The goal of this study was to uncover the influence of professional activity, migration, and gender on dynamics of subjective age and ageing biomarkers. We examined the representatives of investigative types of professions (ITP), 30–75 years old in Russia, (101/62 women), and Russian migrants to the European Union, (101/56 women). ITPs appeared to be ageing slower than statistical standards; men age faster than women; the pre-retirement group (51–65 years old) showed acceleration of relative biological ageing in the Russian sample  against the EU sample, suggesting a boost of pre-retirement stress in Russia; subjectively, Russian people (51–65 years old) feel close to their chronological age, while EU people perceive themselves far below their calendar age . The subjective ageing depends on the country of residence, while biological ageing depends on occupation, gender, and negative expectations of retirement. Ongoing retirement reforms in many countries result in an extended employment period and delayed retirement of a significant number of elderly people; which stimulates the development of healthy active ageing policies ,2. An inVarious environmental, genetic, and personality factors affect the rate of ageing, so that people of the same calendar age would be having different biological and psychological age ,10,11,12In recent years; researchers have increasingly used the indicator “subjective age”—reflecting individual’s health; well-being; their attitude to their profession; as well as themselves ,22. SubjMultidimensional scales are often used for evaluation of subjective age. Such approach considers a person’s assessment of various areas of their life  . In RussThe pace of biological and psychological ageing is unique to each person and depends on many factors discussed above. Some of these factors are individual and depend more on a person: this includes healthy behavior, education, the choice of profession, and occupational activity throughout their life ,28,29. OIn this study, we consider three important factors that influence the rate of individual ageing: (1) the nature of the work and profession, (2) the country of residence and the features of its social policy, (3) the personal efforts that an individual applies to overcome life challenges.The first factor is the nature of the work and profession. Studies in many countries have shown that the representatives of investigative types of professions (ITP) have a longer lifespan, higher average life expectancy, and a lower probability of premature death . AccordiData from studies of public service employees has shown that higher social status, managerial work, and career growth contribute to an increase in life expectancy. The high-level administrators have the lowest probability of premature death, while it is 1.6 times higher for other managers and qualified specialists, 2.2 times higher for office workers, and 2.7 times higher for laborers . MetanalIn Russia, several studies of the connection between the investigative type of profession and life expectancy have been carried out. In 1999, Dr. Avgustova studied life expectancy of famous scientists—146 psychologists; she suggests that, on average, representatives of this profession live for quite a long time, and their average life expectancy was 70.5 years while average life expectancy in Russia was 65 years at that time . The stuThe second factor is the country of residence. Life expectancy varies in different countries and current life expectancy in Russia is at a global average, while in the EU countries, life expectancy is one of the highest in the world ,30,40. ARetirement stress affects the relative ageing of both ITP and labour type workers. A study of Finnish municipal employees revealed an increase in musculoskeletal diseases among men after retirement:  determination according to V.P. Voitenko ,52: thisSubjective assessment of health (SAH) decline: this indicator is included in biological age formula see . It is aStatic balancing (SB): this indicator is also included in biological age formula see . Static Expected biological age (EBA) for different age groups: EBA is a statistical indicator that characterizes average biological age within a specific age group currently living in Russia. The EBA was calculated according to the formulas of Dr Voitenko : for menThe relative biological ageing index  allows us to evaluate how much an individual is older than their statistical age norm in regards to their health condition. Negative values indicate individual youthfulness of a person, and positive values indicate individual ageing respective of statistical norms. This is the main indicator used to assess the dynamics of relative ageing.Subjective psychological age (PA), developed in the laboratory of personality psychology of the Institute of Psychology of the Russian Academy of Sciences (authors K.A. Abulkhanova and T.N. Berezina), based on the concept of personal organization of time ,50 and oIndex of relative psychological ageing . Negative values indicate that a person is younger than their calendar age and is looking forward to the future. Positive values indicate that a person perceives themselves as more mature, wise, and successful than other people at this age.Statistical analysis. We tested normal distribution of age indicators. For the subjective age, biological age, expected biological age, and relative ageing index, the deviation from the normal distribution was not significant. Descriptive statistics were also calculated: average and standard deviation. To assess the influence of the country of residence on the indicators of relative psychological and relative biological ageing in men and women, Anova Factorial was conducted, as well as analysis of variance with the assessment of Fisher criteria (Fisher LSD). Anova Factorial analysis was applied to evaluate the significance of the influence of the following factors: the country of residence and gender, on relative ageing, in different age groups. We also calculated the interaction of these factors. For statistical analysis, we used the program Statistica -12 (SoftStat).Test subjects. The final sample consisted of 202 individuals who are representatives of investigative types of professions according to J. Holland: researchers, employees of research institutes, university lecturers, and professionals in related fields with a scientific degree. The profession of subjects was determined by primary employment. We tested two big groups. One group consisted of ITPs from EU countries: 101 individuals aged between 30 and 75 years (of which 56 women and 45 men). All are immigrants from Russia permanently residing in the EU countries for a period of at least 5 years . All have EU citizenship or residence permit, and most are considering continuing working there until retirement. Most of them are graduates of major Russian universities. By the time of the survey, most migrants had already changed several countries of residence within the European Union . However, the survey was conducted in Scotland (UK) where all respondents were residing at the period of our investigation. Another group were ITPs from Russia: 101 individuals aged between 30 and 75 years (of which 62 women and 39 men). Most of them are also graduates of major Russian universities. Both surveys were carried out from April until September 2019. Both groups were divided into 4 age subgroups: up to 35 years old, 36 to 50 years old, 51 to 65 years old, and above 66. The age and gender composition of the sample is presented in After collecting the data, we conducted extensive data quality checks to identify respondents who were not making enough effort. To increase the severity of the analysis and increase the reliability of the results of the study, we used the direct, archival, and statistical screening methods . We exclThe effect of the place of residence (Russia or EU countries) on the indicators of relative ageing of the ITPs of two genders is presented in The country of residence significantly affects the following characteristics: relative biological ageing, relative psychological ageing and subjective evaluation/self-assessment of health. Gender, in its turn, only significantly affects relative biological ageing and subjective evaluation of health; therefore, relative psychological ageing of ITPs in Russia and the EU does not depend on their gender. The indicator of static balancing is not dependent on either the country of residence or gender of the participants. The data on relative biological ageing of ITPs in Russia and the EU countries is presented in The differences for genders are among the most pronounced . RelativDifferences in relative biological ageing based on country of residence appear only in 3 groups: between men aged 51–65 years (significant), and between women aged 35–50 years and 51–65 years (differences in both groups at the tendency level only). In all different age groups in the EU sample, the ageing of researchers is slower.The table also shows an increase in relative biological ageing in the age interval from 51 to 65 years for both men and women of ITPs. At younger ages, participants living in Russia show tendency for slower relative biological ageing—this indicator is negative and does not exceed statistical standards . At an oThere are no significant differences in static balancing  for different genders or country of residence. However, according to subjective indicator of biological age—the subjective self-assessment of health decline—the differences are significant, based on both country of residence and genders . Women fDifferences between countries and age groups are more pronounced than differences between genders . RelativHowever, the dynamics of ageing within age groups is similar both in Russia and in the EU. Overall, young people (under 35 years old) tend to overstate their psychological age; their relative psychological ageing rates are the highest and significantly differ from the older groups based in Russia, both for all men and women. With age, the trend gradually reverses, and men and women after 65 are prone to understate their psychological age compared to their calendar age, so their relative psychological ageing is negative, and their hopes for future achievements are still high.Differences in psychological ageing index between genders are significant only in one group: women from Russia in the age range between 36–50 years are significantly different from men. At this age, men continue to consider themselves psychologically older, wiser, and more successful, while women are already starting to consider themselves younger.The subjects in the studied samples did not differ much at the beginning of their course of life. These were young people who graduated from universities , obtained professions of the intellectual type. Many graduated with honours and entered a PhD program. Some of them emigrated to continue their education or received a work contract in the EU countries. Other graduates remained home to continue their postgraduate or PhD studies in Russia, found work in research institutes, became university staff or lecturers or engaged with the private sector. They also changed jobs and places of residence, but relocations were limited to the Russian Federation. They had no need to study a foreign culture, language, or to adapt to the laws and customs of another country. In general, they have put fewer personal efforts into building their destiny.For both genders, men and women under 35 show no significant difference in relative ageing index, between the EU or Russian samples a,b. We aHowever, significant differences in the relative ageing index in the 36–50 years group were found between ITP migrants in the EU and Russian residents. The relative ageing index for both women and men who left for the EU is significantly lower than for their ITP colleagues who remained in Russia. This age group of ITP migrants have been working in the EU for 8–25 years, changed several countries of residence, and most received a residence permit or citizenship. In the age group 51–65 years, people have been living in the EU even longer, everyone has citizenship or a residence permit, and have professional achievements. They differ even more from their Russian counterparts in the relative ageing index. We found the greatest difference in men (51–65 years old) who migrated to the EU is that their biological age is below statistical norms a. Men inWe hypothesized that one of the reasons for the differences in relative individual ageing between the EU and Russian samples is the effect of pre-retirement stress, which is more pronounced in Russia due to ongoing retirement reform. The fact of retirement stress has been shown for many countries ,41,46. HA similar uncertainty can be found in any country with an ongoing retirement reform. We compared our data with the indicators of individual ageing of a mixed group of professionals from the Republic of Kazakhstan . InteresThe group of ITPs in Russia exhibited only one sign of retirement stress: they demonstrate an acceleration of relative biological ageing in the age group between 5065 years—a period that includes the years preceding the retirement (55.5 years for women and 60.5 years for men) and the years immediately after retirement a. A mismIn particular, we previously discovered ,50 that The second sign of retirement stress was not found among ITPs living in Russia: they do not have a mismatch of psychological and biological age . On the contrary, the relative psychological ageing index of people under 65 years is positive, i.e., they consider their psychological age to be higher than their calendar age, unlike the representatives of other professional groups in Russia. Perhaps this is because subjective age is the age of psychological and personal maturity, a measure of achievement. It turned out that it is important for ITPs to emphasize their achievements (possibly in comparison to their peers in other types of occupation), thus increasing their subjective age. This differs from the usual tendency of adults in Russia to understate their subjective age against their calendar age b.The second possible reason for the relative biological ageing variation is the country of residence. The ITP respondents who moved to the EU changed several places of residence and do not necessarily bind themselves to any single country with a specific model of retirement scheme. Most of them prefer living in the present rather than thinking about future problems. Perhaps, living in countries more prosperous than Russia has reduced their existential fear of the future.On the other hand, their biological and psychological age is lower than that of their peers remaining in Russia a,b. The This study provided new insights into the rate of the biological and psychological ageing of ITPs. However, some limitations in the data and methods should be considered. Our choice of respondents was guided by voluntary consent to conduct the survey and process the data. Some people refused to take part in the survey, and we are aware that there was an involuntary selection of more proactive respondents (presumably extroverts) and we may have unintentionally excluded certain respondents, such as introverts, from analysis. This might have weakened our results. It is also possible that people who decided to migrate were initially strong and determined, and this possibly explains their greater resistance to stress. Also, their enthusiasm for a change of residence could lead to their ignorance of real problems at new place. Perhaps therefore they experience less stress than their counterparts in home country. However, one cannot exclude that due to changes in the cultural environment and language problems, emigrants do not immediately become full members of society, they are more vulnerable and not adapted to local life. Migrants tend to be in a disadvantaged position in comparison to residents of the country in a similar socioeconomic situation ,40,62. AThe comparison of the relative individual ageing dynamics of respondents of the intellectual occupational types in Russia and Russian migrants to the EU countries allowed us to identify several general trends and differences. We consider general trends to be: (1) the general dynamics of biopsychological ageing, which largely coincides with the dynamics of calendar age; (2) the differences in relative ageing between men and women: both in Russia and in the European Union, men age faster than women, which applies to both biological and psychological age; (3) in general, among representatives of the ITPs, relative biological ageing is slower than the statistical standard, and is, therefore, slower than for most of their peers of other occupational types; (4) the tendency to exaggerate their psychological age by younger people (under 35 years), and to exaggerate it as they grow older—people over 65 years old tend to psychologically consider themselves younger; this applies to both men and women in Russia and in the EU. We also found differences in the dynamics of relative ageing among representatives of investigative occupational types in Russia and Russian migrants in the EU countries. First: Russian ITPs experience retirement stress that affects their relative biological ageing. In Russia, biological characteristics of health begin to deteriorate for both men and women in the age group between 51–65 years, which leads to accelerated ageing of the body; before and after this age interval, accelerated ageing was not observed. For Russian migrants in the EU countries, retirement stress that affects the individual ageing was not found. Second: biological ageing is more pronounced in Russia than in the EU countries. In almost all age ranges, ITPs who moved to Europe are biologically younger than their peers who remained in Russia. Third: there are differences in the dynamics of psychological ageing of the ITPs. Russian researchers under the age of 65 living in their home country estimate their subjective age roughly equal to the calendar age or slightly higher. Russian migrants, in contrast, tend to rate their subjective age below calendar age: women between 51–65 years old estimate their age lower than calendar age by 10 years, and men by 20 years.


In early 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published clinical ethics recommendations for the allocation of intensive care during COVID-19 pandemic emergency. Later the Italian National Institute of Health (ISS) invited SIAARTI and the Italian Society of Legal and Insurance Medicine to prepare a draft document for the definition of triage criteria for intensive care during the emergency, to be implemented in case of complete saturation of care resources.Following formal methods, including two Delphi rounds, a multidisciplinary group with expertise in intensive care, legal medicine and law developed 12 statements addressing: (1) principles and responsibilities; (2) triage; (3) previously expressed wishes; (4) reassessment and shifting to palliative care; (5) collegiality and transparency of decisions. The draft of the statements, with their explanatory comments, underwent a public consultation opened to Italian scientific or technical-professional societies and other stakeholders . Individual healthcare providers, lay people, or other associations could address their comments by e-mail.Eight stakeholders , and 8 individuals  participated to the public consultation. The stakeholders’ agreement with statements was on average very high . The 4 statements concerning triage stated that in case of saturation of care resources, the intensive care triage had to be oriented to ensuring life-sustaining treatments to as many patients as possible who could benefit from them. The decision should follow full assessment of each patient, taking into account comorbidities, previous functional status and frailty, current clinical condition, likely impact of intensive treatment, and the patient's wishes. Age should be considered as part of the global assessment of the patient.Lacking national guidelines, the document is the reference standard for healthcare professionals in case of imbalance between care needs and available resources during a COVID-19 pandemic in Italy, and a point of reference for the medico-legal assessment in cases of dispute. The SARS-CoV-2 pandemic has put the Italian National Health Service  under extraordinary pressure, leading in some regions and in some periods to imbalances between demand and supply of care , 2.At the beginning of the pandemic, there were 5.179 intensive care unit (ICU) beds  in Italy, with wide variations among the 21 Italian regions. During the first wave, in some regions, the threshold of 30% of ICU beds occupied by COVID-19 patients as the maximum of ICU admissions per week was exceeded .Clinical Ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances [In expectation of worsening of the imbalance between the need for ICU admission and the actual availability of resources  caused by the increasing number of people with COVID-19 with acute respiratory failure, on 6 March 2020 the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) issued mstances : in ordeTo our knowledge, these recommendations were the first to be published anywhere on the topic of ICU resource allocation during the COVID-19 emergency. They have been referenced in numerous publications and mentioned in other similar recommendations –8 and haOn 9 July 2020, the Italian National Institute of Health (ISS) invited the Presidents of SIAARTI and the Italian Society of Legal and Insurance Medicine (SIMLA) to prepare a draft document defining the triage criteria for intensive care in the pandemic emergency to be implemented in case of complete saturation of available resources. The draft document was intended as a basis for analysis and sharing with other scientific and technical-professional societies, associations and other relevant stakeholders.After a public consultation, the final version of the document was published on the ISS National Center for Clinical Excellence, quality and safety of care (CNEC) website on 13 January 2021 in the section dedicated to “best clinical practices”. In accordance with Italian Law 24/2017, professional activities in Italy are legally assessed on the basis of their compliance with guidelines published on the ISS CNEC website and, in the absence of these, with best clinical practices like those suggested in this document.This article summarizes the document’s scope, development and content.The general objective of the document was to provide healthcare professionals with a tool for responding appropriately to the emergency due to the current COVID-19 pandemic—which potentially affects the health of the entire community—in the event of an imbalance between healthcare demand and available resources, with particular reference to intensive care resources.to provide healthcare professionals with shared criteria for the admission, stay and discharge of patients in the high-intensity care levels of hospitalization, as well as to guide towards the most appropriate treatment of patients in medium and low-intensity care;to ensure the transparency of healthcare professionals' choices through a clear explanation of decision-making criteria;to preserve trust between people, healthcare workers and the national health system during the emergency.Specific objectives were the following:According to the ISS request, both ethical and legal principles should be at the basis of the document.Right to health—art. 32 of the Italian Constitution: “The Republic safeguards health as a fundamental right of the individual and as a collective interest and guarantees free medical care to the indigent”.Principle of equality and equal social dignity—art. 3 of the Italian Constitution: “All citizens have equal social dignity and are equal before the law, without distinction of sex, race, language, religion, political opinion, personal and social conditions”.Duty of solidarity—art. 2 of the Italian Constitution: “The Republic recognizes and guarantees the inviolable rights of the person, both as an individual and in the social groups where human personality is expressed. The Republic expects the fundamental duties of political, economic and social solidarity to be fulfilled”.Universality and fairness—art. 1 of Italian Law No. 833/1978: “The national health service is made up of a complex of functions, structures, services and activities aimed at the promotion, maintenance and recovery of physical and mental health of the entire population without distinction of individual or social condition and in a manner that ensures the equality of citizens with respect to the service”.Respect for self-determination—art. 32 of the Italian Constitution: “No-one can be obliged to undergo any health treatment except under conditions set by law. The law may not in any circumstances violate the limits imposed by respect for the human person”; Italian Law No. 219/2017 on “Regulations on informed consent and advance treatment dispositions”.Duty to care—a duty that requires physicians to observe the function of guarantee.Duty to guide—how to allocate resources is an ethical duty of decision-makers within the health care system.Duty to plan—health care leaders' duty to plan for the management of foreseeable ethical challenges during a public health emergency.Duty to safeguard—duty to protect health care workers, the population, and especially vulnerable individuals.A Working Group (WG) was formally appointed on 20 July 2020. The members were experts in anesthesia and intensive care , legal medicine  and law (GF and VZ) designated on the basis of their expertise in the field of interest identified through the PESTEL   method oIn a web-conference, using the SWOT analysis  , the WG These are the five areas: (1) Ethics, (2) Law, (3) Organization, (4) Management of incoming patients, and (5) Management of patients in hospital. Within the areas of interest, several questions were identified as preliminary to definition of the statements that serve as the WG answers. The Delphi methodology  was adopBased on the results of this first round, the statements with most differences in agreement were edited and two statements were merged. The WG members were then asked again to express their level of agreement on the title and the 12 statements . The second round gave a high level of agreement (full agreement/agreement) for 8 of the 12 statements. One WG member indicated disagreement regarding the wording of statements 2 and 12, while, respectively, one WG member and two others indicated "indifferent" as the levels of agreement for one of the parameters in statement 6 and for statement 7, respectively. All statements were then accepted and in the following month the WG drafted explanatory comments for them all, in five sections: (1) principles and responsibilities; (2) triage; (3) previously expressed wishes; (4) reassessment and shifting to palliative care; and (5) collegiality and transparency of decisions.https://snlg.iss.it/?p=3272) and the consultation announcement had broad echo in traditional and online newspapers and on associations’ and scientific societies’ websites. All the about 300 scientific or technical-professional societies recognized by the Italian Ministry of Health  and those recognized by the ISS CNEC as possible other stakeholders  could participate in the public consultation by registering on the ISS website. All stakeholders were invited to rate their degree of agreement with each statement using a Likert scale from 1 (full disagreement) to 5 (full agreement), and to make any comments. Finally, those interested in the topic who could not register on the website  could address their comments to the WG by writing to ricerca@siaarti.it.The draft document underwent a public consultation from 19 November to 10 December 2020. This consultation was organized by the ISS CNEC in accordance with its guidelines. The ISS CNEC promoted the consultation through its website (The statements are summarized in Table https://snlg.iss.it/wp-content/uploads/2021/01/Risultati-conslutazione-pubblica-doc-Triage_SIAARTI-SIMLA.pdf). In addition, eight e-mails with comments and criticisms were directly addressed to the WG by experts in palliative care (two), anesthesiology and intensive care (two), legal medicine, oncology, ethics and by an association of retired doctors and widows.Eight stakeholders  participated in the public consultation. The list of stakeholders and their average ratings for each statement was reported on the ISS CNEC website , and those who participated on their own initiative expressed substantial appreciation for the document. The main criticisms focused on the following topics: the inclusion of the age-adjusted Charlson index among the possible triage tools, especially for the importance the index gives to age and oncologic comorbidity; the need to emphasize the role of palliative care experts; and the lack of thorough analysis of ethical issues. One scientific association of critical care nurses strongly disapproved the triage statements (rating statements from 5 to 7 with “full disagreement”) and disagreed with statement 12. These were the only cases of disagreement expressed by the stakeholders. Among those who addressed their remarks directly to the WG, the association of retired doctors and widows expressed legal concerns, sending a letter drafted by a lawyer who questioned the legality of the triage per se.The WG thoughtfully considered all these comments and in some cases modified the statements wording, but not their content. Finally, the WG submitted the final revised version of the document to the ISS CNEC, which published it without asking the WG for any further revisions.Equality: everyone has the full and unconditional right—regardless of age, social condition, ethnicity, etc.—to receive the best available healthcare; professionals have the deontological obligation to oppose any form of discrimination in access to care;Social solidarity: this guarantees attention to those who are most vulnerable and implies solidarity among everyone, taking account of the fact that the health of an individual cannot be considered independently from the health of the community and vice versa ;Self-determination: respect for human dignity and freedom is ensured in the protection of health.Even when there is an extraordinary imbalance between the need and supply of care, the primary and fundamental right to health must be ensured, as an essential element of human dignity, in compliance with the principles of ethics and justice and, therefore, in accordance with the universal egalitarian criterion of access to care. Hence the necessary adherence to the following main principles:The observance of these principles implies first of all the responsibility, at the institutional level, to adopt strategies aimed at preventing as far as possible, with adequate allocation of health resources , serious shortfalls in resources. Secondly, healthcare professionals on the frontlines must implement organizational strategies, in addition to their clinical commitment hence including extraordinary organizational strategies to ensure that each patient receives appropriate treatment. To this end, close cooperation between clinicians and other relevant professionals and institutional representatives is essential. In fact, reporting critical situations may start directly from those engaged in the field, but possible solutions should be offered by an organization of some sort that provides for involvement at every level  of anyone who has the possibility and the duty to make an effective contribution.Once it has been verified that it is impossible to adapt the healthcare response to the scenario produced by the crisis, for the sake of transparency towards both healthcare workers and the community this must be clearly and explicitly stated at all institutional levels.When there is an imbalance between the need for care and healthcare resources, treating sick people according to the “first-come, first-served” approach would not be fair. This rule, unlike the egalitarian approach, risks being discriminatory because—as suggested by one stakeholder during public consultation—the time when the person goes to hospital is likely to be influenced by economic conditions, social context and individual possibilities of the patient or his family. It is therefore essential to apply a system of triage, meaning an assessment aimed at establishing which patients should be given priority for treatment.In intensive care, it is a matter of making an overall comparative assessment of the patients’ conditions, not with the aim of establishing who is more serious or in greater need of care, but who is most likely (or least likely) to overcome the current critical condition with intensive care, with reasonable life expectancy once out of the ICU that is, short-term survival (months) after discharge from the hospital.The proposed triage criteria here have no predefined hierarchy and should not be seen as unquestionable, but should be balanced and viewed in the light of each clinical condition, where one criterion or more may become more important and thus predominate in the clinical decision. In the overall assessment of a patient, assessment tools that can at least serve as an aid for comparative prognostic framing may include the Charlson index –16, the In subjects with previous comorbidities, the severity and stage of illness should be assessed on the basis of objective criteria and parameters .The patient's opinion and preferences regarding treatment are essential for deciding the proportionality of care. The patient's wishes regarding treatment should therefore be explored at an early stage, to avoid triaging people who do not want intensive care.Age in itself is not a criterion for deciding which patients are most likely to benefit from intensive care and therefore cannot be used by establishing age cut-offs in the triage. Other conditions being equal, age may play a role in assessing a patient because the outcome of intensive treatments is likely to worsen with age –30.The triage process should be documented in the medical record, possibly using a specific ad hoc form . The patIf the patient is not able to give consent, any wishes expressed previously must be explored during triage, consulting the database of advance directives too. If the patient has expressed a wish contrary to the treatments indicated that person’s will must be respected, unless there are circumstances established by law . A check must also be made for any shared care plan consulting the patient’s health record and contacting the attending physician .If a legal representative or trustee is present, the physician will contact them.All patients likely to need life-sustaining treatment should be offered shared care planning. The patients and, with their consent, their family members should be adequately informed “in particular about the possible evolution of the current pathology, what the patient can realistically expect in terms of quality of life, the clinical possibilities for intervention and palliative care” .Re-evaluation of the current clinical indication, goals and proportionality of care must be entered in the medical record on a daily basis. Appropriateness and proportionality of care are the ethical and professional prerequisites for any treatment, and the continuation of inappropriate or disproportionate treatment is not permitted.Should it be decided to limit intensive care, due to lack of clinical appropriateness, proportionality or as a result of comparative assessment during triage, the physician must inform the patient, when possible, and family members and legal representatives about the appropriate treatments for each single case, to be provided in a non-intensive setting, at home when possible.If during daily reassessment it is found that the indications for treatment no longer exist or that the treatment is futile in relation to the therapeutic objectives, the patient (if capable of receiving the information) and his/her family or legal representatives must be informed immediately. The need to shift treatment towards palliative care, including palliative sedation if necessary, should be discussed with them. Palliative care should be readily available in the ICU or some other appropriate setting. At admission to the ICU, the patient (when capable of receiving the information), legal representatives and family members should be informed of the possibility of shifting treatment if it becomes futile.The decision to limit intensive care, whether at triage or later, should never be left to a single physician, given the ethical and psychological enormity of any such decision. In usual clinical practice, the decision to discontinue futile treatments is generally shared by the whole medical and nursing team. This model of decision-making and sharing should be adopted for all decisions to limit intensive care, making use also of the possibilities offered by telemedicine under the conditions of physical isolation imposed by the pandemic. The decision should be even more thorough and shared, if possible, in the case of withdrawal of ongoing treatments. If this is not possible, the physician should describe, in the medical record, the circumstances that prevented a team decision, including the fact that there was not enough time for a collective decision.A “second opinion” may be required in situations of particular uncertainty or disagreement within the team.All decisions must be duly justified, documented in the medical record and communicated promptly and understandably to the patient, when capable of receiving the information, to legal representatives and to family members. Even in these times of overloaded healthcare services, communication must remain a priority, and adequate time and space must be allowed.Triage and the triage criteria proposed in this document were applicable from the period during the COVID-19 pandemic when a shortage of care resources arose, and they remain applicable as long as extraordinary resource allocations are necessary. Intensive care triage is applicable to all patients who need intensive care, regardless of the underlying clinical condition; it is therefore an independent process following that of assessing the appropriateness and proportionality of intensive care. Triage does not apply to patients already receiving intensive care.Lacking national guidelines, the document is the reference standard for healthcare professionals’ in case of imbalance between care needs and available resources during a COVID-19 pandemic in Italy, and a point of reference for the medico-legal assessment in cases of dispute.The restricted number of experts and expertise involved in the WG might be considered a limitation, but they were selected as representatives of the scientific societies appointed by the ISS. Furthermore, the SIAARTI was involved in the national Technical Scientific Committee on the COVID-19. Finally, the judgements and suggestions of the stakeholders boosted the involvement of experts.The most important limitation is the lack of strong evidence from the scientific literature about the clinical criteria and prognostic factors for the comparative evaluation of patients.


The administration and governance of grant funding across global health organizations presents enormous challenges. Meeting these challenges is crucial to ensuring that funds are used in the most effective way to improve health outcomes, in line with the United Nations’ Sustainable Development Goal 3, “Ensure healthy lives and promote well-being for all at all ages.” The Good Financial Grant Practice (GFGP) Standard (ARS 1651) is the world’s first and, currently, only international standard for the financial governance and management of grant funding. Through consensus building and global harmonization between both low- and middle-income and high-income country players, the GFGP Standard has achieved a leveling impact: GFGP applies equally to, and can be implemented by, all types of organization, regardless of location, size, or whether they predominantly give or receive funding.GFGP can be used as a tool for addressing some of the challenges of the current funding model. Here, we describe our experiences and lessons learned from implementing GFGP across 4 diverse research institutions in India, Nigeria, Colombia, and the Philippines as part of our National Institute for Health Research Global Health Research Unit on Genomic Surveillance of Antimicrobial Resistance. Unprecedented funds are being pledged and used to support public health research and services globally. In 2004, global health funding was around $14 billion, and this increased rapidly, largely due to initiatives such as the Bill & Melinda Gates Foundation and the US government’s AIDS Initiative .The administration and governance of funds across a wide geographical range and number of global health organizations involve significant challenges. Meeting these challenges is crucial to ensuring funds are used most effectively to meet their intended aim of improving health outcomes, in line with the United Nations’ Sustainable Development Goal (SDG) 3, “Ensure healthy lives and promote well-being for all at all ages” .Developing institutional capacity to receive and administer funding at grantee organizations is a key component in ensuring that institutional structures are effective at managing large scientific grants to achieve intended research aims . SimilarHere, we describe the work undertaken as part of the National Institute for Health Research (NIHR) Global Health Research Unit (GHRU) on Genomic Surveillance of Antimicrobial Resistance in implementing the Good Financial Grant Practice (GFGP) Standard as a method of addressing some of the challenges of the funding model.Despite the unprecedented flow of global health funding into low- and middle-income countries (LMICs), there are often significant gaps in physical infrastructure, human capital, governance, and management structures (including procurement systems) in LMIC research institutes , 7–10. TA lack of funding to support institutional capacity can create a vicious cycle, one in which LMIC organizations are starved of support for indirect costs  , 11. ConHowever, adequately funding indirect costs alone is not always enough to develop institutional financial and grant management capacity. Capacity building support, for example, by establishing and training a successful grants administration office, is sometimes also required to enable institutions to effectively use indirect cost funding, with increasing awareness that this support is a requisite component for managing grant funding . For exaPoor governance and corruption are fundamental challenges for the administration of grant funding, and they represent a significant barrier to universal health coverage by preventing funding from reaching intended recipients and thereby directly impacting research projects and SDG 3. Estimating the scale of this problem is challenging, but it constitutes a significant issue in global health and beyond , 19. In Effective governance within research institutions is crucial to ensure effective decision making, at a programmatic level and more widely, and to improve both accountability and trust within the institution and across its personnel. The development of effective governance through the development of institutional capacity is also an important component in the fight against corruption .The current process for granting and receiving global health funding involves grantors, often high-income country (HIC)–based funders, asking multiple disparate due diligence questions of grantees . There is often a lack of clarity and understanding of what is being asked for and what represents best practice, with due diligence requirements usually differing between funding agencies and institutions. There is also a power imbalance in this relationship, where grantors are requesting information before either programmatic activity begins or funds are transferred, putting onerous requirements on grantees in terms of staff time and cost of compliance. For example, in 2018 and 2019, a Nigerian university had more than 20 due diligence requests from 16 global funders, including UNICEF, the African Academy of Sciences, the International Development Research Centre, UK NIHR, and UK Research and Innovation Global Challenges Research Fund.There is a clear need for the adoption of a standardized and more equitable approach to due diligence, through which LMICs and HICs contribute to the development of a due diligence framework that works for and is better understood by both grantors and grantees. This will improve the identification of key risks and reduce the duplication of effort, administrative burden, and costs for all players .Various existing initiatives attempt to standardize an approach to due diligence. However, their scope is generally limited to specific sectors or countries, and they do not represent a globally harmonized approach .The GFGP Standard (ARS 1651) is the world’s first and, currently, only public international quality standard for the financial governance and management of grant funding . The GFGThe standard was developed by the African Academy of Sciences in Nairobi, Kenya, in collaboration with global grantors and grantees from 22 countries across eastern, western, and southern Africa. This involved some of the world’s largest public and private sector funders, including those that provided funding, Wellcome, UK Research and Innovation, UK Department of Health and Social Care, the IKEA Foundation, the European and Developing Countries Clinical Trials Partnership, and other collaborators, the African Union; UK Foreign, Commonwealth, and Development Office (formerly DfID); the African Organisation for Standardisation; and the New Partnership for Africa’s Development and Coordinating Agency ). CBs will review the adequacy of the procedures, processes, and policies in addressing key organizational risks and the practical implementation of the documents to address those risks (over at least the previous 3 months). If the CB assesses the organization as fully compliant, they will issue a certificate of compliance along with an accompanying audit report detailing findings. This process is supported by an online portal, where grantees can share their certificates and report findings with other grantors. The GFGP Standard, online portal, certification scheme, and CBs are collectively known as the Global Grant Community (GGC) .To avoid accreditation disadvantaging low-resource settings, requirements need to be transparent and ordered, making it possible for institutions that have gaps in capacity to develop a road map to meeting requirements . The GFGWhen completing the GGC portal questionnaire, an organization can identify and track gaps in their current compliance. If this is the case, an implementation plan toward full GFGP compliance should be designed and undertaken. This is likely to include a series of recommendations around designing new documentation or refining existing documentation and then embedding this in organizational practice. Organizations may look to engage an external GFGP implementation consultant or employ a financial and grant management specialist to identify gaps and design effective implementation plans. However, this may be a challenge in resource-constrained settings, where funders are unable or unwilling to provide funding. As the number of GFGP-certified organizations increases, there appears to be scope for cross-institutional mentoring in the initiation phase of the implementation process.Once an organization is confident that their documentation is adequate and has been practically implemented, a CB can be engaged to undertake the GFGP certification (audit). Certification gives the organization international recognition and gives funders and key stakeholders confidence in the effectiveness of institutional financial and grant management.There is a specific focus in the GFGP Standard on improving governance and therefore trust and accountability within organizations. In the development of the GFGP Standard, the importance of effective governance was recognized in the creation of a separate section on governance (section 8) that contains 4 subsections .For example, within the risk management subsection of the standard (section 8.4), there is a focus on the mechanisms that organizations put in place to enable individuals to confidentially report incidents of possible fraud, corruption, and bribery. The CB will check to see whether the procedural steps around disclosing fraud, bribery, and corruption have been followed and can be demonstrated. In this example, any significant issues identified by the CB around governance would need to be addressed by the organization before the CB issues a certificate of GFGP compliance.Through consensus building of grantors and grantees from HICs and LMICs during the development process, the GFGP Standard has a leveling impact, which is significant in the due diligence process, when grantors request that grantees comply with certain requirements. This leveling impact is also created by a “one standard” approach, whereby GFGP applies equally to, and can be implemented by, all types of organization .Organizations can use GFGP in both pre- and post-award due diligence by requesting that another organization complete a self-assessment questionnaire on the GGC online portal against 1 of the standard’s tiers. The requesting organization can then review the self-assessment responses on the GGC portal and follow up with any supplementary questions.GFGP certification simplifies the due diligence process significantly. The GFGP certificate and accompanying report become evidence of compliance across the 4 practice areas, providing the assurance the grantor needs that the grantee organization is compliant with an international quality standard in grant management. The grantor may ask supplementary assurance questions. To support grantors in identifying and asking supplementary questions, the GGC has also designed a set of non-GFGP assurance questions around safeguarding, programmatic delivery, legal and compliance, and health and safety .Although there may be a significant initial investment of time and resources to achieve full GFGP certification, the benefits of simplified due diligence are considerable, with less time and money spent on financial and grant compliance and more resources available to support programmatic delivery.As part of the NIHR GHRU on Genomic Surveillance of Antimicrobial Resistance, we have implemented the GFGP Standard with our 4 partners: a private–public nonprofit research organization in Colombia (AGROSAVIA[Corporación Colombiana de Investigación Agropecuaria]), a medical college in India , a large public university in Nigeria (University of Ibadan [UI]), and a public hospital in the Philippines .GFGP was principally implemented as a method of building and demonstrating sustainable financial and grant management capacity to complement the scientific capacity that has been developed through whole-genome sequencing (WGS) implementation , 25. WGSIn 2019, we worked with the 4 institutes to complete the GFGP self-assessment questionnaire on the GGC portal. Diagnostic assessment visits were then performed at each partner site, with the Nigeria assessment visit performed in partnership with Humentum . These vAGROSAVIA methodically implemented all the gold tier recommendations made following a diagnostic assessment visit in 2019 and has now successfully completed the certification process, becoming GFGP certified at gold tier on 7 September 2021. The 2019 assessment visit estimated AGROSAVIA’s overall compliance with the GFGP gold tier at around 80%. Although AGROSAVIA had advanced systems and practices in place across all GFGP practice areas, international grant funding was a relatively new funding stream for the organization. Consequently, the development and formalization of the international elements of the standard, such as procedures and policies on exchange rates, indirect costs, and recording time/effort on grants, were critical to enable AGROSAVIA to fully comply with the GFGP gold tier requirements.RITM has established a GFGP committee but has yet to implement the bronze tier recommendations. This is largely due to the current challenges faced by RITM in being the principal coronavirus disease 2019 (COVID-19) testing site in the Philippines.UI has also established a GFGP committee to address the bronze tier recommendations; however, this will require a transformational change within UI that may take a number of years to implement. Reaching GFGP certification is likely to be a challenging process for UI. However, given the significant number of funders this public university works with and the large number of principal investigators served by the grant management platforms, and therefore the volume of due diligence requests and funding administered, certification is likely to have significant organizational benefit to the university. We intend to continue to work in partnership beyond the life of this project to address these issues.CRL KIMS is now fully GFGP-certified, as outlined in the following case study.CRL KIMS is a small research laboratory with a self-contained administration function. It has internationally certified  research practices and facilities, but the level of grant management practices was not consistent. Prior to 2019, some financial and operational controls were in place, but these were not consistently applied or documented. A diagnostic assessment visit performed in 2019 identified overall compliance with the GFGP Standard at the bronze tier of around 65%.Six steps were taken in implementing GFGP at CRL KIMS, from the identification of gaps in GFGP compliance through to successful GFGP certification . As a paOnce these procedures were finalized, they were translated into the local language, Kannada, to ensure effective communication among all team members who had different levels of ability in the English language. The translation process was critical for ensuring that all members of the team were comfortable with the detailed procedures.The project then entered the practical implementation phase, focused on embedding the procedures and demonstrating at least 3 months of implementation to the CB (BDO LLP) . This woCRL KIMS was GFGP certified on 15 June 2020, with 2 minor nonconformities (noncompliances) noted in the audit findings report.Certification has brought multiple benefits to CRL KIMS by providing a best-practice structure to the administration function and developing staff knowledge and understanding of financial and grant management. Since certification, CRL KIMS’ organizational credibility has been enhanced, and this has facilitated and expedited the formalization of relationships with external partners and funders. For example, a multinational vaccine company and an Indian private diagnostics company have recently formalized partnerships with CRL KIMS. Obtaining GFGP certification played a major role in reducing the time taken to formalize these agreements and release funds, by 40%–50% (from between 10 to 12 weeks to around 6 weeks), when compared with similar agreements made prior to becoming GFGP certified.There were a number of useful practical lessons learned from implementing GFGP at CRL KIMS and across our GHRU partners .While the benefits of implementing GFGP can be considerable for institutions, our practical implementation has highlighted some areas that require refinement and enhancement.First, some of the GFGP questions appear repetitive. For example, there is some crossover in bronze  and silver (process) tier questions. This contributes to a doubling of the number of questions between bronze and silver, from around 70 to 140, but not a doubling of required effort to comply with the standard. Therefore, a review of bronze and silver requirements would provide greater distinction between the 2 tiers and remove any repetition. This would also ensure that the silver tier better represents more complex organizations, such as research organizations that manage large grant awards, while enabling smaller organizations, such as community-based organizations, to comply with a streamlined bronze tier.Second, although compliance with the GFGP Standard will have an overall positive impact on programmatic delivery for institutions, such as by ensuring appropriate human resource practices to support high-level staffing requirements, there are some areas of the standard where amendments would enhance programmatic delivery. For example, while the procurement section of the standard requires detailed processes and policies to be implemented, the standard does not specifically refer to the need for timely procurement. Inclusion of a clause to this effect would strengthen the standard by addressing the operational risk of sluggish implementation of the procurement practices and the subsequent potential impact on programmatic delivery.It is intended that the GFGP Standard becomes an ISO standard. The Kenyan Bureau of Standards  has submitted the GFGP Standard to ISO as a new work item, and it has been accepted. Progressing to ISO is likely to represent a positive step in terms of driving global uptake of GFGP. However, there are a number of factors that need to be considered and challenges to overcome before this can become a reality.There are currently around 420 to 450 organizations registered on the GGC portal. As this is a new standard, GFGP has yet to reach engagement by a critical mass of organizations or establish a position of long-term sustainability. To reach this point, GFGP requires an increasing number of funders to endorse or advise implementation of the standard and make GFGP-related costs allowable on their grants. This will drive uptake by organizations in the Global North and South and across global health and more widely. The implementation of GFGP by organizations in the Global North is an important development to ensure that GFGP is a truly equitable initiative, regardless of geographical location or organizational type.The equitable development of GFGP has created a powerful new standard that addresses challenges within the global health funding model. In our experience of implementing the GFGP Standard, it has proved to be an effective tool for identifying and addressing key organizational risks and for developing institutional financial and grant management capacity across global health partners in Africa, Asia, and Latin America. To fully assess the efficacy of the GFGP Standard, further work is required in implementing the standard more widely and in analyzing the qualitative and quantitative impact of GFGP certification on institutions.The next steps for GFGP are important ones, but GFGP’s innovative design means that it is well placed to have a long-term future, with the potential to transform the way we give and receive global health funding.


Breastfeeding has an important impact on maternal and child health, and is affected by several factors influencing its initiation and continuation. This qualitative study aimed to assess the main promoting and hindering factors for breastfeeding support in Lebanese daycare centers (DCCs), through the perspective of their directors and employees. The study was based on semi-structured interviews with 13 directors and 9 employees. It explored the influence of various cognitive factors as well as different environment types  on their breastfeeding support. Findings suggested the directors and employees valued improving breastfeeding support in DCCs and the physical set-up of the DCCs allowed for this. However, various other factors restricted their abilities to support breastfeeding in the DCC, including limited knowledge and training on the topic, absence of written internal policies on breastfeeding, lack of enforcement in the application of national policies, and the current mothers’ work policies that negatively influenced the decision to breastfeed. Improvements could be achieved through integrated interventions, targeting the interaction of internal DCCs factors and national and DCCs breastfeeding policies, as well as several social factors, to create a multilevel approach targeting breastfeeding continuation support in breastfeeding-friendly DCCs in Lebanon and the region. Promoting and supporting breastfeeding is a well-known effective public health intervention associated with reduced mortality and morbidity among infants and mothers. Breastfeeding promotes optimal infant growth, cognitive development and immune function, as well as reducing the risk of maternal breast cancer and cardio metabolic diseases ,2. The WVarious endeavors to help with initiation and continuation of breastfeeding have been implemented globally. A top-down approach mainly aims at improving and implementing national breastfeeding policies and programs ,12,13, wDaycare centers (DCCs) play a crucial role in the social environment of breastfeeding mothers, contributing to the lengthening and continued support of breastfeeding ,27,28. IIn view of this worrying situation, determining the supports and constraints for effective breastfeeding support practices in DCCs is a critical step that could assist in designing and implementing targeted interventions and policies aimed at improving breastfeeding support, not only in Lebanese daycare centers but also in other countries inside and outside the Middle Eastern region. In a country where healthcare resources are restricted , addressThis study is a qualitative research study, based on interviews with a purposive sample of daycare center directors and employees working in the region of Mount Lebanon, a peri-urban region in the country of Lebanon. It examines the different barriers and supports regarding breastfeeding in daycare centers based on the employees’ and directors’ perspectives.In Lebanon, daycare centers are private establishments that provide supervision for infants and children up to 4 years of age during the daytime, usually from the end of maternity leave (around the child’s age of 3 months) or later. As per the requirements of the Ministry of Public Health (MOPH) , daycareTwo types of participants were recruited for the study: daycare center directors and daycare center employees. The employees selected for this study were those supervising children aged less than 2.5 years, as the recommendations of the WHO/Lebanese Ministry of Public Health (MOPH) for breastfeeding applies up to at least two years ,33.The primary investigator (MAJ) invited directors from a purposive sample of 16 licensed DCCs located in socioeconomically diverse neighborhoods by phone to participate in the study. Since the data collection was conducted directly after a COVID-19 lockdown, the DCCs’ selection was affected by which DCCs were open as well as the DCCs directors’ agreement to a face-to-face interview. Accordingly, the DCCs were selected from the MOPH and syndicate of daycare centers website, as well as from the researchers’ own networks, until satiation occurred in the interviews. In total, 13 directors (81.1%) consented to participate, six of them agreeing to have their employees approached; this resulted in nine employees participating, one of whom had the dual role of nurse and daycare center manager (D8/E6). Written consent was obtained from each participant.The interviews were conducted using a semi-structured interview guide, previously piloted in a preliminary study targeting the barriers and supports regarding breastfeeding in daycare centers in the northern region of Lebanon . The interview guide was not validated. The selected interview questions were based on the different methods used and findings from previous research concerning barriers and supports regarding breastfeeding in daycare centers ,35,36,37The questions were designed to collect in-depth qualitative data about attitudes, knowledge, and other sociocognitive factors, training, and practices of the director/employee, as well as policies and barriers/supports affecting breastfeeding within the different environmental determinants like the home/work environment, the daycare center’s physical set-up and dynamics, and the mothers’ influence . The parInterviews were conducted in Arabic (84.6%) or French (15.4%), depending on the preferences of the interviewees. The interview guide was translated for this by a native Arabic and fluent French bilingual researcher (MAJ). The researchers continued recruiting participants for the interviews until data saturation was reached and interviews provided no additional information. This occurred after interviews with 13 managers and 9 employees, from a total of 16 DCCs daycare centers that were initially contacted. Since the data collection was performed during the COVID-19 pandemic, and due to the economic and safety burdens present in Lebanon at the time of the data collection, the primary investigator was forced to meet the employees and directors simultaneously in eight daycare centers, except for one daycare center where the employees were interviewed separately from the director.Interviews were audio-recorded and transcribed into English by the principal investigator (MAJ), prior to being securely stored and password-secured. Two of the translated interviews were independently back-translated to Arabic by a second researcher (SM) to ensure translation accuracy and quality. Differences with original audio recordings were checked and discussed by both researchers.The responses to the different questions during the interview were coded using MAXQDA 2020  and analyzed through thematic analysis based on the theoretical framework, starting with open coding. The principal investigator reviewed the responses to the questions and determined the themes, resulting in the coding trees . A selecThe interviews lasted on average 38 min (range: 25 to 52 min). All directors and employees were women, with the exception of one male director, ranging in age from 30 to 65 years See .The directors and employees had different backgrounds, listed in Various cognitive determinants of breastfeeding support were mentioned, which are discussed in more detail below. Quotes reflecting the various themes mentioned are presented in Interviewed directors and employees clearly stated that they intended to provide adequate assistance and facilitation to breastfeeding mothers in the DCC and perceived themselves capable of this, given their knowledge, material, and experience. Although some directors claimed that they could potentially have an impact on parents’ attitudes and mothers’ willingness to breastfeed, most of them believed the mothers  are in fact the sole decision maker concerning breastfeeding continuation in DCCs. This fact discouraged some of them to put in more effort to support breastfeeding. Their educational background affected both the directors’ and employees’ support of breastfeeding. While those with a nursing background were generally most supportive, the employees and directors with another educational background differed in their support, depending on many other factors like age, motherhood, traditions, and culture.In terms of training, most participants followed those set by the government as a requirement for every DCC. The employees and directors both preferred to participate in diverse training courses (preferably certified) on the topic of education and child behavior in general, rather than breastfeeding specifically. Technology facilitated employees’ and directors’ interest in and access to diverse topics, including breastfeeding. It encouraged communication between personnel as well as sharing of new information in groups.All the interviewed directors and employees had a positive attitude regarding breastfeeding in general, and in DCCs specifically. They believed it had a very important impact on the health of both mother and child, with the exception of two directors who prioritized prompt post-delivery return to work and mentioned the inability to track the quantity of milk given and the child’s satiety as a limitation of breastfeeding.Despite their positive attitude regarding breastfeeding, most directors stated that they were not responsible for increasing the mothers’ awareness of its importance, claiming that it was not within their job description. In addition, some mentioned the on-premise presence of parents in general as being a burden, because they would be interfering with the daily practices in the DCC. This added to the current challenges in scheduling the mothers’ visits to the DCC and the employee shortage in the present economic situation in Lebanon.The DCCs’ minimal age of acceptance for children also affected breastfeeding continuation support in the center. The DCCs that accepted younger infants showed the best encouragement and facilitation of breastfeeding. Some directors raised their concerns about the appropriate age at which to stop onsite breastfeeding for different reasons, including sexual labeling, leaving the baby on the breast all the time, and child–mother separation issues.Communication  between the director and the mother/parents appeared to be an effective booster for breastfeeding encouragement in the different DCCs. All directors stated that they had a definite impact on their employees’ encouragement of breastfeeding and that employees influenced each other positively in this regard. Furthermore, employees confirmed this and regarded the director as a role model.All interviewed directors and employees were well aware that a breastfeeding-friendly physical set-up should be private and comfortable in the DCC. All DCCs were very well equipped with the required appliances, like microwaves, fridges, and freezers. Furthermore, the directors stated that they always succeeded in having a private room (sometimes their own office), ready for the breastfeeding mother, not necessitating any extra cost.Most directors indicated that facilitating breastfeeding continuation did not burden the employees with more work nor increase costs. Some indicated that this was due to the small number of mothers that actually breastfed. The DCCs’ management orientation also affected breastfeeding support: in more business-oriented DCCs, breastfeeding continuation was not of prime importance, but rather practicality. Employee turnover did not affect the continuation of breastfeeding support practices in the DCCs.The directors stated that employees were not aware of the details of national breastfeeding policies; they just knew that the mother had the right to breastfeed in the DCC. All directors agreed that gynecologists, pediatricians, nurses, and breastfeeding-friendly hospitals have an important role to play in breastfeeding support and suggested this should be addressed in national breastfeeding policies. They also suggested that the DCC syndicate should have a breastfeeding supportive role in a DCC and in implementing new guidelines that would oblige DCCs to accommodate and encourage breastfeeding mothers.In the opinion of some directors, however, even if the government made breastfeeding support in DCCs obligatory, action first needed to be taken in women’s work settings, prior to changing policies in the DCC. The maternity leave duration was deemed too short for breastfeeding continuation and most work settings were not convenient for pumping breast milk. Some directors also stated that if one of their DCC employees was a mother, they would not approve of several breastfeeding breaks either. They claimed it would affect the work quality and professionalism of the employee.Furthermore, some directors insisted that parents’ decisions and attitudes about breastfeeding were the only factor of importance, even if DCC policies were to change. All the directors regularly conducted a policy review, but few included any written policies on breastfeeding. Increased breastfeeding support was observed when it was included in the reviewed policy. Several DCC directors and employees discussed the lack of training offered by the government. They expressed the need for obligatory training programs on child pedagogy and breastfeeding to boost the interest of employees, directors, and even parents.When asked about the possibility of having a breastfeeding-friendly DCC certification, all directors and employees were keen on applying it in their DCC, most also regardless of the cost or the changes required for certification. One director commented that it could create an added economic burden for DCCs, especially in the current situation and pandemic. Most participants stated that this certification would also encourage breastfeeding continuation and increase the perceived reliability of the DCC. Employees saw this certification as a boost for their career development and approved it directly. One director suggested having the Ministry of Public Health make this certification obligatory for DCCs. In her opinion, it would increase the enthusiasm to apply this certification in the DCC.All directors and employees stated that their practices were affected by their own social background, some more than others. On the other hand, they stated that mothers constituted one of the main pillars of their own sociocultural environment regarding breastfeeding. The DCC mother’s age, body image, generation, family, social background, education level, and nationality were identified as having an undeniable impact on her breastfeeding continuation in the DCC.From the directors’ point of view, the employees’ background could have an impact on the support of breastfeeding in the DCC, although they believed personal decision and personality would be the most important determinants affecting employees’ breastfeeding support.This study aimed at assessing the determinants of breastfeeding support in Lebanese DCCs, from the viewpoints of directors and employees. Most of the study participants had a positive attitude regarding breastfeeding: they were willing to facilitate it for mothers and felt confident to do so. This was in line with studies from other countries, such as the USA  and New Participants indicated that the mother herself was greatly influenced by several factors, like body image fears, physical difficulties, cultural influences, social background, age, and nationality. These factors are largely in line with barriers to breastfeeding in Lebanon in general ,15, showAnother important topic mentioned by the participants was the communication between employees and director, as well as among employees themselves, potentially reinforcing the staff’s breastfeeding support. The age at which DCCs accept children seemed to affect the level of staff support for breastfeeding continuation: the DCCs that accepted younger infants had the highest level of support, in line with findings from Mohd Suan et al. (2017). This indicates a need to focus on breastfeeding continuation support, beyond the initial three months, maximizing the chance of prolonging the breastfeeding period . In lineBoth the directors’ and employees’ educational background affected their support of breastfeeding in DCCs. Nurses seemed to be the most supportive, probably because breastfeeding is one of the main topics in their education. Participants with other educational backgrounds seemed to be more affected by their own social background, culture, and traditions rather than their education. In terms of training, most DCCs followed a list of training topics set by the government that did not include breastfeeding as a main topic, but focused on child safety and education. This discouraged DCC staff’s interest in the subject of breastfeeding, as seen in previous studies ,36,44, iWhen discussing the political environment, our study participants were aware of the National Breastfeeding Policy but were not familiar with its specific content and details. They only knew that there was a policy that permitted breastfeeding continuation in DCCs. This is consistent with the discrepancy between policy and its implementation by governmental institutions in Lebanon in general , as wellAll DCCs in our sample had the necessary equipment for breastmilk handling and had no problem accommodating sufficient privacy and comfort for an incoming breastfeeding mother. However, they did not actively communicate this to the mothers. This highlights the importance of enforcing the application of the national breastfeeding policy in the DCCs, as was discussed in Mohd Suan et al. (2017) . Indeed,n = 22). In addition, a purposive sample was used. In combination with the limitations the COVID-19 pandemic posed for the recruitment, this likely resulted in selection bias, potentially limiting generalizability of the findings. A quantitative study comprising a larger, representative sample can confirm our findings. In addition, although only one male director was included in the sample, this is reflective of the DCC practice in Lebanon in which male DCC directors are rare. One of the strengths of the study is that it is the first study to explore this subject in Lebanon. Furthermore, in several previous studies on the topic [This research should be interpreted with several limitations in mind. Conducting the study during the COVID-19 pandemic led to several hindering factors in terms of data collection and interview responses. In addition, the pandemic might have also influenced the study findings: for instance, it resulted in extra costs  and low practicality of breastfeeding due to hygiene, social distancing, and sanitation purposes in some but not all of the DCCs. The deteriorating economic situation in Lebanon as well as the obligatory reduction in the number of children attending the DCCs created stress for both directors and employees, modifying their responses accordingly. Furthermore, most directors who agreed to have their employees participate in our study requested to do the interview together with the latter to save time. This may have led to socially desirable answers by the employees. Additionally, some of the participants did not want to share their age or certain center characteristics in the interviews. The number of participating employees was further limited due to previously mentioned factors, although data saturation was reached. Although data satiation occurred for both directors and employees, the sample size was limited  at many levels. Consequently, the development of a multilevel framework that identifies different variables associated with breastfeeding support in DCCs is needed to plan interventions that will result in creating a cultural shift toward improving breastfeeding support, continuation rates, access to breastfeeding-friendly DCCs, and therefore improving public health, not only in Lebanon but also in other countries around the world.