This study matches data from the China Family Panel Studies (CFPS) with data on the transformation to industrial artificial intelligence (AI) in cities to explore the effect of this transformation on workers' mental health and its underlying mechanisms in China. The findings show the following (1). The transformation to industrial AI effectively alleviates multiple mental health problems and improves workers' mental health (2). Work intensity and wage income play an intermediary role in the relationship between the industrial AI transformation and workers' mental health (3). Potential endogeneity problems in the relationship between industrial AI and workers' mental health are considered, and robustness tests are conducted . The main results and impact mechanisms remain robust and reliable. This study extends the research on the relationship between industrial AI and workers' health, which has important theoretical implications. Additionally, based on the Chinese context, this research has important implications for the current AI transformation in developing countries. Transition economies with labor shortages can achieve a win-win situation by promoting industrial AI to fill the labor gap and improve workers' mental health. Artificial intelligence (AI) is an important force driving economic and social development, and it is a strategic field in which various countries compete. As the largest developing country in the world, China is currently undergoing an unprecedented process of transformation to AI, especially in the industrial field. The application of AI technologies such as industrial robots is becoming increasingly extensive, and human society is accelerating toward a new stage of high automation. The impact of the transformation to industrial AI on society is far-reaching , and it However, existing studies ignore the changes in workers' mental health in the context of the transformation to industrial AI. The application of new technology has an important impact on workers' mental health . For exaThe analysis above shows that the impact of the transformation to industrial AI on workers' mental health is uncertain . We explBased on the above analysis, we measure the penetration rate of urban robots based on data disclosed by the International Robotics Alliance, which is regarded as a measure of the level the transformation to industrial AI in cities. We match China Family Panel Studies (CFPS) data with data on this transformation at the city level to conduct the empirical analysis. The regression results show that China's transformation to industrial AI effectively alleviates a variety of workers' mental health problems, and robustness tests based on various methods support this conclusion. Thus, we find that in a large transition economy such as China's, if the transformation to industrial AI is in line with the times, then it may help alleviate workers' mental health problems instead of causing fear of technology. Moreover, through a mediating effect model, we find that industrial AI may improve workers' mental health by increasing their wage income and reducing working hours. This research answers the questions of not only whether but also how the transformation to industrial AI affects workers' mental health, which has crucial theoretical and practical significance.The data used in this paper are mainly from the International Federation of Robotics (IFR) and the nationwide CFPS conducted by the China Social Science Research Center of Peking University. The data contain information on the installation of industrial robots in 50 countries from 1993 to 2018, and the industries involved are from the following six categories: agriculture, forestry, animal husbandry and fishery; mining; manufacturing; electricity, heat, gas and water production and supply; construction; and education. We use the industrial enterprise module from the Second National Economic Census data to calculate the number of people employed in different industries in each prefecture-level city . We measure the density of industrial robot installation in each city combined with the IFR data to measure the level of the transformation to industrial AI in the city.CFPS is a national, comprehensive, and highly authoritative large-scale social tracking survey project that collects data from individuals, families, and communities through face-to-face or telephone interviews and off-site follow-up interviews. It leads to changes China's social, economic, demographic, educational, and health conditions and provides a public policy formulation and academic research database. The project is conducted once every 2 years, and five rounds of surveys have been conducted: in 2010, 2012, 2014, 2016, and 2018. A community questionnaire database, a household questionnaire database, an adult questionnaire database, and a pediatric questionnaire database have been established. This paper focuses on the impact of robot use on workers' mental health, uses 2014 survey data, and retains only employed individuals. We chose the survey data from the 2014 wave because there are differences in the way mental health is measured in the CFPS questionnaires for each year. In addition, China started to use robots on a large scale after 2013. After further eliminating observations with missing variables, the final valid sample size is 7,731.This paper focuses on the impact of the AI industrial transformation on workers' mental health, and the dependent variable is workers' mental health. The “Partial Behavior and Mental State Measurement” module of the CFPS Individual Questionnaire asked respondents about six aspects of their mental state in the past month: “How often do you feel emotionally frustrated, depressed, and unable to do anything uplifting?”, “How often are you nervous?”, “How often do you feel restless and have trouble staying calm?”, “How often do you feel hopeless about the future?”, “How often do you find it difficult to do anything?”, and “How often do you think life is meaningless?” There were 5 answer options: 1. Almost every day; 2. Often; 3. Half of the time; 4. Sometimes; 5. Never. The survey reflects workers' psychological state; the larger the value is, the better the psychological state.This paper's core explanatory variable is the transformation to industrial AI, measured by the density of industrial robot installations at the city level. We mainly use the IFR dataset and the Second National Economic Census industrial enterprise data to calculate the industrial robot installation density. Since the IFR data contain only industrial robot installations at the industry level and city-level industrial robot installations are not available, we draw on Acemoglu and Restrepo  to calcuwhere Referring to the existing literature, this paper controls for a series of variables that may affect employees' mental health, including employees' age and age squared; employees' gender, with 1 for male and 0 for female; whether employees have spouses, with 1 for married or cohabiting and 0 for unmarried, divorced or widowed; employees' household status, with 1 for non-agricultural and 0 for agricultural; employees' education level, measured by the number of years of education; household size, defined by the number of people sharing daily activities; household elderly dependency ratio, measured by the proportion of people over the age of 60 years within the number of household members; household child dependency ratio, measured by the proportion of children under the age of 16 years within the number of household members; whether the household is entrepreneurial, with a value of 1 if a household member had been self-employed or started a private business in the past year; household financial status, measured by household income per capita; and household debt status, measured by total household debt. Both household average income and total indebtedness are treated logarithmically. The paper also includes city-level control variables, including urban GDP, urban wage, industrial structure, and unemployment rate. Given that the purpose of this study is to examine the impact of the transformation to industrial AI on workers' mental health, the following benchmark regression model is set.i represents an individual worker and c represents the city where the individual is located. The dependent variable Mentalhealthic denotes the individual's mental health status; the core explanatory variable robotc denotes the level of the transformation to industrial AI in the employee's city. The coefficient γ reflects the marginal impact of the transformation to industrial AI on the individual's mental health, and Xic is a series control variables related to individuals, families, and cities that may affect the mental health of workers. This paper uses clustered robust standard errors at the individual level.In the above equation, robot_USjt denotes the robot use stock of industry j in the US in year t, empc, t = 2008 is the employment of industry j in China in 2008, empj, t = 2008 is the employment of industry j in city c in China in 2008, and emp_empc, j, t = 2008 is the employment of industry j in city c in China in 2008.where Using robot density as an instrumental variable for other countries globally with industrial robot development similar to that in China is a common approach in the relevant literature. The choice of using US industrial robot data is based on the following considerations. First, before 2013, China's robot use had long relied on imports, and the US was one of its main import countries. Second, during the sample period, the development trend of industrial robot applications in the US was relatively close to that in China, and robot technology in the US led the world. Industrial robot applications in the US can reflect the AI trend and satisfy the correlation assumption. Third, there is no evidence that the application of industrial robots in the US directly affects the mental health of employees in China , satisfying the exogeneity assumption.In this paper, the two-stage least squares (2SLS) method is used for the instrumental variable estimation, and the regression results are presented in Before 2013, more than 70% of China's industrial robots were imported from Japan, Europe, and North America  to obtain consistent estimates of the coefficients of the ordered probit model. Therefore, this estimation method is used in this paper, and the results are presented in Above, we control for clustered robust standard errors at the individual level due to heteroskedasticity. Considering that there may be commonality and correlation among different workers within the same city, we cluster the standard errors to the city level and include province fixed effects. After the robustness tests on the above aspects, the key findings of this paper hold. It is thus clear that the transformation to industrial AI in China can effectively improve workers' mental health.The above analysis shows that robot use significantly improves workers' mental health. Then, what are the underlying mechanisms of action? It has been shown that the use of robots increases labor productivity and has complementary effects on workers in non-routine tasks, which in turn increases workers' wages and earnings . MeanwhiIntervariableij represents the mediating variables in this paper, denoting employee wage income and working hours. Xij denotes individual- and city-level control variables. Other variables are defined similarly to those in the benchmark model (2).In the above equation, The regression results are shown in With the new phase of the industrial revolution, an increasing number of studies have focused on the impact of industrial robot applications on local labor markets, including the employment structure, wage levels, and employee health , 26. TheWe found that the transformation to industrial AI significantly improves workers' mental health. Considering that endogeneity problems due to omitted variables may have confounded our findings, we further tested these findings by constructing instrumental variables using US industrial robot data, and the results indicated that the transformation to industrial AI improves workers' mental health. In addition, we conducted robustness tests based on a range of methods, and the results also affirmed that this transformation improves workers' psychological wellbeing. This finding has important theoretical implications. In the existing literature, there are two contrasting effects of industrial transformation on workers' psychological wellbeing: unemployment and low income due to this transformation suppress workers' psychological wellbeing, or high income and low labor intensity due to this transformation promote workers' psychological wellbeing . Our finIn addition, job income and work intensity are important sources of changes in workers' mental health , 27. TheThis paper provides a new perspective for understanding the changes in workers' mental health during the transformation to industrial AI. By linking the use of robots at the city level to workers' mental health at the individual level, this paper improves the understanding of the relationship between technological upgrading and micro-level individual behavior. At the same time, this paper fills an important research gap in the context of AI, thus providing valuable policy implications for international comparisons. Additionally, empirical evidence from China provides reference value for other transition economies to promote high-quality industrial AI. The findings of this paper corroborate those of Cheng et al. , who finThis paper matches CFPS data with urban robot data provided by IFR and uses OLS regression, probit regression, ordered probit regression, and instrumental variables to study the impact of the transformation to industrial AI on workers' mental health. We found that robot use significantly influences workers' mental health, improving all six aspects of workers' mental health. The findings remained robust after a series of robustness tests, such as replacing explanatory and explained variables and replacing regression models. In addition, to avoid endogeneity problems due to omitted variables and two-way causality, the density of industrial robots in the US was used to construct the density of industrial robots at the corresponding sample city level as an instrumental variable. The conclusions showed that the benchmark results are robust and reliable. The mechanism analysis shows that robots significantly increase workers' wage income and decrease workers' working hours, verifying the mechanism effect of robots on workers' mental health levels.With the rapid development of robotics, there is considerable literature focusing on the impact of technological progress on the labor market. However, attention to micro-level of individuals remains insufficient, and even less literature has explored workers' mental health in the context of technological change. Accordingly, this paper examines changes in workers' mental health in the context of the transformation to industrial AI in China. The paper further explores the mechanisms of the effects of robot use on workers' psychological health from the perspectives of both wage income and work intensity. This study extends the research on the relationship between industrial AI and workers' health, which has important theoretical implications. Additionally, based on the Chinese context, this paper has important implications for the current AI changes in developing countries. Transition economies with relative labor shortages can achieve a win-win situation by promoting industrial AI to fill the labor gap and improve workers' psychological health.Of course, there are some limitations in this paper. First, the data used are cross-sectional and do not reveal long-term persistent effects of the transformation to industrial AI on workers' mental health levels. Similarly, limited by data availability, this paper measures the transformation to industrial AI at the city level, which does not accurately reflect workers' exposure to and use of industrial robots. Second, although we explored the mechanisms underlying the effects of the transformation to industrial AI on workers' mental health, we did not explore its boundary conditions in depth. Future research can further explore the mechanisms and boundary conditions of the effects of this transformation on workers' mental health at the micro-level of individuals.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.SY drafted and critically revised the paper for intellectual content. KL and JG made substantial contributions to the concept and design of the work, data interpretation, and the drafting of the article. XH drafted and critically revised the paper and polished the language of the revised draft. All authors contributed to the article and approved the submitted version.This work was funded by the National Natural Science Foundation of China (72163016) and the Special Research Project on Labor Relations of Jilin University (2020LD004).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The 11 years of the devastating conflict in Syria resulted in more than 874,000 deaths, and in more than thirteen million refugees and internally displaced people . The health system was severely affected and has become aid dependent. This study examines aid alignment over a decade of the Syrian crisis from 2011 to 2019.http://oxfamilibrary.openrepository.com/oxfam/bitstream/10546/141974/1/). Aid alignment was explored as part of the 2005 Paris Declaration Framework on aid effectiveness. Based on OECD’s survey on monitoring the Paris Declaration  and based on a proposed methodology to assess aid effectiveness by Burall and Roodman , we designed a sequential mixed methodology to address two main indicators: alignment with national strategies and local procedures, and aid delivery through local systems. The quantitative part investigated the financial alignment of aid using financial data trackers, such as creditor reporting system and the UN-OCHA financial tracking system, and the relevant humanitarian needs estimations by the humanitarian assistance response plans, humanitarian response plans, and humanitarian needs overviews. The qualitative part relied on four focus groups discussions and four key informants interviews with key policy makers, experts and practitioners involved in the humanitarian and health response in Syria, with the aim of interpreting the quantitative findings.Aid alignment involves donors using national systems and institutional structures to manage their aid to recipient governments and aligning their aid policies with development priorities and strategies defined by the partner countries (ROSA Newsletter, Moving towards increased aid alignment in the food and nutrition security sector, 2013. Available from: While the study found an improvement in aid budget alignment with local procedures in Syria from 34% in 2012 to 86% in 2019, we found limited alignment with local strategies. Our qualitative findings pose doubts in the ability of the various data sources of humanitarian needs in Syria to reflect the actual realities, especially before 2014, due to lack of comprehensive local engagement and data systems by then. Therefore, even if the humanitarian budgets seemed to be aligned with the national procedures, the national plans did not seem to align with the actual realities, let alone the increase in the financing deficit over the years of the conflict. The reliance of humanitarian and health aid on governmental structures, as a main recipient, in Syria was much lower than other developing and fragile countries. This is mainly due to the nature of the Syrian conflict where the government is a party to the conflict. Donors were found to have invested poorly in advancing national and sub-national planning in Syria due to donors’ over reliance on the UN-led humanitarian system which struggles in armed conflict settings. As a result, we found a disconnection between field realities, national planning, and humanitarian aid.In light of the dreadful humanitarian crisis in Syria, there has been an adverse aid alignment. Considering the chronicity of the conflict, there is an urgent need to improve aid alignment through more investment in local planning at district or governorate levels. This is especially important to navigate through conflict sensitivities while responding to local needs and initiating local developments. These approaches, combined with adopting health sector-wide approach, could contribute to the humanitarian-development-peace nexus in Syria, which in turn can contribute to a better aid alignment and aid effectiveness. Armed conflict settings are often very aid-dependent, and there are copious amounts of aid received by countries affected by conflicts. While there have been several studies tracking levels of aid to conflict-affected countries , there hAid effectiveness can be defined, as per the World Bank, as “the impact that aid has in reducing poverty and inequality, increasing growth, building capacity, and accelerating achievement of the development goals set by the international community” . Aid effDonors have made efforts to maximize aid impact and deepen development cooperation. These efforts have resulted in formulating fundamental principles and measures for aid effectiveness through four high-level forums in Rome, Paris, Accra and Busan in 2003, 2005, 2008, and 2011 respectively . HoweverIn the literature, there is an argument that the "aid principles" landscape has become significantly crowded recently, with the 2005 Paris Declaration, the Good Humanitarian Donorship agenda and the Fragile States Principles as examples of several different initiatives. However, each of these frameworks is designed to serve specific type of aid; humanitarian, early recovery, stabilisation, or development. It can be argued that many contexts are more complicated than these categories of aid. Additionally, humanitarian actions do not occur in isolation within humanitarian crises but as part of a vast sphere of international interests, especially in conflict settings. As a result, donors should adopt different principles and frameworks, sometimes in the same context .In the Syrian context, there is a transition from "emergency" to "early recovery" after more than 11 years of the conflict . Donors According to the 2005 Paris declaration, there are five main principles for aid effectiveness: ownership, alignment, harmonization, managing for results and mutual accountability . Our stuTo achieve the principle of alignment in the Paris Declaration, donors must “base their overall support on partner countries’ national development strategies, institutions and procedures” . AccordiConsidering the scarcity of the literature on humanitarian aid effectiveness in conflict environments, a key question remains unanswered: Is humanitarian aid less likely to achieve the principles of aid alignment in contexts of conflict and violence? And is this linked to the lack of governance and accountability and the absence of governmental structures in such settings? The Syrian case study might help in answering these questions in relation to aid alignment.The Syrian crisis was described as “the worst humanitarian crisis of the twenty-first century” . From thThe areas of military influence changed dramatically in Syria between 2011 and 2019, and this was accompanied by significant changes at the level of governance and humanitarian and health aid. Figure For simplification, we can distinguish three main areas of control in Syria. (1) The GoS controls central, coastal, and southern areas supported by Russia, Iran, and Shia militias such as Hizabullah. (2) Various opposition forces control areas in northwest Syria in Idlib and Aleppo governorates supported mainly by Turkey. In these areas, two governments emerged; the Syrian Interim Government, which as formed by the National Coalition of Syrian Revolutionary and Opposition Forces in 2013 and operates in Turkish controlled areas in northern Aleppo , and theThe Syrian crisis necessitated a large scale humanitarian response which started in 2011 through local and international NGOs. In 2014, the UN Security Council adopted Resolution 2165 allowing UN agencies to provide aid into Syria through four border crossings to facilitate aid access to areas not under the control of the Syrian government: Bab al-Salam and Bab al-Hawa to deliver aid into northwest Syria, Al Yarubiyah to deliver aid into northeast Syria, and Al-Ramtha to deliver aid into southern Syria . This reAlthough the Syrian government has been accused of several war crimes including the use of chemical weapons against its own people , 31, it According to the UN-OCHA, the top ten humanitarian donors for Syria in 2019 were: the USA, Germany, UK, EU, Canada, Norway, Denmark, Japan, France, and Sweden, respectively. And the top funded sectors in 2019 both inside and outside the response plan/appeal were: food security, health, education, water sanitation hygiene, emergency shelter and non-food items (NFI), and protection, respectively .The study used a sequential mixed methodology to explore aid alignment in Syria between 2011 and 2019. The study design was informed by the OECD’s survey on monitoring the Paris Declaration , 5, and The quantitative part investigated the two indicators using financial data trackers, such as Creditor Reporting System (CRS) and the UN-OCHA financial tracking system (FTS), alongside with using the relevant humanitarian needs estimations by the Humanitarian Assistance Response Plans (HARPs), Humanitarian Response Plans (HRPs), and Humanitarian Needs Overviews (HNOs). The qualitative part was aimed at filling gaps and interpreting the quantitative findings relying on four Focus Groups Discussions (FGDs) with experts and practitioners working for NGOs, INGOs, local health authorities, and health facilities inside Syria all of them are involved in the humanitarian and/or health response in northwest of Syria, and some of them are also involved in northeast Syria. Four Key Informant Interviews (KIIs) with key policy makers and donors involved in the humanitarian and health response in the delivering aid to the various areas of control was then used to validate our findings and form our recommendations.Data on humanitarian and health aid were extracted from the OECD’s Creditor Reporting System (CRS) , and theThere are some differences between the CRS and the FTS datasets due to the different focus of each dataset; with the former being focused on development aid, and the latter being focused on humanitarian aid. The CRS data, therefore, are more comprehensive and offer more details at donors’ and recipients’ levels, including different sectors and reporting values in both constant and current US dollars. In comparison, the FTS data provide continuously updated monitoring of funding progress against the Humanitarian Response Plans and appeal requirements .In this analysis, the term ‘aid’ includes ‘Official Development Assistance’, ‘ODA grants’, ‘ODA loans’, and ‘Private Development Finance’. Aid excludes ‘Equity Investment’ and ‘Other Official Flows’ , 38, 39.To analyse aid trends over the study period, we relied on the constant 2019 US dollar value rather than the current dollar value to account for changes in exchange rates and inflation. The Development Assistance Committee (DAC) deflator converts the amounts back to the value they held in a specific year; in our example, 2019 , 42. TheWe excluded the Turkish humanitarian donor from our analysis due to a classification error in their reporting on the CRS system. The Turkish donor reports the expenses on Syrian refugees in Turkey as an ODA grant, although these expenses did not reach the recipient country—in this case Syria.Data on humanitarian needs and local strategies were extracted from the OCHA database FTS. The FTS database includes inputs from the OCHA’s humanitarian and response plans (HRPs)  and the Data on the use of local systems were extracted from the CRS database. The Paris Declaration recommended that donors use ‘recipient countries’ systems and policies to promote development goals . The perRelying on the above-mentioned databases, we identified several variables to represent donors’ disbursements, humanitarian local strategies and procedures, and the use of local systems. The following table summarises the variables used in the quantitative analysis Table .Table 1LThe financial data were insufficient to understand aid alignment in Syria. We complemented the quantitative analysis with four Focus Group Discussions (FGDs) and four semi-structured interviews with experts, humanitarian practitioners, and public sector officials to fill gaps and interpret the quantitative findings. This was crucial because the quantitative data were not an accurate reflection of what is happening on the ground. This might be related to incompleteness and misclassifications in financial reporting, but more importantly it is related to the conflict sensitivities where the GoS is recognised in such databases as the only representative of national planning, strategies, and local systems.We used purposive sampling followed by snowballing sampling approaches to identify the FGDs participants. The research team invited 31 humanitarian workers in senior positions from medical NGOs and INGOs, local authorities, technical entities, and the Gaziantep’s health cluster to take part in the FGDs in Turkey—Mersin in August 2021. 25 out of the 31 invitees attended the FGDs, and 88% of the participants were from a medical background with a vast experience in humanitarian and health programs. Four FGDs were conducted with an average of 12 participants in each one. The discussions were conducted in Arabic, with one moderator and one note taker for each group. The FGDs were not recorded based on the participants’ preference.The FGDs were followed by four semi-structured interviews with representatives of 4 leading donors in Syria. The interviews aimed at validating our findings and initiating discussions related to policy implications. The feedback from these key informants aligned strongly with areas discussed in the FGDs. The KIIs were conducted in English and they were recorded. They were later transcribed and anonymized using a unique identifier for each participant. Following a thematic analysis approach, data from the FGDs and the interviews was extracted and categorized into different themes.In 2011, 100% of the humanitarian funding was spent without a plan. Between 2012 and 2019, funding without any plan decreased from 66% in 2012 to 14% in 2019. In other words, plan-aligned funding increased from 34% in 2012 to 86% in 2019. Overall, there was an increase in alignment with national needs and strategies over the study period  and Humanitarian Needs Overviews (HNOs) and documenting the development process. Therefore, reliable data about humanitarian needs and appealed funds were unavailable for all parts of the country before 2014.The participants argued that even after 2015, representative data on aid budget alignment with local plans might be limited due to an absence of national bodies to support the development of nation-wide and needs-based response strategies. While the cluster system involves local humanitarian actors in developing response strategies, the engagement of local governance structures in northwest and in northeast Syria in such processes was almost absent. These indicators, therefore, might poorly represent the actual reality on the ground, especially in northwest and in northeast Syria. So, the actual concept of local needs and strategies was not reflected in the mentioned process. For example, several participants mentioned the case of the Strategic Advisory Group, which was established by the Whole of Syria coordination mechanism as part of the health clusters in the various humanitarian hubs. This advisory group in Gaziantep health cluster started in 2016 to engage all local actors—including local governance structures—in needs assessment and response strategies. However, this advisory group has been deactivated in 2018, and accordingly the governance bodies in northwest Syria have since not been involved in needs assessments and in developing response strategies. This deactivation remarkably impacted the local perspectives of needs and response strategies in the development process of the HNO and the HRP. The participants argued that the subsequent HRPs, in 2019 and 2020, poorly represented the actual needs and the sub-national response strategies in northwest and in northeast Syria. The 2021 HRP had not been released yet at the time of the workshop in Mersin in August 2021.Another challenge that might hindered the completeness and the representation of data is the conflict complex geopolitics and the accompanied complexity in the humanitarian structures to navigate through these geopolitics. One participant mentioned that the HNO is usually affected by the political and the military influences in the various areas of control. For example, the GoS is heavily involved in needs assessment in its areas of control. There is precedent evidence that suggests the manipulation of humanitarian aid by the Assad regime , 47. TheDuring the period of our study, we found a tendency for health donors to work through a recipient government in both fragile states and developing countries Fig. . The sitIn contrast to health aid, donors were found to use channels of recipient governments for humanitarian funding in developing countries much more than in fragile states Fig. . This miThe CRS and the FTS databases recognise official governmental bodies only when calculating the percentage of aid going through local systems. The participants in the FGDs argued that this classification should be redefined, especially in conflict settings such as Syria. In conflict settings, the humanitarian principles prevent humanitarian donors and actors from engaging directly with parties to the conflict. In the case of Syria, the GoS is one party to the conflict, which was accused with many war crimes including the use of chemical weapons. The participants, thus, suggested that the use of local systems should be extended to other local actors and grassroot governance structures that represent sub-national levels and local communities that are not parties to the conflict.Additionally, the figures on aid going through the Syria government channels do not represent all aid going through local systems and channels, as the Syrian government does not control all of the Syrian territories. For example, the participants reported that some funding was going through sub-national governmental bodies, such as the Syrian Interim Government in northwest Syria and the Autonomous Administration of North and East Syria; this funding was not reported as going through local systems on neither of the financial tracking databases. There is no information in the CRS system on whether some Syria related funding passed through governmental structures other than the structures and the channels of the GoS.Although the reviewed data suggest that the use of the GoS channels has been very limited, the participants of the FGDs argued that this data might be biased. They argued that the data show the percentages of funds passed through the official governmental bodies of the GoS as a first channel; the data, however, do not consider other channels that are closely affiliated with the GoS, such as the Syrian Arab Red Crescent, Al Bostan charity, and the Syria Trust for Development. These NGOs received significant funding as a first or a second channel, and their response strategies are completely aligned with the GoS plans.Furthermore, the participants discussed the balance between the use of local systems and the possibility of empowering parties to the conflict. While the Paris declaration has an embedded aim that humanitarian responses should contribute to the recipient country’s resilience, this assumption might be tricky to implement in chronic conflict settings where national governments can be parties to the conflict.The participants recalled several incidents when the GoS manipulated humanitarian funding for its own interests, which might have contributed to strengthening its political and military position. This opinion is in line with many reports that mentioned impeding the supply of UN aid to some besieged areas by the GoS, and the flow of UN aid funds to the GoS through NGOs established by relatives of the Syrian President, such as the Syria Trust for Development—which is headed by Asmaa Al Assad, and Al-Bustan Association—which is run by Rami Makhlof who is a member of the Assda’s family , 47.There should be, therefore, other mechanisms to work with local systems in Syria to increase the sustainability of humanitarian aid without empowering parties to the conflict.There have been very limited studies that assessed aid alignment in conflict settings. A review in 2004 for international aid in fragile settings suggested that the incentive effect of aid reform in fragile states is highly doubtful . In SoutThis study contributed to the efforts of evaluating progress towards better aid effectiveness through assessing aid alignment in the Syrian conflict. The official financial trackers, such as the CRS and the FTS, indicate an improvement in aid alignment in Syria between 2011 and 2019 from 34% in 2012 to 86% in 2019—compared to the UNOCHA’s humanitarian and response plans (HRPs). However, our study suggests that this improvement might only poorly reflect the actual realities on the ground. Issues such as data completeness and representation, conflict geopolitics and data transparency, manipulation and politicisation of aid, and the way national and local systems and channels are defined, are all challenges to be considered when assessing aid alignment learning from the Syrian context. Our study thus proposes a key question: how can aid alignment be improved in a context where the internationally recognised government is accused of war crimes?Humanitarian funding increased significantly in Syria throughout the 9 years of the study, in line with the increase in humanitarian needs. In parallel, the availability and the quality of needs assessments and planning processes also improved significantly. In the early years of the conflict, there was no official UN led response covering the whole country. It was not until July 2014, that the UN agencies were allowed to lead the cross border aid to areas out of the control of the GoS. The humanitarian response planning, thus, was very limited before 2014. This explains why the humanitarian funding in 2012 and 2013 was more than the required plans. In 2014, the humanitarian funding was almost equal to the response plans. Later, the deficit in humanitarian funding increased from 2015 onwards. The first consolidated appeal for Syria was launched in 2015 after the UNOCHA led a nation-wide planning process covering the different areas of control, which resulted in the 2015 Syria Strategic Response Plan (SRP) and the 2015 Humanitarian Needs Overview (HNO) .For health funding, which includes both humanitarian and development funding, the gaps in data are more remarkable. There are no overall response plans for the health sector—that covers the whole country—over the study period, neither from the GoS nor from the UNOCHA. Therefore, we were not able to determine to what extent health aid was aligned with the local needs. However, available data showed that health aid had some slight alignment in 2013 and 2015 in Syria, corresponding to the significant peaks in internal displacements in Syria in 2013—with about 3.5 million IDPs , and to The proportion of health and humanitarian aid passed through the structures of the recipient government as the first channel in Syria was much lower than highly fragile and developing countries. Avoiding governmental channels by donors in conflict settings is consistent with the literature, as donors tend to avoid state channels when political commitment is lacking . This haAvoiding governmental channels while ensuring aid alignment in conflict settings can be very challenging. However, it can be done sometimes through working with other local structures at a much lower level, such as governorate or district level. Aid alignment can also be done in such cases through what is called “shadow alignment”. This means that donors can implement projects based on the government’s vision without allocating resources directly through governmental channels . In SyriIn GoS controlled areas, donors can negotiate with the GoS to work directly with local authorities on governorate or district levels without going through the central government. This approach can be appropriate to work in the different areas of control in Syria, as working with the central sub-national health authorities represented by the ministries of health of the different governments, carries risks of corruption, politicization and manipulation of aid. Whereas, working at the level of the health directorates or the other health bodies at governance or district levels, can contribute to increasing the participation of local communities, increasing their ownership of development plans, and reducing the politicization of health aid. However, this is a context specific recommendation as avoiding central governments in recipient countries could weaken the governance and accountability structures.The split of Syria into different areas of control seems to be the de facto reality for the foreseeable future , 71. Con


Geronticus eremita) became one of the rarest birds in the world. In this paper, we trace the history of the species through different epochs up to the present. A particular focus is placed both on its life in and disappearance from ancient Egypt, where the bird attained significant cultural importance, and on the modern endeavour to re-wild and restore the species. The Northern Bald Ibis is an outstanding example of how an interdisciplinary cultural-historical and natural-scientific approach significantly promotes the interpretation of historical evidence as well as helps implement current rewilding and restoration efforts.Once widespread around the Mediterranean region, the Northern Bald Ibis  as triggers for the extinction of the species. The evidence for a triple disappearance of the Northern Bald Ibis  represents a unique basis for studying both the bird’s habitat preferences and its vulnerability. This is because different, mainly anthropogenic, causes stood behind these three historical disappearances, although the disappearances in all three epochs occurred during a period of climate change. There is a growing consensus that the rapidly increasing challenges of biodiversity conservation and restoration cannot be overcome without a thorough knowledge of human society and its history . In an iGeronticus eremita) combines current conservation needs and cultural-historical research questions in an exemplary way. This species is one of the most threatened birds in the world; it was listed as “critically endangered” in the IUCN Red List for 24 years, before being downgraded to “endangered” in 2018 due to extensive protection efforts [The story of the Northern Bald Ibis  to shed light on ecological and cultural-historical peculiarities of the species and, mainly, on the reasons for the decline of the bird’s population in different regions. This interdisciplinary and comparative approach helps generate strategies for current and planned protection measures for the Northern Bald Ibis and other endangered migratory bird species.www.waldrapp.eu, accessed on 22 June 2014) and the underlying feasibility study [This paper specifically refers to studies on Northern Bald Ibis behaviour and ecology done within the framework of a European LIFE reintroduction project , collecting (and interpreting) evidence on bodily remains of this avian species from Egypt and, most importantly, building a palaeographic (sign development) database of the Akh  depictions from all historical periods of ancient Egypt. All material, pictorial and textual evidence on the Northern Bald Ibis attested from ancient Egypt (from ca. 4000 BCE to ca. 630 CE) was analysed and considered. The textual evidence on the hieroglyphic sign of Akh  was examined and analysed according to specific time periods . For the development/degradation of the sign, a special palaeographical table was created and used [The present article thus combines primary research (including direct observation and experimentation) on a specific avian species with secondary research into the development and changes of human approaches to the particular species in history. Both research approaches are presented together in each section of the paper. This yields a “synoptic” study covering both types of research.Bird care, keeping, training and release in the frame of the European project followed well established standards in accordance with the legal framework and under the supervision of Waldrappteam Conservation and Research Experts. The weight of the data-logger was well below the recommended maximum value of 5% of the birds’ body weight of about 1.300 Gram. The loggers were fixed on the lower back of the birds via a Teflon-tubes leg-loop harness. This position is known to causes the least drag and minimize also other disadvantages and risks for the carrier (Cyt.). All translocation and management measures have been implemented in the frame of the European LIFE project LIFE+12-BIO_AT_000143. National approvals were provided by the County of Salzburg (21302-02/239/352-2012), Carintia (11-JAG-s/75-2004), Baden-Württemberg , Bavaria (55.1-8646.NAT_03-10-1) and Italy (0027720-09/04/2013).Geronticus eremita, elderly hermit. Systematically, the species belongs to the order Pelecaniformes and the family Threskiornithidae. The genus Geronticus includes only one more species, the Southern Bald Ibis  native to South Africa. The sexes do not differ significantly. The males are slightly heavier than the females  [The Northern Bald Ibis is a bird with an exotic appearance featuring a long, curved bill, a naked reddish face, framed by an imposing crest of black lancet feathers, and an all-black plumage that gleams metallic in the sunlight . The Latfemales) , with a Geronticus eremita; Once a widespread colonial migratory bird species, the Northern Bald Ibis  were linked to the same habitat by ancient Egyptians. Direct observation showed that the birds formerly dwelled on limestone cliffs on the eastern side of the Nile valley. This very region, called Akhet  by the Egyptians, was also believed to be the dwelling place of the blessed spirits and gods [What remains after the vanishing of this extraordinary bird are cultural traces that can be found throughout the historical area. The richest and most exciting traces are from ancient Egypt. There, the Northern Bald Ibis was inseparably liked with the concept of the Akh (often translated as “the blessed dead” or “effective spirit”) ,46,47,48and gods ,50,51,52The earliest evidence for the cultural meaning of the Northern Bald Ibis stems from ancient Egypt, where the species was used as a pictorial representation for the hieroglyphic sign Akh . The sigMost historical drawings of the Northern Bald Ibis represent adult birds with a bare head and the feather crest ,19,23,48The bird’s importance for the dining tables of the nobility and the clergy even led to protective measures as the populations declined. In Salzburg (Austria), for example, the archbishop’s decrees of 1504 and 1584 criminalized the shooting of Northern Bald Ibises from the Mönchsberg cliff above the city of Salzburg. In the same century, Emperor Maximilian I provided artificial nesting aids in the rock walls in Graz. In the same period, an order was issued in the city of Graz, Austria, where a colony also occurred, that Northern Bald Ibises should not be shot but rather cherished and guarded ,53. Evenhajj. Once a year, the Northern Bald Ibises of Bireçik flew southwards in large numbers, just like pilgrims to Mecca, and they returned in spring after a period common also for pilgrimages [kelaynak is the Turkish name for the species). Presumably for these reasons, this ibis species was less pursued as food in the Arab world.In the Arab region, the Northern Bald Ibis enjoyed a more positive and more significant cultural image than in the Christian world. In the Muslim tradition, the birds were considered semi-sacred for two main reasons. According to the tradition, it was a Northern Bald Ibis that led the Quranic patriarch Nuh  and his family to the fertile lowlands of the Euphrates River after a successful landing of the Ark on Mount Ararat . In the grimages ,33. For A remarkable characteristic of the Northern Bald Ibis is its long and fragile curved bill. It is poorly suited to hunt for mobile prey but perfectly shaped to dig deeply for invertebrates in the soil. This bird is therefore mainly a tactile hunter. Its preferred habitat is open landscapes with low vegetation and an abundance of soil fauna. Under favourable conditions, its diet consists predominantly of worms and larvae ,54, but The flexibility in foraging is also reflected in a diversity of foraging habitats. Northern Bald Ibises once fed in the Syrian Desert , in the A noticeable peculiarity in connection with the feeding ecology is the frequent proximity of the breeding habitats to human settlements. This is evident from historical reports for the former European population ,22,23,26The breeding sites were often close to human settlements, too, but this was most likely more a coincidence than a mutualistic relationship. The Northern Bald Ibis as a colonial breeder that needs cliffs that are structured with niches or ledges . Many suThere is almost no material evidence on the habitat use of the Northern Bald Ibis in ancient Egypt. The only available evidence comes from textual and iconographic sources of religious nature. For example, a study on the meaning and cultural context of the Akh sign provided us with information about the bird’s habitat (cliffs of limestone massifs at the eastern bank of the Nile), character  and flight characteristics during migration . HoweverThe Northern Bald Ibis is a year-round social species with hierarchically structured colonies consisting of up to several thousand individuals. The species is monogamous, with some couples forming long-lasting bonds while others remain together only for a breeding season. Both partners breed and raise the chicks, a behaviour characteristic of many monomorphic species . The fleThe species has a rather moderate repertoire of calls. Most common is the “croop” call, which is used in an affiliative context—the characteristic greeting behaviour with the rhythmic vertical movement of the beak—as well as during agonistic encounters . The “crA noticeable and characteristic behaviour of the Northern Bald Ibis, as of other ibises (Threskiornithidae), is the sunning (or “sun-bathing”) behaviour, in which the bird remains in a stiff upright position with its wings outstretched . Such “sThe species was migratory over its entire historical range, with known wintering sites along the African west coast down to Mauritania and Mali and along the African east coast down to Ethiopia and Eritrea ,10,38,57Zugbereitschaft) in early August [Due to the extinction of all migratory colonies, most of our knowledge about the species-specific migration behaviour comes from the migratory European release population. These birds are descendants of former migratory colonies in the Moroccan Atlas. Research on their physiology, energetics and behaviour has shown that this bird is an enduring migratory species with a pronounced navigation ability. In Europe, they enter into a migratory state  and the Glossy Ibis , which are known to have been kept and mummified in huge numbers [Due to the lack of physical evidence on the presence of the Northern Bald Ibis in Egypt, one can only use pictorial and textual evidence in researching the nature of the bird’s presence in the country. In this respect, the pictorial evidence on the species was much more accurate, precise and elaborate in the early periods of Egyptian history, until the final phase of the third millennium BCE . In late numbers ,80. Judg numbers ,82,83,84The Northern Bald Ibis is an iconic species for both ornithology and Egyptology. The interdisciplinary approach enables tracing the bird’s presence, habits and habitats almost 5000 years back in history. Coincidently, this ibis species is connected with the notion of death and disappearance in both scientific fields. For ornithologists and conservationists, it is best known for being one of the most endangered avian species in the world and a model for current conservation and reintroduction attempts ,10,19. IRecent studies on this bird’s behaviour and ecology, particularly in the context of the European LIFE project, enriched Egyptology with information about the species’ shape, colouring, habitat, social habits, migration periods, routes and formations. With these data, Egyptologists were able to clarify their views on key cultural and religious concepts ,48,85.In turn, in-depth Egyptological studies proved to be valuable for recent research and conservation attempts. Tracing the history of the Northern Bald Ibis several millennia into the past yields significant information about the coexistence of this species and the human population in very different epochs and regions. Such coexistence and relationship worked well for long periods of time, but at some point the situation changed to the disadvantage of the birds. This was the case in ancient Egypt during the final phase of the third millennium BCE , in Euroba . When the species disappeared from Egypt after a climate change early in the third millennium BC, the hieroglyphic ba sign first lost its accuracy and slowly ceased to resemble the stork at all. Then the sign and the Egyptian term ba was given a new meaning (“soul”) and, finally, a completely new hieroglyphic sign  was invented for the ba [In fact, the cultural and historical traces of the disappearance of the Northern Bald Ibis from ancient Egypt are similar to those of the Saddle-Billed Stork. These can thus be used for direct comparison. The Egyptians used the image of the Saddle-Billed Stork as a hieroglyphic sign r the ba ,85. ThusFurther Egyptological research revealed that the Northern Bald Ibis disappeared from Egypt during the late third millennium BC, some 500 years after a major climate change had occurred in the region . OngoingDisappearance of the Northern Bald Ibis in the final phase of the third millennium BCE, in the 16th century AD and in the 20th and 21st centuries occurred in different regions and were caused by a different trigger event. However, they have one important factor in common: Intensified human activity directly or indirectly forcing this bird species to alter its habits and habitat, to change or leave its breeding areas or migration routes. The extinction of the ancient Egyptian population and the European population also correlates with marked changes in the climate . In the Noteworthy in this context is the International Single Species Action Plan for the Conservation of the Northern Bald Ibis, which was published in 2015 and foreseen for a 10-year period : the terProyecto Eremita in Andalusia, Spain, is on the way to establishing a residential colony [In Europe, which lies geographically outside the prioritized areas of the action plan, two successful reintroduction projects are being implemented. l colony , while Wl colony ,10. Thisl colony . An anall colony .Based on the population and habitat modelling, from 2022 to 2028 a second LIFE project is implemented (LIFE20 NAT/AT/000049). This project, covering four countries , aims for a self-sustaining population with at least 360 individuals, divided into 7 breeding colonies at the northern and southern foothills of the Alps and a common wintering site in southern Tuscany. Extensive campaigns are aimed at substantially and sustainably reducing losses from the primary causes of death, which are illegal hunting in Italy and electrocution in the breeding areas. Based on the results of the interdisciplinary investigations and the modelling, climate change is seen as the greatest risk to sustainable reintroduction and various mitigation and compensation measures are envisaged accordingly. This includes, among others, the subdivision of the population into several colonies with breeding areas in different climatic regions, optimization of genetic variability and intensive monitoring. However, the extensive experience with this European release population in combination with the historical facts as presented in this paper should also help to initiate and optimize conservation measures in the entire historical distribution area, especially with regard to the apparent sensitivity of the species to climate change.This interdisciplinary study illustrates the importance of tracing the cultural-historical meaning of a species and human–animal interactions with a special focus on epochs of instability and change. The importance of historical evidence should be understood less in a purely geographical context, as is the case in the current action plan for the Northern Bald Ibis, but rather be included in the assessment of the ecological, cultural and socio-economic framework for species protection measures. The analysis also points to the clear sensitivity of the species to climatic changes and the resulting ecological and cultural framework conditions. Therefore, the assessment, planning and implementation of species protection measures must not be based on the assumption of static ecological and cultural framework conditions. Rather, a dynamic approach is required, such as through suitable modelling . This is


Foodservices in residential aged-care homes (RACHs) play a vital role in providing meals and maintaining residents’ health through good nutrition. However, foodservices are often required to work within a budget, and the costs involved in foodservices are often misunderstood and underestimated. The aim of this work was to design a costing tool that included all relevant costs of a foodservice. A systems approach was used to inform the development of the Foodservice Costing Tool (FCT). Eight domains were identified, including costs that are both directly and indirectly associated with foodservices. The tool was piloted and trialled in the Australian aged-care setting and compared to currently available national estimates of costs. Through four pilots and subsequent trials, the FCT was able to capture the costs of a foodservice system in a small sample of RACHs, although the low response rate may have biased the sample toward those homes that had fewer problems with the FCT. The results highlighted the limitations of currently reported estimates, which underestimate total costs, as they fail to encompass the complexity of foodservices and to recognise that costs extend beyond the kitchen. The FCT is a useful tool and has the potential to be used by RACHs to both measure and understand their costs at a more granular level to ensure cost effectiveness and accountability. Further research is required to validate the tool and investigate the implementation of the FCT on a larger scale. Foodservices provide the sole source of nutrition for the majority of residents in residential aged care, and therefore they should be designed and operated in a way that meets the needs and expectations of residents. However, there are often organisational structures and budgets that impact how foodservices are provided. Foodservice managers play an important role in reconciling the needs and desires of residents with organisational budgets. Complex systems, such as those found in RACHs, can be difficult to cost; however, understanding the costs involved in these complex systems is vital to ensure efficiency and quality.Nationally, there has been an increasing focus on costs and the level of care provided to residents in RACHs, of which the food expenditure has been highly publicised and criticised . This inWith current tools unable to accurately depict costs, there is little known about what the true costs are in running a foodservice in residential (RAC). This has repercussions for management, including difficulties in accurately measuring and understanding costs, the potential for systems to run at a higher cost than anticipated and difficulties in planning or implementing systems due to unmeasured costs . In addiA search of published and grey literature was conducted to identify existing tools that measured costs of hospital or RAC foodservices. It was identified that there were very few tools available to calculate foodservice costs in these settings, with most focused on hospital foodservice and on food and staff costs alone.The Meal Unit Methodology Costing Formula created by the Institute of Hospital Catering Limited was the most comprehensive tool available, and included food, labour and kitchen supplies in its calculation . As it wThe systems approach has long been applied to the management of complex organisations, and was first applied to foodservice by Vaden . When foThe initial tool was tested for feasibility in calculating costs and useability by aged-care staff in three volunteer aged-care homes, located in two major capital cities in Australia between January 2019 and January 2020. Homes were both of small  or medium sizes  and were operated by either not-for-profit or for-profit organisations. A convenience sample was used, with homes known to researchers approached to participate in the study. One home piloted the tool twice, with the first pilot measuring from January 2018 to January 2019 and the second pilot including January 2019–January 2020. The remaining two homes completed one pilot of the tool each for the 2018–2019 financial year. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of The University of Queensland . Informed consent was obtained from all participants involved in the study.There were 4 iterations within the pilot, with feedback incorporated after each iteration. Field notes were kept by the main researcher to record issues that arose with the usage of the tool. This included questions from managers to clarify components of the tool, errors that had been made in the form and missing data. Several changes were made to the content, format, and process of using the tool over the four iterations. These are outlined in After piloting the tool, researchers aimed to validate the FCT using a number of homes of varying size, location and ownership type. Snowballing was used to recruit homes. The study was advertised through multiple channels including through personal networks, through advertisement in newsletters of three national aged-care or foodservice organisations and through social media. No restrictions were placed on the type or number of homes that could participate. While all homes were eligible to participate and were going to be provided with an individualised cost report, a subgroup of homes was going to be selected to be included in the final analysis. This subgroup was to include an appropriate mix of homes that considered their location, bed number and ownership type to ensure the final group would be representative of aged-care homes within Australia. Due to the low participation of providers, there was an inadequate number of homes to complete analysis in this way.n = 26 homes) provided consent to participate in the first recruitment phase; however, due to the rise of COVID-19 in early 2020, a number of participating homes withdrew or paused their enrolment in the study. One provider withdrew 10 homes, and another requested a pause on data collection in its 15 homes. Only one home continued with data collection from this phase. Recruitment was paused during this time due to the large focus on pandemic management for RACHs and anticipated low levels of expression of interest in participating.Three RAC providers (n = 16 homes) expressed interest in participating in the study and seven provided written consent (n = 14 homes). Fourteen homes were emailed the FCT forms. Following subsequent reminders, two providers (n= 3 homes) did not return their forms. This was considered as withdrawing from the study. Five providers (n= 11 homes) partially completed the forms, and only one home completed the entire foodservice costing tool and received a report of their foodservice from phase two of recruitment. Across both phases of recruitment, only two homes completed the FCT. Demographics for homes in the pilot and validation studies are listed in Recruitment recommenced in January 2021, through the previously mentioned channels. Nine providers  . The ranThe allocation of activities to non-foodservice staff varied between homes, with most hours spent on mealtime assistance. On average, mealtime assistance was provided for 45 min at the three main meals. Smaller mealtimes, including morning tea, afternoon tea and supper, took on average 15 min. Activities such as setting and packing up the dining room, taking residents’ orders, meal delivery and meal ordering were regularly undertaken by non-foodservice staff in each home, with an associated cost ranging from AUD $2.38 to $8.65 prpd . This coAn analysis of foodservice staff workflows was completed to understand how staff time was spent in foodservices. Results showed that for each home, the most time was spent on activities relating to kitchen clean up. The second highest was meal production, followed by meal-service preparation and kitchen administration. Activity related to texture-modified meals consumed the least amount of time. Collecting workflow data was difficult for each home, with workflows either non-existent or not reported in enough detail to allow for granular analysis. In order to obtain this information, significant time was spent by researchers creating personalised forms for each home.Two homes completed the FCT  due to the pandemic, multiple snap or prolonged lockdowns across multiple states, a sector under stress due to a national Royal Commission into Aged Care Quality and Safety, increased scrutiny from the media and changes to funding, reporting requirements and accreditation (increased unannounced visits). All of these external events placed significant strain on the aged-care system, and provide potential reasons as to why RACHs may not have engaged in research. It is also noted that Stewart Brown Chartered Accountants completes annual financial benchmarking for 1200 RACHs , which includes an estimation of food and foodservice staff costs. With this information already provided to a large percentage of RACHs, it is possible that there was not a perceived need for the FCT.While five providers failed to complete the FCT, all provided some data. To further understand whether there were areas of the tool that were more difficult to complete than others, an analysis of the submitted data was completed. When mapped across areas of the tool, it became clear that costs for utilities, supplements and non-foodservice staff were most commonly not included. To further explore these costs, an influence diagram was created to understand what determines the total cost of foodservices within RAC. From this analysis, it became evident that while these categories contribute to the cost of the foodservice, they traditionally sit outside the foodservice itself, potentially increasing the difficulty of obtaining this information. An example is staff allocation for nursing and care staff, who may assist in taking residents’ orders, or assist at mealtimes or supplement expenditure. These costs traditionally sit within nursing; however, they are interrelated with foodservice costs. Difficulty in obtaining information from other parts of the system was also evident in communication with homes. Most cited a lack of access to data or difficulty in obtaining data from other people outside the foodservice.n = 6), the average spend on foodservices was AUD $42.65 per resident per day (range $27.91–$54.85) Food expenditure ranged from AUD $9.37 to $11.36 per resident per day, which is consistent with the costs published by Stewart Brown for the same year [The FCT was developed to calculate the total cost of foodservices in RACH due to the limited scope of current tools. Across all trials  and contract catering ($33.14). The average amount spent on food, supplements and cooking ingredients was AUD $12.92 prpd . This wa and contn = 4) are similar to the Stewart Brown figures (AUD $30.66–$39.08). This provides a degree of confidence in the tool to correctly account for costs, and highlights the additional costs that are included in the FCT.Costs reported by the FCT are higher than currently reported costs, which is to be expected due to the inclusion of a larger number of foodservice costs in its calculation. However, if these costs, including non-foodservice staff, maintenance, utilities, large equipment and kitchen-related expenses, are removed for comparison, it can be seen that the total foodservice costs for the majority of homes (The Resource Utilisation and Classification Study (RUCS), completed by the University of Wollongong, proposed a new assessment and funding model for residential aged care in Australia. While it did not provide specific costs, it did identify cost drivers  within the system. Costs were classified as structural or fixed costs. Fixed costs are those that are related to the characteristics of the facility rather than individual care needs, such as general supervision at mealtimes. Variable costs are the cost of care that is required to address the individual care needs of residents. This study found that facilities that are remote or small, or that specialise in Indigenous care, had higher fixed care costs . When coA difference between the FCT and the currently reported figures is the inclusion of costs associated with mealtime activities that are completed by non-foodservice staff, such as supervision or providing assistance at mealtimes. The RUCS study identified that mealtimes contribute to both the fixed and individual costs. The Resource Utilisation Groups-Activities of daily living (RUG-ADL) is designed to profile loss of function using, eating, transfers, toileting and mobility. It measures the resources required to carry out respective functional tasks. An analysis of independent variables showed that function, mobility, and activities of daily living (including eating) were the largest cost drivers for residents . It is tSince the commencement of this work, there have been changes in funding related to food and nutrition as a result of the Royal Commission into Aged Care Quality and Safety. The Royal Commission highlighted a number of areas in which the aged-care system required improvement, one of which was food and nutrition. Recommendation 112 proposed immediate changes to the Basic Daily Fee by providing an additional $10 per resident per day . This reWhile this study adds to the literature around costs of foodservices in residential aged care, there are limitations to its findings. The major limitation of this work is the low recruitment and the subsequent small sample used to pilot and test the FCT. Due to external events, such as the Royal Commission and COVID-19, recruitment was difficult. The study also saw high dropout and non-completion rates. Whether this was due to external events or the use of the tool itself is unknown. Due to the low response rate, the sample might not be representative. In particular, homes that had problems with the FCT might have been less willing to complete and return it. Further research is required to investigate the use of the tool in RAC and its applicability to practice.Due to the prolonged impact of COVID-19, data collection spanned multiple years. This may impact the ability to compare different costs between each of the homes, due to potential changes in the prices of goods. The complexity of foodservices and the need to rely on facility staff to report figures does affect the precision and accuracy of results. While the sample of homes used was small and not representative of Australian aged-care homes, the FCT measured costs in the aged-care setting and identified components of foodservices contributing to overall costs. Further studies are needed to validate the tool and recruit a larger, more representative sample of homes to determine the average spend on foodservices in Australia.While the development and testing of the tool faced many barriers, the final FCT was able to capture the costs of RACH foodservice for a small and possibly unrepresentative sample of homes. It is the first tool to identify the complexity of foodservices and recognise that costs are located within different parts of the residential aged-care system. By ensuring homes are accurately reporting and attributing their costs to all parts of the foodservice, the FCT enables services to demonstrate cost-effectiveness and to potentially justify and plan future system changes in order to meet the needs and expectations of consumers now and into the future.


Mild cognitive or neurocognitive impairment (MCI) may be more prevalent in rural areas. Differences between rural and urban MCI patients in terms of risk factors, course and prognosis are rarely reported. The present review aims to summarize the latest research on MCI in rural areas. A literature search was performed in the databases of PubMed, Scopus and ScienceDirect for articles published over the last decade. Eleven articles were included in this review, reporting on the differences between rural and urban MCI patients. Several risk factors, such as older age, lack of activities and food insecurity have been associated with MCI in both rural and urban areas, whereas others, such as obesity, adverse childhood experiences and plasma chemokine C-C motif ligand 11 , differed according to the place of residence. No specific protective factor for rural women has been reported. There is some evidence that MCI may present earlier in rural residents, but that progression to dementia may be more rapid in urban residents. It seems that there may be clinically relevant differences in the onset, course and prognosis of MCI with regards to the place of residence . Those differences should be taken into account for the design of health policies and service delivery across different settings. Mild cognitive impairment (MCI), or mild neurocognitive disorder, according to the latest classification of the American Psychiatric Association (DSM-5), is a condition that is characterized by cognitive decline with minimal impairment of instrumental activities of daily living of the individual and the preservation of baseline functioning ,2. LargeLess is known regarding MCI in the rural context. It has been suggested that despite improved access to health services, inadequate diagnosis and management of dementia may be still common, particularly in rural areas . AccordiThese notions make the study of MCI in the rural context both timely and relevant. The aim of the present review was therefore to present an up-to-date account of the study of MCI in rural areas, with a focus on the differences between rural and urban patients; and to stress the importance of studying MCI in rural areas for clinical practice and healthcare policy.International Classification of Disease, 10th revision and Diagnostic and Statistical Manual for Mental Disorders-fifth edition, respectively). However, the precise definition of “rural” is still a limitation in the literature [A review of the literature was conducted. The search was run in the PubMed, Scopus and ScienceDirect databases with the use of the key-words “mild cognitive impairment” or “mild neurocognitive impairment” and “rural areas”, with cross-referencing across the databases. It has been argued that PubMed is the optimal tool in biomedical electronic research, whereas Scopus covers a wider journal range and offers the opportunity for citation analysis . Accorditerature ; that isterature . For theterature . The maiThe process followed for the search is illustrated in the flowchart . In the With regards to the risk factors of cognitive decline and MCI, a total of 8 studies were detected . AccordiOther research attempted to address biological factors in patients with MCI in relation to their place of residence. In a study from the USA concerned with Mexican-Americans, data from two cohorts, FRONTIER for rural and HABLE for urban residents, were analyzed . In bothThree studies have been identified that addressed diagnosis and prognosis of MCI in rural elderly residents . A studyThe prevalence of MCI in rural areas has been reported to be as high as over 26% , making Recent research addressing risk factors for MCI in rural and urban contexts has yielded interesting results. As shown in According to recent research, it seems that the risk for developing MCI may be mediated by environmental factors. Urbanicity and the so-called urban stress have been consistently implicated in the pathophysiology of major mental disorders, such as schizophrenia . HoweverIt should be mentioned that the female gender was not consistently reported as a risk factor for MCI in both rural and urban residents across studies ,20. SuchThere is some evidence that people living in rural areas may be diagnosed with MCI earlier than their urban counterparts . On the The place of residence may play a major role in the progression and outcome of neuropsychiatric diseases . The preRecent findings regarding the differences in MCI between rural and urban residents may not be generalized across countries and settings due to differences in methodology and cognitive assessment of participants. Not all studies have used the age limit of 65 years. Some have set the age limit particularly low at 45  or 50 yeThe findings of the present review are relevant, given the marked differences in demographic and socioeconomic characteristics, lifestyle, medical resources and information provision between urban and rural settings . MoreoveIt seems that there may be clinically relevant differences in onset, course and prognosis of MCI with regards to the place of residence . Those differences should be taken into account for the design of health policies and service delivery in different settings. Health disparities between rural and urban areas are well documented  and may Finally, further research is needed on MCI with a focus on rural locations for the better understanding of the impact of living environment on the course and prognosis of MCI. Future research should address potential environmental factors that could be implicated in the onset and course of MCI in rural areas and affect prognosis and outcome. Female rural residents should be particularly studied as there is some evidence that they may be more likely to develop MCI, and no specific protective factors have been identified yet. Indeed, research is ongoing and according to a very recent study, in urban locations there may be more opportunities for social participation, and therefore, the environment is beneficial for cognitive function, alongside the higher education of urban residents . Having The latest research suggests that there may be differences in MCI onset, progression and prognosis with regards to the place of residence, alongside the well-established notion that the prevalence of MCI is higher in rural locations. Different environmental factors may have protective or precipitating effects on cognitive decline, according to place of residence. Future studies should address the impact of rurality on cognitive health by elucidating the mechanisms underlying cognitive decline and by investigating the risk factors that may be associated with the rural context. Meanwhile, prevention strategies should be employed, with a focus on rural-dwelling women. Prevention may comprise of the early detection of MCI in rural areas, nutritional interventions, enhancement of social participation and interventions for the elimination of rural-urban disparities in education and socioeconomic status.


Introduction: Many employees report high physical strain from overhead work and resulting musculoskeletal disorders. The consequences of these conditions extend far beyond everyday working life and can severely limit the quality of life of those affected. One solution to this problem may be the use of upper-limb exoskeletons, which are supposed to relieve the shoulder joint in particular. The aim of this literature review was to provide an overview of the use and efficacy of exoskeletons for upper extremities in the working environment.Methods: A literature review was conducted using the PICO scheme and the PRISMA statement. To this end, a systematic search was performed in the PubMed, Web of Science and Scopus databases in May 2020 and updated in February 2022. The obtained studies were screened using previously defined inclusion and exclusion criteria and assessed for quality. Pertinent data were then extracted from the publications and analyzed with regard to type of exoskeleton used as well as efficacy of exoskeleton use.Results: 35 suitable studies were included in the review. 18 different exoskeletons were examined. The majority of the exoskeletons only supported the shoulder joint and were used to assist individuals working at or above shoulder level. The main focus of the studies was the reduction of muscle activity in the shoulder area. Indeed, 16 studies showed a reduced activity in the deltoid and trapezius muscles after exoskeleton use. Kinematically, a deviation of the movement behavior could be determined in some models. In addition, study participants reported perceived reduction in exertion and discomfort.Discussion: Exoskeletons for upper extremities may generate significant relief for the intended tasks, but the effects in the field  are less pronounced than in the laboratory setting. This may be due to the fact that not only overhead tasks but also secondary tasks have to be performed in the field. In addition, currently available exoskeletons do not seem to be suitable for all overhead workplaces and should always be assessed in the human-workplace context. Further studies in various settings are required that should also include more females and older people. In many industrial working environments, the work load for employees is decreasing due to automated processes and use of robots. However, certain tasks and activities will continue to be performed manually in various professions such as in nursing and in the skilled trades, where a high degree of individuality, mobility and flexibility is important. And even in highly automated operations, e.g., in the automotive industry, human manual labor is essential for certain assembly steps and employees cannot (yet) be replaced by robots .Although causes for musculoskeletal disorders (MSDs) are multifactorial , one of the main contributing factors is the biomechanical overload of the musculoskeletal system, which can be facilitated by regularly lifting heavy loads or performing monotonous repetitive work . The shoTo this end, many employers try to improve workplaces from an ergonomic point of view, e.g., through technical modifications, organizational changes  or protective equipment . AnotherExoskeletons can be classified according to their field of application ; type of support ; or supported body segment . With regard to the working environment, most exoskeletons that are currently being developed and tested provide relief for the back, the hips and the shoulders . Due to There is a wide variety of upper-limb exoskeletons with regard to construction forms and types of support. To date, the most common commercially available exoskeletons are shoulder-supporting exoskeletons that usually have a rigid structure on the back and arm cuffs, which are coupled . In addiA review published in 2015 showed that many different exoskeleton types exist for industrial use . Most upSince 2015, the number of published studies on the use of upper-limb exoskeletons in the workplace has increased significantly, and there have also been significant changes to the design of these exoskeletons. Therefore, the aim of this literature review was to provide an updated overview of the current state of research on the use and efficacy of upper-limb exoskeletons in the working environment.We conducted a literature review based on the PRISMA Statement  and systAfter the search was conducted, all duplicates were removed and the retrieved publications were screened for suitability based on their title. In a second step, the abstracts of all remaining studies were screened. In the final stage, we read all full texts of the remaining studies and used our aforementioned predefined inclusion and exclusion criteria to decide whether a study would be included in the review or not. The literature management process was done using the Citavi software . For a flowchart of the study selection process, please refer to All relevant data of the included studies were extracted and recorded by using a standardized data extraction form. The form included general information such as the authors’ names, publication date, title, study design, research question or objective, and study participants and their characteristics . Furthermore, it contained information about the exoskeleton that was examined  and the study protocol . We also extracted information on the results of the study, the limitations as stated by the authors and further information such as funding source. After data collection, the data were synthesized. Attention was paid to the different tasks, forms of construction and support provided by the exoskeletons.All included studies were assessed for quality by using a modified and adapted version of the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool (QA) for Before-After (Pre-Post) Studies with No Control Group . This toThe initial search in May 2020 yielded 119 publications from PubMed, 502 publications from Scopus and 178 publications from Web of Science databases. After removing the duplicates, 530 studies remained for the title and abstract screening. After this screening stage, 510 studies were excluded and 20 studies remained. The updated search in July 2021 and February 2022 resulted in 26 more publications. Eleven studies were excluded as they had less than seven study participants. No study was excluded due to poor quality. Thus, a final number of 35 studies was included in this review . The resn = 32) published within the last 4 years (2018 and later). All studies can be considered quasi-experimental studies: 27 were conducted in the laboratory setting, six in the field setting , and two studies . 59.1% of participants were male (n = 376), 17% were female (n = 108) and no gender information was provided for 24.1% of participants (n = 153). The average age of participants ranged between 20 and 51 years; it was above 40 years in five studies (n = 111) was not reported. In almost all studies, participants were described as healthy, or as having been free of symptoms of MSDs in general or for certain areas and time periods. Six studies , Airframe , EksoVest , Mate , an active upper-limb exoskeleton from the ExIF Project ((n = 4), ShoulderX  and Paexo . 72% of exoskeletons were passively operated. Only four models were active exoskeletons, and one exoskeleton (n = 11) only supported the shoulder joint. Three exoskeletons ,skeleton  was repokeletons  were endkeletons  supportekeletons  only supn = 31), the use of the exoskeleton (no exo/with exo) was regarded as an independent variable. Nine studies additionally included different weights or support settings of the exoskeletons. In five studies, different models were compared in addition to the first condition (no exo/with exo). Furthermore, in three other studies, different support modes of one exoskeleton were compared.In most studies . Six of the field studies were conducted in automotive assembly plant and one in a fruit orchard.n = 21) examined the exoskeleton based on muscle activity of the involved muscles in the shoulder, arm and upper body. Furthermore, kinematic parameters (n = 12) such as the range of motion (ROM), joint angles trajectories and body segments speed were used for evaluation. Other objective parameters were heart rate during task (n = 5), postural balance (n = 3), time taken to complete a task (n = 3), energy expenditure during task (n = 2) and number of repetitions completed (n = 2). The main subjective parameters used in the studies were ratings of perceived exertion , usefulness (n = 5) and ratings of perceived discomfort .Most studies  activity was found . In addiIn the field setting, only three studies investigated muscle activity among study participants who wore an exoskeleton, and two found a significantly reduced activity of the anterior deltoid . Iranzo Two studies also investigated muscle activity of study participants when carrying objects with suitable exoskeletons with elbow joint support. The investigators reported that the use of an exoskeleton reduce the activity of the triceps brachii , biceps Kinematically, an increased shoulder abduction and an increased shoulder flexion could be found during the OHW for the Paexo Shoulder exoskeleton, , wherebyFor static holding tasks, In a field setting, For carrying weights, two studies showed an increased flexion angle (elbow) and abduction angle (shoulder) . FurtherFive studies revealed a reduction in heart rate for OHW in participants who wore an exoskeleton in the laboratory setting . SimilarReduced RPE was reported for OHW in both the laboratory and field settings, as well as during static tasks . FurtherFurthermore, when comparing three different exoskeletons , 12 participants rated the Paexo and nine participants the ExoVest as the best supporting system for OHW. No participant voted in favour of the Mate Exoskeleton . In anotIn a 4-week field test, All studies included in this review had at least moderate study quality , and onln = 32) were published after 2017. In addition, ten studies were conducted or supported by industrial companies, which underlines the economic and scientific importance of this topic. Compared to a previous review published in 2015  for tasks on shoulder level and OHW, especially in the laboratory setting. They can therefore be considered effective in relation to their main task and relieve the shoulder joint. According to Although some studies in the workplace setting provided first evidence of a reduction in the employees’ workload , the effects did not always reach statistical significance. This could be due to the fact that the respective exoskeletons are primarily optimized for their actual application purpose and peripheral tasks, which are unavoidable in the field, are not supported or even disrupted. However, the longest field study included in this review  failed tFurthermore, our review has shown that exoskeletons also appear to be effective for transporting/carrying objects, i.e. they significantly reduced the muscle activity of triceps brachii and the metabolic rate. However, only two of the included studies examined exoskeletons for transporting/carrying objects, evidence is thus limited and further research is needed.Kinematically, most models showed good agreement with the movement without exoskeleton with the respective users. In some models, the ROM was slightly reduced; it can thus be assumed that the exoskeletons do not reproduce the full ROM of the human being, especially in extreme positions. For the Paexo exoskeleton, two studies showed increased shoulder abduction angles and elbow flexion angles during use, as well as greater shoulder flexion and rotation in the neutral zero position. In addition, regarding the Airframe exoskeleton, one study  showed aIn a further comparison  with thrIn general, most studies only had a short wearing period and brief familiarization period. Future research should apply longer periods of familiarization as movements generated by the exoskeleton likely disturb the user. It is thus preferable that the user first familiarizes him-/herself with these new tasks. Since human movement is usually very efficient, wearing an exoskeleton without proper familiarization could lead to a more inefficient movement overall and may facilitate fatigue of the user. However, an adaptation is possible through learning effects, and it is possible that the user’s movement can adapt to the support provided by an exoskeleton when worn over a longer time period.It should also be noted that in one study , the intn = 3) are applicable to a narrower range of tasks due to their complexity and size. We also found that the evaluations carried out were multi-faceted and investigators considered many different objective and subjective parameters. This is mainly due to the heterogeneous requirements that exoskeletons have to meet depending on the individuals who wear them and the tasks they are used to provide support for. In order to achieve an efficient and goal-oriented use, it is important to create a balance between the characteristics of the exoskeleton, the needs of the users and the requirements of the work process  and results are thus comparable only to a limited extend see also . A standUnfortunately, the majority of participants of the included studies were males. Due to sex differences in anatomy and physiology, it is likely that males and females may differ with regard to the evaluation of exoskeletons. Since exoskeletons by nature have to fit very closely to the body, the accuracy of fit and adaptability, but also the distribution of pressure at the contact points and their position are decisive. Therefore, future studies should pay closer attention to a balanced gender ratio of participants. Furthermore, the conclusions derived from our review mainly apply to individuals aged 40 years and younger, and the average age of participants was over 40 years in only 5 of the included studies. However, since the current average age of workers in Germany increased from 41.9 to 44.1 years between 2004 and 2017, and is predicted to increase to up to 45.2 years by 2030, the studies are not entirely reflective of the working population . In addiThis review has some limitations. First, the search, selection process, and data extraction were performed by only one author (TM), which does not entirely comply with the requirements of the PRISMA Statement. As a result, bias may have been present during the selection and evaluation processes. Second, for the systematic search, the term “exoskeleton” was used as the main keyword. This term has only emerged in the last 10–15 years and is now well established. It is thus possible that previous studies with similar approaches that used other terminologies, such as “personal lift augmentation device (PLAD)", “muscle suit” or “wearable device” may not have been detected. However, the review by The number of upper-limb exoskeletons available for use in the working environment has increased significantly over the last few years. Most studies focus mainly on tasks at overhead level when designing and using exoskeletons. Preliminary evidence shows that use of upper-limb exoskeletons may provide relief for the user with regard to their target movement, with effects being stronger in the laboratory than field setting. Furthermore, it is recommended that an individual wearing an exoskeleton should always be assessed and evaluated beforehand in relation to the workplace and the respective exoskeleton. At this point, exoskeletons cannot be considered a tool for mass use, but rather should be used carefully in employees with a confirmed need. The current body of research on the effectiveness of exoskeletons in a workplace setting is limited by short wearing times as well as limited sex and age distribution of participants which are not representative of the majority of workers. Future studies should thus apply longer exoskeleton wearing times and follow-up durations, as well as include more women, older individuals and persons with pre-existing medical conditions.