Background: The provision of home-based care for frail older adults in Italy and Israel is predominately provided by live-in migrant care workers (MCWs). However, despite the important role that they play in filling the demand for home care, MCWs often experience labor rights violations. This not only impacts the well-being of MCWs but also leads to lower-quality care being provided to people in need of support. Method: This scoping review used Arksey and O’Malley’s methodological framework to map literature. This article aims to analyze the scope, main topics, themes and gaps in the existing academic literature on how micro and macro level indicators impact the working and living conditions of live-in MCWs in Italy and Israel. Scopus, Pubmed, and Web of Science Core Collection were searched for peer-reviewed articles. Search terms were adapted from the Multilevel Framework of Transnational Care Migration (MFTCM). Themes were developed using Braun and Clarke’s method for conducting reflexive thematic analysis. Articles were included if they focused on Italy and/or Israel, included analysis on the working and living conditions of live-in MCWs at the macro and/or micro levels, were written in English, and were published between 2015 and 2020. Results: Out of the 1088 articles retrieved, 33 met the inclusion criteria. A total of 18 articles focused on Italy and 14 on Israel, and one focused on both Italy and Israel. The majority of articles in Italy (84 per cent) and Israel (53 per cent) included analysis on care regimes. Only 37 per cent of articles in Italy and 20 per cent in Israel included analysis on gender regimes. At the micro level, 80 per cent of articles in Israel discussed Power/Class Asymmetry, compared to 37 per cent in Italy. In total, six themes were developed. At the macro level, these themes included funding care work, MCWs as a pragmatic approach, care in the home, and valuing care work. At the micro level, the themes included being part of the family, and perceptions on class asymmetries. The findings presented in this review show that MCWs in both Italy and Israel face many of the same challenges in accessing decent work opportunities, despite contrasting employment and migration policies in each country. This can be partially attributed to the undervaluing of care work because of racialized and gendered notions of care. At the macro level, this has contributed to a lack of political will to develop long-term sustainable solutions to create or monitor decent work standards for MCWs. At the micro level, this has led to power imbalances between MCWs and people in need of care and their family members, resulting in MCWs being expected to work hours beyond those contractually allowed, having little to no time off, and experiencing emotional, physical, and sexual abuse. Conclusion: This study provides a review of the most recent contributions to the fields of labor migration and health concerning the MCW markets in Italy and Israel. While there have been many studies in each country that detail the labor rights violations experienced by MCWs, this is the first review that develops themes around the underlying causes of these violations. By thematically analyzing the findings of recent studies and current gaps in existing knowledge, this scoping review assists in building the groundwork for the development and implementation of policy, strategies, practice and research to improve the rights and migration experiences of MCWs. Home-based care—defined as any form of assistance provided to a patient directly in the home —is oftenThe demand for home-based care for older adults is rising across many high-income countries . From thBoth Italy and Israel face challenges in providing long-term care to older adults due to their ageing populations. In Italy, 23.3 per cent of the population are over the age of 65 and the number of people over the age of 85 is estimated to have increased by 80 per cent between 2005 and 2020 . In IsraFamilies in both Italy and Israel have turned to hiring migrant care workers (MCWs) to fill long-term care gaps in home-based care . In 2019The MCW market in Italy is mainly funded through unregulated cash for care schemes, with workers hired directly by the person in need of support or their family members . The “inThe MCW market in Israel has been built on an in-kind care benefits scheme, with people in need of support allocated a set number of hours of care per week depending on their age, income level, and a needs-based assessment that measures whether the older adult’s level of dependency requires them to have assistance or supervision for most hours of the day ,31. EligOne of the main pull factors for migrants to work in the care sectors in Italy and Israel is that wages are often higher than jobs available in the countries of origin of the MCWs ,35. UndeThe exploitative working conditions and labor rights violations experienced by MCWs have longstanding and negative impacts on the well-being of workers. In the case of Italy, returned MCWs have been identified by Ukrainian psychiatrists as having a specific depressive disorder called “Italy syndrome”, which is caused by the exploitative living and working conditions experienced by workers in the care sector . In IsraThe Multilevel Framework of Transnational Care Migration (MFTCM)  is a conThe macro level of the MFTCM focuses on the intersection of migration, gender, and care regimes. Gender regimes refer to how household and care work organization is seen as an expression of gendered cultural scripts within a society. This determines which tasks and responsibilities are viewed as masculine and feminine. Migration regimes refer to the rules for non-nationals entry into and departure of a country. This ultimately decides which migrants are granted employment, social, political and civil rights and whether they have access to settlement and naturalization. Care regimes include which care responsibilities are distributed between the state, the family, and the market. The meso level examines the organization of care and the role of networks in supporting MCWs and their families. This includes networks made up of MCWs, their families and friends, as well as both formal and informal organizations, for example, private and state recruitment agencies. The micro level focuses on the individual practices, identities, and positions of MCWs. This includes gender-specific characteristics, the migrant’s position in transnational social spaces, and their class and ethnicity. Consequently, the micro level aims to identify the social constructs of masculinity and femininity, ethnicity/class in daily actions, the meanings of private and public workplaces and the gender-specific consequences of migration experiences for women and men migrants .Italy and Israel were selected as comparative countries for this review, as they share several common traits concerning the development, demand for, and structure of their MCW markets. First, Italy and Israel are among the countries that have the highest reliance on MCWs to provide home-based care ,43. SecoIn contrast, historical differences in cultural, political, and economic development have led to divergences between Italy and Israel at the macro level in the provision of public benefits to support the care market, and their migration and employment laws. At the micro level, these differences can result in deviations in how class, ethnicity and gender dictate the power dynamics between MCWs and people in need of support and their family members. Consequently, by comparing the similarities and differences between the two countries, it is possible to gain a greater understanding of how different micro and macro level factors are influencing the working and living conditions of MCWs in each country and which best practices, if any, can be drawn from these two cases.This article aims to provide an overview of how micro and macro level indicators detailed in the MFTCM impact (both positively and negatively) the working and living conditions of live-in MCWs. In this regard, this study has the following research question:What are the scope, main topics, and gaps in the existing academic literature on how micro and macro level indicators detailed in the MFTCM impact the working and living conditions and opportunities of live-in MCWs in Italy and Israel?Identifying the research question;Identifying relevant studies;Study selection;Charting the data;Collating, summarizing and reporting the results.This article uses Arksey and O’Malley’s methodological framework for conducting scoping reviews . This meMCW literature spans a wide range of fields, including migration and immigration studies, sociology, health and ageing, anthropology, politics, and social policy. The scoping review methodology outlined by Arksey and O’Malley  has beenStage 1. Identifying the research questionThe research question used in this scoping review was identified through a preliminary search of existing literature on MCW markets in Italy and Israel. It quickly became apparent that there is a wide range of literature available in both countries on the working and living conditions of MCWs. However, there have not been any review articles which develop themes in the existing literature on which aspects positively or negatively affect the working and living conditions of MCWs in each country.From a labor rights framework, both Italy and Israel have ratified the 8 core ILO conventions under the Declaration on Fundamental Principles and Rights at Work, while Italy has also ratified the ILO Domestic Workers Convention (No. 189) (C189). Consequently, both countries have an obligation to uphold the labor rights of MCWs. Government officials and practitioners that work on MCW issues in both Italy and Israel need up-to-date information about how government interventions and policies, and the individual actions between MCWs and people in need of support and their family members influence the working and living conditions of MCWs. Identifying these factors will therefore assist in developing strategies and frameworks to improve the working conditions of MCWs.The poor working conditions in the care sector not only impact the well-being of MCWs but also reduce the quality of care being provided to people in need of support ,48. The The MFTCM was identified as an appropriate analytical model to use in this review as it combines themes from a wide range of thematic areas. While this framework analyses transnational migrant care work from the macro, meso, and micro levels, this article only analyses the macro and micro levels to allow for a sharper comparison in results.Stage 2. Identifying relevant studiesDue to the interdisciplinary nature of research on migrant care work, several electronic databases from different fields, including Scopus, Pubmed, and Web of Science Core Collection, were used to search for articles (the most recent search was executed in July 2020). As the MCW field is one that is constantly changing and is also largely dictated by policy and regulatory frameworks, only articles published between 2015 and 2020 were included. This allows for a more recent and up-to-date comparison of the literature.The keywords used in this review were based on the micro and macro levels of the MFTCM. These included:Macro level: gender regime, migration regime, care regime, welfare state, care culture, employment regime;Micro level: gender, class, ethnicity;Actions/Actors: informal caregiving, informal caregiver, family caregiver, migrant care worker, migrant domestic worker, domestic worker, care worker, migrant.The full search terms, including the Boolean operators used, can be found in Stage 3: Study selectionTexts were included in this scoping review if they provided qualitative, quantitative or mixed-methods analysis on factors that influence the working or living conditions and experiences of MCWs. Articles were only included if they focused on live-in migrant care work and if they provided analysis at the micro  or macro (regimes) levels. Texts had to include analysis specifically on Italy and/or Israel. Articles that included analysis on other countries were also included, provided some of the analysis was on Italy or Israel and that it was possible to separate the data and findings that focused on one or both of the countries. Only texts included in peer-reviewed journals were included. This was decided as it was not always possible to access full versions of certain books and grey literature. Likewise, only texts that were written in English were included, due to language limitations of the researcher who conducted this review.In total, 1093 texts see  were ideStage 4. Charting the dataOverall characteristics of the articlesTo organize the data included in the studies, data charts were created. The first chart  below foOut of the 33 included articles, 18 focused on Italy ,60,61,62Characteristics of the articles focused on ItalyFive studies were from the field of Migration ,44,56,62A total of 16 studies had a qualitative design ,61,62,67Two studies were from 2015 ,65, two In terms of participant samples, 11 studies included MCWs ,59,61,62Characteristics of the articles focused on IsraelFive studies were in the field of Health ,62,67,68Eight studies were qualitative ,69,71,72Three studies were from 2015 ,64,65, tIn terms of participant samples, nine studies included MCWs ,68,70,71Characteristics of the article focused on both Italy and IsraelThe one study that focused on both Italy and Israel was from the fields of Ageing/Gerontology and Social Policy. The study sample included key informants, and the study was published in 2020 .Mapping of micro and macro level factorsThe second chart  focuses Macro levelKey concept 1: Gender regimeArticles focused on ItalyEight studies focused on Italy 37 per cent)  per cent,55,59,62Articles focused on IsraelThree studies focused on Israel (20 per cent) ,48,65. TKey concept 2: Migration regimeArticles focused on ItalySeven studies focused on Italy 37 per cent)  per cent,56,61,62Articles focused on IsraelSix studies focused on Israel (40 per cent) ,64,67,69Key concept 3: Care regimeArticles focused on ItalySixteen studies focused on Italy (84 per cent) ,60,61,62Articles focused on IsraelEight studies focused on Israel (53 per cent) ,68,69,72Key concept 4: Employment regimeArticles focused on ItalySix studies focused on Italy (32 per cent) ,58,61,62Articles focused on IsraelSix studies focused on Israel (33 per cent) ,64,65,69Micro levelKey concept 5: GenderArticles focused on ItalySeven studies focused on Italy 37 per cent)  per cent,53,55,59Articles focused on IsraelSix studies focused on Israel (40 per cent) ,48,65,68Key concept 6: Power/Class AsymmetryArticles focused on ItalySeven studies focused on Italy 37 per cent)  per cent,55,59,61Articles focused on IsraelA total of 12 studies focused on Israel (80 per cent) ,69,70,71Key concept 7: Culture, Ethnicity and ReligionArticles focused on ItalySix studies focused on Italy (32 per cent) ,50,55,56Articles focused on IsraelEight studies focused on Israel (53 per cent) ,67,68,71Stage 5. Collating, summarizing and reporting the resultsTo develop themes from these articles, this review used Braun and Clarke’s methods for conducting reflexive thematic analysis ,74. One Findings from each study were initially deductively coded under the micro and macro level indicators detailed in the MFTCM. These headings were represented as parent nodes. This coding process was conducted separately for articles from each country. Since the MFTCM is focused on the interaction between regimes at the macro level and the interaction between individuals at the micro level, it was important to reflect on how codes fit within these interactions, rather than strictly coding under the key phrases from the mapping of articles. Consequently, under the broad subheadings used in the MFTCM, themes were then identified inductively and labelled as child nodes. These themes were identified as being broader patterns within the findings that shared a core concept ,74. Oncefunding care work, MCWs as a pragmatic approach, care in the home, and valuing care work. At the micro level, the themes included being part of the family, and perceptions on class asymmetries. Each theme first starts with a summary of the overall theme before analyzing how the findings from the reviewed articles fit into these themes.In total, six themes were developed. At the macro level, these themes included Macro LevelTheme 1: Funding care workThis theme focuses on which mechanisms the government uses to meet the demand for home care. At the care regime level, this includes how home care services are funded, for example through cash allowances or in-kind services. This also covers who can receive these allowances and under which conditions, including any needs-based assessments or financial barriers, as well as any restrictions on how these allowances or services are used. In this regard, low levels of financial support for people in need of support, either in the form of in-kind services or cash allowances can result in MCWs being underpaid, if people in need of support are not able to afford decent wages for MCWs. Furthermore, attaching needs-based restrictions on access to care and services can assist in filtering home care funding to those most in need of support. However, if only those with high levels of dependency receive support, then MCWs are likely to experience a higher level of care burden.The Italian context of funding care workFrom the Italian government’s perspective, building a home care market based on the hiring of MCWs is a way to cheaply meet the demand for support in an ageing society . ThroughThe most commonly used cash for care scheme in Italy, the indennità di accompagnamento, does not have any restrictions on how it is used. This reinforces the likelihood of families hiring MCWs outside of the formal sector, as there is no obligation to formally hire workers ,34,52. HThe Israeli context of funding care workTo meet the demand for MCWs, Israel has outsourced the management of MCWs to care agencies. Under this system, people in need of support are allocated a certain number of care hours based on a needs, financial and age assessment. People in need of support are then able to exchange their care hours to hire a live-in care worker. This model has resulted in a greater degree of MCWs with regular migration status as people in need of support are required to go through a care agency to hire care workers ,34,48.The Israeli care system can increase the likelihood of work-related abuses for MCWs, as only older adults with higher levels of impairment qualify for care hours. This is especially relevant for MCWs who provide care for older adults that have cognitive impairments, as they are more likely to be aggressive than other older adults . MoreoveTheme 2: MCWs as a pragmatic approachAt the migration regime level, the state must decide how to structure its migration rules and procedures to facilitate the arrival of migrants into the home care sector. This can include using a formalized care system, with regular migration channels available, or using an ad-hoc regime, which favors choosing to ignore the presence of migrants with irregular migration status. The decision on which path a country takes is often determined by a practical compromise between needing to meet the demand for care and the level of acceptance of migrants within society, which is also based on the gendered and familial norms and expectations around care and whether MCWs are viewed as contributing to the breakdown of these traditional norms. These assumptions then also feed into the employment rules and regulations for MCWs.The Italian context of MCWs as a pragmatic approachItaly has seen an increase in anti-migration sentiment and xenophobia in recent decades, which can partially be attributed to the rise of the Lega Nord party, a right-wing party that has been part of successive right-wing coalitions since the 1990s ,54. The For some people in need of support, hiring a MCW is a compromise to keep care within the home, even if they would prefer that their children take care of them ,53. HiriTo increase the ease of migrant workers to enter the care sector and despite the anti-immigrant sentiment within Italy, the Italian government has on several occasions made it easier for MCWs to live and work in Italy. Consequently, while workers in other sectors have often faced restrictive migration rules, the Italian government has expressed more leniency towards MCWs ,54,57,62While regularization processes have assisted MCWs to enter the formal economy, this has been done on an ad-hoc basis, which can increase stress for MCWs as they are unsure when they may gain regular migration status ,50,54. TThe Israeli context of MCWs as a pragmatic approachThe gendered expectation of familialism in Israel has driven the demand for women MCWs in the home care sector. With more Israeli women being employed in the workforce, families have turned to MCWs to fill the care demands of people in need of support . This caWhile MCWs are relied on to fill the demand for home-based care in Israel, this has not resulted in MCWs gaining long-term residency rights. The Israeli migration regime has been built on viewing migrant workers as temporary guests ,34,39,63Theme 3: Care in the homeFamilial care regimes often result in a preference for care being provided in the home, rather than at formal care institutions. This can be viewed as a reflection of the tradition of care being provided by informal caregivers in the home. However, providing care at home results in several complications for MCWs, due to the isolating nature of home-based care. This theme also explores how the home care setting influences the expectations of the types and frequency of care being provided by MCWs. For live-in MCWs, there is often an expectation that care should be provided around the clock. This has serious complications for MCWs, as it limits their ability to take much-needed rest or time off from work. Because MCWs must spend most of their time in the home of the person in need of support, there is often a lack of oversight by labor rights inspectors, which reduces the opportunities for MCWs to report labor rights violations.The Italian context of care in the homeThe Italian care regime can be viewed as being built on familial notions of care, where family members have traditionally taken on the role of primary caregivers. Because of the family nature of care, the majority of care has taken place in the home environment and many people in need of support prefer to receive care at home, rather than in an institutional setting ,50,61.Providing care in the home can result in labor rights issues for MCWs. Firstly, there is an expectation from both people in need of support and their family members that care should be provided round the clock and that workers are available at all times to provide care. This often-unspoken rule of 24/7 care can lead to MCWs having isolating experiences, with little opportunities to leave the home environment or take time off from their job ,56,58,60The Israeli context of care in the homeProving home-based care presents several barriers to decent work for MCWs in Israel. Providing care can be a socially isolating experience for MCWs, as they often have few opportunities to be able to leave their workplace or to take time off of work, as similar to Italy, there is an expectation for MCWs to provide round the clock care ,48,64,70Ayalon and Green  found thThe home care setting also makes it difficult for workers to report labor rights violations. Social care workers are supposed to monitor MCWs regularly through visits. However, in practice, this may only occur every four months. Moreover, these inspections mainly focus on the quality of care being provided to people in need of support and their well-being, rather than on the well-being of MCWs .Theme 4: Valuing care workThis theme explores how values associated with care work influence the type of training and support available to MCWs, as well as how these values shape the adherence towards labor rights for MCWs. Gender stereotypes are common in the home care sector, with many people in need of support and their family members viewing women as ‘natural carers’. This can cause care work to be undervalued and treated as low-skilled work. Negative perceptions in society towards migrants also contributes to this issue, resulting in MCWs having few opportunities to receive skills training or recognition and this can also lead to a lack of understanding of the rights of MCWs by people in need of support and their family members. Additionally, strong familial care regimes can result in the preference to favor the rights of families over paid care workers.The Italian context of valuing care workThe familial care regime present in Italy has resulted in the state preferring to protect the interests of families over MCWs ,44,54. CThe Italian government has also ratified ILO C189, which provides minimum standards and rights for domestic workers in Italy . NeverthCare work in Italy is often undervalued due to familial and gendered assumptions of care, with the state and families often seeing women as ‘natural carers’ . FamilieThe Israeli context of valuing care workAyalon and Green  found thMicro LevelTheme 5: Being part of the familyThis theme explores how MCWs and people in need of support and their family members navigate their relationship with each other. Due to the personal and close nature of care work, MCWs frequently form close bonds with the person that they provide care for. Consequently, people in need of support often refer to MCWs as being one of the family. These relationships are often ones of fictive kinship, with people in need of support and their family members using the notion of being one of the family as a way to gain control of this relationship and to get workers to perform tasks outside of their usual job. At the same time, MCWs may also choose to lean into this closeness, as a way to gain benefits from the person they provide care for. While other workers prefer to keep their work relationships strictly professional.The ability of MCWs to negotiate these relationships is often built on the intersection between gender, age, ethnicity and class. How workers navigate these relationships has severe consequences for their well-being, due to how dependent they are on the person they care for to provide them with food and shelter. Building a solid relationship with the person in need of support has the potential to assist MCWs with maintaining their regular migration status and therefore their right to stay in the country, their future job opportunities and the amount of spare time and freedom they have.The Italian context of being part of the familyMCWs and people in need of support often form close bonds with each other due to the amount of time they spend together . HoweverHow MCWs navigate relationships with the person in need of support and their family members has a strong influence on their well-being and rights at work ,55. MCWsBecoming too close to the person in need of support can in some instances lead to the person in need of support becoming too attached to the MCW, which limits the amount of free space and time that MCWs have . This caMCWs, therefore, have to decide whether they want to try and form professional relationships or whether they want to lean into the narrative that they are part of the family ,51. HoweThe Israeli context of being part of the familyMCWs often show commitment and dedication to the person that they provide care for ,69,71. TAssumptions on gendered norms of caring also dictate how MCWs are treated by people in need of support. For women MCWs, the failure to perform according to the person in need of support’s desired familial intimacy can result in their dissatisfaction . Women MCultural perceptions around care were also used to justify the structure of the relationship between MCWs and the family members of people in need of support, with some employers viewing themselves as ‘natural managers’ and seeing MCWs as ‘natural caregivers’ ,48,67. ATheme 6: Perceptions on class asymmetriesThis theme explores how the decision and assumptions around the reasons why MCWs choose to migrate into the care sector are influenced by economic disparities. For many, migration presents an opportunity to send money to family members back home and improve their livelihoods. Assumptions around the rationale for migration are often grounded upon class asymmetry, with people in need of support and their family members using economic disparities as a justification for providing poor working conditions or pay for MCWs. Furthermore, rigid employment laws that do not take into account the short-term goals and the uncertainty around migration, can result in MCWs having to choose between increased labor rights protections or increased income.The Italian context of perceptions on class asymmetriesIncreased wages were a common motivation for migrants to work in the care sector, presenting workers with the opportunity to send money to family members back home and to create a better life for their family and children ,59,61. OEconomic motivations can sometimes lead to MCWs losing some of their employment rights. Current pension requirements in Italy require workers to contribute for 10 years before they are eligible to receive pension benefits . BecauseEconomic disparities between MCWs and people in need of support were used by families to justify the poor treatment of MCWs, with some employers expecting MCWs to be grateful for the opportunity to earn higher wages, even if the workers were being paid low wages . TherefoThe Israeli context of perceptions on class asymmetriesIncreased wages were a motivating factor for MCWs to move to Israel ,67. LikeThis perception of class disparity was also a source of discontent for some MCWs, as there were many other reasons as to why MCWs decided to move to Israel, including for religious purposes . Thus, sIn this study, to better understand the scope and gaps in the academic literature on how micro and macro level factors impact the working and living conditions of MCWs, reviewed articles were mapped against key concepts derived from the conceptual model offered by the MFTCM. This mapping assists in identifying topics and areas where future research is needed. Furthermore, four themes at the macro level and two themes at the micro level were developed based on the findings from the reviewed articles.funding care work focuses on the instruments used by governments to meet the demand for home care. This covers who can receive these instruments and under which conditions, as well as whether there are any restrictions on how they are used. MCWs as a pragmatic approach discusses the migration rules and procedures used by the government to facilitate the arrival of and long-term residency rights of migrants employed in the home care sector. The theme analyses how these rules are developed based on a compromise between meeting the demand for home care alongside the gendered and familial norms and expectations around care and whether MCWs are seen as contributing to the breakdown of these norms. Care in the home explores how the preference in familial care regimes for care to be provided in the home influences the types and frequency of care provided by MCWs. Moreover, it examines how the home cares setting can result in a lack of oversight on the employment conditions of MCWs. Valuing care work focuses on how gendered and familial expectations around care alongside perceptions of migrants in society influences if and how the work performed by MCWs is valued.At the macro level, being part of the family discusses how the intersection of age, gender, ethnicity and class determines the types of relationships formed between MCWs, people in need of support and their family members. Additionally, it analyses how and whether MCWs can choose to navigate these relationships. Perceptions on class asymmetries analyses how perceptions around class asymmetries between MCWs and people in need of support are used as a justification by people in need of support to justify the poor working conditions of MCWs.At the micro level, The findings in this review can assist policymakers, labor rights, care, and migration practitioners, researchers, and local authorities in identifying under which areas interventions are needed to improve the working and living conditions of MCWs.funding care work, the use of unregulated cash for care schemes has contributed to increased informality in the Italian MCW market. In contrast, the more regulated system of using care hours in Israel has resulted in a higher degree of formality in comparison to Italy. These findings are in line with previous research which has shown that the use of unregulated cash for care allowances in Austria, Germany, and Spain, has led to increased informality in their respective home care sectors [As detailed in the theme  sectors ,76. In c sectors ,76,77,78MCWs as a pragmatic approach show that the formalization of the care markets itself does not lead to increased rights if the rights granted under employment and migration regimes are not enforced [The findings presented in the theme enforced ,80. Takienforced . Similarenforced ,83.Parallels can be drawn between the migration rules and procedures that govern the MCW markets in Israel and Japan. Both countries view MCWs as temporary guests, which has resulted in the creation of migration policies that offer few avenues for MCWs to stay long-term or to have a right to a family life ,85,86,87care in the home, there is extensive literature that has highlighted that live-in care and domestic workers often experience social isolation and are rarely covered by labor rights inspections [Comparable to the findings displayed in the theme pections ,90,91,92pections ,94,95,96valuing care work, many of the challenges that workers face in Italy and Israel are related to the undervaluing of care work because of racialized and gendered notions of care. The undervaluing of reproductive labor is not unique to Italy or Israel, and many studies in the care and domestic work sectors have evidenced that this undervaluing leads to less recognition and rights for care and domestic workers [The findings presented in this review demonstrate that MCWs in both Italy and Israel face many of the same challenges in accessing decent work opportunities in the care sector, despite the fact that the rules and regulations that govern MCW markets in each country have gone down different paths. As expressed in the theme  workers ,99,100.being part of the family that the relationship between MCWs and people in need of support and their family members is one of the most important factors that determines whether MCWs have positive or negative employment experiences. Previous studies on the care and domestic sectors in Cyprus, Spain, Malaysia, Thailand and Taiwan have found that fictive kinship relationships are common and that this form of relationship is frequently used by employers to manipulate workers to accept poor working conditions or to perform tasks outside of their usual role [This review has also shown in the theme ual role ,101,102.ual role ,103,104.perceptions on class asymmetries, previous research has shown that the migrant care and domestic sectors are often marked by a high degree of social and economic inequality [Similar to the findings presented in the theme equality ,107,108.equality ,110.This review has identified several key challenges that MCWs face in accessing decent work in the care sector. Nonetheless, it is important to note that care work in itself does not increase the vulnerability of workers, rather it is often a lack of enforcement of labor rights that puts MCWs at risk of labor rights violations. Consequently, there are several steps that the Italian and Israeli governments can take to improve the rights of MCWs.funding care work, increased funding is needed for people in need of support in Italy to pay for long-term care services. Increasing the amount of funds provided through cash for care schemes would assist people in need of support and their family members to pay MCWs fair wages. Furthermore, this would also help families to meet the requirements set out in Italy’s National Collective Agreement for Domestic Workers [Concerning the theme  Workers . Neverth Workers ,60.MCWs as a pragmatic approach, it is important that a more sustainable and long-term route for non-EU MCWs to enter the sector in Italy is created. The current process of relying on ad-hoc regularization processes may assist MCWs in the short term but it also contributes to the exploitation of workers, as it often forces workers to enter the country through irregular channels [Linking to the theme channels ,50,54. Mchannels ,47,48. TMCWs in Israel should be afforded the right to a family life, in line with the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (ICRMW). The current practices of requiring MCWs to leave family members behind in order to migrate into the care sector, or that require MCWs to leave the country if pregnant, or risk losing their regular migration status leads to increased tension and emotional distress for MCWs ,112.Allowing MCWs to be employed as live-out care workers in Israel may also assist in improving the living and working conditions of MCWs . The curcare in the home, both the Italian and Israeli governments need to prioritize the enforcement of labor rights for MCWs. While the home setting of care work makes it difficult to put in place monitoring procedures, labor inspections provide an avenue for determining whether MCWs are facing labor rights violations [Regarding the theme olations . Additioolations . For Isrolations . This isolations .valuing care work, both the Italian and Israeli governments should run education, information and awareness-raising campaigns around the value of paid and unpaid care work and the work provided by migrant workers. This will assist in combatting harmful stereotypes and assumptions present in the care and migration spheres and would likely help to reduce the negative assumptions around class disparities presented in the theme perceptions on class asymmetries. Likewise, societies which have more gender-responsive public policies have been shown to hold more gender-equal values and to support increased equality in the division of paid and unpaid work. Consequently, both governments should take a gender mainstreaming approach to the implementation of public policies [Relating to the theme policies .being part of the family and perceptions on class asymmetries [It is important that in both Italy and Israel, MCWs, people in need of support and their relatives understand which rights MCWs are entitled to. Providing language training to MCWs will increase the likelihood that MCWs will understand their rights . This wimmetries .Almost all of the articles focused on Italy included in this review were qualitative. While this is useful in gaining an in-depth understanding of the interactions between MCWs and other actors, more quantitative research is needed to gain a better understanding of the magnitude of labor rights issues experienced by MCWs.being part of the family shows that MCWs are often heavily reliant on people in need of support and their family members. Consequently, it is important that future research includes analysis on the experiences of people in need of support and their family members with MCWs. This will assist in increasing the sustainability of MCW markets, by ensuring that the challenges faced by each member of the MCW–person in need of support–informal caregiver triad can be overcome. A large number of articles focused on Israel included either MCW–person in need of support dyads or MCW–person in need of support–informal caregiver triads, with most of these dyads and triads having a quantitative focus. Consequently, more qualitative research on these dyads and triads would assist in gaining a better understanding of these relationships in this country context and beyond.Few of the studies in Italy samples included people in need of support or their family members. The theme Looking at the mapping of articles against key phrases in the MFTCM, for Israel few articles included an analysis of the gender dimension at the macro level. As gender norms are deeply ingrained in the field of care work, future research is needed to shed light on how these care norms shape the interactions between MCWs and other actors in MCW markets. In addition, few study samples included men MCWs, and none explored the experiences of people that identify as non-binary or genderqueer. Further research is therefore needed to gain a greater understanding on whether these groups experience any specific challenges in the care sector.Only one researcher conducted the data extraction and analysis for this review. While the researcher used a structured approach to conduct this review, there is a chance that some data may have been missed or excluded. Moreover, because the researcher used reflexive thematic analysis, the development of themes was shaped by the work and educational backgrounds of the researcher . ConsequThis article only analyses migrant care work models from the macro and micro levels; therefore, the role of some actors at the meso level were not included and properly considered in this review. Almost all of the articles included only focused on the role of the country of destination in developing care worker markets. Because care markets are transnational, it is also important to consider the role of countries of origin in the development of a more comprehensive understanding of this specific sector.All of the articles reviewed in this article were published in academic journals. There is still the need for a more comprehensive review of grey literature that relates to migrant care work in these two countries. Due to the difficulties that migrant workers face in accessing decent work opportunities, there are a large number of organizations that provide support services to migrant workers. Since these organizations often produce reports and research for programming, a comprehensive review of existing research could help to increase the knowledge base on strategies and activities that can be helpful to improve care outcomes for migrant workers, people in need of support, and informal caregivers.Despite these limitations, this work contributes, also thanks to its comparative approach, to enhance our understanding of the main areas in which research efforts should focus upon to find ways to improve the conditions of MCWs at a cross-national level.This study provides a review of the most recent contributions to the fields of labor migration and health concerning the MCW markets in Italy and Israel. While there have been many studies in each country that detail the labor rights violations experienced by MCWs, this is the first review that develops themes around the underlying causes of these violations. By thematically analyzing the findings of recent studies and current gaps in existing knowledge, this scoping review assists in building the groundwork for the development and implementation of policy, strategies, practice and research to improve the rights and migration experiences of MCWs.In the wider context, the findings of this scoping review are not only applicable to Italy and Israel, but may also apply to other MCW worker markets, especially in countries with familial care regimes. The methodology used in this scoping review could be used as a template to conduct further cross-national analyses on MCW markets in other countries. This would assist in building a comparable understanding of the common challenges and best practices around maintaining decent work opportunities for MCWs worldwide.One commonality between Italy and Israel, and one of the largest challenges to overcome in both countries, is that care work—whether it be paid or unpaid—is routinely undervalued. At the macro level, this undervaluation of care work has contributed to a lack of political will to develop long-term sustainable solutions to create or monitor decent work standards for MCWs. Instead, both countries have used MCWs as a low-cost solution to fill long-term care gaps. At the micro level, this undervaluation has led to power imbalances between MCWs and people in need of care and their family members. This often results in MCWs being expected to work hours beyond those contractually allowed, having little to no time off, and experiencing emotional, physical, and sexual abuse.Consequently, while policy measures are an important part of creating decent work opportunities for MCWs, these measures in themselves do not lead to increased rights for workers if these rights are not being enforced or people are not aware of them. The MCW markets in Italy and Israel do not need to be synonymous with exploitation and abuse. To provide better living and working conditions for MCWs, it is important that the Italian and Israeli governments work together alongside organizations that work on care and migration issues, local government officials, people in need of care and their family members, MCWs themselves, and researchers in order to develop new strategies and measures to enforce and maintain the rights of MCWs and to increase the recognition of the value of care work.


Gait is a basic cognitive purposeful action that has been shown to be altered in late stages of neurodegenerative dementias. Nevertheless, alterations are less clear in mild forms of dementia, and the potential use of gait analysis as a biomarker of initial cognitive decline has hitherto mostly been neglected. Herein, we report the results of a study of gait kinematic time series for two groups of patients (mild cognitive impairment and mild Alzheimer’s disease) and a group of matched control subjects. Two metrics based on permutation patterns are considered, respectively measuring the complexity and irreversibility of the time series. Results indicate that kinematic disorganisation is present in early phases of cognitive impairment; in addition, they depict a rich scenario, in which some joint movements display an increased complexity and irreversibility, while others a marked decrease. Beyond their potential use as biomarkers, complexity and irreversibility metrics can open a new door to the understanding of the role of the nervous system in gait, as well as its adaptation and compensatory mechanisms. Within the large family of neurocognitive disorders, neurodegenerative dementias  are receAccording to the degree of disability, it is customary to distinguish between dementia (or major cognitive impairment) and mild cognitive impairment (MCI). MCI was forged as a concept to designate those patients with abnormal cognition, lying between normal ageing and very early dementia. Its importance is twofold. On one hand, MCI is a common condition, especially in developed countries, with high incidence (21.5–71.3 per 1000 people/year) and prevalence 3–42%) .In recent years, molecular, neurophysiological and imaging biomarkers have provided insights into the patient’s natural history, demonstrating a consistent profile during the full staging of AD  ,8. MoreoA promising new approach is represented by gait analysis, as this is an altered domain in MCI and dementia, and as a consequence, its study may contribute to improving our understanding of the neurobiology of neurocognitive disorders. Alterations of gait occur in early phases of cognitive decline ,18. Rececarriers . Mean pecarriers ,21 and bcarriers ,23, and carriers ,25,26,27carriers ,29,30 ancarriers .Most of these reports stress the importance of spatiotemporal variables to distinguish MCI patients from healthy controls, but only few go deeper into the gait kinematics of patients with cognitive impairment . KinematAs described above, some attention has been devoted to the study of changes in kinematic and spatiotemporal parameters obtained with IGA in conditions of cognitive impairment. However, no attempt has yet been made to analyse gait signals as time series, for instance to assess their complexity, which should be altered or modified as a result of motor system lesion and system re-adaptation in patients with cognitive impairment. The rationale behind this is that brain signals to the muscles which provoke joint movement may become less continuous and less coordinated; inefficient joint movement noise may be added as a consequence of failure of some neuronal networks; and those signals may produce poor configurations that may not respond (or may respond wrongly) to purposeful cognitive commands such as changing velocity.Herein, we present a cross sectional study aiming at analysing the complexity of gait in a cohort of patients with cognitive impairment in the stages of MCI and mild AD (mAD). For this, we rely on two complementary metrics. On one hand, the complexity is measured through the well-known permutation entropy (PE) ,38,39, aThe remainder of the paper is organised as follows. There is a limited effect of age on the PE and IRR of joint time series. Only IRR of hip rotation and forefoot adduction shows a significant effect, but with a relatively small effect size. The preferred walking speed influences both PE and IRR, but not in an equivalent way. PE of all joint kinematic time series, with the exception of the one referring to pelvic obliquity, shows a decrease for higher walking speed. In contrast, IRR is only increased at higher speed in hip flexion, knee adduction, knee flexion, ankle flexion, ankle rotation and forefoot flexion.PE of the time series is generally not changed in the group of patients with MCI. Only PE of ankle rotation is decreased in patients with MCI, this effect being higher with decreasing walking speed. The effect of MCI on PE of forefoot adduction is dependent on the interaction with walking speed; specifically, at higher speeds, there is a decrease in the PE of forefoot adduction in MCI patients in comparison to healthy subjects.PE of the kinematic time series shows different changes in the group of mAD. PE of pelvic obliquity and hip flexion shows a significant difference for mAD in comparison to healthy subjects, which is dependent on the walking speed. Specifically, patients with lower preferred walking speed show a higher increase in PE of these two time series. Moreover, the decrease in PE of ankle flexion at higher walking speeds is more pronounced in patients with mAD with respect to healthy subjects.IRR of pelvic tilt shows different changes in the MCI and mAD groups. There is a decrease with respect to healthy subjects if walking speed is not considered, but IRR rises higher than in healthy subjects (for whom there was no effect of WS) when WS increases. In the case of MCI, IRR of ankle rotation is increased in comparison to healthy subjects, but this difference decreases at higher walking speeds. In the case of mAD, there are significant effects for IRR of hip flexion, hip rotation and ankle flexion, which are lower than in healthy people, this difference being less marked as WS increases .In contrast to linear mixed models, random forests are able to capture multidimensional patterns, which may help to detect more complex differences in entropy and irreversibility for different degrees of cognitive impairment. Herein, we report the performance of random forests trained with real data, in terms of the classification score, and compare it with the performance of random forests trained with 10 randomly shuffled data sets—see Using either entropy or irreversibility of kinematic time series, random forests detect differences between groups, with a classification score between The bottom panels in In In this paper, we have shown that PE and IRR of joint kinematic time series along the gait cycle are modified in two stages of cognitive decline. Both PE and IRR depend on the walking speed. Moreover, the differences throughout different levels of cognitive impairments are also dependent on preferred walking speed, which is decreased in some patients. Interestingly, the effect of ageing seems more limited than the impact of cognitive dysfunction and walking speed. We have also demonstrated that the differences in kinematic complexity may allow discrimination between groups with different cognitive involvement. Lastly, we have demonstrated that PE and IRR provide complementary properties to provide more in depth insight into the complexity of gait kinematics. The relationship between PE and IRR in a gait cycle depends on the joint described by the kinematic time series, and on the group of patients in which it is studied.In biological terms, measures of complexity such as PE and IRR may help in better understanding the processes of motor impairment/adaptation that occur in people with cognitive impairment. There are changes in complexity that are shared by both groups of patients: for instance, the amount of irreversibility of the pelvic tilt kinematic signal is decreased in both groups (MCI and mAD), being lower in patients with lower walking speed, thus denoting a decreased complexity of this joint movement in patients with slower gait. Interestingly, there are changes in complexity that are not shared by both groups of patients. We have shown that there is an increase in complexity at distal joints in MCI (decreased PE of ankle flexion and increased IRR of ankle rotation) that is higher in patients with MCI and lower speeds, and that is yet practically absent in patients with mAD. In parallel, patients with mAD show a decreased complexity for proximal joints  and for the forefoot flexion. These differences are again sharper in patients with lower WS. The increase in differences in patients with lower WS deserves special consideration. Two hypotheses can be proposed. Firstly, patients with cognitive impairment may use different kinematic complexity when they walk more slowly. Secondly, patients who walk more slowly may also be more severely affected in terms of motor capacity, with a consequent stronger alteration of kinematic complexity. It is difficult to check which one of these two hypotheses is true with our experimental design; further studies are needed to clarify how patients with cognitive decline adapt their gait complexity to different walking speeds.The discrimination between groups based on complexity measures of kinematic joint time series is also a finding of biological significance. It is worth highlighting that, while it is in theory possible to build a diagnostic tool based on the presented results, this is not the aim of this work. On the contrary, classification models are here used to quantify the differences in gait adaptations in people with mild cognitive alterations. The presence of significant motor alterations in early/mild phases of cognitive deterioration, and the understanding of their biological foundations, is relevant for interpreting changes in later phases of cognitive impairment. Previous studies demonstrated that motor impairment slowly progresses from early phases, although symptoms were believed to only arise in later phases ; in conti) gait complexity changes at early mild cognitive impairment, and  . InclusiControl subjects had a similar age and sex distribution to the groups with cognitive impairment. Two subjects were discarded for orthopaedic or clinical reasons, making a final number of 87 volunteers.Note that the two groups of patients do not match in number due to the limited availability of participants that fulfilled the inclusion criteria. However, the size of both cohorts is large enough to support the statistical significance of our results. Additionally, group imbalance has been taken into account in the classification tasks, through the execution of the same tasks on randomly shuffled data.Our local Ethics Committee approved this study and individuals were all subjected to examination after informed written consent. The work was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki).Gait analysis was performed with a Codamotion system . Twenty-four light emission markers were attached to the same number of positions of the subject’s legs, according to an anthropological segment model designed by the manufacturer, and signals were recorded at 200 Hz while the subjects were performing the task. Subjects were incited to walk 10–15 times from one end to the other of a 7 m long walkway path  at their natural, spontaneous speed. The system acquired continuous real-time kinematic data during each complete walk over the walkway. After the acquisition session, individual gait cycles were isolated, by manually marking their beginning (heel contact) and their end (next heel contact of the same foot). Cycles were then reviewed to select those in which the gait was more stable, which usually coincided with those obtained from the 3–5 central meters of the walkway. Next, each selected cycle was again reviewed to check the consistency of the signal reception. The whole post-acquisition selection process was performed by two independent reviewers, with the help of a custom software programmed in R. This program is designed to detect abnormalities in cycle marking or signal reception, and to eliminate outliers in discrete kinematic parameters that might mean marker failure or displacement, and which might have escaped the manual revisions. This data validation process resulted in 25 valid cycles from each side . For every side gait cycle, we studied the time series (201 time epochs) of the 3 angular planes  from 5 joints .The concept of permutation patterns, and especially of permutation entropy (PE), was introduced by Bandt and Pompe in a seminal paper in 2002 . In shorN data points. A vector of consecutive points can be associated to each time index t, such that D, also known as the embedding dimension, to 3, due to the limited length of the available time series [Let us start with a time series e series . We addiormalism .permutation pattern, defined as the permutation that should be applied to the vector to obtain a sorted sequence. To illustrate, suppose that p:Each vector can then be associated to a As has exhaustively been studied, PE values close to 1 suggest the presence of stochastic (random) processes; on the other hand, irreversible whenever there is a lack of invariance of its statistical properties under the operation of time reversal [f, In mathematical terms, a time series can be defined as reversal ,61. Thusgression . Assessit the pattern We here measure the irreversibility of gait dynamics through the metric based on permutation patterns recently proposed in . Note thamount of irreversibility of a time series. Specifically, let us consider the distributions Using a similar idea, one can easily calculate the Values of lmer in R. We used beta coefficients for fixed effects as effect statistics, and their 95% CI were calculated by means of parametric bootstrapping.We estimated the mean difference in the permutation entropy and the amount of irreversibility of the kinematic joint time series between groups  by means of mixed effect models. We considered subjects and side nested on subject as random intercept. As fixed effects, we included group according to cognitive performance, age, normalised walking speed and the interaction of normalised walking speed and the cognitive group. This analysis was performed using package MCMCglmm package in R [We used Bayesian, bi-response regressions for continuous variables programmed with non-informative priors  using the age in R  to calcuage in R . We usedi) its recognised accuracy in classification tasks, usually superior to other models; (ii) its resilience to overfitting, especially in the case of limited availability of instances in the training phase; and (iii) its computational efficiency. In all tasks, we used the implementation included in the scikit-learn Python library [Classification tasks were performed through the well-known random forest (RF) model . This mo library . Except N times, with N being the number of instances in the data set. All data, except for those corresponding to a single instance, were used for training, for then for obtaining the prediction on the excluded instance. The final accuracy was then calculated as the fraction of times  corresponding to a correct classification.In order to estimate the generalisation accuracy of all models, a leave-one-out cross-validation (LOO CV) strategy was implemented . An inde


The integrity and the wholesomeness of the food served to school pupils cannot be overlooked, especially when one considers the magnitude of health and sanitation issues that are plaguing the West African nations. This study aimed to investigate some of the personal hygiene practices by the pupils and the hygienic conditions in which food is cooked and served to these school-going children under the Ghana School Feeding Programme (GSFP). Participants. There were 720 respondents for the study, comprising 600 pupils, 60 teachers, and 60 kitchen staff members from 20 schools. Information was obtained using questionnaire, observation, and unstructured interview instruments.  A cross-sectional and descriptive survey research designs were used in the study. Purposive and simple random sampling techniques were employed in selecting participants.  Findings from the study revealed that the majority of pupils (92% in Wa and 65% in Cape Coast) did not wash their hands with soap under running water. No hand washing centers for pupils were also seen in most of the schools studied. Majority of the cooks did not have health certificate, and neither had attended any in-service training in two years. In both Wa and Cape Coast municipal schools, none of the kitchen staff admitted that pupils and teachers ever complained about the meals they served to the pupils.  The GSFP in basic schools forms part of the integral diet of the school children; hence, provision of good quality food can affect the health, learning, and physical activities of these children. Observational checklist revealed that most of the kitchen staff do not strictly adhere to basic food hygiene practices, and this affects the wholesomeness of the food served to the children. There is, therefore, a need for kitchen staff training on hygiene and food preparation practices. When the Ghana School Feeding Programme (GSFP) started in the year 2005, it gave the impression to be a quick-win intervention against hunger and school drop-out. This programme offers one hot nutritious meal each day for school children in some selected public schools funded by the government. However, ten years down the lane, the programme seems to be fraught with difficulties in its implementation. Unanswered issues cited by critics of the programme include the nutritional quality of meals served, the conditions under which food ingredients of the GSFP are procured and stored , 2, and The health of the children, the safety of the food ingredients used in the meal preparation , and theThis is counterproductive to the achievement of the goals of GSFP, as it disrupts teaching and also affects the maintenance of a hygienic environment for food preparation. Suleman et al.  further According to Bolton , young cHoddinott and Yohannes  take theInformation regarding the health and safety of the food served under the GSFP is scarce. Data on hygienic conditions of the kitchens and water quality for the food preparation is scanty. However, the integrity and the wholesomeness of the food served to the school pupils cannot be overlooked, especially when one considers the magnitude of health and sanitation issues that are plaguing the West African nations. Therefore, the specific objectives of this study were to (1) identify bowl and hand washing practices by the pupils and sources of water for cooking meals under the GSFP and (2) assess the hygienic conditions under which food is cooked and served to the pupils. This study was part of a project to investigate the nutritional quality and safety of meals served under the GSFP in Wa and Cape Coast municipal schools in Ghana.The study was conducted in two major capital towns, Wa and Cape Coast in the Upper West and Central Region of Ghana, respectively. The choice of schools for the study was based on Ghana population and housing census 2010  data thaThe target population included all teachers, pupils (upper primary), and kitchen staff found within schools benefitting from GSFP in the Wa Municipality and Cape Coast Metropolis. The choice of teachers, pupils, and kitchen staff, therefore, enabled the generation of first-hand information on the conditions under which food are cooked, served, and eaten under the GSFP.P < 0.05), a critical z-score of 1.96% , with 95% ± 2.58 confidence interval.A total of 720 respondents participated in the study. This sample size was computed using Graph Pad Prism Version 16, statistical software. The following parameters were used: standard normal variance . The upper primary pupils were chosen for this study because they could read and write and will better understand the questions being asked without much assistance. For the teachers and headmasters or headmistresses, each headmaster or headmistress was automatically selected from each school including a teacher specially assigned to see to the GSFP. One teacher was randomly selected from either class 5 or class 6 from each school. The total heads of schools and teachers were 60. One head, matron, or caterer in charge of cooking food for these school children was automatically selected and 3 cooks were randomly selected from each schools' kitchen staff making a total of 60 as shown in A pretested standardized validated questionnaire, consisting of closed-ended questions with multiple-choice answers and open-ended questions, was used to solicit information on the hygienic conditions of meals prepared and served to the pupils. The reliability test carried out during the pretest produced Cronbach Alpha values of ≥0.75 for all the sections. According to Pallant , CronbacAn unstructured observational guide was developed to assist in identifying hygienic practices of pupils, teachers, and kitchen staff. Data were analyzed using Statistical Package for Social Sciences software version 22.0 . DescripOf the 360 pupils studied from Wa schools, the minimum, mode, mean, and maximum age were 10, 13, 14, and 20 years, respectively; for Cape Coast schools, they were 9, 12, 12, and 16 years, respectively, as shown in Aspergillus niger from soapy water used by preschool children for hand washing. Hence, the use of communal bowl for washing bowls and hands could be a possible route for faecal contaminants to be present as much as Aspergillus which has been reported as a cause of invasive pulmonary aspergillosis [When respondents were asked who washed the bowls from which school children ate, in Wa, the responses indicated that 98.0% of the bowls were washed by the school pupils and the statement was supported by 93.0% of their teachers, while 66.7% of the kitchen staff claimed they wash the bowls for the pupils . In Capegillosis .To resolve the contradiction, field observation revealed that some of the pupils washed their bowls during break time but there were other schools where kitchen staff were also seen washing the bowls. One intriguing observation made was that, in most schools in Wa and Cape Coast, the feeding bowls were provided by the pupils except three schools in Wa where the school provided feeding bowls bought by contributions made by the pupils. Although, most of the pupils brought their bowls from the house, some were found washing their bowls after eating in the communal bowl meant for washing bowls and hands.Findings of the sources of water for hand washing and meal preparations revealed that the regular source was pipe-borne water, while others used local dug out wells. All of the respondents in Wa and Cape Coast  mentioned that they used pipe-borne water for cooking meals . Other sMost schools visited in Wa and Cape Coast had standing pipes on the school compounds from which pupils drank water. In one school in Wa, for example, parents had provided two poly-tanks which had been filled with water for pupils to drink and wash their hands. However, in another school in Wa, water had not been provided for the pupils to wash their hands or to drink and they had to buy from water vendors. They reported that the water they bought was not enough to drink, let alone to wash their hands. The insufficient water in some of the schools can compel some of the pupils not to wash their hands before eating their meal. This situation can also force the kitchen staff to reuse contaminated water for cleaning plates for eating by the pupils, and this can result in food contamination, thereby having a serious consequence on the children's health.Findings, as represented in Food service providers are sources of foodborne illness outbreaks . AccordiIt was observed that out of the 12 schools studied in Wa Municipality, 7 had their cooks wear uniforms and had their hairs also covered. The meals were dished into covered containers before sending them to the classrooms. In Cape Coast, the situation was somewhat different. Out of the 8 schools visited, only 2 had their cooks in uniforms. Most of the cooks did not cover their hair either, but when interviewed they said that they knew they should cover their hair. However, the meals were dished into covered containers before sending them to the classrooms. This is similar to a study by Monny et al.  in GhanaThe environment where the caterers cook the food was found not to be tidy. Dirty water made while cooking was also thrown in front of the cooking areas. Dirty cooking utensils were also seen piled up around the cooking areas in two of the schools, and litter was seen in the surrounding area. The presence of garbage at the place of cooking can attract more flies to the surroundings thereby increasing the chances of food being contaminated. These findings align with a study by Muide and Kuria  in KenyaIn both Wa and Cape Coast municipal schools, animals like goats, dogs, and chicken were seen roaming around some of the open kitchens. This observation was encountered more often in Wa than in Cape Coast. There were also open gutters around some of the kitchens in Cape Coast with flies in them. Two schools had their kitchens built inside the school among the classrooms and the kitchens used gas to cook. Mice were seen during the observational tour in some of the kitchens in Cape Coast Metropolis schools, but this was denied by the kitchen staff. It is important for those cooking and preparing the food to do so away from potential sources of contamination such as rubbish, wastewater, and animals .All the pupils in both Wa and Cape Coast schools had issues with food served to them. A majority (over 50%) of all the pupils in both schools complained of the meal having an offensive smell, partially cooked, presence of foreign materials, watery soup, and the color of the food not appealing. However, the response from the teachers in both schools disagreed with what the pupils reported except for the fact that they also agreed to the claim that the soup served to the pupils were light and watery .Findings in In one of the schools in Wa, almost all pupils in the upper primary rejected the food. This was because the food was not tasty according to the pupils. This was confirmed by the teachers including the head teacher, as they stated that the food served was less than what could be described as food for humans. Although the pupils rejected the food, the caterers consistently cooked the meals and this resulted in a lot of leftover foods. Where the surplus eventually ended up was unknown but it could best be guessed to end up in the homes of the cook or refuse dumps. In both Wa and Cape Coast municipal schools, none of the kitchen staff admitted that pupils and teachers ever complained about the meals they served to the pupils.This study investigated the hygienic practices by school-going children and hygienic conditions in which food is prepared and served under the GSFP. The results indicated that the majority of the pupils do not practice good hand washing. The use of communal bowl for washing bowls and hands could be a possible route for faecal contaminants, especially where outdoor latrines did not have associated hand washing facilities. The conditions under which the meals were cooked, served, and eaten were generally fair, but for a couple of schools in Wa, the conditions were poor. This paper, therefore, recommends that the government through the assembly should provide potable drinking water to the schools. This can be done through the provision of tap water or boreholes to the schools so that kitchen staff in the schools can have access to potable water. The Municipal Assembly of Wa and Cape Coast should also ensure the supply of dustbins and Veronica Bucket to the schools especially those under the GSFP to improve food hygiene and sanitation in the schools.


The purpose of the study is to evaluate a user-friendly, comprehensive, fully integrated web- and mobile-based application that was specifically developed to guide learners and help them practice and train in pulpal and periapical diagnosis.  The software was designed for assistance in the diagnosis of the pulpal and the periapical area. The software contained questions and tests, e.g., presence or absence of signs and symptoms, cold test, percussion, palpation, and radiographic examination that the user must answer to arrive at the final diagnosis. An electronic survey was prepared to evaluate the effectiveness, productivity, and accurateness of the software. The software and the electronic evaluation survey were sent by e-mail to dental students, endodontist, general dentists, and dental interns who study or work in four Saudi dental colleges. Data was analyzed using descriptive statistics.  A total of 203 questionnaires were completed. Results showed that 29% of the participants were highly satisfied with the software; 40% gave a very good rating about the application satisfaction, while only 2% reported a poor degree of satisfaction with the software. Results also showed that students accurately selected the correct diagnosis but received relatively low diagnostic proficiency scores because they did not request diagnostic data in a pattern similar to experts.  In conclusion, the software is promising as an effective and efficient tool for teaching and assessing the diagnostic skills of learners. The importance of advanced diagnostic skills in the practice of endodontics has been underscored in the 2008 AAE-sponsored symposium on endodontic diagnosis . The diaEndodontic diagnosis is similar to a puzzle, in that diagnosis cannot be made from a single, isolated piece of information . The cliDiagnostic skills need practice, training, and experience to develop. Educators and instructors have the responsibility of providing as many experiential opportunities to allow learners  as necessary for them to gain confidence. However, the limited number and variety of clinical experiences a student is exposed to during their education makes it difficult to gain efficiency and expertise. Dental students in most dental schools have a few years of supervised clinical patient treatment, which may not be sufficient to see enough cases to the level of proficiency. As for other learners (practitioner), an expert consultation might not be at hand.Computer-Assisted Learning (CAL) or Computer-Assisted Instruction (CAI) has become a popular method to provide information to students, patients, and practitioners. . CAL hasThe purpose of the study is to evaluate a user-friendly, comprehensive, fully integrated web- and mobile-based application that was specifically developed to guide learners and help them practice and train in pulpal and periapical diagnosis.An English language web-based mobile endodontic and periapical diagnosis training application was developed using JQuery Mobile Web framework and JavaScript technology platforms. The mobile iOS application was developed to serve as an adjunct to the process of learning. The application could be used as a decision support aid using real case scenarios, or a training tool with multiple case scenarios imbedded. The requested data fields included the affected tooth number , extraoral and intraoral clinical examination questions, presence or absence of signs and symptoms, cold test results, percussion, palpation, periodontal probing, and radiographic examination. A decision tree with specific treatment options was structured; then definite outcomes and probabilities to occur were determined. Finally, the most preferable treatment was estimated by computed calculations. The software also suggested treatment options and predicted prognosis. There was an option to upload radiographs either directly from the phone camera or scanned and uploaded to the application. Each user could log in using his/her own username and password to the system then upload patient personal data, affected teeth, and signs and symptoms that were collected from the patient; then the program gave a diagnosis and suggested treatment options for the case according to the information analyzed by the program. This application was developed to work with numerous decisions related to patient's signs and symptoms included in the design.The researchers visited 4 dental schools to introduce the application (King Saud University-College of Dentistry (KSUCD), Riyadh Al-Elm University-College of Dentistry (REUCD), Imam Abdulrahman University-College of Dentistry (IAUCD), and King Abdulaziz University-College of Dentistry (KAUCD) at the beginning of the school year through a short presentation. All dental students, interns, general dentists, endodontic board residents, and endodontists were asked to participate in the study. Names and emails of all interested participants were collected during the introduction, and the application was sent by e-mail to 408 potential participants with a link to download the software and instructions explaining its benefits and usage.A feedback survey was developed that consisted of 20 close-ended questions, and 3 open-ended questions were included in the application . A preteA 5-point Likert scale with 5 = excellent and 1 = poor was used. Data were entered and analyzed using SPSS PC+ 16.0 version statistical package. Descriptive statistics were analyzed.A total of 203 questionnaires were completed  resulting in a 50% response rate. Distribution according to levels is shown in Most of the participants (43%) found that it is easy to learn how to use the application, whereas only 1% found it difficult. The visual appeal was reported as excellent by 41% of the participants. However, only 42% found the organization of the information and terms used in the application very good. More than half (54%) of the participants reported that it is easy to use the application. Approximately 43% of the participants thought that applications such as this one was reliable, whereas only 1% found it was not. Regarding effectiveness, 41% found the application very effective, whereas only 3% did not. Out of the sample participants, 40% said the application had a very good effect on their productivity after use. More than half (64%) of the participants stated that the diagnosis provided was accurate, when used in case scenario mode. However, in comparison to traditional (paper-based) systems used to assist in the diagnosis procedure, 90% reported that the use of the application is better. Two-thirds (68.5%) of the participants confirmed that there is a high or very good chance to use the software in the future, while only 7% reported that there is a poor chance of using the software in the clinic.Overall, 29% of the participant were highly satisfied with the software; 40% gave a very good rating about the application satisfaction, while 2% reported a poor degree of satisfaction with the software. Satisfaction rate of the software is shown in Endodontics practice requires knowledge and problem-solving skills in order to derive an accurate diagnosis, treatment plan, and patient prognosis . TreatmeIt is a personal and cognitive experience, and many of the qualities of a good diagnostician are of an interpersonal nature and are based on interest, intuition, curiosity, and patience. Other skills the diagnostician must master include knowledge and experience. Knowledge is the most important asset the dentist must possess via complete understanding of basic information regarding diagnosis of pulpal pathosis, ability to formulate the right treatment plan for each case, and evaluating the given treatment and expected prognosis. Diagnosis can be difficult, and it is necessary to obtain a differential diagnostic approach. The decision to undertake root canal therapy should not be made in isolation. Patient considerations including medical conditions, physical impairment, and motivation to maintain oral health must be taken into account .Historically, there have been a variety of diagnostic classification systems advocated for determining endodontic disease. In 2008, the American Association of Endodontists  standardThe present study described a mobile web software application that has been created to be used for endodontic diagnosis training. Benefactors can include dental students, interns, and general dentists who need help with additional practice in diagnosing patient endodontic problems. The simulated program assesses diagnostic proficiency and accuracy (through choice of correct answers) by comparing it to an expert diagnosis. The software guides the learner through the sequence of patient data requests to arrive at a diagnosis. It is important to evaluate software developed for this kind of training to make sure participants are likely to use it. It must be easy to learn and easy to use, visually appealing, and organized in a clear way. Even though working with e-learning has been shown to lead to better decision-making skills , 16, parThere is some evidence to suggest that CAL is time efficient compared to traditional methods . EndodonThere are many benefits to extending the use of such software. Information can be easily uploaded and programmed to serve as case database and can be continuously updated and shared to be used by all. Engaging students in the creation of content can be a good way to help faculty cope with the increasing demand for learning material . It is rDespite the limitations of the study, evaluation of the e-learning platform as provided in the application developed for this study was positive and seemed helpful in motivating learners practice clinical decision-making in self-directed manner.


COVID-19 has been declared a worldwide emergency and a pandemic by the World Health Organization. It started in China in December 2019, and it rapidly spread throughout Italy, which was the most affected country after China. The pandemic affected all countries with similarly negative effects on the population and health care structures.The evolution of the COVID-19 infections and the way such a phenomenon can be characterized in terms of resources and planning has to be considered. One of the most critical resources has been intensive care units (ICUs) with respect to the infection trend and critical hospitalization.We propose a model to estimate the needed number of places in ICUs during the most acute phase of the infection. We also define a scalable geographic model to plan emergency and future management of patients with COVID-19 by planning their reallocation in health structures of other regions.We applied and assessed the prediction method both at the national and regional levels. ICU bed prediction was tested with respect to real data provided by the Italian government. We showed that our model is able to predict, with a reliable error in terms of resource complexity, estimation parameters used in health care structures. In addition, the proposed method is scalable at different geographic levels. This is relevant for pandemics such as COVID-19, which has shown different case incidences even among northern and southern Italian regions.Our contribution can be useful for decision makers to plan resources to guarantee patient management, but it can also be considered as a reference model for potential upcoming waves of COVID-19 and similar emergency situations. COVID-19 is a disease that was reported in Wuhan, China in December 2019 . The virThe virus also spread in other countries across the world with different modalities and aggressiveness. During its first wave, from March to May 2020, Italy had the second highest number of patients who were infected. All countries reported difficulties in answering to the high number of requests for ICU beds and reliable detection of the real infection numbers. In countries where the virus spread later with respect to Italy, such as the United States, France, Spain, and other European countries, it diffused with similar trends but with different absolute numbers, as reported by the World Health Organization ,8-13. NeRegions such as Lombardia in the north of Italy have been strongly affected by COVID-19, and it seems that this is due to a large number of patients who were asymptomatic already in the middle of January 2020 and late adoption of containment measures such as limitation of circulation and delay in applying rules such as smart working -17.We focus on the problem of rapidly estimating resources during the exponential phase of the COVID-19 emergency, in particular, being aware of the differences among regions in terms of health structure resources such as ICU beds. We show how the proposed model scales at the regional level and how it can help decision makers plan expansions of resources near saturation or reroute patients to neighboring regions.The prediction of COVID-19 diffusion is a relevant problem, and it has been discussed in other papers -20. SomeThe model presented here has been assessed comparing the simulated and predicted resource values with the measured ones. The rapid diffusion trend in high-income countries’ populations and in cities with high density stressed the health structure in many countries. Indeed, a small portion of patients with COVID-19 require ICU admission. The exponential diffusion in terms of an increased number of infections per day required a larger number of ICU beds than the ones available. We report our model as being scalable at both the regional and subregional levels. We claim that it can be used in different countries and in future contexts where virus diffusion will require well-planned health resource management ,25.The paper is structured as follows. The Methods section reports the proposed assessed model and the Italian infection data. The Results section reports the application of the model on three sample regions out of 20, Lombardia (north), Toscana , and Sicilia (south). The Discussion section reports on the limitations of this study and comparisons with other work. However, our model is general enough to be successfully applied to other pandemic situations in other contexts.Italy was affected by COVID-19 by the end of January 2020, starting from northern regions such as Lombardia and Veneto. By the end of February, the increasing trend of infection numbers per day obliged the governments at the regional level—and at the national level starting on March 10–to introduce containment measures.For example, on March 26, 2020, in Italy, we had 24,747 total reported COVID-19 infection cases, of which 20,603 had the disease, 1809 had died, and 2335 had recovered from it. Regarding patients who were infected, 9268 were treated in their homes since they did not have severe illness, 9663 were hospitalized, and 1672 were admitted to ICUs. The trend continued increasing until April 19, 2020, which has been the peak of COVID-19 infections in Italy.In reaction to the exponential growth of patients who are infected that require hospitalization, one possible measure adopted by many countries has been to build emergency hospitals dedicated to patients with COVID. In Italy, one strategy consisted in improving existing structures by extending the number of ICU resources and beds, and using dedicated health structures. For example, one study  focuses Italy has approximately 5200 ICU beds in total, which have been dimensioned by design to be equal to 80% of their average occupancy at any given time. In addition, they are allocated at a regional level proportional to the local population and are usually managed locally. Because of ICU bed limitations, many patients have been moved from ICUs to subintensive units or to other regions to free up spaces. Indeed, ICU slots are often used for treating postsurgery patients and patients affected by pulmonary diseases. At the date of the peak , almost 2635 ICU beds were occupied, 108,257 infections were confirmed by swab tests, and 25,033 patients had recovered without using ICU beds. Thus, most of the infections were asymptomatic, and patients quarantined at home. Even if the number of required ICU beds is less than the total number of available ICU beds in Italy see , the infThus, performing a flexible and reliable model that can predict and control resource requirements and distribution at a regional scale is required. The number of patients in the ICUs is also related to the requests of other clinical units such as emergency units for non–COVID-19, but still serious, diseases .Moreover, considering that the average survival time for patients with COVID-19 that die has been measured to be approximately 10 days after ICU admission, the need to plan resources is urgent. It may involve making new ICU beds and planning logistics to move patients among regions or to optimize the grouping of patients with COVID-19 in dedicated health structures. It is trivial that such a decision must be based on the correct estimation of ICU beds that are occupied by patients, but this estimation is still a matter of discussion .We report here the description and assessment of the proposed model by using Italian cases.We start by considering a time window of six consecutive infection values (one reading per day) from the official Italian COVID-19 data set. We then calculate an exponential fitting function for these values, since we know that the viral phase follows an exponential growth., where x is time  and y is the number of infections. We use the calculated fitting equation to predict the number of patients infected with COVID-19 for the succeeding days; for the first time window, we predicted 1086 total infections on the seventh day. We compared the predicted value with the observed infections  from the data set, and we calculated the difference and the percentage increase, which will be useful during the assessment phase. We then proceeded by extending the time window by 1 day, and we redid all the steps .In To assess the precision of the first step, we considered the calculated percentage increase between the predicted values and the observed ones. As reported in In the second step, we consider the number of occupied ICU beds as a function of the number of COVID-19 infections. In this case, we adopted the weighted average as a fitting function. For each time window  is considering a time window in which ICU resources are surely available with respect to the requests. For instance, we performed experiments that modeled the nonexponential infection phase with a Verhulst logistic model, but again, when there is no emergency, the ICU predictions are not useful since resources are largely available.The final goal is to predict the number of future beds needed in the ICUs as a function of the level of infection in a given region. The ability to predict future resource occupation can be a powerful and useful tool for local decision makers with the responsibility of managing and optimizing clinical resources during the emergency.We report the application of the presented model for three Italian regions: Lombardia, Toscana, and Sicilia, which represent a balanced sample of northern, central, and southern Italian regions. We extracted and transformed the relevant data from the official Italian COVID-19 data set and considered the total number of patients who were infected and the ICU beds occupied by patients with COVID-19 reported by the various local health structures.In the data set, we have 17 total features  and one reading per day for each region. We selected the features of interest and aggregated the tuples by region before estimating the prediction model parameters. For each region, we considered the number of infections, and we calculated an exponential fitting equation. By using such an equation, we were able to estimate the number of patients who will be infected in the succeeding days. We then considered the relation between ICUs and infections, with which we can use the predicted infection levels to estimate future values of ICU and resource occupation. These predictions can be a valuable tool for rapidly planning ICU resources in case of shortages during clinical emergencies in general, for instance, by reallocating patients in other regions with lower levels of ICU occupancies.In Similar to the Lombardia region, we report the application of the proposed model to COVID-19 infection data and resource necessity prediction for both the Toscana and Sicilia regions . ,28. 12,2The COVID-19 pandemic has been characterized by the rapid spread of an aggressive virus, which has stressed the health system. We think that patient management is strictly related to the ability of health structures to deal with this kind of disease, which requires nonstandard protocols such as the use of respiratory devices. We think that, by using a scalable predictive model at regional and district levels, the granularities may support decision makers  in better managing the emergency.The COVID-19 pandemic has reached different regions in various countries worldwide. Furthermore, it is expected that the virus will cyclically reappear in the near future. To this end, the proposed model could be applied during these new outbreaks and as a decision support tool in other similar pandemics or situations where resource prediction is necessary.