Afghanistan has been in an active state of conflict and war for twenty continuous years. Social services like health and education have been badly affected, facing issues such as service disruption, brain drain, and generalized instability. Health indices that provide proxy indicators for general population wellness, such as maternal health, child mortality, and immunization coverage, show that the health services available to the Afghan population are sub-optimal. Investment in social service and interventions has increased. The World Bank and the United Nations through its agencies  and United Nations' Children's Fund (UNICEF) are providing social support through targeted and strategic programs. However, the topographic and environmental realities of Afghanistan, with its broad mountain coverage, propensity toward natural disasters, and latent conflict, has made data and information gathering arduous. Since data is essential for measurement and management, the WHO Health Emergencies (WHE) information management unit at WHO Afghanistan has delivered an innovative form of data analysis, specialized and targeted at providing improved information on communities that are not adequately covered by health services. Deploying a geographical information system (GIS) approach, the WHE team has collated primary and secondary data from a combination of datasets to produce a far-reaching piece of analysis. The analysis of underserved communities in hard to reach, remote locations, provides a live, evidence-based information product. This provides a working tool that is essential to primary health programming and intervention in Afghanistan. The estimates show that approximately 9.5 million individuals in 22,181 villages across 34 provinces are underserved by primary health services. This paper is presented to explain the underpinning methodology. The generalized insecurity in Afghanistan, caused by the extended state of war and exacerbated by the recent change in government, means there are substantial gaps in social services; healthcare is thus deeply affected . Health 1–and with populations scattered amongst several pockets of settlements, providing stationary primary health services to adequately cover these populations is a challenge, for which high-quality data interpretation is the most viable solution.Afghanistan's current humanitarian development trajectory is trending downwards. The United Nations Development Program mentions that the pace of development started slowing down from 2012, with increased insecurity and instability , topography, and social profiling, factoring all the dimensions to determine where additional services are most needed. The specific data sources per each data dimension are listed below:Humanitarian Data Exchange (HDX). For Rivers and roadsAfghan Geodesy and Cartography Head Office (AGCHO) for admin boundaries.Esri landcover 10 m resolution from 2021: Landcover.Digital elevation mode.An illustration of the deployed layers is seen in The quality of the output is directly symmetrical to the quality of the constituent datasets. The depth of the datasets and validation process undertaken to qualify them for inclusion in this analysis is described per dataset below.There is no current national population census in Afghanistan; the last census was conducted in 1979, and planning figures currently used in Afghanistan are based on a growth factor with the 1979 census as base data. As such, deciding on the most credible, evidence-backed population dataset presented a first-line challenge. This was resolved by settling on population figures from the world pop datasetWorldPop researchers worked closely with the Afghan national statistical offices to integrate satellite-based mapping of all residential compounds in the country with other geospatial datasets and recent small area population enumeration in a spatial statistical modeling framework. New population estimates were produced at national, provincial, district, enumeration areas, and 100 m grid cells for the country, with associated measures of uncertainty. Cross-validation showed strong predictive ability, particularly at district and provincial scales.”“Population figures were also collated for the community level.This is the largest and most comprehensive evaluation of stabilization interventions ever undertaken by USAID. The MISTI dataset contains five semi−annual iterations or ‘waves′ of surveys conducted by Management Systems International (MSI) from September 2012 through November 2014 to assess the impact of USAID projects on stability and resilience at the district and village levels in Afghanistan.″11“Population data used for the white area analysis Health Facility Presence is the key factor determining the adequacy of service availability. Data on health resource status and availability is collected in the Health Resources Availability Monitoring software (HeRAMS). HeRAMS is self-reported and routinely updated by field-level implementing partners and is currently the most comprehensive dataset of health resources available in Afghanistan. Health presence and resource availability at current levels show there are a total of 4,242 health facilities, consisting of The core determinant of vulnerability in Afghanistan's population is the earning status of each citizen. This by extension determines the access they may have to health care. The data source for this dimension of the analysis is the UNDP survey from 2021All datasets were gathered in one unified geodatabase and imported into Access-MOD; this is the gold standard in terms of dataset management. The next step was processing. The collected data was rigorously validated through quality controls i.e., data cleaning . This was repeated and cross-applied throughout the data flow framework. Other checks for reliability, completeness, and external validity were applied. After the data was consolidated into Access Mod, the measures of access were then calculated based on the following criteria:Measure physical accessibility to health care i.e., the travel time by walking distance of 1 hour or four kilometers based on the SPHERE framework i.e., between each community or settlement and the nearest health facility. In this analysis, 4,242 health facilities meeting the definition of basic package of health services (BPHS) were considered, excluding all hospitals. Hospitals were excluded because the metric of health care coverage defined under the SPHERE Framework is pegged at the primary health care level.Estimate geographical coverage (a combination of availability and accessibility coverage) of an existing health facility's catchment area.There are more than 4,000 public health facilities operating in Afghanistan. However, due to the scattered population, geographical terrain, and environmental realities, these facilities are unevenly distributed within and among the provinces and districts. As a result of this, more than 25% of the Afghan population resides in areas where primary healthcare services are not accessible within 1-h walking distance from their homes. In actual practice, a health facility might be, in certain cases, within half a kilometer of the village, yet it is inaccessible due to physical barriers like deep or fast-flowing rivers, snow cover, or precipitous terrain.In addition to complex emergencies, geographical barriers also hinder access to healthcare for many, particularly for those who reside in remote, hard to reach areas. The WHO carried out a geospatial analysis of underserved areas in Afghanistan in September 2022; substantial improvements in the health system and the health status of the people of Afghanistan have been achieved in recent years. Despite these improvements, Afghanistan's health indicators are near the bottom of international indices  were covered by existing health facilities, however, 22,181 villages were identified as underserved areas with a population of 9.5 million (25%) in 34 provinces residing in areas where primary healthcare is not accessible within 1 h's walk from their homes or camps. More details on underserved population distribution across the provinces is found in In order to disseminate findings and make the underserved area information more accessible and, by extension, actionable, the WHO health Information management team developed an online health Information portal for products and information. The analysis of underserved areas is shared through a GIS online dashboard on this portal, where health partners and stakeholders can easily access the information and take the necessary actions in order to reach the most vulnerable population using a credible evidence base.In This analysis has deployed the best available resources and tools. However, due to the constraints of the working environment, some limitations are acknowledged and declared herewith:Population data: as has been acknowledged, Afghanistan has been in a prolonged state of war. As such, the last nationwide census was conducted in 1979, despite the fact that these should be conducted every 10 years. The absence of a national census has left a credibility gap—as key stakeholders tend not to agree on the which dataset represents the most accurate projection of the total population. This analysis was based on world pop data, which is a robust projection. Nonetheless, the absence of a national census is a limitation. This is also true of the settlement data, where MISTI data collected in 2014 is the only source of settlement population counts.Facility coordinates: facility presence is a baseline requirement for this analysis. A high level of effort was deployed toward collecting high-quality data on facility locations. Nonetheless, this data was collected on a self-reporting database. In some instances, the pace of collection  was not in pace with the update cycle incorporated into the underserved area analysis.https://dashboard.whe-him.org/index.php/maps-3/.The framework for disseminating this analysis and directing its power to relevant stakeholders has been conducted through information management products and through the launch of a public portal at In future versions of this analysis, additional layers and dimensions of data will be added. These include new features such as location radius catchment calculation (from any point on the map).https://dashboard.whe-him.org.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: RM and AK are the co-technical lead in producing this paper and provided the core text and resources in the methodology section. JS is the technical lead of the HIM team and he has collated the technical data in the methodology and written up the overall narrative of the report. AA is the team lead of the World Health Emergencies section and this analysis has been done under his facilitation and supervision. He is a public health professor and has provided the editorial oversight to ensure technical validity and rigor. All authors contributed to the article and approved the submitted version.


The increase in traditional and complementary medicine (TCM) methods has revealed the necessity of determining relevant behavioral tendencies among healthcare users. In our study, the evaluation of TCM approaches of healthcare users living in North Cyprus in terms of treatment effectiveness, patient trust and patient satisfaction, and the effects of these variables on patient loyalty, were investigated. Data were collected utilizing the scale approach as well as the survey technique in order to measure the variables in the study. A total of 452 participants completed the survey. TCM has a positive effect on treatment effectiveness, patient trust and patient satisfaction. Patient trust and patient satisfaction have a positive effect on patient loyalty, whereas treatment effectiveness did not have a significant effect on patient loyalty. There is a significant and positive mediating effect of patient trust and patient satisfaction between TCM and patient loyalty. However, the mediating effect of treatment effectiveness is not significant between TCM and patient loyalty. This study will help researchers and practitioners understand the importance of attitude, trust, effectiveness, satisfaction and loyalty in relation to TCM. It is suggested that studies that measure the behaviors of patients should increase in order to obtain better health outcomes. It is essential to ensure that all people and communities have access to the healthcare they want and need, without financial strain. Traditional medicine can now be considered a kind of basic healthcare for people. Traditional medicine has taken a position in many people’s daily health-seeking habits, particularly in the cultural area, and has become an important component of health services . TraditiTCM applications, which are continually evolving, have begun to spread globally and are retaining their popularity. People have started to research, prefer and use TCM all over the world. One of the important reasons for the development of TCM applications is the fact that the health industry has become a major business, i.e., it has essentially become a market on its own. Individuals cannot benefit equally from the offered health services; thus, it leads to individuals looking for different alternatives and being interested in health solutions that may be easier to access . AnotherA patient who has a positive perception of treatment can perceive the treatment’s effectiveness as positive. Positively perceived treatment can enhance trust and satisfaction and thus, result in loyalty.The current study adds to the literature in certain ways: It is one of the first known studies to investigate patients and TCM. For this reason, it reveals that studies that measure the behaviors of patients should increase in order to obtain better health outcomes. The success of TCM applications is due to the effective, efficient and safe application of these methods by professionals with expertise in this field, and the high benefits to be created for individuals in this direction. As a result, in order to assess the size of the impact of TCM applications, which are rapidly spreading among individuals, it is necessary to determine the degree of satisfaction with these applications, how much trust they have in them, the effectiveness of the treatments provided and the loyalty of individuals towards the applications. Following that, showing the relationship between the proper connections and these progressive variables will allow us to see the development direction of these practices, which take on a new dimension in the eyes of people as a whole. Academic and administrative research on TCM applications in the field of health has increased evaluation studies on this subject in recent years. The purpose of this study is to assess the TCM perspectives of people living in North Cyprus in relation to treatment effectiveness, patient trust, and patient satisfaction, as well as the effects of these variables on patient loyalty.According to the present literature, individuals can go to whichever health institution they want based on their economic status and health insurance, and this condition has caused people’s expectations to differ and change. The demand for TCM applications, which has been spreading rapidly, especially in recent years, has created a competitive environment in the health sector. It is clear that all health institutions value the effectiveness of the health service or treatment they provide, as well as patient happiness, trust, and loyalty, and that they endeavor to improve the quality of the health services supplied. Therefore, concepts such as service quality, patient attitude, and patient loyalty in health services are areas worth researching.The concept of attitude can be explained in three different contexts based on how it is formed and how it changes in individuals. First, although it may occur in connection with the values, general goals, language, emotions and development of individuals, the person’s attitude may change at this point. The second context is the social relations that affect the attitudes of individuals, especially with the influence of social media and culture. The third context is socio-historical and affects the attitudes of individuals to socio-political, economic and climatic events. Therefore, attitude can shape or change people’s attitudes in personal, social and historical contexts . A persoH1. Traditional and complementary medicine attitudes are positively associated with patient trust.The extent of the relationship between physician and patient varies. This has become a challenging process for healthcare providers. Trust and communication seem to play a vital role in a healthy and effective doctor-patient relationship. Individuals can better adapt to the therapy offered and the medical advice given if trust and communication are formed, according to the papers analyzed in connection with the subject, and these factors are components of success in all fields of study . As a reSatisfaction can be measured by how well the user experience, as a result of utilizing the product or service, satisfies the buyer’s expectations regarding the value . There iH2. Traditional and complementary medicine attitude is positively associated with patient satisfaction.Patient satisfaction is considered an indication of health service quality. Patient satisfaction can be defined as the attitude and compliance of practitioners and patients, loyalty, clinical results, technical competence, accessibility and efficacy within the boundaries of the healthcare offered . From thEfficiency is evaluated as achieving the desired result for defined resources . IndividH3. Traditional and complementary medicine attitude is positively associated with the effectiveness of the treatment.In order to determine treatment efficacy, comparisons of active treatments should be made, and patients, clinicians and interventions representing the practice should be examined . For an An individual’s attitude can be shown by the information they have in the face of an event, case, or circumstance, as well as their favorable or negative feelings toward that occurrence, as well as their discourses and actions on the subject . KnowingPatients’ trust in healthcare professionals is at the heart of clinical practice. Patients, in particular, must trust their doctors with their lives and health, and doctors must act in such a way that this confidence is maintained. Other health professionals, such as nurses and psychotherapists, are subject to similar requirements under the code of conduct. The foundation of effective treatments and patient-centered care in this setting is directly proportional to patients’ faith in healthcare providers . One of H4a. Patient trust mediates the relationship between traditional and complementary medicine attitudes and patient loyalty.H4b. Patient satisfaction mediates the relationship between traditional and complementary medicine attitudes and patient loyalty.H4c. Treatment effectiveness mediates the relationship between traditional and complementary medicine attitudes and patient loyalty.In light of the previous literature, the following research model is presented in model 1. The study is a cross-sectional type of research. It is a quantitative study in which numerical data were obtained using descriptive and relational research models, and within these data, the current status of the subject was investigated using the descriptive method and whether there was a relationship between the relational method and the variables.n > 200) to reduce the sampling error. Therefore, a random sample was used. Sekeran and Bougie (2013) suggested that 384 would be a sufficient sample size for a population above 100,000 [Data were collected simultaneously both face-to-face and online between January and March 2022 due to COVID-19 restrictions. The online survey is distributed through social media channels to randomly selected individuals from North Cyprus. This study includes all individuals over the age of 18 participants, randomly selected from the patient population living in North Cyprus using the disproportionate stratified sampling method. Because it would be difficult to contact the whole population of the research in terms of time, expense and examination, the convenience sampling approach was used to select a sample to reflect the study population in the research. Therefore, the random sampling procedure obtained a representative sample of the target group. In Structural Equation Modelling methods, the sample size should be large enough . While evaluating the data, descriptive statistical methods  were used. According to the distribution characteristics of the data, parametric and non-parametric tests and statistics determining the relationship were used.This study includes 452 participants that live in Cyprus and represent the population from the different regions of the country, and that are evaluated statistically to take part in the research. The majority of participants are female: 239 participants (52.9%). The majority of participants are university-educated or higher: 288 participants (63.7%). The majority of participants are from Nicosia: 130 participants (28.8%). The demographic characteristics of the participants and the distribution of the regions they live in are given in The distribution of the participants in terms of awareness about the term TCM, usage status and frequency of use is given in The majority of participants in the research have heard of the term TCM: 322 participants (71.2%). The majority of participants use both traditional and complementary medicine: 282 participants (62.4%). Most of the participants use it very rarely (39.9%).In the attitudes of the participants towards traditional and complementary and modern treatments, the effectiveness of treatment effectiveness, patient trust, patient satisfaction and patient loyalty were examined. Patient trust, treatment effectiveness and patient loyalty variables show clearer expressions in individuals. In patient satisfaction, expectations and satisfaction conditions differ and it is obvious that the effects vary among individuals. In this direction, the attitudes of the participants towards traditional and complementary treatments. This has led to the preference of modern medicine in terms of trust, effectiveness and loyalty. Since there are more relative conditions in patient satisfaction, traditional and complementary treatments and modern treatments have been determined at a close level. Efficiency distribution by attitude is given in p < 0.05, comparative fit index (CFI) = 0.97, goodness of fit index (GFI) = 0.91, root mean square error of approximation (RMSEA) = 0.04 and standardized root mean square residual (SRMR) = 0.04). To test the discriminant validity of the study, AVE and the squared correlation between the variables have been checked. In addition, the method of single latent variable has been applied to test the common method variance. The results have implied that common method variance does not exist in this study.Confirmatory factor analysis (CFA) has been conducted to investigate the factor loadings and the validity of the constructs of the study. p < 0.05). It is found that TCM has a significant and positive effect on the treatment efficacy, patient trust and patient satisfaction. These results confirm H1, H2 and H3. In addition, the results showed that patient trust and patient satisfaction had a positive and significant effect on patient loyalty.The relationship between the participants’ perspectives and their attitudes toward TCM, treatment effectiveness, patient trust, patient satisfaction and patient loyalty were investigated and the results are presented in p < 0.05). These results confirm H4a and H4b but do not confirm H4c. The representation of the results is given in The participants’ perspectives on the relationship between treatment effectiveness, patient trust and satisfaction, TCM attitude, and patient loyalty were investigated. The mediation and indirect effect of treatment effectiveness, patient trust and satisfaction were investigated by employing 95% bias-corrected bootstrapped confidence intervals (N = 5000). There was no significant mediation impact between treatment efficacy, TCM attitude and patient loyalty; however, there was a significant and positive mediating effect in other criteria (With the diversification of individual wants and needs, it is clear that the search for new orientations in the health system, particularly TCM treatment approaches, is on the agenda, and that they are fast growing and popular all around the world. This is an indication that the healthcare market is changing and that there will be increasingly fierce market competition among healthcare institutions. Therefore, providing satisfactory healthcare to patients, gaining the trust of patients and, as a result, acquiring loyal patients are key in the competitive process between healthcare institutions. After reviewing the literature, this study is one of the few studies in which these relations with TCM attitude are made. The study aimed to evaluate the TCM approaches of healthcare users living in Northern Cyprus with treatment effectiveness, patient trust and patient satisfaction, and to investigate the effects of these variables on patient loyalty. This study showed that attitude towards TCM is affected by patient trust, patient satisfaction, and patient loyalty. For example, trust and satisfaction are directly related to each other. Patients who trust their doctor will be more likely to be satisfied with the service and care provided. With this positive feedback loop, ensuring trust will result in better service and increase trust and happiness . In addiExamining the behavioral dimension of individuals against TCM treatments may facilitate the introduction of TCM. In this study, traditional and complementary medicine and patient behaviors are examined. Patient trust, satisfaction, effectiveness and loyalty are considered. The treatment effect does not mediate. Trust and satisfaction mediate results. The findings can assist key stakeholders, including TCM practitioners, consumers and policy makers, to improve the process to improve positive attitude towards TCM treatments and improve service quality. Evidence-based TCM treatments need to be developed to increase the use of TCM treatments in Northern Cyprus. At this point, public practices and support are important. The present study provides theoretical contributions to researchers. To the best of our knowledge, this study is the first to investigate patient behavior related to TCM treatments in Northern Cyprus. The findings of this study have an improving effect on how the researchers’ behavior towards TCM treatments is also affected by different factors. The results may provide insight for future research for researchers to explore different views on patient behavior in TCM treatments in Northern Cyprus.The study has certain limitations: It was performed in a single country and it was prepared with the current opinions of the participants, as a one-time analysis. In order to increase comparability, the study can be conducted in different countries. Finally, higher number of participants could not have been reached due to COVID-19 restrictions.In conclusion, this study makes a significant contribution to the literature on individuals receiving TCM care. In the results, significant relationships were found between the direct effects and mediating effects of patient trust and patient satisfaction on patient loyalty. This research helps researchers and practitioners to understand the importance of attitude, trust, effectiveness, satisfaction, and loyalty to the advantages and disadvantages of treatments at the point where they evaluate the behavior of individuals towards traditional and complementary medicine methods. Providing community awareness training with public support and integrating these practices into primary healthcare will help them lay the foundation for improving health-related outcomes. It is suggested that studies that measure the behaviors of patients should increase in order to obtain better health outcomes.A supportive approach by all stakeholder groups in the health sector would ultimately lead to a more efficient, safer, and more effective use of TCM treatment practices.


Training opportunities for health product regulators are among the critical aspects in the strengthening of regulatory systems across the world. The need for training is reasonably higher among the National Regulatory Agencies (NRAs) in the Low- and Middle-Income countries (LMICs) which are faced with many regulatory challenges mostly rooted in the low availability of resources. The current study aimed at evaluating the suitability, impacts, and challenges related to the training of regulators from LMICs offered by the Swissmedic in collaboration with the World Health Organization (WHO).An exploratory case study design using a qualitative approach was adopted to collect data from a total of 17 NRAs in different WHO regions using in-depth interviews and qualitative questionnaires.The participation of the trainees in the training was revealed to be motivated by the need to apply the obtained knowledge in addressing various challenges within their NRAs. Many lessons covering all key areas of health products regulation were reported by the trainees, whereby most of the lessons were already being implemented within their respective NRAs. However, challenges related to human, financial, and infrastructural resources were highlighted to hinder the ongoing efforts in putting the learned aspects into practice. Additionally, areas in which further regulatory assistance and suggestions for improving the training activities were pointed out.The highlighted gains from the WHO-Swissmedic collaborative training program call for other agencies and organizations to join hands in offering much-needed support towards addressing critical challenges facing the regulatory sector in the LMICs. This is mainly contributed by limited opportunities for formal training in regulatory sciences, high turnover rates among staff, and fast advancements in knowledge and technology related to health products –6.To address the challenges around the limited competencies of regulators across the world, the WHO drafted a competency-based framework to guide the training activities for regulators . Moreovevia strengthening the capacity of the participating regulators through experience sharing and knowledge exchange.To address some of those challenges, the Regulatory Systems Strengthening (RSS) team of the World Health Organization (WHO) and the Swiss Institute for Therapeutic Products (Swissmedic) collaboratively organized regulatory training activities aimed at regulators from the LMICs. The training was developed in accordance with the WHO’s support to the implementation of the National Regulatory Agencies’ (NRA) Institutional Development Plans (IDP) via oral presentations, group discussions and presentations, case studies, and giving of reading materials. To enhance interactions between the trainers and the trainees, the aspects of having questions and answers sessions, supervised discussions and exercises are built into the programme.The NRAs participating in the training are invited by the WHO based on a set of pre-selected criteria, including their regulatory preparedness. The invited NRAs are mandated to select the staff to attend the respective training based on their prevailing needs for capacity building, among other factors. A total of 30–35 trainees are usually invited per training round, whereby they are trained The training is delivered by the sharing of knowledge and skills on up-to-date methods and procedures for processes in areas of Quality Management System (QMS), Registration and Marketing Authorization (MA), Market Surveillance and Control (MC) and Vigilance (VL) in accordance with the WHO and other international standards and good practices. The capacity-building component of the training is intended to not only directly benefit the participants on an individual basis; rather it is meant to generate a deeper impact on the performance of their respective NRAs in the various aspects covered during the training. This study, therefore, aimed at evaluating the suitability, impacts, and challenges associated with the collaborative offering of training to regulators as an approach to strengthening regulatory systems in LMICs.2.An exploratory case study design using a qualitative approach was adopted to explore the factors influencing trainees’ selection and their motivation, lessons learnt, their implementation, existing challenges and suggestions from the trainees and their immediate supervisors, as well as their trainers , 9. The A total of 17 NRAs from the countries shown in via a pilot study involving the first 2 NRAs. Following the pilot study, further modifications were made to increase clarity, enhance flexibility in the order of the questions and ensure that the allocated time was adequate.In-depth small groups- (2–3 participants) or one-to-one interviews were conducted between January – July 2022. A semi-structured interview guide was used to explore the perceptions, experiences and suggestions of the trainees and trainers 6 months to 4 years after taking part in the previous training rounds. The interview guide contained open-ended questions designed to probe aspects before, during and after attending the training . The suiAll interviews were conducted by the same interviewer using video calls on an online based platform . Each interview was conducted in the English language and lasted for a total of 45–60 min. A saturation of shared information as revealed by the recurrence of similar aspects/themes was realized after 13 interviews with the trainees, however, 4 more were conducted to arrive at a total of 17 interviews (34 trainees).Responses from the trainees’ immediate supervisors were obtained using a qualitative questionnaire survey entailing open-ended questions targeting long-form written answers . To ensuData analysis was carried out by inductive thematic analysis as previously described by Braun and Clarke . This waFollowing the transcription process, six of the generated transcripts were randomly selected and validated by a pair of authors who did not participate in the generation of the transcripts.Thereafter, all transcripts were further read and re-read by a team of four authors to identify the meanings, senses and initial patterns in the interviews.Secondly, initial codes were generated from a systematic appraisal of the entire data set aimed at identifying many distinct patterns possible while capturing both semantic and latent features of the data. Corresponding data extracts were thereafter matched and collated to each of the identified codes whereby, some extracts were coded more than once. Moreover, some new codes identified during the coding and analysis process were added to the initial codes.Searching for themes was done by allocation of related codes and associated data extracts into possible themes. Through further careful evaluation of the existing relationships, candidate sub-themes and themes were generated. A further rearrangement of the candidate themes and sub-themes was done while paying close attention to their internal homogeneity and external heterogeneity. This was achieved by team-oriented reviewing of coded data extracts as well as entire data set levels. This process was associated with dividing, merging, and discarding the candidate themes based on their ultimate validity.Furthermore, defining and naming the themes was done through proper identification of the essence and scope of the data captured in each theme. This was followed by the generation of the accompanying detailed narratives under each theme. Ultimately, the writing of the final report was conducted by a generation of a complete description of the data to provide a concise, coherent, and logical account of the information available in the analysed data.Each study participant was issued a detailed informed consent and took part voluntarily. To ensure the confidentiality of the information, the NRAs’ and participants’ identities were concealed upon the first transcription, whereby codified identifications were issued.3.3.1.Several factors were reported to influence the nominations of the NRA staff to take part in the training. These included their current role(s), having a particular leadership position, educational background, and level of experience were among the stated bases for their nominations. Particularly, trainees denoted the need for acquiring more knowledge to be capable of addressing the required Corrective and Preventive Actions (CAPAs) from the previous WHO benchmarking activity in their NRA. It was anticipated that attending the training will sharpen their knowledge and skills, hence ensuring the successful addressing of the CAPAs.Moreover, other trainees pointed out specific areas in which they anticipated an in-depth understanding of their handling by the Swissmedic. These included the registration procedures, reliance systems, pharmacovigilance of Covid-19 vaccines, Quality Management Systems (QMS) and use of Information Management systems (IMS) in regulatory activities. In addition, trainees reported looking forward to the creation of new partnerships towards having more opportunities for regulatory collaboration and an exchange of ideas and/or experiences.3.2.Lessons of diverse nature were highlighted by the trainees. The lessons cut across areas of regulatory collaboration, pharmacovigilance (PV), organization of regulatory systems, effective evaluation of medicines, and the use of IMS. Moreover, lessons around the concept of reliance, modalities for seeking technical assistance, as well as identifying and adopting best practices from other NRAs were shared. For example, some trainees reported shifting their focus from only generating PV reports to ensuring the presence of functional PV systems.Furthermore, the trainees reported on lessons on the importance of having well-structured and operational systems, good organization, delegation and oversight of regulatory functions, as well as good political support and legal frameworks. Other areas included a better understanding of QMS, risk-based principles, effective training of regulators, digitalization of regulatory procedures, careful planning for available resources and strict measures to keep agreed timelines.“… we were privileged to know most of the things, especially with the QMS in the Swissmedic, … they are not necessarily interested with certifications but with ensuring that the system is in place, is running and is also in use … The main thing is for people to know what they are supposed to do and continually implement it …, we should move our focus from ‘certification, certification’ .The trainees reported implementing various aspects learnt from the training within their NRAs. The implementation of these changes was aimed at shortening processing time, optimizing the use of the available resources, improving access to medicines, and avoiding unnecessary regulatory procedures.Implemented changes in regulatory practices involved the establishment of online registration systems, the creation of specific windows for the submission of applications, and the dropping of laboratory analyses for Market Authorization (MA) renewals. Also reported were the creation or expansion of technical committees, the establishment of reliance and other collaborative systems, as well as the application of various risk minimization measures.“… seeing an SRA like Swissmedic doing a reliance approach encouraged us to proceed in this aspect too. This helps us to keep our resources for products which really need deeper and closer evaluations…” .Other trainees reported on the creation and modification of various regulatory documents of various natures. In some NRAs this went along with the development of documents related to the overall legal framework.“Before, I was more focused on the activities to do, but after the training, I changed the focus to developing the documents, there are many SOPs to be developed.” .Also stated were organizational adjustments primarily aimed at reducing the complexity of the regulatory activity and installing QMS without a focus on external certifications. In some settings, these efforts went along with the digitalization of regulatory activities and finetuning of the efforts towards the WHO benchmarking. Other trainees reported having established different training programs for the NRA staff and part-time dossier evaluators.3.3.The need for further support in areas of developing functional quality as well as risk management systems, creation of continuous collaborations between NRAs, increased access to evaluation reports and training materials, and more hands-on training opportunities were highly stressed among the trainees. Through further assistance in these areas, it was hoped that the NRAs can attain more regulatory proficiency towards the provision of better and more reliable services .“There are a lot of things that we do that are not written down in any way. So, people tend to do their own things and sometimes it is by word of the mouth. Nothing is really written down anywhere except for the act and the regulations. I think that is the area that we really need to strengthen, assistance in helping us to develop a documented system before we start thinking about anything else .“… we gain more knowledge on practical regulatory training. In that way we can get better things from other regulatory authorities… we should not only be limited to lectures.” .There was an agreement among many trainees that future training activities should offer more depth in the shared content. Moreover, it was proposed that more discussions should focus on the ongoing realities within the LMICs. In that, some trainees were in favour of the inclusion of more case studies and examples from the LMICs. Others suggested increasing the duration of the training while offering them more frequently.The aspect of having hands-on training was highly emphasized and it was commonly indicated that practical exposure will add an important element to the training. Additionally, it was recommended that future training activities should aim at selecting trainees with similar levels of experience and/or inviting NRAs with similar maturity levels to each round of training. This was viewed as a way to avoid difficulties in following some of the shared contents among those with very limited levels of experience.“I think for me if it is possible, the training in terms of the scope should not be too wide, must be in-depth and detailed. For example, if we would like to focus on process validation, we focus on it for say 1 day and in-depth and in terms of a better understanding of process validation, rather than discussing many things just on the surface. Of course, yes you learn a lot but on the surface for a lot of things, so basically, maybe for the new officers, they may learn a lot, but for experienced officers, you just get in terms of the surface, and you might not learn a lot.” .On the other hand, the Swissmedic trainers insisted on the need to find a balance between the available time and what is to be shared. They suggested more efforts be put into the preparatory phase of the training. In that, the prior sharing of guidelines and other documents to the trainees was proposed. This was postulated to allow more effective use of the available time during the training. They added that they are restricted by the necessity to observe confidentiality, which poses a big challenge in delivering hands-on training.“I think the confidentiality issue is really the main topic even for us. We are dealing with some information from the companies that they know that this information will not be disclosed…” .3.4.The training was referred to have imparted knowledge and skills which were essential for the successful discharging of many regulatory actions under emergency situations. Some trainees reported having conducted operational threat analyses, developed relevant guidelines for Emergency Use Authorization (EUA), and put relevant technical committees in place. Other trainees mentioned the timely application of the concept of horizon scanning which enabled adequate preparations before the arrival of various Covid-19-related products. Also, through the establishment of reliance systems, and enhanced collaborations with other agencies, important regulatory actions were facilitated in the face of the Covid-19 pandemic.“It helped us with different procedures and steps of bringing the vaccines within the country. When we got the vaccines, it was very late and was 6 months to expire, the training really helped us on how to handle that challenge.” .3.5.Trainers from the Swissmedic regarded the training as a suitable model for the provision of regulatory support. They revealed that offering the training had significantly decreased the previous workload on offering consultations to individual NRAs. Further, the trainers acknowledged receiving many questions from the trainees which could reflect the level of their interest in understanding Swissmedic’s operations. However, it was pointed out that the differences in resource availability and legal frameworks could limit the application of shared knowledge and skills.“I do not know to what extent the way we do things can be extrapolated to less privileged countries. But I think the way we transfer the knowledge can be a model for similar applications, where one country has the knowledge and is happy to share it with others.” .Challenges in meeting the training needs of the participants were revealed to be rooted in differences in legal frameworks and the diversity of countries participating in the training. On the other hand, the presence of an established routine and experience in offering the training, as well as the collaborative organization with the WHO-RSS team were revealed to avoid many challenges in offering the training.“We present the Swiss situation based on the Swiss legislation… we do not know exactly what the legal frameworks in the other countries are so that we can address our presentations for the next time in a different way… also participants in the next rounds will come from different countries, it is not so easy for us to anticipate the needs of the participants.” .The trainees’ immediate supervisors reported improved abilities in the conduction of GMP and PV inspections, more focus and in-depth assessments of the dossiers, adoption of risk-based evaluations, as well as the initiation or increased applications of reliance and horizon scanning concepts within their NRAs. Also acknowledged were more efforts among the trainees on increasing regulatory collaborations, improving QMS, planning, efficient use of resources, development of policies, and drafting of new guidelines.Similar to the trainees, challenges related to poor organizational structures, limited number and expertise among regulatory staff, poor infrastructures and equipment, and financial constraints were also communicated by the supervisors. These challenges were stated to hinder the full realization of the benefits of the training.3.6.Existing bottlenecks in the NRAs’ organizational structures were reported to be associated with confusing or contradicting dynamics. For example, some trainees referred to their NRAs’ involvement in the regulation of a very broad range of aspects including products, premises, and personnel to limit some of their efforts for implementing intended changes. Moreover, hesitancy to change particularly by those managing the NRAs was revealed to restrict the implementation of many learnt aspects. Similarly, limited organizational transparency, a strong negative influence of politicians, and a lack of strong legal frameworks were stated .“The difficulty is that a lot of time you have to convince the management and the executive on the benefits of adopting some of these approaches… the challenge is to get the management to buy your proposal for changes to be implemented. It is a complicated situation…” .Furthermore, lacking direct access to evaluation data summaries, the closed nature of evaluation reports, and language barriers were indicated to limit the evaluation of products based on reliance. Other trainees implicated the lack of adequate knowledge and skills, understaffing, high turnover rates among the experienced staff, limited internal budgets and shortage of external funding as aspects impairing their efforts to implement the learnt aspects .“At the moment we are only two regulators here, headed by the chief pharmacist, who also looks after other units, so it is not only us. The regulatory work is done by just the two of us.” .In addition to better experiences reported in implementing learnt aspects among the WHO Maturity Level 3 (ML3) NRAs, the nature of the prevailing limitations was noted to differ depending on the maturity level. For example, while participants from the NRAs with lower maturity levels reported inadequate primary infrastructures, a lack of QMS and functional legal framework, those from the ML3 NRAs highlighted challenges related to further training of the available staff, installing measures to regulate novel medical products, establishing functional IT-based systems, a few to mention.4.4.1.via regular training needs analyses, among other aspects, as discussed further in the subsequent sections  could minimize the associated challenges , 15, 16.The reported implementation of various learnt aspects by the trainees underscores the role of regulatory training in the strengthening of regulatory systems in the LMICs. In that, the NRAs in the LMICs can potentially attain more robust and thorough regulatory processes towards better access to safe, effective, and good-quality medical products , 13. Mor4.3.The full realization of the benefits of regulatory training requires effective measures to address the various challenges affecting the implementation of learnt aspects highlighted in this study. These should include streamlining the nature and scope of discharged regulatory functions, adopting more effective organizational structures, , 23, 24 Moreover, the need for observing confidentiality was painted at the centre of the difficulties in accessing product evaluation reports from SRAs. This and related aspects like the lack of mutual trust, and differences in regulatory and legal frameworks potentially impair the complete realization of the benefits of implementing the concept of reliance , 23, 27.4.4.The high demand for further regulatory assistance revealed in this study could be explained by the dramatic changes in modern regulatory sciences driven by rapid technological advances in drug discovery and development. Recent findings have reported the presence of minimal or complete lack of capacity to execute medicines regulation functions in more than 90% of the NRAs in Africa . MoreoveThe existing high need for various sorts of regulatory training is related to the very low availability of advanced formal training in health products regulatory affairs within the LMICs . AdditioThe current study has indicated that the execution of many regulatory functions during the Covid-19 pandemic was facilitated by the application of knowledge, skills and principles gathered from the training, particularly the concepts of recognition and reliance, as well as horizon scanning. These findings were similar to the recent reports on the presence of big changes in regulatory practices brought about by the Covid-19 pandemic and necessitate detailed training on regulatory preparedness in public health emergencies , 34, 35.The execution of proposed improvements on the training is however dependent on the core objectives and scope for its establishment and the implicated additional resources. Nevertheless, revising the objectives for the possible accommodation of the given suggestions is highly recommended. In general, the need for more resources to implement such suggestions calls for the possibility of other agencies to join these valuable efforts in offering support in all or selected aspects , 29, 37.Improved capabilities of the trainees in discharging their regulatory roles were acclaimed by their immediate supervisors to have advanced the NRAs’ performances on different frontiers. On the other hand, the suitability of the training in the provision of regulatory support to NRAs in LMICs was echoed by the trainers. However, based on the increased gradual increased interest in the training, continuous improvements to the program are needed , 7, 33. 4.5.Considering the highlighted huge need for further regulatory support among the NRAs in the LMICs, further broad and well-coordinated efforts in improving the current training and offering other similar opportunities are warranted. Thus, the following set of measures is highly recommended:Ensuring offering of regular training opportunities to regulatory staff based on both individual and organizational capacity-building needs.NRAs in LMICs should ensure proper planning and allocation of the available resources towards enabling the effective execution of their core regulatory functions.To maximize the available benefits, internal challenges limiting the effective implementation of lessons learnt from different training activities should be continuously addressed.In addition to regulatory training, the WHO and other interested parties should continue strengthening other sustainable and inclusive means for the provision of regulatory support.Future training activities should seek to include trainers, case studies, and experiences from NRAs based in the LMICs.Other NRAs and related institutions capable of offering any form and scope of regulatory training should highly consider doing so.With the experience and lessons from the ongoing training activities, the WHO should seek to address the existing challenges in organizing future training activities.4.6.Although all the interviews were conducted by a single interviewer who had no previous link with the training project, two of the researchers involved in the data coding and analysis were involved in the overall organization of the training activities. Thus, the possibility of compromised independence of the coding and analysis cannot be entirely excluded. Moreover, the qualitative nature of this study hindered the benchmarking of the level of participants’ knowledge and other quantitative indicators before the training and their follow-up in later stages, so as to generate more evidence on the overall impact of the training.Besides, the strengths of this study include its qualitative nature which allowed for the in-depth exploration of the aspects related to lessons learnt, practices, and experiences among the trainees, their immediate supervisors as well as the trainers. In that, the trainees involved in this study had different levels of expertise in areas representative of all core regulatory functions. Moreover, the involvement of those groups favoured the evaluation of the underlying constructs from different perspectives. Also, this study has presented the findings representative of the views of trainees from NRAs having a broad diversity in their geographical locations, economic statuses and levels of regulatory maturity.5.Training regulators as a means of providing regulatory support is a promising approach to promoting sustainable advancements in the regulatory landscape among the LMICs. The potential hosted in this modality is nevertheless hindered by the limited availability of training opportunities. In addition to the need for suitable trainers, of essence are also coordinated identification of training needs, financing, and the overall organization of the training activities.The current study has revealed high relevance and key contributions of the ongoing collaborative training of the regulatory workforce from the NRAs located in the LMICs across the world. Many learnt aspects across all key domains of regulatory practices were shared by the trainees. In addition, the existence of widespread efforts to ensure their successful implementations in local settings was implicated by the trainees and mirrored by their supervisors. Moreover, the training activities were reflected to offer much-needed support to meet an array of knowledge, skills and resources required to enable effective regulatory responses in times of public health emergencies.However, several challenges rooted in the organizational structures and process, availability of resources as well as geographical and political diversities among others, were revealed to limit the optimal realization of the benefits of the training.The original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants. Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article.AK: conceptualization, study design, data collection, data analysis and interpretation, visualization, validation, writing the original draft, review, and editing. RD and LP: conceptualization, study design, literature search, data collection, data analysis and interpretation, visualization, validation, writing the original draft, review, and editing. HS: conceptualization, study design, validation, writing the original draft, review, and editing. All authors contributed to the article and approved the submitted version.This study was funded by the World Health Organization.RD, AK, and HS are working with the World Health Organization. LP is working with the Swissmedic.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 skeletal sex and ancestry of unidentified human crania can be inferred both from physical and from molecular features. This paper depicts and discusses the experiences of physical and molecular anthropologists on a set of commingled crania from the largest Mediterranean shipwreck disaster on 18 April 2015, in order to facilitate identification of human crania. Twenty-one disarticulated crania that were recovered from the above-mentioned shipwreck were analyzed to estimate skeletal sex and ancestry, following a physical and a molecular pipeline. The physical analyses applied morphological and metric methods that provided posterior probabilities for the crania to be classified into a sex or ancestral group. The molecular analyses were performed on petrous bones via a shotgun sequencing approach that allowed us to determine the sex of each individual and to retrieve the complete mitochondrial genome, Y chromosome single nucleotide polymorphisms, up to 597573 SNPs across the human genome from each individual. The morphometric sex analyses showed that most crania belonged to male individuals, although some estimations remained uncertain or undetermined. Inconsistent results were obtained for ancestry estimation as well, since morphological methods classified the crania mostly as European/White, in contrast to the most numerous African forms determined by craniometric analyses. This quite agreed with molecular analyses that identified only African males. Overall, undetermined and contrasting results were obtained between disciplines, preventing the creation of reliable and sound biological profiles that could provide guidance on the sex and ancestral group of the victims. Therefore, the times may not be mature for a merger of physical and molecular anthropology. However, future investigations of this research avenue would pave the way to the possible development of novel tools, methods, and wider reference databases that could address the limitations of both disciplines. Recently, humanitarian emergencies related to forced migrations have intensified, and thus, 82.4 million people are estimated to be forcibly displaced worldwide . UnfortuSkeletal sex and ancestry can be inferred both from anthropological evidence and from molecular evidence. Traditionally, physical anthropologists have deemed the human cranium as a reliable indicator for sex and ancestry estimation of unknown remains. On the basis of morphology and metrics, the cranium presents dimorphic traits between sexes ,7 and itSince ancestry can be considered to be the genetic inheritance everyone receives from their ancestors and from population members that have occupied the same place of origin for long periods of time, molecular anthropologists could also provide valuable support to infer the biogeographical origin via DNA analysis. Recent advances in molecular technology associated with the possibility to also simultaneously genotype hundreds of markers from degraded bone samples have resulted in accurate and efficient estimation of an individual ancestry that could implement anthropological studies with additional evidence. DNA profiling has played an essential role in the positive identification of victims of several humanitarian cases, including mass burials in Guatemala ,15 and BThe fusion of physical and genetic anthropological methods, although apparently useful, may create further complications in the interpretation of a biological profile. In this article, we aim to share the experience of the application of both methods on a set of commingled crania belonging to the largest Mediterranean shipwreck disaster on 18 April 2015, in order to facilitate identification of human crania. In the context of the examination of the remains of circa 1000 victims, the present study focused on 21 disarticulated crania of these victims that were analyzed from a physical and genetic perspective in order to infer biological sex and ancestry. The final purpose, along with aiding identification, is to present the challenges that the practitioners faced when working on such a peculiar set of unknown remains and to highlight how forensic anthropologists  can try to interplay in a conjoined investigation to provide more robust information and how this combination may still need further research for proper integration.Regio Decreto  and is encompassed within the identification project of the victims enshrined in an MOU between the University of Milan and the Italian government. The crania were brushed with water and soap to remove dirt and soft tissue on the external surface and within the skull. Morphological and metric analyses were performed prior to sampling for DNA typing. Dental development was investigated through radiographic images performed with a portable dental X-ray unit  and X-ray tube ). There were 14 crania with completed dental development (the apices of the third molar completely closed). Seven crania presented evidence of on-going root growth of third molars which were evaluated according to Mincer et al. [The sample included 21 disarticulated crania that were recovered from the shipwreck of 18 April 2015. The study complies with Police Mortuary Rules  and the r et al.  and was The morphological analysis assessed the 11 morphoscopic traits originally suggested by Hefner : anterioMetric data were acquired using a microscribe digitizer, and the 3Skull software  that obtSkeletal sex estimation was based on the five morphological traits suggested by Walker : nuchal Bone samples were processed in the molecular anthropology unit of the University of Florence, a state-of-the-art facility dedicated to the analysis of degraded DNA samples. To remove potential contaminants, the outer layer of petrous bones was brushed using a dentist drill with disposable tips as suggested by Pinhasi et al.  and irraRaw data were demultiplexed, allowing for a maximum of one mismatch in each index, and processed through the EAGER pipeline (v1.92.59)  keeping Before genotype calling, reads mapped onto the human genome were authenticated by deamination and fragmentation pattern analysis using mapDamage2.0 . The preThe molecular sex was estimated from each individual by comparing the number of alignments to the Y chromosome and the total number of alignments to the X and Y chromosomes in the libraries prepared .https://reich.hms.harvard.edu accessed on 16 November 2022) selecting only 7566 modern individuals . The software smartpca from the EIGENSOFT package (v16000) [Genotyping was carried out on the BAM files. A pseudo-haploid genotype was reconstructed for each individual with pileupCaller  by performing a calling of 597,573 alleles from the 1240 K + human origin dataset. Subsequently, genotyped data were merged with the human origin panel and the 1240 K dataset ((v16000)  was usedhttp://empop.online/ accessed on 19 December 2022) to calculate the frequency of the genetic profile within the reference database and to assess its worldwide distribution through heatmaps [To perform the mtDNA analysis, reads were processed with EAGER and alignment to the mitochondrial reference genome (rCRS) using CircularMapper, a tool that considers the circularity of the mtDNA . Reads wheatmaps .https://isogg.org/tree/ accessed on 13 December 2022), starting from the BAM file. Reads with mapping quality ≥30 were selected.The Y chromosome haplogroup was also determined using the Yleaf 2.2 software , a PhythRegarding morphoscopic ancestry, 14 crania were classified as White and 7 crania were classified as Black, according to the OSSA scores . The decAn OSSA score identifies two major categories, i.e., Whites and Blacks, based on the score assigned to six of the traits suggested by Hefner . Althougt-test on the PC1 scores of Somali vs. West Africa and Zulu yields . PC2 shows less dispersion and serves mainly to separate the cranium with Hainan affinity from the others.Based on the craniometric data, the population affinities are as follows: Somali 10, West African 7, Zulu 1, Portuguese 1, Euro-American 1, and Hainan 1. The posterior probabilities are generally low, only eight posterior probabilities are ≥0.7, five of which belong to Somali. Lower posterior probabilities are consequently distributed over several groups. Such a pattern indicates that low posterior probability crania do not fit well into any of the reference samples, which is to be expected given the likelihood that migrants come from populations other than those represented by the reference groups. Nevertheless, a strong African pattern emerges, 18 of 21 crania classify as either West African, Zulu, or Somali. The principal coordinate (PC) plot is shown in The results are strongly suggestive of a substructure among these 21 crania. A course mesh can use the available samples to identify the substructure. Some groups that may have been on the ship are not represented, for example, Eritreans, and they predate the migrants by many decades. Future work may be able to more accurately identify a substructure.Determined: When the morphoscopic methods agreed on the classification group , the sex classification followed the ancestry estimation, and therefore, the appropriate equations by Krüger et al.  for SoutUncertain: When the morphoscopic ancestry estimation provided consistent results between methods, but the cranium presented mixed traits and therefore mixed probabilities according to the equations for sex estimation. For eight crania, a definitive judgment could not be expressed, as the coexistence of feminine and masculine traits produced mixed probabilities from the equations: four crania were F/M and four were M/F.Undetermined: When the morphoscopic ancestry estimation classified the cranium into different population groups, it was not possible to choose the appropriate re-calibrated equation by Krüger et al. . TherefoFor the morphological sex estimation, the results can be regrouped as follows:Cranial traits for sex estimation present inter-population variation ; thus, tFollowing the craniometric analysis, the sex discriminant classified 7 of the 21 crania as female, although two had approximately equal posterior probabilities , and therefore no firm conclusion could be drawn. The remaining five crania had relatively high posterior probabilities for female. Based on sex established by DNA, these are clearly misclassifications. What this tells us is that cranial morphology of some migrants is more gracile than the Zulu from which the sex discriminants were derived. A human cranium may present mixed traits that prevent an exact classification into single groups, both for ancestry and sex. As observed in this study, some cases could not be classified as male or female because they presented mixed probabilities according to different traits, and the sex/ancestral group into which a cranium was classified differed according to the method. The size of the sample was limited to 21 crania that were already genotyped for identification purposes; inter-individual variability of such fluctuating features for sex and ancestry estimation within this pool of crania may be therefore clarified by increasing the sample. When applying statistical methods for ancestry and sex estimation, anthropologists must consider that the reference population data may not be appropriate and representative of the sample of the study . AnotherDNA was extracted from the petrous portion of the temporal bone of 21 individuals, double-stranded DNA libraries were created, and a shotgun approach was used to determine the sex of each individual and to retrieve the complete mitochondrial genome, Y chromosome single nucleotide polymorphisms (SNPs), up to 597,573 SNPs across the human genome from each individual. In Subsequently, sex estimation was determined by considering the ratio of sequences aligning to the X and Y chromosomes and the molecular analysis highlighted that all crania belonged to individuals of male sex. Regarding the ancestry estimation, 597,573 SNPs were selected across the human genome. The SNPs called for ancestry estimation of each individual are summarized in As can be observed in In an attempt to assess ancestry at the geographical area level, PCA was performed for the single African population after dividing it into three different areas . Individuals from Central and South Africa were not considered since the numbers of individuals in our datasets were low. It can be observed in In addition, to investigate the potential influence of sex biases in the biogeographical ancestry and to estimate when the common patrilineal and matrilineal ancestors lived, Y chromosome and mtDNA haplogroup were determined using, respectively, Yleaf and Mitomaster.https://github.com/genid/Yleaf accessed on 22 December 2022).The Y chromosome results in terms of reads that mapped on the Y chromosome, number of SNPs called by Yleaf, QC scores, and haplogroup assigned by the software are reported in As can be observed in https://phylogeographer.com/scripts/heatmap.php accessed on 30 December 2022), was used to show where most people with that specific haplogroup lived, or the ancestors who likely lived there. The results are summarized in Y heatmap, a relative frequency map for Y haplogroups developed by Hunter Provyn and Thomas Krahn . This is in agreement with the molecular analyses that show that the crania exclusively belong to male, African individuals. Based on the identity cards that were found associated with some of the victims of the 18 April 2015 shipwreck (but not necessarily associated with these crania), it seems likely that this ship carried people from Sub-Saharan countries. Clearly, no documents were found with the disarticulated crania; therefore, this is a completely unknown sample with respect to sex and ancestry. This hinders the evaluation of the accuracy of the estimations. However, this work did not aim to compare the accuracy rates of anthropological methods against DNA typing, but aimed to stress the elemental interdisciplinary teamwork of physical and molecular anthropologists and the difficulties that may emerge when dealing with biological profiles especially of migrant populations. Skeletal sex and ancestry estimation results based only on morphological traits of the cranium have been found to be 92% accurate compared to the DNA results . AccuracNovel specific formulae that are more accurate for a given population can be suggested and tested for their validity, proving their reliability when applied to the appropriate sample . HoweverDespite this, as shown in Again, our results cannot not be supported by antemortem data, but this was not the scope of the project. On a final note, physical and molecular analyses can produce contrasting results where an anthropologist is not able to confidently determine sex and ancestry, thus preventing the elaboration of the biological profiles and the identification activities. Although a strict reliance on reference groups still represents a drawback when analyzing completely unknown specimens, an approach that intertwines physical and molecular anthropology may start breaking through this everlasting issue with further comparative studies. As such, the expectation of the authors is that investigation of this research avenue would pave the way to the development of novel tools, methods, and reference databases that may help to overcome the limitations of both disciplines.This paper presents the anthropological and genetic analyses for sex and ancestry estimation of 21 disarticulated crania that belong to unidentified migrants who perished in the Mediterranean shipwreck of 18 April 2015. This study highlights the drawbacks that challenge physical and molecular anthropologists when presented with such a peculiar set of remains. In some cases, physical and molecular analyses produced differing results  highlighting that the methods were still strictly linked to reference populations. Within the context of a migrant population, the application of a multimethod approach that combines molecular and physical evidence may provide valuable insights for elaborating the biological profiles of unidentified crania. However, according to the authors’ experiences, a method to merge the two disciplines and to reach a univocal and conclusive result is still to be fully explored.