Well-organised and managed workplaces can be a source of wellbeing. The construction, healthcare and information and communication technology sectors are characterised by work-related stressors  which are associated with poorer mental health and wellbeing. The MENTUPP intervention is a flexibly delivered, multi-level approach to supporting small- and medium-sized enterprises (SMEs) in creating mentally healthy workplaces. The online intervention is tailored to each sector and designed to support employees and leaders dealing with mental health difficulties (e.g. stress), clinical level anxiety and depression, and combatting mental health-related stigma. This paper presents the protocol for the cluster randomised controlled trial (cRCT) of the MENTUPP intervention in eight European countries and Australia.Each intervention country will aim to recruit at least two SMEs in each of the three sectors. The design of the cRCT is based on the experiences of a pilot study and guided by a Theory of Change process that describes how the intervention is assumed to work. SMEs will be randomly assigned to the intervention or control conditions. The aim of the cRCT is to assess whether the MENTUPP intervention is effective in improving mental health and wellbeing (primary outcome) and reducing stigma, depression and suicidal behaviour (secondary outcome) in employees. The study will also involve a process and economic evaluation.At present, there is no known multi-level, tailored, flexible and accessible workplace-based intervention for the prevention of non-clinical and clinical symptoms of depression, anxiety and burnout, and the promotion of mental wellbeing. The results of this study will provide a comprehensive overview of the implementation and effectiveness of such an intervention in a variety of contexts, languages and cultures leading to the overall goal of delivering an evidence-based intervention for mental health in the workplace.Please refer to Item 2a and registration ISRCTN14104664. Registered on 12th July 2022.The online version contains supplementary material available at 10.1186/s13063-023-07537-0. Mental health difficulties and disorders in the workplace severely impact businesses through absenteeism/presenteeism, decreased productivity, workplace accidents and even self-harm and suicide . EmployeCertain workplace-related factors may contribute to the development, exacerbation and maintenance of mental health difficulties. For example, an association with the risk for depressive disorders has been found for the combination of high demands and low control , for theAccording to a systematic meta-review, there is moderate evidence that workplace factors such as high job demands, low job control, role stress, bullying and low social support can be associated with a heightened risk for the onset of negative mental health outcomes . WorkplaThe literature on workplace mental health interventions indicates that a multi-level approach which encompasses the organisational level and the individual level can be successful in reducing burnout –29, anxiIn addition to a multi-level approach, interventions that are tailored to the needs of the specific workplace or sector have the potential to be more effective . This inWell-organised and managed workplaces can be a source of wellbeing –46. TherThe MENTUPP workplace intervention targets clinical mental disorders (depression and anxiety disorders), non-clinical mental health problems  and mental health stigma and supports positive mental wellbeing by adopting the multi-level approach. The MENTUPP intervention aims to protect mental health by promoting mental health in the workplace (primary prevention), reducing work-related risk factors (secondary prevention) and targeting mental health problems as they develop (tertiary prevention)  by proviThe overall goal of the MENTUPP intervention is to improve mental health and mental wellbeing in the workplace, with secondary aims of reducing stigma, depression and suicidal behaviour by providing tailored mental health promotion materials for the construction, healthcare and ICT sectors. MENTUPP provides SMEs with easily accessible tools for leaders and for employees that make it possible to address mental health issues on the workplace-level and the employee level.Based on the results and experiences of a pilot study , 54, theThe manuscript has been developed in line with the SPIRIT reporting guidelines .A cRCT will be conducted with SMEs in two conditions, intervention and control, within each of the three sectors: healthcare, construction and ICT. Quantitative and qualitative evaluation data will be obtained and guided by the RE-AIM framework  and the Organisations that fit the criteria of being an SME will be invited to participate in the study. SMEs are defined as organisations with fewer than 250 employees . A smallIndividuals will be eligible to participate in the MENTUPP intervention if they are (1) full- or part-time employees, including contractors, supervisors and individuals on sick leave or other types of authorised leave (e.g. maternity or care leave); (2) employed within an eligible SME in the construction, healthcare or ICT sector; (3) aged 18 years or older; and (4) willing to give their informed consent for participation. Any individual within an organisation who has any type of managerial or leadership role will be referred to as ‘leader’ in the MENTUPP project.t-test with a significance level of 0.05.In each of the nine countries, local research officers will use convenience sampling to recruit a minimum of two SMEs in each of the three sectors, yielding a total of at least 54 participating SMEs, half for intervention and half for control. An average of 65 participants per SME will be recruited at baseline. Allowing for an estimated attrition rate of 65%, based on the pilot study and previous literature , 61, thiThe MENTUPP intervention has been developed and designed to improve mental health and wellbeing and reduce stigma in the workplace and is facilitated through the MENTUPP Hub, an online platform that presents interactive psychoeducational materials, toolkits and links to additional resources  expected as a result of the intervention . An overThe outcome evaluation will examine the effectiveness of the MENTUPP intervention to generate the expected proximate, intermediate, and long-term outcomes. For the economic evaluation, a range of costs will be measured in addition to the proximate, intermediate and long-term outcomes. Participants will be invited to complete the six validated questionnaires and bespoke survey measures at three time intervals: baseline, 6-month follow-up and 9-month follow-up.Mental wellbeing and quality of life: The World Health Organisation – Five Wellbeing Index (WHO-5) Depression: Patient Health Questionnaire (PHQ-9) Anxiety: Generalized Anxiety Disorder Scale (GAD-7) Depression Stigma: Depression Stigma Scale (DSS) Burnout: Burnout Assessment Tool (BAT) Presence (level) of psychosocial risk factors, work resources and stressors: 19 items selected from the Copenhagen Psychosocial Questionnaire, Version III (COPSOQ-III) Six validated instruments consisting together of 61 items for the outcome evaluation will be administered to participants:Two bespoke surveys, a pre- and post-intervention survey, will be used to measure various aspects related to the outcome, process and economic evaluation of the MENTUPP intervention. The pre-intervention survey will be conducted with all participants at baseline and consists of 34 items: sociodemographic and work-related information, experience with mental health difficulties, initial expectations and intentions with regard to MENTUPP, presenteeism and absenteeism, healthcare and mental healthcare use, and proximate and intermediate outcomes of the MENTUPP intervention. The post-intervention survey is conducted with all participants at 6-month and 9-month follow-up and consists of 28 items and overlaps largely with the pre-intervention survey. Data are collected related to the following themes: experience with the MENTUPP Hub, experience with mental health difficulties, presenteeism and absenteeism, healthcare and mental healthcare use, and proximate and intermediate outcomes of the MENTUPP intervention , a monitoring instrument, user data of the MENTUPP Hub users, and a focus group with the local research officers.A monitoring instrument developed by the MENTUPP consortium will be used to collect information from each of the participating SMEs in close consultation with the main contact person or designated ‘Champion’ to inform the process evaluation. The instrument will track relevant information related to the process evaluation. Information about the organisation at the time of recruitment, including information about mental health-related activities and mental health support for employees in the organisation at the time of recruitment and after implementation of MENTUPP, will be gathered in the monitoring instrument. Furthermore, information on the implementation of MENTUPP in the organisation (events and activities that may impact implementation) and cost-related outcomes at the level of the SME will also be collected.Pseudonymised log data of the MENTUPP Hub will be extracted at 6-month and 9-month follow-up as part of the process evaluation (feasibility and reach) to provide detail on the intensity and frequency of the use of the MENTUPP Hub online platform.After the 6-month follow-up, focus groups with local research officers in each country will be conducted to collect more in-depth qualitative information with respect to the implementation process, appropriateness, feasibility, and maintenance of the MENTUPP Hub. During the focus group the following topics will be discussed: experiences regarding the recruitment and participation at the SME and employee level, experience with the implementation process of MENTUPP in the SMEs, country, sector specific characteristics, online format of MENTUPP and barriers and facilitators to implementation.For the economic evaluation, the six validated scales, the two self-developed surveys, the monitoring instrument and the log data of the MENTUPP Hub users will all be used to conduct a cost-effectiveness and cost-consequence analysis. Costs will be monitored in relation to conducting e-mental health tools and printing of leaflets and posters in all recruited SMEs. Costs in terms of productivity will be monitored via productivity/SME economic and employee turnover, absenteeism and presenteeism in the intervention and control SMEs. Absenteeism will be assessed by both self-report using customised items deduced from the iMTA Productivity Cost Questionnaire  and the Qualtrics , a GenerThe outcomes gathered from the six survey measures will be analysed in linear and logistic mixed effects models. The analyses will incorporate baseline and both follow-up timepoints. Changes to the outcomes will be assessed between the intervention and control groups in these models. Furthermore, descriptive analyses will be conducted on baseline characteristics and both follow-up characteristics to understand the findings from the mixed effects models. Differences between countries will be analysed in accordance with the Aspen/Indigo study .Descriptive statistics will be used to analyse numeric data of the process evaluation collected via the monitoring instrument, the bespoke surveys and the user data. Qualitative data coming from the focus groups and the monitoring instrument (open text fields) will be analysed thematically. Data gathered via the focus groups with research officers will be audio recorded, transcribed, translated to English where necessary and analysed via thematic analysis. The process evaluation will be informed by the framework based on the three themes of implementation, mechanisms and context .Adherence data are collected in the intervention group in three ways: via the pre-intervention survey, the post-intervention survey and the log data of the Hub. The pre-intervention survey asks participants to indicate whether they have positive expectations about the intervention at start and are intending to make use of the intervention. In the post-intervention survey, respondents are asked to indicate how much time they spent in the past months on MENTUPP-related activities. Finally, the log data of the Hub allows tracking which respondents registered for the Hub, how many times they visited the Hub, how much time they spent on the Hub and how their Hub visits are spread in time during the implementation period. Exploratory analyses will be conducted on the adherence data and results on the intention of respondents to adhere to the intervention at start, the amount of adherence during the intervention period and subsequent withdrawal from the intervention will be reported in accordance with the 2010 Consolidated Standards of Reporting Trials (CONSORT) statement.A cost-consequence analysis will be conducted to compare differences in costs and outcomes between the intervention and control groups to be calculated; this allows the costs of delivering and implementing MENTUPP to be compared with the different measures collected in the outcome evaluation. Multiple incremental cost-effectiveness ratios comparing costs with different outcome measures can then be determined.Three perspectives will be used in the economic evaluation: an employer perspective, a healthcare perspective and a societal perspective. The employer perspective considers the costs of mental health issues that are borne by the employer in terms of productivity loss as indicated from data from the surveys. The costs of implementing the intervention will be calculated from the surveys, the monitoring instrument, and the log data from the MENTUPP Hub users. The healthcare perspective only includes costs that are expended on healthcare services funded by the health system and will be analysed based on usage of data from the surveys. The societal perspective includes all costs borne by the whole of society, including productivity costs or other costs not borne by the health system or the employer. This will include data from the surveys, the log data from the MENTUPP Hub, and the monitoring instrument to consider time investment and routine rather than research-related travel costs associated with implementing MENTUPP.Data on the resources required to develop and implement MENTUPP are being collected and appropriate unit costs will be attached to time and materials used. Bespoke questionnaires have been designed to collect data from individual participants in the two arms of the trial on health service use at baseline, 6-month and 9-month follow-up periods; this will be compared with outcome data collected for these individuals over the same time periods. Data on changes in workplace productivity, including absenteeism and presenteeism are also being collected. Country-specific unit costs for healthcare service use, as well as country and industry-specific hourly wage rates, will be applied to all service utilisation and productivity impacts. To allow for multi-country comparison, final costs across countries will be converted into purchasing power parity adjusted international dollars for a common price year using the Campbell-Cochrane Economics Methods Groups EPPI-Centre Cost Converter .Differences in mean costs will be compared between the two arms of the trial using bias corrected and accelerated bootstrapping. Incremental cost-effectiveness ratios (ICERs) per change in each of the six main outcomes will be calculated at 6-month and 9-month follow-up points. Statistical uncertainty will be explored through bootstrapping 5000 randomly resampled pairs of costs and each of the six outcomes and cost-effectiveness planes will then be drawn.Primary statistical analyses will be run on an intention-to-treat basis, whereby all participants are included according to their group allocation and irrespective of their adherence to the intervention. Secondary analyses will be performed to account for non-adherence to the intervention. Per-protocol analyses will be run, excluding participants from the intervention group who spent hardly any time on the Hub (e.g. visited the Hub only once). In additional analyses, adherence scores will be entered either as a categorical or continuous factor in the statistical analyses  to identify whether non-adherence or low-adherence alters the outcomes in the intervention group. At follow-up, we expect quite a bit of dropout and thus missingness of data with respect to the primary and secondary outcomes. Based on inspection of the data , the most appropriate approach for handling missing data  will be chosen as no additional outcome data will be collected from participants who have withdrawn.Ethics approval has been received from the institutional ethics committee from each of the local research officer’s institutions and the trial is registered with ISRCTN clinical trial registry (ISRCTN14104664).The duty of care protocol and standard operating procedures for local research officers established and used in the pilot study will be applied in the cRCT . ContactData management and analysis will be controlled by MENTUPP consortium partners based at KU Leuven. The lead investigators of KU Leuven are responsible for developing and updating the data management plan, monitoring the implementation of the data management plan and managing the multi-country datasets. The Data Protection Officers of KU Leuven and UCC are responsible for the data security and privacy protection. KU Leuven is not involved in implementing interventions and collecting data and is only involved in accessing and analysing pseudonymised data. A Joint Data Controller Agreement was signed between members of the MENTUPP consortium to uphold their mutual roles and responsibilities. The use and transfer of participant data is covered by the EU GDPR, 2016 that ensures the protection of an individual’s privacy. Personal data will be collected as part of the informed consent process; however, the data will be stored separately from the evaluation data and will not be shared or reported outside the research team. A unique identification code will be generated for each participant  and willThe data collected during this trial will be analysed and reported in peer-reviewed publications and at conferences for academic and experts in the area of occupational psychology, workplace mental health and implementation science, and in webinars/blogposts for the public. Peer-reviewed publications will be prepared in line with the MENTUPP Publication Policy. Where possible, feedback will be provided to each SME based on the findings relevant to their own organisation, country and sector, provided there is an adequate sample size. The findings will also be reported back to the funding agency.The MENTUPP intervention employs a multi-level approach targeting employees and leaders within an organisation and the organisation as a whole. The materials presented through the MENTUPP Hub are designed to support SMEs in promoting mental health in the workplace for the construction, healthcare and ICT sectors, which have been associated with significant and specific workplace stressors –83. AlthThe results of this study will provide a comprehensive overview of the implementation of such an intervention in eight European countries and Australia. The MENTUPP project will not only provide an evidence-informed, tailored intervention for employees and employers of SMEs but will also provide a thorough evaluation regarding implementation processes, effects and economic impact and thereby, provide results about mental health outcomes, the associated costs and benefits, as well as a better understanding of the barriers and facilitators to using these tools in real-life settings across the healthcare, construction and ICT sectors.This study has several strengths. Firstly, a pilot study was conducted in the same countries prior to conducting the cRCT, and thus the implementation and evaluation of the intervention has been ecologically validated. The MENTUPP intervention, as well as the implementation and evaluation strategies, has been optimised based on a systematic review and discussion among Consortium members and external stakeholders of the experience of conducting the pilot study. The visual prompts within the intervention have been enhanced and the intervention content has been refined based on feedback received during the pilot study. The implementation process has been improved by simplifying the registration procedure, which was identified as a significant barrier for participation during the pilot study. Furthermore, the evaluation strategy has been refined to reflect the core research questions and reduce the number of questions, which will improve participant experience. Moreover, a comprehensive ToC has been developed that describes in detail how we assume the intervention to work, under which conditions and what kind of changes we expect to see on the different organisational levels in the short, intermediate and long term .The present study will contribute to the advancement of workplace mental health intervention programmes by designing an evidence-based and pilot-tested intervention based on implementation facilitators identified in the pilot study. This resulted in an optimised intervention and implementation strategy that adopts a flexible approach to the implementation of the intervention, which has been shown to be a facilitator to successful implementation in the literature , 86. ThiApproximately 50% of an individual’s waking hours are spent working and this can be much more for some sectors, namely the construction, healthcare and ICT sectors –89. ThisThe intervention is available in eleven languages at present to ensure delivery to individuals in a language that most people are familiar with. This increases the likelihood that the intervention will be available to all employees of an organisation in their preferred language. Access to content in their preferred language also allows employees to relate to the intervention material and contributes to reducing stigma that can often be present in relation to help-seeking and support. This is particularly useful for employees in the construction sector who are known to be a mobile workforce. Finally, the evaluation strategy involves the use of well-standardised, internationally used measures of mental health and wellbeing and psychosocial workplace risks. The various measures will provide an accurate assessment of the outcomes experienced by participants and within organisations.Some of the limitations associated with the study relate to the current challenging times, including the COVID-19 pandemic , increase in the cost of energy and the crisis in Ukraine (particularly for bordering European countries). These challenges may inhibit an organisation’s ability to opt into and adhere to the intervention and are outside the researchers’ control. However, the research team has attempted to alleviate these challenges by facilitating access to the intervention in a self-paced manner for workers to access in their own time, by presenting relatable material on the pandemic and tips on how to cope during the pandemic. The intervention has also been translated to the Ukrainian language to accommodate workers who may have been displaced due to the war.The participation of SMEs and participants within SMEs is voluntary, which may cause self-selection bias to the study whereby SMEs and participants who already have an inherent interest in mental health may choose to participate. Self-selection bias into the study may limit the external validity of the study and limit the generalisability of results. However, very few research projects about mental health have been conducted in the construction industry. Therefore, even if the more interested workplaces select themselves into the study, it will be an improvement to document experiences from this sector which will help with future initiatives. Furthermore, the extensive process evaluation will nevertheless give us rich knowledge about these workplaces that will help to understand what is needed to also reach less motivated workplaces. Self-report measures employed to capture any potential change to mental health outcomes may also be influenced by response bias. As outlined above, the flexible approach to the trial may result in some variability in the reach and the implementation of the intervention in SMEs. However, this flexibility is an integral part of the study and considered a strength when applying interventions in real-life conditions.The MENTUPP intervention is a multi-level, tailored, flexible and accessible workplace-based intervention designed to support SMEs in promoting and protecting mental health and wellbeing in the workplace, specifically for the construction, healthcare and ICT sectors, which have been associated with significant and specific workplace stressors. The results of this study will provide insight into the effectiveness, as well as the process and economic evaluation of the MENTUPP intervention in nine countries.Additional file 1.Additional file 2.


This study aimed at assessing the extent to which the general Saudi population has embraced digital health medical applications to meet their health-related needs so that the Saudi Ministry of Health and government can appropriately be guided on scaling up digital health across the country. As such, this study was guided by the question of to what extent the Saudi people use digital health mobile-based applications. This was a cross-sectional study utilizing snowballing sampling approach. Frequencies, Chi-square, and Spearman rank correlation statistics were used to offer descriptive and inferential analysis of the variables. The majority of the participants were economically able to afford smart devices that have medical apps, had at least an app on such devices, and highly regarded the benefits of the apps. Unfortunately, their understanding of how to use such apps was limited, and this posed a barrier to embracing digital health alongside difficulty downloading apps and medical ethical concerns. Although there is a willingness, extra effort is needed from the Saudi Ministry of Health and the government to promote the uptake of digital health in Saudi Arabia. The use of digital information electronically transmitted, stored, and obtained to promote health-related activities and services has been encouraged by the world health organization . As suchMoreover, properly applying the approaches of digital health and medical applications can also improve access to high-quality and costly approaches that can improve outcomes ,8. MobilAttitudes toward the use of digital healthcare and medical applications are markedly affected by individuals’ knowledge and awareness . There aAn analytical cross-sectional study was conducted between October and December 2021 in Saudi Arabia.All people in Saudi Arabia aged at least 15 years old and having a smart device at the time of data collection were eligible to participate in this study. A snowball approach of sampling was used to identify participants. Any person with a link was urged to send it to a friend(s). Opening the link and filling in the questions in the link implied informed consent to all participants.Data were collected using a researcher-designed survey. A link to the survey was shared by the researchers to all their friends, and they were encouraged to share it with as many people as possible across the country. The sharing of the link was through Facebook, Twitter, Instagram, LinkedIn, and WhatsApp. A pre-coded pre-tested questionnaire done specifically for this study contains background questions in addition to other close-ended questions that can investigate awareness and attitudes toward digital health and medical applications. The participants had to answer multiple questions, including demographic factors and questions related to the study objectives. Five different items on the questionnaire measured the knowledge and awareness of the participants. Questions developed regarding knowledge include (1) the number of medical applications that have been downloaded on the mobile device, (2) how much the participant knows about medical applications, (3) the number of official Saudi authorities’ applications that have been used, (4) and whether they faced any difficulties while completing the data in the application. Awareness questions included (1) whether the subjects had heard of digital health, (2) the number of medical applications on the device, (3) how much they know about smart devices’ medical applications, (4) whether they have benefited from those applications in medical uses and situations, (5) and whether they agree that using medical applications on a smart device is necessary.p < 0.05.Data were entered, coded, and processed using Microsoft Excel and the software Statistical Package for Social Science (SPSS) (Version 23). Descriptive statistics were generated for all variables. A correlation was computed to investigate if there was a statistically significant association between participants’ educational level, number of apps on their devices, and knowledge of smart devices medical apps. All the data were ordinal; thus, Spearman rank correlation statistic was calculated. A Chi-square test was run to determine whether there was a significant difference in using medical apps among participants of differing characteristics. All statistical tests were considered significant at Ethical approval was obtained from Almaarefa University, Riyadh, Saudi Arabia. Confidentiality and anonymity were maintained throughout the study, and the collected data were only used for the purposes described in the study objectives.As indicated in r (507) = 0.178, p = 0.000. The direction of the correlation was positive, meaning that highly educated participants tend to have more knowledge about smart devices and medical applications and vice versa.X2 = 4.97, df = 1, N = 736, p = 0.026).As far as the benefits of using medical applications are concerned , most ofWhile the majority of the participants reported having no barrier to the use of medical applications on their smart devices , the thrAs electronic health records gradually replace paper-based methods in healthcare, the manifestation of such changes needs to be assessed in Saudi Arabia. While evidence shows that Saudi Arabia has adopted electronic health records ,17,18, tIn this study, most participants had at least a medical app on their smart devices. In a previous study, Atallah et al. reported similar findings about mentally challenged people ; each ofThe majority of the participants in this study largely believed that the medical apps were good. However, they reported having little knowledge about the use of these medical apps. The knowledge of medical applications was affected by the education level of the participants. The study findings show that the participants who were more educated were more likely to understand medical apps compared to those who were less educated. On the contrary, the majority of the participants were above college-level education, yet, with little knowledge. Implying that other factors could have been responsible for this observation that the study did not explore well.It is important to note that most of the participants had never suffered from any chronic illnesses, were not taking regular medicines, never faced a medical condition requiring urgent intervention, and had never been in a situation of using medical applications to know the medical history for the sake of saving an injured person. Subsequently, the correlation statistic indicated that the participants who had never been in a situation of using medical applications to know the medical history for the sake of saving an injured person used the medical apps on their smart devices less than their counterparts who had been in such a situation. As such, while it was important to understand digital health considering the general population, it is also important to note that some of the questions asked created a limitation to this study. The respondents had not much knowledge of the asked subject areas. While the majority of the participants had never heard about digital health, their major source of information was the Internet, and less health worker communication. Similarly, other studies have indicated that even among health workers, medical app utilization is low due to personal reasons . Some heDigital health education can be emphasized and enforced at the medical/health students’ training level. Or short courses can be developed to be occasionally provided to the health workers in practice. In a different way, Brown and Bewick propose engaging the end users  throughout the process of developing an app or before the formal rolling out of the app . The autThis study showed that the participants were financially stable enough to own smart devices that could accommodate medical applications. The majority of the participants were residing in owned apartments and of Villa type, and their monthly income level was between SAR 6000 and SAR 10,000. As such, one would be moved to conclude that they can afford smart devices and the costs involved with the digital health approach.The importance of digital health records has been demonstrated by many participants. Participants indicated that digital health improves the process of making the right decision, provides a faster medical intervention, and enhances communication between different healthcare teams. Similarly, studies elsewhere have pointed to digital health being of benefit to both patients and healthcare workers ,27,28. AFor the Saudi Arabia government, this current understanding is good and shows an upward trend toward the desired full penetration of digital health in the country, which was shown to be very low in 2019 . As fullThe following applications have been provided by the Saudi Ministry of Health and can freely be downloaded on any device; Sehhaty, Tawakkalna, Tabaud, Seha, Mawid, and Tataman . Most paThe commonly reported barriers to digital health were knowledge about application use, the privacy of medical data, and difficulty downloading the apps. The same barriers have been reported previously in Saudi Arabia. Aljohani and Chandra assert that for Saudi Arabia to succeed fully in digital health, the apps should be reliable enough to provide accurate and up-to-date data . AdditioThe World Health Organization asserts that embracing digital health at both local and distant levels would tremendously address and enhance the struggling healthcare systems in developing countries that have trained doctors, clinicians, equipment, and infrastructure constraints . It is bThis study obtains its strength in the snowballing sampling method that was able to reach many people with relevant information and the expert review of the proposal by the institutional review board. Unfortunately, it is limited by the lack of generalization due to the non-randomness of the sampling process and the subjective nature of the questions that would attract responses as understood by the participants. Furthermore, this research does not distinguish between respondents from urban and rural settings. Maybe such a distinction would create different findings.This study has shown that digital health among Saudis has several benefits that are on both the side of healthcare and personal health. While many participants already have medical apps on their smart devices, the current study findings indicate that there is a knowledge gap pertaining to their use. Other non-knowledge-related barriers to medical app utilization exist that make people hesitant to both have apps on their smart devices and uncomfortable using them. Given the fact that the Saudi government was at the center of the initiation of digital health in Saudi Arabia, it has an additional role in addressing the barriers hindering the understanding and use of medical apps. This study had several limitations, as indicated throughout the discussion, that make it inappropriate to generalize the results to other study settings. Additionally, further research is needed to fully evaluate the progress on digital health uptake among healthcare workers and how the healthcare workers are motivating the patients or potential patients to embrace it.


An increasing number of patients are using online information regarding medical issues; however, the Internet is not subject to content ratings or filters. Unreliable information found on the web can heavily influence patients to the extent that it can lead to wrong decisions in the choice of treatment. In our daily experience we meet more informed patients and given the increasing use of polyurethane-coated implants in breast reconstruction in Europe, we wondered about the level of information available online. Our study aims to assess the quality of information available online on breast reconstruction with polyurethane-coated implants.Assuming that the most used search engines are Google and Yahoo, we used a search strategy to identify online information regarding prepectoral breast reconstruction with polyurethane-coated implants. The selected websites were divided into 5 groups , and the quality of information was assessed by using an expanded version of the Ensuring Quality Information for Patients (EQIP) tool, which is a checklist applicable to all existing types of information.Fifty-six websites were selected and were categorized into 5 groups: 17 practitioners, 9 hospitals, 13 healthcare portals, 7 professional societies, 10 encyclopedias. The average score was 17 points (range: 12 – 25). We found 13 reliable websites with a score higher than 20 using the expanded version of the EQIP tool, whereas 43 were deemed unreliable, as they scored lower.Proper communication between surgeon and patient is crucial in the therapeutic choice, as the available online information presently is scarce and can lead to wrong decisions if not properly verified. Breast cancer (BC) is the most common malignancy in women, as reported by the World Health Organization, and its incidence is increasing yearly in most parts of the world.7Currently, immediate breast reconstruction with prosthetic devices is the most popular option after mastectomy,11The development of the prepectoral technique in breast reconstruction has allowed surgeons to solve most of these issues. But underneath it, all capsular contracture (CC) remains one of the most common complications after implant placement.Subpectoral breast reconstruction has been performed more often in the past decades; however, its downsides—animation deformity,,Polyurethane (PU) foam-coating was implemented to silicone implants over 50 years ago, aiming to reduce the risk of CC, which characterized first and second-generation implants with a smooth surface.,The web has increasingly become the main source of information for patients, with nearly half of the European population using it to find health information online; therefore, most patients with BC seek answers to their queries even before consultations with experts.However, misinformation and “fake news” are rampant, making evidence-based, reliable information more important than ever as it guides patients in the informed decision-making process. For this reason, we decided to assess the quality of patient information on the characteristics of these prostheses online. Our study aims to precisely evaluate the quality of information published on the PU-coated implants and the breast reconstruction with them.,The study was conceived in August 2023. Assuming that the most popular search engines are Google and YahooThe first part of the questionnaire focuses on the type of medical intervention, the procedures, and the services offered during hospitalization and postoperative management. It also analyzes benefits and adverse effects and risks, both from a qualitative point of view, such as the reduction of the risk of prosthetic CC, the greater adherence of the prosthesis to the surrounding tissues, the longer duration, or disadvantages, such as greater difficulty in insertion, or the extraction of the same, and the higher cost. From the “quantitative” point of view, we mean to convey data on the same subjects but in the form of numbers with statistical analysis.The second section analyzes who provides the information, who produces or promotes the documentation, whether the document is updated, and whether there is a bibliography with articles supporting the statements. The last part evaluates whether the text is written clearly, directly, and easily understandable for most users without using specialized or difficult terminology. Each question is assigned the same score of 1, thus obtaining a result between 0 and 36. A score of 20 corresponds to the 75th percentile; therefore, a website with a rating of 20 points or more is considered reliable, whereas a website with a low score is considered unreliable.Fifty-six websites were selected and were categorized into 5 groups: 17 practitioners (30%), 9 hospitals (16%), 13 healthcare portals (24%), 7 professional societies (12%), and 10 encyclopedias (18%). All of them underwent qualitative and quantitative assessment using the expanded EQIP tool. . The aveAnalysis of the identification data section showed that most websites presented a date and a logo. Almost 40% of the sites did not disclose who produced the documentation, and 93% did not disclose any source of promotion or financial sponsors. Only 13 sites reported a bibliography of reliable data used in the document. The assessment of data related to the last section of the tool is characterized by a discrepancy in the perception of benefits and risks—although the description is accurate, a lack of graphic sections and images is reported in 9 cases, which could hamper their clear understanding.Our study was conceived to analyze the quality of information available on the web about breast reconstruction with PU-coated implants, as the request for this type of reconstruction has increased by patients. The information available online on this topic is copious, and the information available on the Internet varies in quality. The analysis of the websites selected in our study showed a lack of online information, especially regarding the description of alternative procedures and the side effects of the same, managing potential complications, identifying red flags, and resolving quality of life and cost issues. Overall, only a few websites were able to expose the problem regarding the use of PU prostheses for breast reconstruction, informing readers correctly about the risks and benefits and, above all, mentioning the alternatives to them.Hospital portals have collected average EQIP values higher than the websites of operators and professional societies, with all categories lacking reliable references and often even without mentioning who produced or sponsored the document. Hospital portals had higher reliability, with 45% scoring above 20. In comparison, practitioner portal sites and encyclopedias scored significantly less. Additionally, we point out that most evaluated websites lacked information on the topics in the content data section.None of the websites evaluated in this study met all 36 elements of the modified EQIP tool. The reason can be identified both in the lack of any process of reviewing or management of the information for the sites that are available online and attributed to the fact that major search engines such as Google or Yahoo list the websites on a most viewed basis, rather than listing the findings according to quality and reliability.,,For implant-based immediate reconstructions, the devices can be placed both in the submuscular and prepectoral plane with the benefits of prepectoral procedures by sparing the pectoralis major muscle, no functional impairment is caused,34,35,36but the problem arises because of the unreliability and poor quality of the information that patients can find online. Finding and managing high-quality Internet information on breast surgery can be difficult;In recent years, thanks to the ever-increasing spread of online news,However, our study has some limitations: first, only English-language websites were included in our selection,Our study offers a report on existing information relating to breast reconstruction techniques with PU implants available to BC patients or women who want to undergo cosmetic breast surgery. Although the information available on the web is not subject to a control of the source's reliability, it can influence the patient and his questions to the physician about the personal clinical condition and the therapeutic decisions related to it. The quality of the information available, while better when offered by hospital portals compared to operators, professional societies, and encyclopedias, should be improved: we believe that the Internet should not be used as the main source of medical information, and physicians should maintain the role model, waling these patients through the intricacies of gender-reassignment surgery. Medical information to be published on online portals should be carefully planned, setting up which information to give and how to make it readable. Raising the readability level can make the difference between successful or failed communication, significantly improving the management of breast reconstruction, making patients comprehend the different procedures and better able to choose their reconstructive option.Not required.The authors report no conflict of interest.


More than four decades of war in Afghanistan has been both a main driver for poor mental health, and a barrier to the development of crucial mental health services. A study conducted by BMC Psychiatry in 2021, across eight regions in Afghanistan, found staggering levels of depressive and anxiety disorders among the general population. Almost one-half of those interviewed (47.12%) reported having high levels of distress in the last month, and almost 40% (39.44%) reported experiencing impairment to their lives due to poor mental health. Yet, despite the common experiences of much of the population, mental health is a hugely stigmatized topic of discussion in Afghanistan, due to a myriad of cultural, religious, socioeconomic and environmental factors. And now, under the de-facto Taliban government, mental health has been deprioritized in the face of a crumbling economy and acute levels of poverty, all but forgotten. This paper sought to review the impact and change to mental health services under the de-facto government, and to provide the reader with greater awareness into the current situation in Afghanistan and equip them with insight into how to respond to the mental health needs of Afghans. Factors such as unemployment and poverty increase the risk of developing mental health disorders, and often the most vulnerable groups are also the least supported, in terms of accessing healthcare and advocacy.1 Despite the high levels of poor mental health, treatment gaps continue to be high, with a scarcity of human resources, stigma, lack of prevention and promotion programs, as well as a lack of integration of mental health into primary care settings often being the cause.2 In addition, there is a lack of investment in mental health treatment in Afghanistan; the estimate for mental health is <4% of the overall health budget.3 A promising approach would be for national and international actors to provide additional investment in human resources and integrate mental health by ‘piggy backing’ on existing public health programs.4Mental health disorders disproportionately affect lower-middle income countries. It has been estimated that globally 29% of people with psychosis receive mental health treatment; in high-income countries that percentage is 70%, in low-income countries it is as low as 12%.5 For many, this trauma is internalized and minimized, increasing the likelihood of developing mental health conditions. Despite this, the mental health services across Afghanistan are insubstantial, and there is little funding for, or understanding of, mental health within the medical field. There is poor mental health literacy across Afghanistan, with much of the population finding it difficult to describe mental health distress and issues effectively. Without the appropriate language to reflect their experiences, Afghans are limited in the ways they can seek help.6In Afghanistan, much of the general population lives in a perpetual state of distress, exacerbated by a prolonged conflict that has ravaged the country for decades, and, as of late, unpredictable and volatile political instability. A 2018 European Union survey found that 85% of the Afghan population had experienced or witnessed at least one traumatic event in their life, with an average of four.3 And even then, those who do use them can experience abuse, such as forced hospitalizations,3 or being taken to religious shrines by family members where they may be tied and chained.7 Symptoms of mental illness are often categorized as a punishment from God, and harmful misconceptions mean mental illness is often considered a ‘weakness’ or defect in the person.7 In 2022, the WHO reported the prevalence of stigma around mental health resulting in those with mental disorders often being perceived as weak, lazy and unintelligent.1 These consequences extend beyond the individual and can affect the family unit, with the widely held belief that one person's ‘bad’ behavior can potentially lead to illness or even disability of a family member. Instead of being offered psych-medication or a form of psychotherapy, many of those with mental illness are instructed to pray for recovery, or are simply ostracized from the community.A report in 2021 found that <10% of the population utilizes any mental health service.3 Without appropriate support, Afghans may feel compelled to self-medicate for mental health disorders. Substance abuse is a common form of self-medication, with the reciprocal link with depressive disorders being well documented.8 Afghanistan has the highest number of opiate users globally, with an average in 2015 of 12.6% Afghan adults using drugs, compared with a lower global average of 5.2%.8 It is highly likely that this percentage has grown over the last 7 y.8 Substance abuse, particularly if it leads to addiction, only exacerbates poor mental health.There is a trend of misdiagnosing and overprescribing in Afghanistan, with patients presenting with psychosomatic conditions being prescribed medication, for example, for stomach issues, in place of being offered psychological support.This combination of factors—high levels of trauma and instability, high levels of stigma and severely limited resources—has led to unprecedented and widespread mental illness in the Afghan population, and a mental health service ill equipped to respond. In this commentary paper, we provide an overview of mental health (MH) and mental health and psychosocial support (MHPSS) in Afghanistan, based on our findings through interviews with individuals who have worked in this sector—including a hospital director in Bamiyan, and a former member of the Ministry of Public Health (MoPH) in Afghanistan—all remaining anonymous for their own safety; in addition to our own experience in Afghanistan providing MHPSS services to communities and through consultancy services; supported by a comprehensive review of relevant mental health programming reports. A number of critical issues related to mental health including the accessibility afforded to different demographic groups, the significant increase in trauma experienced by women under the de-facto government and the deprioritization of MHPSS, are discussed. There exists a number of standardized approaches to MHPSS developed by international organizations such as the WHO; however, these approaches are not contextualized and therefore are not applicable in places like Afghanistan, where infrastructure and resources are severely lacking and trauma is chronic. By synthesizing our own knowledge and experience on the ground, with findings from the literature review and the primary data gathered from fellow mental health experts, we were able to identify in what ways the situation has changed since the de-facto government came to power. This paper seeks to summarize our findings and expertise for the benefit of international development actors and health practitioners; to provide insight and a broader understanding of the situation in Afghanistan, as well as to outline key approaches to implementing an effective mental health response under current circumstance.9 A 2019 report found that >90% of suicides committed by women in Afghanistan are directly attributed to untreated mental illness,7 and a 2021 report found that 9.1% of women have reported having suicidal thoughts at one point in their life. While there is no one singular reason for this epidemic, one cause of developing a mental illness is abuse. Violence against women and girls is widespread and, according to a study by the United Nations Population Fund, 87% of Afghan women have been victims of at least one form of physical, sexual or psychological violence, and 62% have experienced multiple forms of abuse throughout their life.10 Alongside mental health stigma, there is significant stigma associated with abuse, leading many women to remain silent.The causes and rates of poor mental health in Afghanistan are not uniform. Different demographic groups are treated differently in society and are able to access support in different ways. Women in Afghanistan report higher levels of depression, anxiety and post-traumatic stress disorder (PTSD) than men, as a result of the heightened sociocultural stressors placed on them.11While women are likely to receive additional trauma, it is important that men are not neglected when it comes to mental healthcare. Young men in particular face challenges, and frequently stigma around seeking help is more acute among men than women, meaning they are less likely to come forward for support. This lack of support for men can indirectly affect women, particularly if unaddressed, as there is a significant correlation between trauma and domestic violence.12 Because of the conflict in Afghanistan, young people have lost decades of opportunity, in education, health and employment, as well as the opportunity to participate in politics. Armed non-state groups have profited from the vulnerability and disillusionment felt by youth, developing effective methods of recruitment and radicalization that the state is unequipped to deal with. As a result, children who have been radicalized and trafficked, transnationally or from within Afghanistan, often experience acute psychological trauma. But there is a significant lack of systematic psychological support services available to these children, especially with regard to effective interventions aimed at rehabilitation and reintegration of radicalized youth.Afghanistan in general has a youth bulge and economic hardship and lack of prosperity affects the younger generation more than any other group.13 is facing a mental health crisis since the Taliban government came into power in 2021. After a relatively peaceful 20 y since the previous Taliban government, the Hazara have once again come under attack for their religious and ethnic identity. In October 2021, a Shia mosque in southern Kandahar was attacked, killing at least 47 people and wounding 70 more.13 More recently, an attack on Abdulrahim Shahid High School in Kabul killed 30 and wounded scores of others.13 Furthermore, the group is heavily marginalized. For example, as the Taliban government took power, Hazara judges and judicial staff were removed from their positions, dismissed on the basis of not aligning with the administration's vision.13 With this onslaught of violent attacks, and the expulsion from political and social circles, thousands of Hazars are experiencing the effects of repeated trauma, an increase in paranoia, acute stress and depression.14The Hazara people, an ethnic minority group who make up an estimated 15–20% of Afghanistan's population,15 However, more recently, in the north of Afghanistan, rural areas in Andrab, Panjshir and some parts of Balkhab are experiencing higher levels of violence and discrimination, which in turn impacts how healthcare operates, with mental healthcare practically non-existent. In other areas, including parts of Badakhshan, some rural communities reported having to travel for up to 9 h to receive even basic health treatment.The quality and availability of mental health services also fluctuates regionally and negatively affects those living in rural settings to a greater extent. A WHO report from 2018 found that 87% of Afghanistan's population were within a 2-h distance of a health facility.16 Of the 217 students involved in the study, 70% reported experiencing significant PTSD symptoms, and 38.6% reported heightened suicide ideation. Although this was a very specific, highly educated and mostly female group of subjects, the findings illustrate how likely it is that the events of 2021 have contributed to the already high levels of trauma in the wider population. There are also increasing concerns about the ability of individuals to meet their basic needs and, in part due to the freezing of foreign reserves to prevent misuse by the Taliban, Afghans are increasingly facing poverty and starvation. According to The United Nations Development Program (UNDP), 97% of Afghans will fall into poverty this year. The World Food Programme also predicts that >20% of the population (8.7 million people) are at risk of famine-like conditions. These figures are stark, and legitimate fears about survival will be affecting many in the country. This widespread trauma and persistent political instability limits the ability of Afghans to live secure, fear-free lives. Anxieties about regime change and future violence, and the residual stress, lead to tangible impacts on mental health and quality of life.The overthrow of the Islamic Republic of Afghanistan by the Taliban in August 2021 followed 3 mo of intensive conflict. Although data about the impact of these events on the mental health of the population are limited, one study of university students from August to November 2021 revealed incredibly high levels of trauma.19 Alongside this, the Taliban does not have a history of understanding or prioritizing mental health. As a result, there is a lack of faith in the new government to continue funding health services to the same extent as their predecessors, or treat members of the population who are inhibited by mental illness with respect or dignity.In a 2019 survey by the Asia Foundation, only 13.4% of Afghans reported having sympathy or support for the Taliban.18 with most of the patients who were previously working or studying being treated for depression and anxiety.18 This hostile environment will be having significant impacts on mental health across the country, particularly on already vulnerable groups.Under the current regime, there are well-founded fears about the stripping back of rights, particularly for women and girls, and the impact this could have—and is already having—on the population. Evidence of this occurring is already present, with a ban on girls’ secondary education being implemented in March 2022, and increasing limitations on the right of women to work. A report from early 2022 found that women make up to 75% of those who visit Herat's psychiatric hospital, with an increase of 7% in the number of mentally ill women receiving psychological treatment since a year prior,19 At an individual level, as symptoms of mental illness intensify, quality of life is increasingly impacted. One's ability to engage with everyday activities is undermined and relationships often break down. In a country like Afghanistan where the ability to be productive and contribute to the family unit is vital, the implications of low productivity can be fatal. At a societal level, the greater percentage of the population that is struggling with poor mental health, the less productive and robust the economy is.Widespread poor mental health impacts both the individual and society. Leaving mental illness untreated can lead to chronicity and the development of psychosomatic disorders, ultimately increasing suffering and the cost of care.20 Recently there has been a shift in understanding, whereby mental health and psychosocial well-being is not only considered a health problem, but a social problem affecting all aspects of life, including peace and stability.21 The use of MHPSS in fragile and humanitarian contexts has increased and we are seeing the integration of mental health into wider health responses, and, less so, into wider social programming in protection or education sectors.20 MHPSS is a multifaceted and holistic approach to mental healthcare that not only treats the problem, but also works to build capacity of community-based responses, raise awareness of mental health and de-stigmatize the conversation, and equip people with coping skills and greater resilience; with the aim of reducing the likelihood of mental health disorders developing in the future. There is a growing appreciation for approaches to healthcare that are community based and contextualized to the culture, as well as the religious and familial structures of the beneficiaries. This is particularly relevant in Afghanistan, a widely patriarchal society with religion at the helm. Creating evidence-based approaches that apply to the population, in line with social values and cultural practices, not only address poor mental health but improve psychosocial well-being. Psychosocial support facilitates resilience, fosters dignity and independence, improves emotion regulation and promotes social cohesion and cooperation.22 It addresses both the psychological and social needs of people on an individual and community level.Mental health is seldom prioritized in humanitarian relief efforts, and currently only 2.1% of government health budgets globally are allocated to mental health.However, despite the need for mental health reform in the country, MHPSS in Afghanistan remains scarce. The changeover of regimes only impeded any progress being made, and mental health has been further deprioritized with a devastating effect.23 Geographical access was also in focus, with only 10% of the population living within a 1-h walking distance of a health facility.24 It was not until the expansion of the strategy in 2005 that mental health was designated as a top priority.25 However, given the wider challenges of delivering on healthcare, issues such as maternal and child health, nutrition and communicable diseases all remained a higher priority.26Soon after the previous Taliban government (1994–2001) was ousted and with the establishment of the Islamic Transition Government of Afghanistan in 2002, the new government developed 14 developmental programs within its National Development Framework. One such program was formed by the MoPH, the Consultative Group on Health and Nutrition, a group of national and international actors put together to inform health-related policy and development. And thus, the Basic Package of Health Services (BPHS) was designed, a core package of essential health services developed to address priority health needs and make basic healthcare accessible to all. At the time, maternal mortality rates and under-five mortality rates were dire, and a particular focus of the UNDP.27Prior to the change of governments in 2021, the BPHS had been contracted out to non-governmental organizations (NGOs) across 31 provinces. Levels in Afghanistan's healthcare system were distinct, and outpatient care and community support were provided through six different types of facilities:Health postBasic healthcare delivered in its simplest form, and can be as humble as a room in someone's house dispensing aspirin.Basic health centers (BHCs)A small center frequently set up in an existing building that has been transformed and rarely newly built, as NGOs rarely have capital to build infrastructure.Mobile health teams (MHTs)Teams of healthcare professionals that go into communities, and even family homes, to provide care. Particularly used in emergencies or to serve hard-to-reach or rural populations.Comprehensive health centers (CHCs)Similar to a BHC, but has the capacity for an overnight stay; and a CHC Plus has the capacity for slightly longer stays.District hospitalsSmall to medium hospitals situated across each province.Provincial hospitalsLarger hospitals with greater capacity, frequently situated in provincial capital cities.The BPHS was designed to be scaled up rapidly by contracting work out to NGOs; yet the contracts were flawed and breach of contract was common. For example, BPHS contracts did not require infrastructure changes of any kind, such as a wall around the compound, which for many ‘makeshift’ centers meant a lack of privacy. In Afghan culture, modesty is regarded as highly important, and so families were unlikely to send members, in particular women, to seek medical care at such a place.Care was not standardized across Afghanistan, despite the uniformity of BPHS requirements, because there was a lack of consequences for those organizations that did not meet contractual obligations. The BPHS would dictate the number of skilled staff and service lines each kind of clinic needed. For example, a BHC may be required to have one manager, one administrative staff member, one doctor, one nurse, one laboratory assistant and so forth, and would be provided an Essential Medicine List, where it might say, the center must have rabies shots and pain medication available. However, there was often a dearth of certain qualified practitioners, and in some cases centers would claim they were unable to find anyone to fill vacancies in order to save on budgets. The MoPH could do nothing when centers failed to recruit, as the lack of qualified medical practitioners was common knowledge. Furthermore, the requirement for a mental health professional was very uncommon. Those trained in mental health will often work for NGOs as opposed to hospitals or other clinical settings. This is, at least in part, due to NGOs offering a substantially higher salary than the state can provide.The MoPH had a shepherding role over the NGOs providing healthcare in 32 of the country's provinces—with everything overseen by the ministry—despite it having little part in implementing care. In 2002, when decisions were being made on how the new republic would operate, an overwhelming amount of unmet need was identified. There were gaps in every sector, even in farming and livestock management, despite Afghanistan being an agrarian society. Thus, the government outsourced health to NGOs, with the U.S. Agency for International Development (USAID) playing a significant role in this process, and divided primary care from secondary and tertiary care. Primary care would be provided through the BPHS, divided by catchment; each province would govern the levels of healthcare in this vicinity. Few new structures were built; instead, healthcare was delivered in existing, often unfit, infrastructure.In 32 of 34 provinces in Afghanistan, the BPHS was operational, and implemented by NGOs. The remaining two provinces, Kabul and Kapisa, received direct government healthcare, operating under USAID's Health Sector Resiliency project. Kapisa was kept under government provision with the intent of using this province as an example to exemplify the ineffectiveness of government-delivered healthcare. However, this ploy was not successful, and the province in fact proved to operate just as well as the provinces under NGO care. This was due to the unique situation of its staffing. Kapisa's healthcare workforce were people who were from the province themselves, which fostered a ‘local sense of ownership’ among healthcare workers and recipients.28 A report from 2018 on the hospital found patients were often overstaying, due to a severe lack of adequate outpatient mental health services.28 Often, people will go directly to hospitals to seek help, and bypass smaller health centers, knowing they have greater capacity and are more likely to have appropriate medicine and trained doctors. However, this in turn overwhelms the hospitals.There are few mental health institutions in Afghanistan, and these are scattered across the country with limited capacity and low levels of coverage. Afghanistan has a total of two psychiatric hospitals in the country, one in Kabul and one in Herat. The Red Crescent Secure Psychiatric Institution, a high security psychiatric hospital in Herat, houses >300 patients, some of whom are at times chained and sedated.Mental health services are currently operating under the previous government's system, headed by the Department of Mental Health within the MoPH. These services were already deprived of capacity, quality and access under the previous government, but with the deprioritization of mental health this has further deteriorated and the MoPH at present is struggling to be an effective coordinating body. Stigma has remained a main barrier to receiving care, and the everyday situational risks of living in Afghanistan have meant mental health is no longer in focus. This risks creating a system where mental health will not be understood, advocated for, integrated or culturally competent.29 A significant contribution to this was the Sehatmandi project, with a US$600 million budget; administered by the World Bank and implemented by the MoPH, this project was designed to increase the utilization and quality of healthcare by supporting the delivery of BPHS across all 34 provinces.30 This was a 3-y project that ran from June 2018 until June 2021, with many Afghans in the health sector hoping for renewal. But, with the withdrawal of major international funding under the Taliban government, this has not materialized. A report from September 2021 found that only 17% of the >2300 health clinics under the Sehatmandi project were fully functioning.31 With the lack of funding, many clinics previously operating under the Sehatmandi project have not been able to pay staff and are struggling to maintain sufficient supplies of medicines, including psychotropic drugs.15 As a result, Afghans are forced to travel further for essential medical care, to self-medicate, or to go without.Over the past two decades the financing of health systems in Afghanistan was largely supported by international donors such as the WHO and USAID; however when the Taliban took power international donors immediately suspended most of their funding. This funding constituted >70% of government expenditure, according to a report by The International Committee of the Red Cross (ICRC), including many health facilities.32 Now, with soaring prices and inflation, an estimated 17 million Afghans (in a population of roughly 38 million) are experiencing serious food insecurity, and, compounded by the looming famine in many parts of the country, healthcare, and in particular mental healthcare, is viewed as a non-essential cost for many Afghans.33A report by the MoPH from 2017 found that while primary healthcare in the country is perceived to be dependent on international donors, in reality, a large proportion of total health spending is carried by households.34 And others, such as CARE, have psychosocial counselors on staff when responding to emergencies, such as the recent earthquakes in Paktika and Khost.35 However, mental health has been deprioritized since the Taliban government came into power, and health concerns such as malnutrition take priority.Since the changeover of government, the Afghan people have become more desperate for psychological support. Organizations such as HealthNet TPO have continued to deliver mental healthcare through MHTs, prescribing medicines and providing counseling.People in Afghanistan are widely exposed to adversity, whether it be from individual circumstances or national crises. MHPSS is about empowering people to be able to respond to difficult circumstances, cope with adversity and build resilience; improving their overall quality of life. Negative emotions linked to circumstances someone is not in control of, such as conflict or disaster, only perpetuate symptoms of poor mental health. And so, promoting a future-oriented perspective is key to improving mental health. Short of major political and medical reform in the country, mental health needs to be prioritized by the international NGO community, to see progress and recovery for those struggling with persistent mental health disorders. There are several key approaches NGOs and the medical community can take to better respond to mental health needs in Afghanistan.Strengthening the systemTo effectively address the mental health needs of Afghans, it is imperative that a framework of family-focused and community-based care is established and supported. Afghanistan is a low-resource country and providing stand-alone clinical mental health treatment is not sustainable in the long term. Developing and implementing a framework in which social, public health and clinical services are delivered in tandem at a community level can help to fill the gaps in previous models of healthcare, in particular improving coordination of care, addressing the comorbidity of physical and psychological conditions, and lessening the need for outside referrals. Furthermore, in Afghanistan, where family is the most important social unit of society, family-focused care would greatly improve accessibility for the most vulnerable members of a community. For example, a woman's mental health is highly affected by that of her husband's, and so, by treating the major issues of the head of the family , the health of the remaining members of the family can be positively affected. Likewise, in treating a child, the health needs of the primary carer—often the mother—must also be treated.Advocacy for change: hearing from the community2. Raising awareness and advocating for mental health through a bottom-up approach should be a high priority. Advocacy is most successful when the target community is asked to become part of the solution and encouraged to participate in deciding how mental health support is delivered, in a way that is socially and culturally acceptable to its members.Leading by example: the role of national professionals3. A promising approach would be to utilize the influence of leadership in the medical field. It is unrealistic to try and de-stigmatize a population without adjusting the attitudes and beliefs of the medical force serving them. Afghanistan is a heavily community-driven collectivist society, with great importance placed on the opinions of community leaders. De-stigmatizing and normalizing discussions around mental health are essential for large-scale recovery to occur, and health professionals can take on a major role in changing the narrative.Working alongside the government4. The current government is focused on security, hunger and other crises, with mental health not viewed as a priority, and an absence of capacity or incentive to change this is apparent. If the government cannot meet the need for mental health services independently, it has to be subsidized externally. NGOs and international INGOs should work with health practitioners on the ground to deliver MHPSS, under government oversight.Building the capacity building of health practitioners5. Investing in people and services , training and providing ongoing supervision to health practitioners is a realistic way of reaching greater numbers of Afghans in need. Large hospitals or health centers are not always accessible, physically or socially, and so building the capacity of rural health practitioners, those working with women, and those with access to minority communities, is important.Since the regime change in August 2021, mental health has been deprioritized on both an individual and a governmental level. Despite this, the need for contextualized mental health support remains high as conflict-related trauma is intensified by restrictions imposed by the de-facto government and the poverty that has ensued from the withdrawal of international support. Mental health facilities and practitioners remain few and far between, despite the greater numbers of people, in particular women, seeking psychological support. The withdrawal of funding from international sources has halted potentially significant programs from materializing; however, it is difficult to predict to what extent these programs would have impacted the masses, as previous health programs failed to fully integrate mental health into the public health response. With the de-facto government far removed from the mental health needs of the Afghan people, it is up to international NGOs to step in and support in building the capacity of existing systems so as to create sustainable change in the mental health response.


Occupational injury protection is essential to safeguard the basic rights of workers. This article focuses on a group of gig workers who have emerged on a large scale in recent years in China and aims to explore their status of occupational injury protection.Based on the theory of technology-institution innovation interaction, we adopted the institution analysis to assess the work-related injury protection of gig workers. The comparative study was used to evaluate three cases of occupational injury protection in China for gig workers.Institutional innovation failed to respond to technological innovation and provided insufficient occupational injury protection for gig workers. The work-related injury insurance was inaccessible to gig workers due to they were not treated as employees in China. The work-related injury insurance was not available to gig workers. Although some practices were explored, shortcomings remain.Behind the flexibility of gig work is insufficient occupational injury protection. According to the theory of technology-institution innovation interaction, we believe the reform of work-related injury insurance is increasingly essential for improving the situation of gig workers. This research contributes to expanding understanding of gig workers' situation and may offer a reference to other countries on protecting gig workers against occupational injuries. In recent years, the gig economy has been a prominent topic in the field of work . It is sGig workers seem to benefit a lot from the flexibility of work. However, they are facing more occupational injury risks like traffic accidents, impaired physical functioning, anxiety, depression, etc., , 7–9. AcIn the web of science, we searched English papers with “gig work” “gig worker,” or “gig economy” as the subject words, respectively. Meanwhile, we searched the relative Chinese articles on the website of China's national knowledge infrastructure with the subject words “零工” or “零工经济,” because these two words are used more commonly in China. We only selected papers published in core Chinese journals since these papers usually have better quality. All the searches were set for the last 10 years, that is from January 2013 to December 2022. We got 608 articles in English and 188 articles in Chinese. Gig work and workers are a rising segment of the economy and have piqued the curiosity of scholars, especially in the last 3 years. From In terms of research content, existing literature focused more on gig work or workers themselves. There are three primary characteristics of gig work, including project-based compensation, temporary, and flexibility in when/how/where the work is performed . Among tAt the time level, working hours are flexible . Gig worAt the spatial level, the flexibility leads to a tendency to bring work into their lives , 22. In In summary, the occupational injury risks faced by gig workers in a state of freedom to work stem from several sources: Firstly, the lack of clear and fixed working hours for gig workers means that the normal right to take sick leave is lost. Platforms can encourage them to work at a fast pace by setting up competitive evaluation mechanisms, reducing rest time, and granting workers no right to paid leave, which may lead to an increased incidence of illness and an increased risk of occupational injury when working with illness . SecondlHowever, gig work is undertaken without the safety nets found in traditional employment . Gig worIt is found that existing studies examined the working status of gig workersm , 44, 45,Institution analysis and comparative study are adopted in this article. The theory of technology-institution innovation interaction sets the framework for this research, instructing us to focused on institution innovation. The institution analysis of work-related injury insurance will contribute to showing the occupational injury protection of gig workers. The comparative study is used to explore the pros and cons of three kinds of occupational injury protection and show the occupational injury protection status of gig workers furtherly.Based on the theory of technology-institution innovation interaction, we analyzed the institution of work-related injury insurance which is an important institutional arrangement to ensure the safety and health of employees in China. We examined the accessibility and applicability of institutions separately to see the consequences of the institution's failure to innovate. The status of occupational injury protection for gig workers is shown through institution analysis.The theory of technology-institution innovation interaction combines technology and institution because they are closely related in the innovation systems , 48, 49.In this article, the gig economy is dependent on the input of digital technology and human capital. The flexibility of gig work is generated, but with occupational injury risks for gig workers. An effective institutional arrangement is important for protecting gig workers and then promoting the development of the gig economy. It has been shown that digital technology has given rise to the gig economy, we are wondering if is there a response to digital innovation. In a state where the technology is updated but the institution is not, what is the status of occupational injury protection for gig workers? The method of institutional analysis was adopted to give the answers in this article. We tested the applicability of the work-related injury insurance to gig workers based on the institution's condition of participation settings and protection.In 2017, the State Council issued the “Opinions on Doing a Good Job in Employment and Entrepreneurship for the Current and Future Period,” which proposed to improve the employment and social security and other systems that adapt to the characteristics of new employment patterns; In 2020, the National Development and Reform Commission and 13 other ministries issued the “Opinions on Supporting the Healthy Development of New Business Patterns and Modes and Activating the Consumer Market to Drive Opinions on Expanding Employment,” with emphasis on exploring policies to adapt to cross-platform and multi-employer flexible employment in terms of rights and benefits protection and social security.Data in this article are collected from the official websites of central and local governments in China, the website, and the WeChat official account platform of DiDi Travel. The documents involved are “Measures on Occupational Injury Insurance for Flexibly Employed Persons ” and “Rules for the Implementation of Occupational Injury Insurance for Flexibly Employed Persons,” “Trial Measures for County-wide Participation in Work-Related Injury Insurance for Employees in New Industrial” and Guanhuaibao. According to the information, three models of exploratory practice of occupational injury protection for gig workers were presented. The comparative study was used to make comprehensive presentations of the advantages and disadvantages of each exploratory practice. The covered subjects, financing options, and mode of operation are included to make a comparison among the three cases.The theory of technology-institution innovation interaction guides the analysis of the current state of workers' occupational injury protection. To better respond to the gig economy, the government should follow the established goals and principles for institutional innovation . HoweverWork-related injury insurance is an important part of social security, providing employees with protection against work-related injuries through mutual assistance and risk-sharing. The work-related injury insurance is employer-contributed in China, and employees are not required to pay contributions. Workers can only be recognized as employees if they sign an employment contract with the employer. In terms of traditional labor relations, if the employer and the worker do not have an employment contract, very few companies will take the initiative to pay for work-related injury insurance for gig workers . The ambIn a state where workers' work-related injury insurance is absent, platforms can also provide safety protection for those working in the gig economy by purchasing commercial insurance, but some platform companies have failed to take effective measures. If workers are insured as individuals, this means that the cost is much higher than the group schemes offered by large employers, which is linked to economies of scale and the greater bargaining power of large employers . AccordiFirst, the flexibility of working time and space makes it difficult to identify work-related accidents. The work Injury Insurance Regulations in China stipulate that the injury will only be recognized as a work-related injury if it occurs during working hours, at the workplace, and is caused by work. The working hours of gig workers are often irregular, and the completion of their work may occur at any time of a day. Meanwhile, the development of digital technology allows people and establishments to complete their work even when they are spatially separated . This alSecond, it is ambiguous who is liable as an employer for the corresponding payments. The Work Injury Insurance Regulations proposed “If an employee suffers from an accidental injury at work or an occupational disease and needs to be suspended from work to receive medical treatment for the injury, during the period of suspension from work, the original salary and benefits shall remain unchanged and shall be paid monthly by the employer.” The absence of employers of gig workers is a direct result of the lack of availability of work injury benefits provided by employers.Third, the compensation for treatment is difficult to measure when an injury occurs at work due to the unstable income of gig workers. Although the level of disability is usually used as the standard for determining compensation for treatment under work-related injury insurance, many compensation items are linked to one's monthly salary. For example, lump-sum disability benefits, disability allowances, funeral benefits, dependent's pensions, lump-sum work-related death benefit, etc., the amount of payment for these items is the worker's salary for a certain fixed number of months. As the income of gig workers is mainly based on the number of tasks completed, the income of different workers is bound to vary from one worker to another, and the monthly income of each individual is unstable, given that they are free to work at their own time and place of work. In addition, the income of gig workers is hidden, with the same worker taking on multiple jobs on multiple platforms. Hence, it is hard to determine the exact remuneration of part-time workers .In short, the contents of the work-related injury insurance in terms of contributions, recognition and compensation for work-related injuries are not compatible with gig workers. Being exposed to high occupational injury risks but without the necessary protection makes gig workers more vulnerable.The lack of protection for gig workers has gradually received attention in China. Relevant government departments in various regions are gradually exploring, and some platform enterprises are also experimenting with it. Three main ways for gig workers to obtain safety protection against occupational injuries have been formed: Purchasing commercial insurance by platform, establishing separate occupational injury insurance by the government and following the existing work injury insurance system see .As can be seen from In Wujiang, Nantong and Taicang of Jiangsu Province, the government led the establishment of occupational injury insurance. This approach is more targeted, yet it also increases the economic costs and the fragmented system will pose new challenges to the development of the national social insurance system. For example, it increases the operating cost of the social insurance system, weakens the ability of the social insurance system to help each other, and increases the inequality among people. In Wujiang, for example, in terms of coverage, anyone who is flexibly employed in the region in the form of providing labor for remuneration or earnings and who is not covered by the “Regulations on work-related injury Insurance” can be insured, with no restrictions on household registration. This means that gig workers, who mobile frequently, have the opportunity to participate in the insurance and receive protection, which is important for expanding the coverage of the work-related injury insurance system. In terms of contributions and benefits, participants pay an annual lump-sum occupational injury insurance premium of RMB 180 in March each year. During the trial period, if participants are already enrolled in flexible workers' pension insurance or medical insurance, they can be subsidized by the government to the tune of RMB 120 per person each year when they are covered by the work-related injury insurance. On the whole, the premium for work-related injury insurance for flexibly employed persons is about 50% of the average local premium for work-related injury insurance, and the treatment is also at about 50% of the treatment for occupational injury insurance. In this case, although gig workers are provided with occupational injury protection, classifying gig workers as flexibly employed actually absolves platform enterprises of their responsibility to pay contributions, increasing the burden on the government and the individual workers. At the same time, as the level of compensation is lower than that of work-related injury insurance for employees, it is also a matter of concern whether gig workers can get adequate protection from it. In terms of management and operation, the government-led model with commercial insurance companies is an innovation that can not only reduce the management burden of the government, but also help to bring into play the professional advantages of commercial insurance institutions and improve the operational efficiency of the system, while it will take a longer time to test the actual operation effect.Jiashan county of Zhejiang province tries to include gig workers directly into the target of work-related injury insurance protection. The relevant policy stipulates: e-commerce, online taxi, network food delivery, express logistics, and other new industrial enterprises operating on the platform should establish labor relations with the employees, who can participate in separate work-related injury insurance during their employment. Considering the fact that this group may have multiple jobs, each employer should separately participate in work-related injury insurance for them. The insurance is paid by the platforms, and the contribution base is calculated according to the average monthly salary of employees in the province in the previous year, and the base is adjusted according to the month following the publication of the above data by the province, and the contribution rate is tentatively set at 1.1%. Gig workers do not pay individual contributions. The taxation department has set up a “new industry injury” directory specifically for the collection of work-related injury insurance for gig workers, the collection of the directory contribution base, rate, and the amount payable by the social security agency approved and passed to the taxation authorities for collection. In this model, workers are essentially identified as employees, and platform companies are considered employers. There is no difference in coverage for gig workers and other employees. Although this initiative in Jiashan County is easy to operate and manage, it also increases the burden on platform enterprises. The work-related injury insurance should not only protect the basic rights and interests of the workers but also take into account the economic burden of the platform enterprises. At the same time, the high mobility of gig workers will also lead to a further increase in employment costs for enterprises. The direct inclusion of gig workers in the work-related injury insurance system temporarily solves the problem of participation, after which a series of issues still need to be clarified, such as whether and how to connect between work-related injury insurance platforms and different regions.From the demand perspective, the flexibility of the gig economy dictates that workers have more freedom, particularly at the time and space level. However, with the incentives of platforms, gig workers are motivated to work longer hours, work harder and adapt to the uncertainty of the working space to earn more income, which leads to more occupational injury risks. The need for occupational injury protection for gig workers is a necessity. From the supply perspective, we explored the occupational injury protection of gig workers through institutional analysis and comparative studies. It is found that work-related injury insurance is inaccessible and does not apply to gig workers. Each of the protection models explored has its disadvantages. Occupational injury protection for gig workers is insufficient.Behind the flexibility of gig work, there are increasing occupational injury risks and a lack of protection. The debate on the relationship between gig workers and platforms is the most important obstacle to gig workers' access to work-related injury insurance, and cannot be unified in the short term. However, the problem of the lack of occupational injury protection for gig workers needs to be resolved urgently. Who will provide occupational protection for gig workers? In terms of extending coverage, a government-led social insurance system is more advantageous . It helpThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.XR conceptualized, designed the study, and performed the analysis. XR and YZ wrote the first draft and supervised the research. All authors have read and agreed to the published version of the manuscript.