < 0·001)  compared to the control group  and did not change after the intervention (results not shown). The intervention had a positive effect on women’s knowledge about hygiene measures in the newborn, such as hand washing ‘after changing the diaper’, but this difference was due to a higher reduction in control group Table .A3). Concerning the knowledge about where to go in case of emergency after childbirth, the percentage of women that reported the ‘health center’ or the ‘hospital’ was not different between groups .We found a positive non-linear dose–response association between the number of home visits and the prevalence of exclusive breast-feeding in the first 6 months of life Fig.  and knowP < 0·001)  .There was no effect on exclusive breast-feeding in the first 6 months of life among women that reported zero, one and two home visits, but receiving between three and seven home visits increased the prevalence of exclusive breast-feeding at diminishing returns, compared to the control group (01) Fig. . Also, rThe CV felt very satisfied with the intervention. The main perceived benefits were in the orientation and personalised support provided to pregnant women, mainly first-time mothers and teenage mothers. They acknowledged the value of the training they received, as they were not aware of many of the recommendations to prevent maternal mortality and, more importantly, neonatal mortality.The CV mentioned that, in the UMR, the information that the women receive is very limited and they clearly recognised that the suggestions for maternal and neonatal care are explained in more detail during the home visits. Most of the visits lasted more than an hour, reflecting the care taken by the volunteers not only to offer information but to empathise with the beneficiaries and their families. Mention was made of the need to offer more support and attention to women who were single mothers, since they often lacked the approval and support of their relatives.Another of the contributions identified was that the pregnant women learned to plan activities around the upcoming childbirth. The contribution of the orientation was particularly noted in terms of savings, identifying a vehicle for getting to the hospital in advance and identifying a shelter where mothers would stay before giving birth in the company of a family member.In the opinion of the volunteers, other contributions of the programme focus on the creation of links with other localities, their residents and families who were given support during the pregnancy. At the beginning of the programme, the CV felt afraid or embarrassed to initiate the visits, so they began by visiting pregnant women who were relatives or close friends. Subsequently, this fear disappeared and they visited the women who were assigned to them with greater confidence. Several CV reported remaining in contact with the participants and visiting the children from time to time, at the request of the mothers themselves.There were very special cases where the CV accompanied the women to the hospital, even during the moment of delivery. They helped facilitate the relationship in the hospital, with nurses and doctors. Cases were reported of breast-feeding and health complications. The volunteers themselves solved a number of problems by giving advice on breast-feeding, essentially in cases of low milk supply, or problems with the nipples. They taught postures for breast-feeding the child, massages to stimulate the milk supply and rubbing the nipple to help the babies suck properly. Women were also taught to use a breast pump in specific cases (breast pumps were not provided as part of the intervention).With regard to the material used, they highlighted the great support provided by the manual and the way it was structured through stories. Through the questions and reflection on the cases read, it was possible to make the best recommendations, especially to women who do not know how to read or write. The cards were used to identify the stage of pregnancy in order to tailor the recommendations to the stage.With regard to the self-evaluation of their work, the CV said that they were not very satisfied since they did not manage to make all the planned visits. No one evaluated their work as 10 out of 10, since they acknowledge not having been fully involved in their work, although they acknowledge having done everything possible.Lack of accurate information about the date of birth of the children, with the purpose of making the postpartum visits at the right time (caused by the lack of communication with nurses and the families of the beneficiary women).Rainy weather, although this did not stop them making their visits, unless the roads were blocked or the river overflowing.Failing to attend to their own households in order to provide attention to others, which involves a lot of organisation in order not to abandon their own families.Perception that work in the most remote localities puts their safety and women’s health at risk (due to the difficulty of access).Presence of dangerous animals in certain locations (dogs or jaguars).Hunger, given that they did not have time to eat on the days they made home visits, until they arrived at their homes at night (they report having gone hungry).Workload: they preferred to make as many visits as possible in a single day so as not to have to leave their homes so many days each week.Criticism: they were criticised by other women in their communities for accepting several positions at the same time and for ‘walking around’ (paying little attention to their own homes).Several volunteers decided to continue accompanying pregnant women and supplying them with information from the programme, but only those who lived in their own community. This suggests that women living in very remote areas did not receive the same orientation and support from the programme.Barriers identified to fulfilling their job were the following:Provide blood pressure monitors.Provide monetary support for transportation, especially for activities that require visits to another community.Look for more people who want to volunteer and not fill too many programmes with the same volunteers from one community.Some recommendations that the CV offer for future interventions:We find that the intervention ‘Caring for the Newborn and the Mother at Home’ had a positive effect that was highly significant in reports of exclusive and predominant breast-feeding in the first 6 months of the baby’s life. It was also effective at increasing knowledge about the benefits of breast-feeding, the knowledge of obstetric and neonatal warning signs, the hygienic care of the newborn and preparation for the birth. Also, we found a dose–response relation at decreasing rates between the number of home visits, breast-feeding and knowledge of warning signs. The results suggest that the intervention has the potential to reduce the prevalence of diarrhoea and respiratory illness in children, although it was not statistically significant – all of which are mechanisms that have the potential to reduce maternal and neonatal mortality. that has been used in other similar studies and evaluations of health and nutrition interventions at the community level,30,31. Furthermore, differences between groups were reduced through weighting by a propensity score which increases the validity of the estimations.The cluster quasi-experimental design with intervention at the community level and repeated cross-sectional independent samples of women and their children is a valid impact evaluation design, has proven to be an effective intervention to improve breast-feeding practices in the long term,17,33,34. It also reduces diarrhoea incidence among infants, supporting the results found in this study.Meanwhile, breast-feeding counselling, an activity very similar to that carried out in these home visits, which includes the community support step of the Baby-friendly Hospital Initiative. In countries with high child mortality rates, home visits increase key practices such as early initiation of breast-feeding, exclusive breast-feeding, skin-to-skin contact, delaying the first bath, and hygienic practices such as washing hands with soap and water and healing the umbilical cord in hygienic conditions,13–17. Also, home visits have shown to be effective in reducing neonatal mortality due to sepsis, hypothermia and neonatal mortality.There is evidence that training community health workers for providing a continuum of care to pregnant women and newborn improves survival among these groups, which explains one of the biological mechanisms through which the intervention could reduce the prevalence of diarrhoea and respiratory illness among children.Likewise, there is evidence that exclusive breast-feeding for the first 6 months of life reduces the risk of infectious diseases in children, as well as the risk of death in children in the first year of lifeHowever, there are some limitations of the study. Since we analysed two independent cross sections of women, any differences in unmeasured characteristics that could be associated with the analysed outcomes could bias the results. Although we reduced differences between comparison groups using a propensity score technique to balance observed characteristics at the individual, household and community level, any difference in non-measured characteristics such as women’s ethnicity, education level, civil status, number of children, type of delivery and employment status that have been associated with breast-feeding practices in Mexico could bias the results. However, the probability that this occurred is minimal, since these women share cultural and sociodemographic characteristics., which could underestimate breast-feeding indicators due to memory bias. However, we expect that the recall bias was not differential between groups. Moreover, baseline prevalence of breast-feeding in the studied communities was similar to those estimated by ENSANUT, which used status quo indicators.Also, we measured breast-feeding practices by recall and not by status quo as recommended by WHO. While the possibility that differences between women in control group could remain, the deterioration effect was not seen on all analysed outcomes, so the results could suggest that the intervention preserved knowledge from deterioration over time.Some outcomes deteriorated between baseline and follow-up in the control group, principally those related to knowledge of newborn and obstetric warning signs. Deterioration of antenatal care knowledge among pregnant women after an intervention was implemented is also reported in another trial,40. It is possible that mothers have reported better practices because they knew – due to the home visits – that they should do so and not because of the positive effect of the intervention. However, it is likely that this effect does not fully explain the positive results on breast-feeding, given that there were other outcomes that did not produce positive reports, such as early initiation of breast-feeding.The design of the intervention does not make it possible to fully exclude the findings due to the Hawthorne effect.Besides, we could not estimate the effect of the intervention on maternal and neonatal mortality, since a very large sample size was required. Instead, we reported positive effects on breast-feeding practices and the knowledge of warning signs in newborns and mothers, which have the potential to reduce neonatal mortality. Providing information to mothers empowers them to make better health decisions, as previously documented with indigenous women in MexicoLikewise, the implementation had some limitations. The CV carried out the home visits in adverse conditions due to the terrain, the climate and the dispersion of the homes in the communities under study. These factors caused difficulties, since the CV not only visited their own community but neighbouring communities as well, which involved transport costs, though these may be diminished as more volunteers are trained, eliminating the need to travel longer distances.Another clear limitation, and one to be considered in future planning sessions, is that there are places like the studied communities where mothers go to stay in special shelters immediately before and/or after giving birth, which prevented the full implementation of the intervention immediately after birth. The fact that the CV did not have a system for identifying the expected date of birth of the baby made it difficult to locate the mothers in time..Although it was a pilot study, one-fifth of women in the intervention group did not receive any home visit due to the implementation barriers already mentioned. However, almost all women received one visit during pregnancy, two thirds received at least one postpartum visit and 59 % received the expected number of visits which makes the findings plausible. This evaluation shows the effectiveness of the intervention in real conditions, so its potential effect may be greater if implementation and coverage are improved. Many home visit programmes around the world face this challenge, which must be addressed to reach the most vulnerable populationWe recommended (1) to scale up the intervention and increase coverage in communities with high poverty levels, in which a similar effect would be expected in the indicators under analysis, (2) to estimate the cost and effectiveness of the intervention if a public health institution performs all the training and implementation to determine the viability of their scale, (3) to implement home visits only in the CV’s community of residence to reduce time and transport costs and (4) to analyse the feasibility of granting economic support to the CV, so that they can cover their transportation and food expenses.. As part of the recent transformation of the health system in Mexico, priority will be given to community prevention, so home visits must be an essential intervention that can be granted as part the new Health Institute for Wellbeing (INSABI), that recently replaced Seguro Popular, whose objective is to provide free medical services to the population without social security.Since the PROSPERA programme and its health component no longer exists in the country, the most vulnerable populations are at risk of not receiving primary health care services. Home visits during pregnancy and postpartum could be a way to reach pregnant women and children in highly marginalised rural areas to ensure they receive prenatal care in health facilities. ‘Caring for the Newborn and the Mother at Home’ should be implemented by health institutions that have trained and managed community health workers, such as the IMSS-Bienestar programme, which is part of the Mexican Social Security Institution and provides health services to people living in marginal rural and urban areasThe impact evaluation shows a positive effect of home visits during pregnancy and postpartum on women’s knowledge of obstetric and neonatal warning signs and in reports of exclusive and predominant breast-feeding in the first 6 months of life. These are mechanisms that have the potential to reduce neonatal mortality. Home visits should continue to be implemented as a complementary strategy to the provision of postnatal care in marginalised communities due to their potential positive effects on the health of mothers and their children.


Patient-centered care is particularly important for patients undergoing fertility treatment because of their emotional involvement and their constant contact with providers. To the best of our knowledge, to date, there have been no rigorous studies of the discrepancies between the patients’ perceptions of the care they received and the providers’ perceptions of the care that they provided, in specific dimensions and elements of patient-centered care.To compare provider and patient perceptions of the extent to which care in Israeli IVF units is patient-centered.A previously validated survey instrument was used to assess the patient and provider perceptions of ten dimensions of patient-centered care: accessibility of providers, provision of information and of explanations, communication skills of providers, patient involvement in the treatment, respect for patient values and needs, continuity and transition in treatment, professional competence, care organization, physical comfort, and emotional support. The patient survey and the provider survey were conducted in 2016–2017; both surveys were carried out in 8 of 25 hospital-based IVF units in Israel. Seventy-six providers and 524 patients (response rate 79%) participated in the surveys.The perceptions of patients and providers were similar regarding seven of the ten dimensions of patient-centered care, although there were some differences in patient vs. provider scores by unit. There were three dimensions with substantial provider-patient score differences: Moderate-sized gaps were found relative to the provision of information and explanations  and respect for patient values and needs (1.92 vs. 2.47). A large gap was observed relative to emotional support (0.96 vs. 2.54).Providers appear to underestimate the needs of fertility treatment patients for information, respect, and emotional support. The observed differences between what patients feel about their care and what providers assume they provide, especially regarding emotional support, indicates a need for ongoing, specific feedback to providers as to the patient-centeredness of the care they provide. The particularly large patient – provider gap relative to the provision of emotional support highlights the importance of increasing the attention paid to the psychological impact of fertility treatment and of giving patients an opportunity to consult a counselor who is familiar with problems associated with fertility treatments.Efforts to improve the patient-centeredness in FT should begin by establishing a national ongoing feedback mechanism, involving all 25 IVF units operating in Israel working in collaboration with the Ministry of Health. The findings from this joint effort should be shared with the public. In addition, we recommended appointing one professional in each IVF unit to be in charge of promoting improvements in the patient-centered care for that unit. Assigning a mental health professional  to each and every IVF unit is also of crucial importance. Fertility treatment (FT) necessitates constant contact for patients with providers and carries a heavy psychological and physical burden , 2. We tPCC is especially important in Israel, where the prevalence of IVF treatments is the highest in the world, and the success rate (as measured in live birth per treatment) is lower than in other advanced countries . This maPatient-centered care (PCC) refers to patient - provider relations that are characterized by partnership, respect and provider’s responsiveness to the patient’s preferences, needs and values . There iProviders and patients might agree as to the importance of PCC in general , but theSpecifically with regard to FT, providers appeared to underestimate the importance of PCC for patient satisfaction , 24, 25,It is not yet known what patients’ and the providers’ perceptions of PCC in Israel are, either for FT, or in general. It is also not known whether there are discrepancies in perceptions between Israeli providers and patients. More importantly, to the best of our knowledge, to date, there have been no rigorous studies of the discrepancies between the patients’ perceptions of the care they received and the providers’ perceptions of the care that they provide, in specific dimensions of patient-centered care and the even more specific elements comprising each dimension.The purpose of the current study was to compare provider and patient perceptions of the provision of PCC in IVF units in Israel. The specific objectives were: (a) To examine patient assessment of specific dimensions of the FT experience and compare between the dimensions; (b) To examine providers assessments of those dimensions and compare between the dimensions; (c) To assess whether, and to what extent, there are gaps between FT patients and their providers in their perceptions of the provision of specific dimensions of PCC and the even more specific elements comprising each dimension.This study was part of a broader multicenter study that was conducted using a mixed method approach, in-depth interviews with directors of IVF units and surveys of FT patients and providers, which included, in addition to PCC, other important concepts for FT patients, such as quality of life and wellbeing related to FT (forthcoming). For the purpose of the current paper we will focus on the quantitative data alone and will emphasize the differences in perceptions between FT patients and their providers.The study was conducted in eight of the 25 hospital-based IVF units in Israel. We selected IVF units to reflect the diversity in their characteristics: location , magnitude (less or more than 500 treatment cycles conducted each year), and ownership . The 25 hospital-based IVF units were sorted into the five types of units that exist in Israel, where the definition of these types emerged from combinations of these characteristics. For each type, where there was a choice to be made among several units, we picked the study units randomly. Within the public hospitals, we made sure to include, government, health plan and independent hospitals. Among the for-profit hospitals, the choice of study unit was simple, as only one of the four IVF unit managers agreed to participate in the study. It is worth mentioning that the units in the public and the for-profit hospitals differ in some relevant characteristics, such as the prolonged relationship that the patients in the for-profit hospitals have with their own physicians, starting with visits in their office, followed with the procedures conducted in the hospital, vs. the relationships that the patients in the public hospitals have with the unit’s team. Having said that, it is important to note that patients in public hospitals will often be treated by the same physician, due to the small number of physicians working in the unit.Data were collected after obtaining required ethical approvals. The study received approval from the Ethics Committee of both The Myers-JDC-Brookdale Institute and Tel-Aviv University. Furthermore, since the research was carried out in IVF units located in hospitals, after obtaining the consent of all IVF unit managers, approvals were received from the Ethics Committee of each of the eight hospitals involved. FT Patients received an explanation of the research and signed an informed consent form.The patient study population consisted of all patients who visited any of the participating IVF units during the one-year data collection period, which began in October 2016. Since a random sampling method from patient lists was not possible, due to the reluctance of the managers of the participating IVF units to reveal the list of patients who receive treatment in their unit. Therefore, a two-stage sampling method was used: unit selection, as was described above, and quota sampling in each unit, during a random day visits, up to a minimum of 50 participants in each unit. The number of questionnaires collected varied across the units, due to the long length of time required for filling out the questionnaire and the desire to give every patient the opportunity to complete the questionnaire. Therefore, we distributed questionnaires to all women present in the units on the days chosen for the study, counting the completed questionnaires only at the end of the day, while making sure the minimum quota was met.Patients were recruited at the participating IVF units. The research team visited each unit on an average of six times until the minimum quota per unit was recruited. The provider study population consisted of all physicians, nurses and other professionals working in those units during the study period. Providers responded to the questionnaire during visits of the research team in the IVF unit, mostly during staff meetings, or through emails, with a minimum chance of hearing or seeing the other providers’ responses.The study sample consisted of 524 FT patients and 76 providers who responded to the questionnaires. The providers sample included 22 physicians, 20 nurses, 18 administrators, 11 laboratory workers, 2 technicians, 2 auxiliary staff and a social worker. The inclusion criteria for the patient survey was being a non-pregnant woman undergoing FT in one of the participating IVF unit. We did not include spouses to avoid a possible bias from marital differences, and pregnant women to avoid a possible bias from a successful treatment. Inclusion of IVF treatments only (while excluding other fertility treatments such as ovarian stimulation or intrauterine insemination) was settled on to minimize as much as possible differences between the various types of treatments.and who were approached by the study team . The main reasons for patient refusal to participate in the study were: lack of time, emotional state, language problems, spouse’s refusal, and fear of exposure.The patients’ survey achieved high response rate of 79%, which ranged between 71% and 86%, in the different units. See Table Table We used a Hebrew version of the Patient-Centeredness Questionnaire (PCQ) – Infertility that was developed in the Netherlands by van Empel and her colleagues , combineThe study tool included 52 questions about 10 various dimensions of the FT experience: accessibility of providers; provision of information and explanations; communication skills of providers; involvement of patient in treatment; respect of the patient’s values and needs; continuity and transition in treatment; professional competence; care organization; physical comfort; and emotional support. Table FT patients were asked to evaluate on a 0–3 scale their experience on each of the 10 dimensions. Providers were asked, on a corresponding questionnaire adapted to providers, to score on the same scale the degree of their agreement with various descriptions of the treatment given in their unit.The dependent variables were: providers’ and patients’ scores in the various dimensions of PCC and the gaps  between those scores. No gap  indicated an agreement between providers and FT patients in regard to the extent to which the dimension of interest characterized care in the IVF unit. A gap meant that there was a difference between the patients’ and providers’ perception of the provision of the dimension of interest, regardless to the question of who’s score was higher.The patient survey and the provider survey data were analyzed quantitatively using IBM SPSS Statistics Version 24. The analysis included the calculation of scores given by FT patients and by the providers in the various dimensions of PCC, and the gaps between average FT patient scores and average provider scores. The gaps were calculated in absolute value. We then calculated these scores and gaps per participating unit. The data were weighted to reflect the differences in the number of treatment cycles conducted annually at each unit.FT patients indicated they felt that not all dimensions of PCC were implemented to the same extent, as can be reflected by the different scores that they gave to the 10 various PCC dimensions  and in the scores for the various dimensions of PCC , and the organization of the treatment, they had low assessments of the providers’ performance in providing them with the emotional support they felt they needed.Although one might hypothesize that patients’ experience in regard to PCC in FT would differ between countries, it seems that our findings regarding Israeli FT patients are consistent with those reported regarding FT patients in other countries , 30. In The second main finding was that providers underestimate FT patients’ need for certain dimensions of PCC, as can be reflected in the gaps between the FT patients and providers scores in these three PCC dimensions: information and explanations, respect for values and needs and emotional support. Most importantly, these gaps indicate a disagreement between FT patients and providers regarding the degree to which these dimensions were implemented. Clearly, FT patients’ perception of the care they received, on the one hand, and the providers’ perception of the care that they provide, on the other, do not always conjoin in fundamental dimensions of PCC.The third principal finding was that there were substantial differences among IVF units in their scores on the various dimensions of PCC. The healthcare system in Israel, including FT, is required to adhere to all standards regarding patient experience and PCC, including, for example, addressing patients’ emotional needs, and patients’ involvement in care . Given tThe last main finding was the prominent patient-provider gap concerning emotional support. Not only did FT patients give emotional support the lowest score among the various PCC dimension, while providers scored it the highest, but of all dimensions, emotional support captured the largest gap between patients and providers in all IVF units. One possible explanation might be that providers assume they manage to fulfill their patients’ need for certain dimensions of PCC, while their patients do not feel so. Another possible explanation might be that providers do not necessarily think it is part of their duty to address patients’ emotional needs. In a study examining attitudes of physicians in fertility clinics in 15 countries regarding the emotional needs of their patients, less than half (45%) thought that being able to address the emotional needs of patients was necessary, and 72% reported needing improvement in their ability to identify the needs of patients for emotional support . MoreoveIn FT and other medical fields as well, it seems that providers fail in recognizing the emotional needs of their patients. In a study on cancer patients’ emotional distress, the oncologists recognized the presence of severe distress in only about a third of the severely distressed patients, and the oncologists’ recommendations for supportive counselling did not correlate with patient distress . Indeed,The observed differences and gaps between what FT patients feel about their care and what providers assume they provide, particularly the gap in emotional support, requires special attention and identifies the need for specific feedback for providers regarding how their professional performance meets the needs of FT patients. Attempts at improving PCC begin by giving appropriate feedback to providers  and gainAccordingly, in the current study each unit participating was presented with a personal feedback report, containing the scores of the patient in that specific unit on the 10 dimensions of PCC, and a comparison to the other units. Thus, providers and unit managers could examine the scores on each dimension and each element, and see the focal points required for change, and what should be preserved in their practice, in order to improve the PCC of the patient being treated in their unit.In line with the above, the four elements comprising the emotional support dimension, that should be addressed are: being informed about the psychological impact of treatment; giving the opportunity to consult a counselor who is familiar with problems connected with treatment; receiving information on support group for FT patients; and ensuring that a partner and/or family members are given an information brochure. It is important to examine which effective interventions can be developed in order to improve the PCC in fertility treatment, since even extensive interventions involving providers in fertility clinics , or tailThis study has several limitations. First, the data collected in the current study are limited to women treated in one of the eight sampled units, out of 25 IVF units currently operating in Israel. As mentioned above, a random sampling method from patient lists was not possible, for reasons of reluctance on the part of the managers of the participating IVF units to reveal the list of patients receiving treatment in their unit. Therefore, a two-stage sampling method was used: unit selection and quota sampling in each unit. For these reasons, it is possible that the women who participated in the study did not represent all women undergoing FT in Israel.However, the units were sampled so that they reflected the diversity in their characteristics , and it can be presumed, with due caution, that the women participated in the current study represent the variety of the characteristics of the women undergoing FT in Israel, for example in terms of their religion, their country of birth and their place of residence. In order to delve into specific socio-cultural differences in PCC perceptions, further research is needed, with a greater representation of women from minority groups in Israel.Furthermore, the current study design, which included data collection from each patient at one time point, did not allow causality relationships to be examined. Longitudinal research could lead to better understanding of cause and effect relationships in the context of PCC of women undergoing FT. However, the findings from the current study are valuable and might serve as fundament for future research. Subsequent studies will benefit from approaching all units operating in Israel, in terms of deepening the understanding of the differences between IVF units.Providers appear to underestimate FT patients’ needs for information, respect, and emotional support. The observed differences between what patients feel about the care and what providers assume they provide, especially regarding emotional support, indicates a need for ongoing, specific feedback to providers regarding the patient-centeredness of the care they provide. The particularly large patient-provider gap regarding the provision of emotional support highlights the importance of increasing the attention given to the psychological impact of fertility treatment and of giving patients an opportunity to consult a counselor who is familiar with problems associated with fertility treatments.Fertility problems significantly reduce the quality of life and increase anxiety and depression levels. Patient-centeredness is associated with patient wellbeing, quality of life and reduced distress. In order to help patients get through fertility treatments with reasonable wellbeing, we see it as the duty of health care providers, to improve the patient-centeredness of the care that they provide. Our recommendations hereafter concentrate on the “what, how and who” that should be considered in order to do so.It is essential, but not sufficient, to increase attention to the importance of the patient-centeredness and the patient-provider gap regarding this issue, and the current study has already increased attention to this. It is also important to assist providers and unit managers in receiving ongoing feedback regarding the extent to which their professional performance meets the needs of their patients.The current study’s scope covered only eight participating units out of the 25 IVF units operating in Israel, and data were collected at only one point in time. We recommend disseminating the current research tool nationally, to all IVF units operating in Israel and guiding the providers and unit managers about conducting an ongoing patient survey. This could be done through a collaboration of the Ministry of Health’s program for monitoring the IVF units, and the corresponding authors. Sharing the individual units’ scores, preferably by the providers themselves, with the general public, might help patients in the process of making an informed decision about the unit where they will receive treatment. This might be done via the hospitals’ internet site, or other online platforms.In order to improve the patient-centeredness we recommended appointing a professional in each unit who, as part of his or her job in the unit, will be responsible for promoting improvements in patient-centered care in the unit. This appointee should see it as his or her mission to bring the patient-centeredness perspective to bear on all processes and procedures being done in the units, e.g. distributing guidance pamphlets to patients and allocating designated spaces in the unit in case of renovations. It is important for the unit manager to support this activity and that professional guidelines will be developed by existing hospital resources units, such as the hospital social service unit. This appointee might also be responsible for the ongoing feedback process and for presenting the findings at the national level, especially in relevant professional conferences, such as the Annual Conference of the Israel Fertility Association (IFA). It might be beneficial to place in this position a professional who is part of the clinical team, in order to enable the other providers to identify with and internalize the importance of patient-centeredness.It is also very important that a mental health professional  be assigned to each and every IVF unit, as part of the unit’s permanent staff. Presently, the majority of units in Israel do not have a mental health professional assigned to them on a permanent, full-time basis. As a result, they usually involve a mental health professional only in urgent times, when acute aid is needed. This structural feature of the units makes it very difficult to give the patients the emotional support they need.The required mental health professional position should be responsible for initial intake for each new patient, and for giving emotional treatment within the unit. His or her presence in the unit should be prominent and significant, including participation in meetings or professional discussions in the unit, such as daily professional staff meetings regarding treatment outcomes. The mental health professional can also support the patient-centeredness’ appointee, and initiate and organize professional seminars on relevant issues. It is important to note that a mental health professional who is an integral part of the FT team, can also support the providers themselves, giving them the support they need to continue caring for their patients and reducing burnout.


The COVID-19 pandemic and its public health control measures have led to worldwide interruptions in healthcare service delivery, and cancer services are no exception. These interruptions have exacerbated the effects of previously reported barriers to accessing cancer care which was reportedly low even before the pandemic. If these effects are not mitigated, the achievements in cancer control that had already been made could be watered down. Measuring the impact of COVID-19 pandemic control measures on delivery of and access to cancer services in Uganda as well as other countries worldwide can inform the design of current and future responses to epidemics while putting into context other diseases like cancer that have a high burden. Worldwide, Coronavirus Disease 2019 (COVID-19) (SARS-CoV-2) cases have increased rapidly since the first case was reported in December 2019 in Wuhan City, Hubei Province, China . EstimatThe cancer burden is rising in Uganda; according to the 2018 GLOBOCAN estimates, over 32,617 new cases and 21,829 death related to cancer were estimated to have been registered in Uganda in 2018. The most common cancers among women are cervical cancer and breast cancer, with incidences of 50.2 and 31.2 per 100,000 of the population, respectively. Prostate cancer is the most common cancer among men, with an incidence of 58 per 100,000 of the population. Kaposi Sarcoma, lung cancer, and liver cancer also contribute to the burden of cancer in this population . Among cThe COVID-19 lockdown measures implemented in Uganda are based on WHO-issued guidance and include the use of restrictive physical distancing to limit the spread of the virus. In this paper, we focus on restrictions of public and private transport, restriction on income-generating activities, observance of person-to-person physical distancing of 2-4 meters, and observance of a daily curfew because they could influence the delivery of and access to cancer care services . To adheCancer care services are already underutilized even before the COVID-19 pandemic as seen in the literature and this has been attributed to various barriers. The underutilization and delay to seek for cancer care services have been attributed to barriers to access of cancer care services  such as a limited number health facilities offering cancer care services, long distances to healthcare facilities, transport costs, treatment costs and a limited number of cancer care providers. These barriers affect the utilization of cancer care services with the degree of utilization varying by cancer type. For example, a study done in two districts in Eastern Uganda in 2016 found that only 4.8% of women had ever screened for cervical cancer .Cancer care service delivery has been disrupted during the pandemic and effects are likely to vary per country. In Uganda, the suspension of the screening services and outreach programs has disrupted the efforts from sensitization campaigns on screening to treatment services, and it poses a big threat to the early detection of cancer cases. Therefore, we anticipate an increase in the proportion of patients who present with advanced stages of cancer in the period after lifting the COVID-19 pandemic lockdown measures that restrict access to cancer care services. The difference in days between oncologist appointments and treatment schedules requires that patients move between their homes and the cancer care centers. Considering the current lockdown measures, like limitations in public transport, the barrier to transportation to cancer care facilities has been exacerbated. The cost of public transport has almost doubled for most of the routes plied by public transport companies, in a bid to cover the cost of the reduced carrying capacity of their vehicles. This increases the financial burden of seeking care for cancer patients. The restrictions on economic activities have rendered the proportion of the people impoverished, and they are unable to meet the costs involved in seeking care. These dynamics on utilization and access to care can lead to an observation of a decrease in the numbers of detected cases of cancer during the COVID-19 pandemic period and an increase in cases detected during the period when lockdown measures affectting access to cancer services are fully lifted. Also, there can be variation in the proportion of individuals who present with advanced-stage cancer during pre, during, and post-COVID-19 pandemic era. Furthermore, there can be an increase in loss to follow up of patients after a diagnosis of cancer, poor adherence to treatment schedules, delays in access to cancer care after a diagnosis , and increased mortality and reduced survival rates of patients. To understand how the COVID-19 pandemic measures in Uganda have impacted on the utilization and access to cancer care services, data collected by cancer registries can be used to quantify the effect.Population-based cancer registries like the Kampala Cancer Registry are vital public health tools that can inform strategies for cancer control in a population and can be utilized to measure the impact of the COVID-19 pandemic on cancer care delivery and access in a population. Even before the COVID-19 pandemic, cancer registry data been providing information on cancer incidence, stage at diagnosis, and cancer survival and mortality for a given population that they serve.COVID-19 control measures are going to affect the delivery of and reduce access to cancer care services in Uganda. These measures can exacerbate the effects of previously reported barriers to delivery of and access to cancer care services such as the limited number of health facilities offering cancer care services, long distances to healthcare facilities, transport costs, treatment costs, and a limited number of cancer care service providers. These can widen the gap to access cancer care services in Uganda. Also, there can be a reduction in the number of new cancer cases registered in the population-based cancer registries. There is a need to synthesize data collected by cancer registries to measure the impact of COVID-19 control measures on delivery of and access to cancer care services in Uganda to inform the current and future response to epidemics while putting into context other diseases like cancer that have a high burden. There is a need to explore innovative strategies that can ensure continued delivery of cancer care services while observing COVID-19 pandemic control measures to avoid watering down the achievements that had been made in cancer control and other health concerns in Uganda.


Family interventions in schizophrenia are evidence based and have been adapted to different cultural settings to improve their effectiveness and acceptability. The Arab world has a unique set of socio-cultural norms and values that cannot be ignored when developing or implementing such interventions. There is a lack of research on the feasibility of delivering family interventions for schizophrenia in the Arab region. The aim of this review is to synthesise the available evidence about culturally-adapted psychosocial family interventions in the Arab world. The review identifies the content and characteristics of these interventions, determines the strategies used to adapt them to Arab culture successfully, assesses the feasibility and acceptability of the interventions, and evaluates the effectiveness of these interventions for service users and their families.Five electronic databases were searched including MEDLINE, CINAHL, Cochrane Library, PsycINFO and EMBASE for articles written in Arabic and English from inception to August 2019. Data were extracted and synthesised narratively.Six studies were retrieved from the search: three randomised control studies, two non-randomised studies and one qualitative study. There is limited evidence about culturally-adapted family interventions in the Arab region. However, the cultural adaptation process was comprehensive, and the implementation was reported to be feasible and acceptable. The methodological quality of the included studies was generally poor, so there is a risk of underestimating the effect size of the interventions due to lack of rigour and the presence of bias.The present review provides the foundation for future work regarding family interventions in the Arab world, and confirms the feasibility of implementing such interventions with some modifications. Furthermore, the data suggests that any family-oriented intervention for schizophrenia is likely to be better than standard care in improving the outcome for patients and their families. Family interventions have been recognised as evidence-based practice and are recommended by national and international clinical guidelines –3. AlthoFamily interventions have consistently shown positive outcomes for individuals living with schizophrenia and their families –11. HoweRecently, researchers have shown an increased interest in culturally adapting family interventions to different cultures to improve the acceptability and effectiveness of the treatment , 18–23. The Arab region consists of 22 countries that share a common language, cultural traditions and history. Arab culture, including religion and tradition, plays a vital role in the political, social, and economic life of the region . One impIn addition to Arab familial nuances, the Arab World has its own distinctive socio-cultural beliefs about mental illness, which heavily influence their help-seeking behaviours. First, Arabs associate the symptoms of mental illness with religious and cultural beliefs. They often believe that the cause of mental illness is due to evil spirits, demons, black magic or even as a result of God’s punishment . As a reThere are many practical barriers to mental healthcare in Arab countries, such as literacy rates, lack of resources and trained healthcare providers . In addiDespite the promising positive effect of family intervention in Western countries, this type of intervention has not yet been incorporated into the treatment for patients with psychotic disorders in the Arab world. To date, little is known about culturally-adapted family interventions for schizophrenia within Arab culture, making it challenging to design and test such interventions. In order to develop effective family interventions, the successes and failures of previous service-user and caregiver experiences require further exploration.Finally, the purpose of this review, which is part of a larger study, is to synthesise the available evidence regarding culturally-adapted psychosocial family interventions in the Arab world. It will identify the content and characteristics of these interventions, determine the strategies used to successfully adapt these to Arab culture, assess the feasibility and acceptability of the interventions, and evaluate the effectiveness of culturally-adapted interventions for service users and their families.https://www.crd.york.ac.uk/prospero/A mixed-method systematic review following the Preferred Reporting Items for Systematic Review and Meta-analysis was conducted . The proFive electronic databases were searched including MEDLINE, CINAHL, Cochrane Library, PsycINFO and EMBASE for articles written in Arabic and English from inception to August 2019. The databases were searched using the keywords and their associated Medical Subject Heading (MESH) “schizophrenia or psychosis” AND “Arab or Bahrain or Egypt or Iraq or Jordan or Kuwait or Lebanon or Libya or Morocco or Oman or Palestine or Qatar or Saudi Arabia or Sudan or Syria or Tunisia or United Arab Emirates UAE or Yemen”. When the key terms of “family intervention or psychosocial intervention or psychoeducation” were added, it limited the number of results to only 5–8 studies. As there is no specific database that covers Arabic mental health journals, these were searched individually by finding the list of the journals from Google and by contacting researchers in the related field from different countries. Furthermore, reference lists of previous related systematic reviews and Arabic studies were hand searched to identify any additional relevant studies. An example of the search strategy for a PsycINFO is available in the supplementary material.Articles were included if they met the following inclusion criteria: 1) all study designs that evaluated or developed any type or format of culturally-adapted psychosocial family interventions in the Arab world. The interventions could be relevant psychoeducation, family therapy, counselling, communication and problem-solving skills training or CBT. 2) Participants who were relatives or family members caring for an individual with schizophrenia or related disorders. 3) The majority of carers (70% or above) were adults of 18 years or older, and the majority (70% or above) of people who had schizophrenia or related disorders based on ICD-10criteria. Articles were excluded if 1) The intervention did not include family members or caregivers 3) Languages were not Arabic or English.www.covidence.org), an online software product that improves the efficiency of creating and maintaining systematic reviews. Based on predetermined inclusion and exclusion criteria, the team members independently undertook the initial screening of titles and abstracts. Two team members (A.S. and L.R.), independently screened the full texts of selected abstracts. A. S is a PhD student and L. R is a lecturer with a PhD. They both went through proper training and have experience in conducting and appraising systematic reviews. Areas of disagreement were resolved by consensus or by K. L, who is a professor and an expert in the field.The results were exported to Covidence  is consistent with good quality studies according to the JBI tool . The stuInterventions in the six studies were delivered in Egypt  and JordTwo studies reported the process of adaptation and modification of the original manuals. Hasan et al. (2014) used the framework of Atkinson and Coia, which covers Bloom’s Taxonomy of Learning Domains, while Rami et al.  used theFirst, the psychoeducation components included signs, symptoms, aetiology, diagnosis, treatment, as well as relapse signs and management strategies for schizophrenia. Additionally, it included facts and myths about schizophrenia, and how these effect the persons’ thoughts, emotions, and behaviour. The treatment component included information about medication, its side effects, anticipated benefits of the medicine, non-pharmacological treatment, adherence to treatment, the importance of follow-up, and information regarding prognosis. Furthermore, leaflets were distributed to participants during sessions that had information regarding schizophrenia, high expressed emotion families, notes and homework assignments for problem solving, and communication skills training . Second,The strategies for adaptation included different themes, but the common themes in all studies were language, context and delivery, and family. Language adaptation was reported in all studies; the content was modified and translated into simple Arabic, and the complexity of psychoeducation was simplified. The context and delivery adaptation were reported in most studies, as researchers delivered the intervention in individual therapy sessions instead of groups to facilitate the cultural context of Arabs. All studies acknowledged the important role of the family and its distinct structure and processes.Rami et al. (2018) was the only study which reported a detailed process of cultural adaptation. They piloted the intervention before the actual study to assess the acceptability and linguistic accessibility, and they modified the intervention accordingly. Moreover, the theme of concepts and illness models was incorporated by increasing the number of sessions regarding the biological basis of the illness from one session in the original BFT manual to two. They adapted the content to incorporate cultural norms and practices by including folk stories relevant to the cultural and religious beliefs of the participants. Further to these adaptations, the programme in Rami, et al.  was shorFeasibility included the assessment of recruitment, attendance, retention (the proportion of participants who complete therapy sessions) and the compatibility of the interventions with available resources. All studies reported a feasible recruitment process without significant barriers or difficulties. Attendance was also feasible because three studies , 44, 45 Acceptability is defined as “a multi-faceted construct that reflects the extent to which people delivering or receiving healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention” . Hasan eThe outcomes reported across the studies varied, and most of them did not distinguish between primary and secondary outcomes. The most frequently reported outcome was severity of symptoms using the Positive and Negative Syndrome Scale (PANSS) , 45, 46.In this review, there was a paucity of local studies to guide the ongoing development of family interventions. Egypt and Jordan are the only two countries from the 22 countries in the Arab world that have published peer-reviewed papers in this area. It is widely acknowledged that there is limited local research to guide the culturally appropriate development of different services in mental health care in the Arab region , 51. TheThe cultural adaptation process of family interventions in the Arab world was consistent with some of the themes reported in previous studies including language, content, concepts and illness models, cultural norms and practice, context and delivery, and family setup , 18, 19.Exploring a framework that involves a collaboration between traditional healers and mental health professionals may have a positive outcome because the family may feel more comfortable sharing their concerns and accepting the intervention. Many studies of traditional healers encourage such collaboration to improve patient care . In a syThis review identified two Arabic translated and adapted manuals that can be used in future studies in the Arab world with little modification depending on the specific country’s norms and traditions.One interesting finding was that all the interventions except Ahmed & Ghaith  were in All papers reported some level of adaptation, with Rami et al.  being thThe findings of our review suggest that the adaptation process for family interventions in the Arab world appears robust because it is congruent with the themes from previous systematic reviews. It also gives a clear indication that such interventions are feasible and acceptable enough to be applied in Arab countries.Assessing the effectiveness of the interventions was not the main goal of this review. Even if it had been the main goal, the evidence was not available, mainly because of the poor methodology of the included studies. There was clinical heterogeneity in the characteristics of the included studies, such as study design features, methods for diagnosis and evaluation, follow-up, and treatment duration. However, the similarities included recruiting participants from outpatient clinics and using PANSS to measure improvement in clinical symptoms. All studies except Ahmed & Ghaith  includedThe studies showed a positive effect favouring the intervention groups in different outcomes, such as the severity of symptoms, quality of life for service users and their caregivers, social function, adherence to medications, knowledge of schizophrenia, and burden and attitude towards mental illness. The severity of symptoms using the (PANSS) was a common outcome measure used in all studies except Ahmed & Ghaith . Though The qualitative study by Al-HadiHasan et al.  exploredOne strength of this review is that Arab participants had a similar culture and language, which could be considered unique compared to previous systematic reviews that included several cultures , 19. MorA major limitation of this review was the small number of included studies that were variable in design, characteristics and in the components of the interventions. These limitations restricted the conclusion regarding the different objectives of the review, and made the meta-analysis impossible. Furthermore, there was little distinction made between primary and secondary outcomes of the included studies, which caused some confusion and made it difficult to interpret whether the treatment effects differed across outcomes. It is worth noting that the quality of most studies was poor, and these were limited by incomplete information despite efforts to contact authors for clarification. Because the review included only published papers, this could cause publication bias. Therefore, the result should be interpreted with caution.It was not possible, with the available literature, to come to a conclusion regarding the effectiveness of such interventions in the Arab world. However, the recommendation of national and international clinical guidelines to integrate family intervention into routine care, invites more efforts to improve the delivery of such intervention in Arab countries. If this care cannot be integrated fully, at least simple written materials can be offered to patients and their families. The patients and families can then access these materials at their convenience and discuss their understanding with the treating team during follow-up appointments. This may improve the family’s confidence in dealing with the patient’s challenging behaviours and give them clear expectations. This method is simple and requires minimal staff training and resources, which is suitable for use in Arab countries that have limited resources. Arab countries should take action to fight the stigma of mental illness. This could be initiated by conducting mass media awareness campaigns. In addition, when culturally adapting family interventions, researchers may want to collaborate with traditional healers and include culturally relevant discussions about spirituality.The findings of this review confirmed that the attempts to develop and test culturally adapted family interventions are still quite fragmented in the Arab world. Therefore, a systematic process of developing and evaluating such interventions should be applied for the benefit of a more substantial proportion of the Arab population. Further research using a more suitable methodology, such as an RCT with a large sample and specific outcomes, is recommended to establish and gain a better understanding of the possible effects of such interventions in Arab countries. Another avenue for future research would be to assess family outcomes and the acceptability of such interventions for healthcare professionals and to identify barriers to implementation.This study set out to identify the content and characteristics of culturally-adapted family interventions in the Arab world and to determine the strategies used for adaptation. Additionally, it aimed to assess the feasibility, acceptability and effectiveness of these interventions. The present review provides the foundation for future work regarding family interventions in the Arab world and confirms the feasibility of implementing such interventions with some modifications. The data suggested that any alternative family-oriented intervention for schizophrenia - even a short term one - can be better than standard care, and it could improve the outcomes for both patients and their families.Additional file 1.Additional file 2.


Deep Learning (DL) networks are recent revolutionary developments in artificial intelligence research. Typical networks are stacked by groups of layers that are further composed of many convolutional kernels or neurons. In network design, many hyper-parameters need to be defined heuristically before training in order to achieve high cross-validation accuracies. However, accuracy evaluation from the output layer alone is not sufficient to specify the roles of the hidden units in associated networks. This results in a significant knowledge gap between DL’s wider applications and its limited theoretical understanding. To narrow the knowledge gap, our study explores visualization techniques to illustrate the mutual information (MI) in DL networks. The MI is a theoretical measurement, reflecting the relationship between two sets of random variables even if their relationship is highly non-linear and hidden in high-dimensional data. Our study aims to understand the roles of DL units in classification performance of the networks. Via a series of experiments using several popular DL networks, it shows that the visualization of MI and its change patterns between the input/output with the hidden layers and basic units can facilitate a better understanding of these DL units’ roles. Our investigation on network convergence suggests a more objective manner to potentially evaluate DL networks. Furthermore, the visualization provides a useful tool to gain insights into the network performance, and thus to potentially facilitate the design of better network architectures by identifying redundancy and less-effective network units. Deep Learning (DL) is a powerful neural network technique, which has been one of the most revolutionary developments in artificial intelligence (AI) research in this decade, e.g., ,3,4,5,6.In cross-validation evaluation, the accuracy of model outputs provides an objective score to compare the performance of DL networks. However, the accuracy rate does not provide insights into the networks. For example, it is not traceable to know which components of a network are responsible for the effectiveness of the network, or what roles a given unit plays in the network. Consequently, the DL networks are still treated as “magic classifiers” that mysteriously tackle hard tasks that conventional ML cannot solve. The lack of an in-depth theoretical understanding of DL limits further applications of the technique in various areas, such as network security and digital healthcare.The present study aims to provide a microscopic view of the DL networks based on the information theory. Our focus is on mutual information (MI)—a metric quantifying the amount of information shared between two random variables. The MI is a theoretic measurement, which is independent of any classifiers to reflect the relationship between the variables even if the relationship is highly non-linear and hidden in high-dimensional data. There are two key advantages of introducing MI as an indicator in an evaluation framework. First, when two networks achieve similar accuracy rates, the one with a higher MI is more suitable for the classification tasks with multi-instance decision making. For example, in Reference , video sCurrently, there is a growing interest in using MI to interpret and improve DL networks ,10,11,12In our paper, we evaluate our framework by deploying three networks, including multi-layer perceptron (MLP) network , Le-Net In comparison with the work in ,10,11,12This paper is structured as follows: Classical convolutional networks are widely used in the pattern recognition community in recent years. AlexNet is an eight-layer network, which includes five convolutional layers and three fully connected layers, to classify millions of images into 1000 object categories. The use of CNNs has been promoted heavily and adapted in classification applications since the work achieved the best performance in the ImageNet ILSVRC 2010 contest ; SimonyaAdditionally, DL networks have also been applied to image synthesis and style transfer in computer graphics. For instance, Reference  presenteRecently, the development trend of DL is that the networks either become much deeper, . Entropy, conditional entropy and MI, as a set of objective metrics, have been successfully adapted into many fields. For example, MI is one of the most common metrics in medical image registration . A pair Information theory has also received much attention in the field of visualization over the decade ,26,27,28Recent studies investigated visualization techniques as an intuitive way to gain the insight of DL methods, e.g., ,29,30,31The information plane work ,9 has poi layer convolving from the j kernel is obtained by weighting and summing the local input signals from the C channels and spatial window whose size is .x and y represent the spatial coordinate of the feature map; I is either the original image or a feature map from previous convolutional layer; C is the channel number and k are the convolutional kernels. In contrast, fully connected layer refers to a number of neurons that are connected with all the activations passed from a previous layer to obtain global features. This type of dense connection is the basics of the traditional multilayer perceptron (MLP) neural networks  as it reflects how each kernel shares mutual information with its classification.The information plane visualization reveals the striking evolution patterns of DL network layers during training and provides an objective indicator for the comparison of network convergence and performance. However, as shown in the The box plot technique is one of the visualization techniques to analyze the MI statistics of convolutional kernels in the network. As illustrated in The response maps generated from the first convolutional layer are more intuitive visual representations as they correspond to low-level visual features. We visualize the response maps by convolving the kernels that have the four highest and lowest MI values with a random sample in the test set to show the link between MI and feature representations. As illustrated in The box plot of the MIs in the second blocks of the two networks are illustrated in Y) to a binary flag to indicate how individual kernels contribute to the recognition of each digit . In this case, the MI value between each kernel and the label ranges in . For each kernel in the first two blocks of the LeNet and the DenseNet, we calculated this MI value for each of the ten-digit classes (0–9) at every 5000 iterations during training  it can be used as an independent metric to evaluate new network architectures in addition to the accuracy rate; and (ii) it can be integrated into the optimization process for achieving better network performance.It is found that MI can be used to evaluate whether the network architectures are suitable for particular tasks. In specific, the MI becomes relatively stable and close to its IB bound on the information plane plots, for a dataset that has been well solved by DL methods . However, the MI values drop significantly during training when processing a more difficult dataset  and the convergence is farther from the IB bound.Based on the observation from From the visualization results in Based on the observation from The following analysis is summarized from Based on the observation in In addition to the MNIST dataset, we apply the visualization techniques on another popular dataset, Fashion MNIST  See App. It is aIn this paper, we attempted to bridge the gap between DL’s wide applications and its theoretical understanding via visualizing an information theoretic metric—MI. We (i) used three DL networks including ReluMLP, LeNet, and DenseNet; (ii) examined the evolution of MI during the training stage; and (iii) analyzed the response maps selected based on the MI in DL networks. Our work is indicative of the further use of MI in a number of ways. Practically, it can be (i) used as an independent metric to evaluate new network architectures; and (ii) integrated into the optimization process to achieve a better network performance. The use of MI could also enable the improvement of network architecture design by providing a better recognition of the role of each block in the networks and by removing redundant network components. We note that our observations are based on limited sets of networks; thus, further studies are needed to validate our work by evaluating via more datasets and network architectures. In practice, our findings can be used to guide the selection of suitable network architectures based on a particular task at hand and to evaluate the reliability of the new dataset for transfer learning. Furthermore, the findings from the analysis will aid to the simplification of the network, hyper parameters tuning as well as designing new optimization schemes.In short, our current approach is most useful for investigating, tuning and selecting optimal network structure and hyperparameters that have a great potential to be used by model developers. In future, we plan to focus on using our techniques to help in practical applications and embedding the MI into various learning algorithms to automate the model building. Furthermore, our ultimate aim is to bridge the gap between DL’s theoretical understanding and its wider applications.