In today’s interconnected world, environmental uncertainty is higher than ever. Under the new economic normal, innovation-driven has become the key to the transformation and upgrading of various enterprises. Employees’ behavior affects the company’s innovative performance, but it is also deeply affected by the dynamic work environment. The sudden epidemic has greatly increased the environmental dynamics and uncertainties faced by individuals, and also caused many changes in individual behavior. However, the research on the mediating mechanism and boundary conditions of how the dynamic work environment affects employee behavior and results is relatively few. Based on uncertainty reduction theory and innovative performance theory, and following the research paradigm of “environment-behavior-performance,” a moderated mediation model with job crafting as the mediating variable and voice behavior as the moderating variable is constructed. Through the statistical analysis of 210 valid questionnaires for employees in different types of enterprises, the mechanism of how the dynamic work environment affects innovative performance by promoting employees to carry out job crafting is discussed. According to the test results, the dynamic work environment has a significant positive impact on individual innovative performance, and job crafting plays a mediating role in the relationship between the two. In addition, voice behavior positively moderate the relationship between dynamic work environment and job crafting, and the indirect relationship between dynamic work environment and innovative performance through job crafting. With the transformation of enterprises from an industrial economy to a knowledge economy, competition among enterprises has become increasingly fierce. Due to the development of emerging technologies such as “Internet +,” cloud computing, and block-chain, various new industries, new formats, and new models are constantly emerging, bringing huge opportunities and challenges to enterprises. In today’s interconnected world, the environment is more uncertain and dynamic than ever before. Facing the uncertainty and dynamics of the environment, enterprises must solve the problem of how to promote the long-term development of the organization through innovation, so as to improve organizational performance, and maintain a unique competitive advantage in the era of technological iteration and change. Therefore, innovation is not only a trend in increasingly competitive dynamic environment, but also a necessary way for enterprises to gain competitive advantage. The innovative performance of an enterprise depends on the innovation behavior of employees. Employee innovation is the foundation of enterprise innovation. Under the catalysis of time, a certain number of individual-level innovation will bring qualitative changes to the organization and give the organization a new lease of life. Therefore, the continuous accumulation of employee innovation has contributed to the production of organizational innovation, which is one of the decisive factors of organizational innovative performance . In thisGlobal competition continues to intensify, technology continues to update, and the pressure to survive has become more obvious. These changes have made every organization and individual in a dynamic environment with full of uncertainties . How to Effectively stimulating the initiative and creativity of employees in a dynamic and complex environment is the key to a company’s control of uncertainty. The dynamic changes of the environment and the enhancement of employees’ individual awareness mean that organizations need to shift their perspective to the proactive behavior of employees. In the proposition of work design, employees can also actively participate in it, and the concept of job crafting came into being. During the COVID-19 epidemic, medical staff rushed into battle, willing to contribute, and reshaped the mission and value of their job. During the resumption of work, employees worked remotely and reinterpreted their working relationships. The post-90s and even post-00s have embodied the spirit of responsibility of the new generation of employees. Studies have shown that when employees are in an environment with greater work pressure and higher autonomy, they will proactively implement their job crafting . The jobOn the one hand, dynamic work environment will expose employees to a large number of potential development opportunities. On the other hand, dynamic work environment will also bring unforeseen accidents or disturbances to employees’ work and career development. The work pressure faced by employees has increased significantly, and small work errors may cause greater losses . In thisThe contribution of this research is mainly reflected in the following aspects: First, it enriches the research between dynamic work environment and its result variables. This research confirms that the cognition of the dynamic work environment can promote the innovation performance of employees, thus enriching and expanding the research between the dynamic work environment and its results. Second, by introducing the mediating variable of job crafting, this research can discover the key role played by the environment characteristic variables of employees, and also supports the important role of job crafting. This provides a new perspective for explaining the relationship between the dynamic work environment and innovation performance, opens the “black box” of positive effects in the dynamic work environment, and provides a good realistic explanation for the performance dilemma of employees in the post-epidemic era. Finally, by constructing a moderated mediation model, it more comprehensively reflects the complex process of the dynamic work environment affecting innovation performance of employee. On the basis of self-loss theory  and sociThe following section presents the relevant literature review and forms hypotheses for testing. The methodology of testing the hypotheses is outlined, followed by the analysis of the results. Discussion, implications, conclusion as well as the limitations and future research are provided in the final section.Dynamic is a key feature of the environment, which refers to a certain degree of rapid, unpredictable and turbulent changes . The dynThe impact of the dynamic work environment on the organization and employees should not be underestimated. The strength of uncertainty affects the behavior of organizational managers and employees in facing environmental changes with the complexity, ambiguity and turbulence . In a dyEmployees’ innovative performance is a good idea or result generated and realized by an individual, which can benefit organizational performance . EmployeH1: Dynamic work environment has a positive impact on employees’ innovative performance.According to the purpose of this research, this study constructs the theoretical framework of “dynamic work environment-job crafting-innovative performance”. Job crafting is a kind of “contextualized” activity, embedded in the environment, and its behavior itself and its results are affected by the characteristics of the environment . DiffereAccording to the uncertainty reduction theory, when faced with dynamic changes in the work environment, employees will take a series of actions to reduce the uncertainty they face, so they are more likely to respond to challenges and changes by actively changing work tasks. According to the theory of resource preservation, individuals with more resources will obtain resources in the process of interacting with the surrounding environment, and make full use of various opportunities to create resource surpluses to resist other losses. In other words, in the process of job crafting, employees hope to obtain more resources to achieve resource appreciation, that is, performance improvement.As a series of behaviors independently carried out by employees, job crafting can improve work performance by increasing work input, adaptability and enthusiasm, and can bring out positive results of person-work matching, and achieving a win-win of work meaning and work performance . StudiesH2: Job crafting plays a mediating role in the influence of dynamic work environment on employees’ innovative performance.Research shows that with the deepening of social cognition and psychological capital theoretical research, as well as the profound changes in the employment relationship between organizations and employees, the voice behavior generated by the proactive personality will have an impact on job crafting behavior and innovative performance. The research on voice behavior was first proposed by Hirschman in 1970. He believed that voice behavior was an expression of whether employees were satisfied with their work. The higher the satisfaction, the more inclined employees are to implement voice behavior . Van et In a dynamic work environment, voice behavior is a way of interaction between employees and the organization. On the one hand, voice behavior indicates that employees are encountering cognitive conflicts. On the other hand, it means that employees are open and accepting when facing cognitive conflicts . First oH3a: Promotive voice behavior will positively moderate the impact of the dynamic work environment on job crafting. That is, when employees adopt promotive voice behavior, they are more likely to adopt job crafting in a dynamic work environment.H3b: Prohibitive voice behavior will positively moderate the positive impact of the dynamic work environment on job crafting. That is, when employees adopt prohibitive voice behavior, they are more likely to adopt job crafting in a dynamic work environment.Hypothesis H2, H3a, and H3b together construct a mediation model with moderating. As employees’ voice behavior can moderate the relationship between dynamic work environment and job crafting, this research further predicts that the impact of dynamic work environment on innovative performance through job crafting will also be moderated by employees’ voice behavior. In the research on individual performance of employees, many studies believe that employees’ voice behavior can significantly improve process fairness and result fairness , therebyH4a: Employees’ promotive voice behavior will moderate the mediating role of job crafting in the relationship between dynamic work environment and innovative performance. That is, the higher the level of promotive voice, the stronger the mediating role of job crafting.H4b: Employees’ prohibitive voice behavior will moderate the mediating role of job crafting in the relationship between dynamic work environment and innovative performance. That is, the higher the level of prohibitive voice, the stronger the mediating role of job crafting.In summary, the construction model of this research is shown in The post-epidemic era is a period of normalization and uncertainty. The data collection for this study is in March-April 2021. The research sample mainly selects employees from some companies in the Suzhou National High-tech Industrial Development Zone in China, and has experience of working at home. The formal survey is conducted through a self-managed online questionnaire system and is conducted by random sampling. The formal survey was completed within two months. During the investigation, the respondents were required to answer questions objectively and fairly based on the principle of seeking truth from facts. A total of 240 questionnaires were distributed in this study. After excluding invalid questionnaires, 210 valid questionnaires were obtained, with an effective rate of 87.5%. In terms of sample distribution, the distribution of male and female ratios is relatively balanced. The age distribution is mainly 26-35 years old , and the industry and job types are also widely distributed .The scales used in this study are mainly derived from mature scales in the academic community, which have been proven to have good reliability and validity in domestic and foreign studies. All scales use the Likert 5-point scale, 1 means strongly disagree, and 5 means strongly agree. The specific measurement of each variable is as follows.(1)The independent variable is the dynamic work environment. Using the 3-item scale developed by (2)The dependent variable is innovative performance. A 10-item scale designed by (3)The mediating variable is job crafting. Using (4)The moderating variable is voice behavior, including two dimensions: promotive voice behavior and prohibitive voice behavior. Adopting In order to ensure that there is a good discrimination validity between the aspects involved in this study, confirmatory factor analysis is used to analyze the competition model on the discrimination effect of dynamic work environment, job crafting, innovative performance, promotive and prohibitive voice behavior. The degree was tested. The results are shown in P < 0.001). The hypothesis H1 is supported.This paper uses SPSS to construct a regression model of dynamic work environment and employees’ innovative performance, and conducts regression tests. The results show that the dynamic work environment has a significant positive impact on employees’ innovative performance , and job crafting can significantly positively affect innovative performance . The indirect effect value of dynamic work environment that affects individual innovative performance through job crafting is 0.136, P < 0.001, and the 95% confidence interval is , excluding 0. The hypothesis H2 is supported.This study used Bootstrap sampling inspection method, set a significance level of 0.05, and sampled 5,000 times to test the mediating effect of job crafting in the impact of dynamic work environment on employees’ innovative performance. The results show that the dynamic work environment can significantly positively affect job crafting , which shows that the hypothesis H3b is supported.Further, in order to test the moderating effect of voice behavior, the promotive voice behavior, prohibitive voice behavior, and dynamic work environment are first centrally processed, and the interactive items of promotive voice behavior and dynamic work environment are constructed. As well as the interaction terms of prohibitive voice behavior and dynamic work environment are constructed, they are put into the model for testing. The results show that after controlling for the main effects of promotive voice behavior and dynamic work environment, the interaction item of promotive voice behavior and dynamic work environment has a significant positive impact on job crafting , indicating hypothesis H3a is supported; After controlling the main effects of prohibitive voice behavior and dynamic work environment, the interaction term of prohibitive voice behavior and dynamic work environment also has a significant positive effect on job crafting The dynamic work environment has a positive effect on employees’ innovative performance. The dynamic work environment is a realistic situation that employees have to face. In particular, the COVID-19 has made every individual, every organization, and even every country deeply aware of the uncertainty, complexity and dynamics of their environment . In a dy(2)Job crafting is an effective way for employees to cope with the dynamic work environment. The results of this study support that job crafting can mediate the positive relationship between dynamic work environment and innovative performance. The results indicate that the impact of dynamic work environment on innovative performance does not occur directly, but requires the mediating effect of job crafting. Logically, this is consistent with the fact that external environmental factors cannot directly affect organizational performance to play a positive role. Just as external environmental factors need to rely on a series of management behaviors of the organization leader to indirectly affect organizational performance. The work environment’s impact on employees is not direct, but requires a series of actions by employees to have an impact on their performance, which is in line with the “environment-behavior-performance” research paradigm. This finding is consistent with the research results of (3)Voice behavior is the internal motivation for employees to actively respond to changes. The results of this study show that employees’ promotive and prohibitive voice behaviors both play a positive role in moderating the relationship between the dynamic work environment and job crafting. Subsequently, the research results further support the moderated mediation model. The interaction between the dynamic work environment and the employees’ promotive voice behavior has an impact on employees’ innovative performance through the mediating effect of job crafting. The interaction between the dynamic work environment and employees’ prohibitive voice behaviors also affects employees’ innovative performance through the mediating effect of job crafting. Based on this, this study believes that voice behavior is the internal motivation for employees to take active countermeasures when faced with a dynamic work environment. Whether it is promotive or prohibitive voice behavior, it can play a strengthening role.The results of this study provide important implications.(1)Both organizations and individuals should actively adapt to the dynamic work environment and inspire their own vitality. It is absolutely not a bad thing that organizations and individuals should pay attention to the dynamic work environment. On the contrary, it may activate the organization and individuals, and prompt individuals to actively make changes to improve innovative performance. Especially when employees are facing greater work pressure, they are in the purpose of protecting their own resources, and they will put forward suggestions that are beneficial to the work, showing more behaviors of seeking resources and less behaviors of reducing requirements. Therefore, when faced with a dynamic work environment, organizations should guide employees to objectively analyze and predict the dynamics and complexity of the work environment. First, the organization must allow employees to fully perceive opportunities and provide them with adequate organizational support to help them tap and use the challenges and opportunities in the environment. Second, organizations should encourage employees to grow and develop independently, give them more space for autonomy, make employees feel self-satisfied and respected, and make work and personal interests more consistent. In this way, employees will show more challenging behaviors and proactive personality, so as to be more proactive in “self-upgrading” to achieve the improvement of innovation performance. In addition, organizations and individuals need to take a long-term view and enhance their environmental sensitivity and adaptability. Although the cultivation and maintenance of these capabilities may require a certain cost, compared with their potential performance, the benefits far exceed the cost.(2)Organizations must fully understand the importance of job crafting and encourage employees to take the initiative in job crafting. One of the ways to effectively deal with the dynamic work environment is to craft job. Therefore, organizations should make full use of the situation, employees, and job characteristics to allow employees to perceive more opportunities for job crafting, actively adjust work content and relationship boundaries, actively seek resources and challenging work, and reduce inhibitory work requirements. Organizations should give employees appropriate work autonomy and decision-making freedom to motivate employees to implement job crafting, so as to better complete their work tasks. In the work arrangement and design, the organization should enhance the matching of people-work, improve work input and efficiency, and provide employees with resources and substantive assistance, reduce the obstacles they encounter in the process of job crafting, and stimulate innovative behavior. At the same time, organizations must actively meet the needs of employees for job crafting and interpersonal communication, cultivate and train employees’ proactive personality and environmental adaptability, encourage them to actively learn and adapt to the dynamics and complexities faced in work, and improve their response to changes and the ability to solve problems. Organizations also need to actively create a good work environment, such as environmental pressure, leadership style and methods, and organizational policies, to help employees establish organizational identity and role recognition as soon as possible, so as to better engage in work and improve innovation performance. In addition, the organization should provide timely feedback on the behavior and results of employees’ job crafting, and actively encourage, recognize and guide them to form a virtuous circle.(3)Organizations should improve the management system and mechanism for employees’ voice behavior, and establish a smooth communication channel for employees’ voice behavior. Firstly, it is necessary to establish an organizational mechanism for employees to participate in decision-making, broaden the channels for voice behavior, plan the path of voice behavior, and improve the voice behavior process, so as to ensure the normalization and implementation of voice behavior to a greater extent. Secondly, organizations must reform their organizational structure, strive to implement flat management, ensure the effectiveness, timeliness and smoothness of participation in the system. They must also give full tolerance and respect to voice behaviors. Managers are required to give employees feedback in a timely manner, and adopt reasonable and workable voice. Thirdly, it is necessary to create an open, tolerant and innovative cultural atmosphere, and increase the enthusiasm of employees to make voice behavior. Managers should strive to cultivate non-employment relationships with employees. The basis of employees’ voice behavior is the mutual trust and effective communication between managers and employees, which reduces the psychological barriers for employees to participate in voice behavior. With this, employees can actively put forward new ideas and innovative suggestions. In addition, organizations can consider including the voice behavior into employee performance appraisal indicators, and develop a positive and effective incentive system of voice behavior, so as to encourage employees to continuously improve the content and the quality of their voice behavior, and put forward more targeted voice with commercial value.Studies show that the dynamic work environment has a significant positive impact on employees’ innovative performance, and job crafting plays a mediating role in the relationship between the two. In addition, voice behavior positively moderate the relationship between dynamic work environment and job crafting, and the indirect relationship between dynamic work environment and innovative performance through job crafting.This research still has certain limitations. Future research can be considered from the following aspects. First of all, this study only carried out research based on the research paradigm of “environment-behavior-performance”. It did not consider the impact of the dynamic work environment on employees’ other work attitudes and behaviors, nor did it consider other possible influence mechanisms. Future research can try to explore the different impacts of the dynamic work environment and its impact mechanism, so as to further expand and enrich the research on the impact of the dynamic work environment on employees’ work attitudes and behaviors. For example, studies have shown that in a dynamic work environment, organizational identity, work commitment, feedback seeking behavior, etc., have an impact on employees’ work attitudes and behaviors, which in turn will affect employees’ innovation performance. Second, this study considers the moderating effect of employees’ voice behavior, but this is only one of the boundary conditions that may affect whether employees will actively their job crafting in the face of a dynamic work environment. In fact, there are more factors that will affect the process of action. For example, supervisor support, leadership-member exchange relationships, and employee uncertainty tolerance, etc., may all have an impact on the relationship between the dynamic work environment and innovative performance. Future research can continue to explore the boundary conditions of the dynamic work environment affecting the specific process of innovative performance. For example, with the normalization of the epidemic, there may be new changes in the psychological mood and behavior of employees in the post-epidemic era. At the same time, with the increase in work goals and work complexity, it may be more difficult for employees to manage their own negative emotions. At this time, employees need more organizational context power to provide them with emotional assistance, so as to enhance the positive effects of situational modification and cognitive change. Therefore, future research can focus on the influence mechanism of variables such as organizational context.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Ethics Committee of Wuhan University of Science and Technology. The patients/participants provided their written informed consent to participate in this study.JW distributed the work done in the project, searched the background materials, designed the analytical characterization, and empirical study frame and has done the critical revision and editing.The author declares 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.


Introduction: In this study we aimed to perform the first research on the current state of compulsory basic and clinical courses in genetics for medical students offered at medical faculties in six Balkan countries with Slavic languages .Materials and Methods: The study was conducted from June to September 2021. One representative from each country was invited to collect and interpret the data for all medical faculties in their respective country. All representatives filled a questionnaire, which consisted of two sets of questions. The first set of questions was factual and contained specific questions about medical faculties and design of compulsory courses, whereas the second set of questions was more subjective and inquired the opinion of the representatives about mandatory education in clinical medical genetics in their countries and internationally. In addition, full course syllabi were analysed for course aims, learning outcomes, course content, methods for student evaluation and literature.Results: Detailed analysis was performed for a total of 22 medical faculties in Bosnia and Herzegovina (6), Croatia (4), Montenegro (1), North Macedonia (3), Serbia (6), and Slovenia (2). All but the two medical faculties in Slovenia offer either compulsory courses in basic education in human genetics (16 faculties/courses) or clinical education in medical genetics (3 faculties/courses). On the other hand, only the medical faculty in Montenegro offers both types of education, including one course in basic education in human genetics and one in clinical education in medical genetics. Most of the basic courses in human genetics have similar aims, learning outcomes and content. Conversely, clinical courses in medical genetics are similar concerning study year position, number of contact hours, ECTS (European Credit Transfer and Accumulation System) and contents, but vary considerably regarding aims, learning outcomes, ratio of types of classes, teaching methods and student evaluation.Conclusion: Our results emphasise the need for future collaboration in reaching a consensus on medical genetics education in Balkan countries with Slavic languages. Further research warrants the analysis of performance of basic courses, as well as introducing clinical courses in medical genetics to higher years of study across Balkan countries. Medical genetics is one of the most complex, comprehensive and multidisciplinary medical specialties covering all stages of life and organ systems, simultaneously placing a special emphasis on ethical, legal and social implications of genetic testing. Moreover, the integration of the fascinating advancements in the development of genetic and genomic testing methods into various parts of medicine occurs at an accelerated pace. Therefore, most countries in Europe, especially Western Europe, have long recognised not only the importance of introducing medical and laboratory genetics as separate medical specialties, but have also put effort into raising the level of genetic literacy among medical students as the future health professionals who will be involved in the care of patients with genetic disorders .The Balkan area is a geographical region in the south-eastern part of the European continent, associated with different cultural and historical classifications. One of these includes the classification according to the languages spoken in specific countries, such as Slavic, Romance, Turkish and other languages. Countries with Slavic languages include Bosnia and Herzegovina, Bulgaria, Croatia, Montenegro, North Macedonia, Serbia and Slovenia. In fact, these countries are not only associated by Slavic language but also similar higher education and health systems.Unfortunately, Balkan countries with Slavic languages have encountered many historical obstacles that have left inevitable consequences in terms of significant delays in both introducing medical and laboratory genetics as medical specialties, as well as recognising genetic education at medical faculties as an indispensable tool for future physicians of the 21st century. Consequently, the advances in medical genetics internationally have not been accompanied always by an adequate level of application in clinical practice nor raising genetic literacy among medical students locally in the Balkans. Furthermore, most countries have not yet introduced medical or laboratory genetics as medical specialties, which inevitably reflects on the (poor) position of genetic education in the integrated undergraduate and graduate medical education system.Genetic education of medical students is a critical prerequisite for appropriate care for patients with genetic disorders . BecauseThis retrospective study was conducted from June to September 2021. To investigate the current state of basic and clinical compulsory courses in genetics for medical students at medical faculties in Balkan countries in which Slavic languages are spoken, the study was designed so that one representative from each of the selected countries was invited to collect and interpret the data for all medical faculties in their respective country.via e-mail in June 2021 with a letter of invitation to participate in the study. The representatives were chosen based on their expertise, as well as national and international excellence in the field of both basic human genetics and clinical medical genetics. The letter of invitation contained all the relevant information regarding the research, including an explanation of the background, aims, materials and methods. In addition, in this invitation letter, the representatives were sent and asked to fill a questionnaire about the basic and clinical compulsory courses in genetics offered in their respective countries at medical faculties for medical students and a due date was provided. All six representatives  filled the questionnaire and were sent a second e-mail with the request to send the full syllabi for each course mentioned in the questionnaire. The second e-mail also contained a detailed explanation of the reasons for requesting the full course syllabi .An additional four representatives from four different Balkan countries with Slavic languages  were contacted All representatives participated in the research voluntarily. Considering that this research is a retrospective study, no approval of ethical committees was necessary.A short questionnaire was designed with the aim of collecting the relevant data about basic and clinical compulsory courses in genetics for medical students at medical faculties in Balkan countries in a concise and uniform manner. The questionnaire consisted of two sets of questions.The first set of questions was factual and contained specific questions about mandatory education, including the names of the medical faculties in their respective countries and titles of basic and clinical compulsory courses in genetics offered at each medical faculty for medical students. In addition, for each course, the representatives were asked to grade the appropriateness of the study years on which the courses are offered at each faculty (level too low/appropriate/too high), number of contact hours (insufficient/appropriate/too high), and ECTS (underestimated/appropriate/overestimated).The second set of questions was more subjective and inquired the opinion of the representatives about mandatory education in clinical medical genetics in their countries and internationally. The questions were: “Do you think that there should be a single, uniform curriculum for all compulsory courses in medical genetics in your country?”, “Do you think that there should be a single, uniform curriculum for all compulsory courses in medical genetics internationally?”, “Is medical genetics recognized as a medical specialty in your country? If yes, from which year”, “Is laboratory genetics recognized as a medical specialty in your country? If yes, from which year”, and “What are the main obstacles for optimization of the courses in your country?”.Data extracted, analysed and compared from full course syllabi were course aims, learning outcomes, course content, methods for student evaluation and literature.Representatives of six Balkan countries with Slavic languages  participated in the research. Detailed analysis was performed for the total number of medical faculties in these countries, which is 22 . All but two medical faculties  offer either compulsory courses in basic education in human genetics (16 faculties/courses) or clinical education in medical genetics (3 faculties/courses). On the other hand, only one medical faculty offers both types of education, including one course in basic education in human genetics and one in clinical education in medical genetics . Data on the 20 medical faculties that offer compulsory courses in genetics for medical students is shown in A total of 17 compulsory basic courses in human genetics are offered at 17 medical faculties in five countries  . While mRepresentatives of Bosnia and Herzegovina, Montenegro and North Macedonia agree that the position of the courses regarding the study years is too low. On the contrary, the representative of Serbia considers that the positions for the basic courses are appropriate in their country but emphasises the importance of introducing additional mandatory education in clinical genetics in the later study years. A special emphasis should be placed on the Faculty of Medicine, University of Split (Croatia), where the title of the basic course “Immunology and Medical Genetics” does not reflect its content, which is a mixture of both basic and clinical topics.In addition, representatives of Bosnia and Herzegovina , Croatia, Montenegro and Serbia agree that the number of contact hours and ECTS is appropriate for the respective courses. On the other hand, the representatives of Bosnia and Herzegovina  and North Macedonia state that the number of contact hours and ECTS in insufficient.The analysis of full course syllabi across different Balkan countries , focusing on the important molecular mechanisms that are important to human health, as well as the diagnosis and therapy of human diseases. Furthermore, learning outcomes were also comparable regarding knowledge, skills, and attitudes, although the biggest differences can be attributed to the level of performance required from the student. Moreover, the course content is again similar with certain specificities; however, the topics are relevant for medical students and up to date for the field of modern human genetics. The topics cover a wide array of content, from the structure of nucleic acids and chromosomes to the basics of genetic disorders aetiology  and modern methods for detection of genetic disorders. Finally, the biggest differences are present in the methods for student evaluation, especially in terms of grading and number of tests used. Although student evaluation is based mostly on the assessment of knowledge, some courses use only written exams, whereas others use both written and oral exams. With a few exceptions, the acquisition of skills is not assessed in most courses, i.e., assessment does not reflect the expected learning outcomes regarding skills.A total of four compulsory basic courses in medical genetics are offered in two countries  . Two of All representatives agree that the position of the respective courses in the study year is appropriate. On the other hand, the representative of Montenegro stated that the number of contact hours and ECTS in insufficient for their course, whereas the representative of Croatia agrees that it is appropriate.Finally, an additional course offering mandatory education in clinical genetics is integrated with pediatrics at the Faculty of medicine, University in Maribor (Slovenia). However, the program is focused only on genetics in the paediatric period and was therefore excluded from further analysis. In addition, in Slovenia at the Faculty of Medicine, University of Ljubljana some of the medical genetic topics are included in other basic or clinical courses.Unlike the basic courses in human genetics, the four clinical mandatory courses in medical genetics  are simiThe course “Medical Genetics” offered at the Faculty of Medicine, University of Rijeka (Croatia) consists of 17 h of lectures, 15 h of seminars and 13 h of practicals. The entire course is conducted exclusively through active learning methods and is designed and performed through case-based reasoning, thus achieving both clinical reasoning and a simulation of the actual physician-patient relationship in practice. The learning outcomes were determined and derived in accordance with key competencies according to Core Competences in Genetics for Health Professionals in Europe published by the European Society of Human Genetics specifically for physicians who are not specialists in medical genetics . The finThe course “Medical Genetics” offered at the Faculty of Medicine, University of Zagreb (Croatia) consists of 20 h of lectures, 5 h of seminars and 20 h of practicals. Practicals are conducted at the clinics for pediatrics and the final exam is a written test. On the other hand, the third course delivered in Croatia, “Medical Genetics” at the Faculty of Medicine, University of Osijek (Croatia) consists of 27 h of lectures and 18 h of seminars.Finally, the course “Clinical Genetics”, which is delivered at the Faculty of Medicine, University of Podgorica (Montenegro) resembles the course “Medical Genetics” at the Faculty of Medicine, University of Rijeka regarding the aim and learning outcomes, although it has more contact hours, thus enabling a wider approach in topics. The final exam consists of the practical and oral part.The representatives of all six countries agree that there should be a single, uniform curriculum for all compulsory courses in medical genetics in their respective countries. The representative of Bosnia and Herzegovina believes that it would allow easier cooperation and coordination of program. However, the representatives of Croatia and Slovenia believe that although a common framework would be helpful, some variations and freedom should be allowed between faculties due to specificities in medical genetics practice in each country and curricula of other subjects. The representative of Croatia emphasises that this curriculum should not be provisory but should also be aligned with the already existing document Core Competences in Genetics for Health Professionals in Europe published by the European Society of Human Genetics specifically for physicians who are not specialists in medical genetics (ESHG).The representatives demonstrated more variation in their answers to the question on whether a there should be a single, uniform curriculum for all compulsory courses in medical genetics internationally. For example, the representatives of Croatia, Montenegro and Serbia think that a common framework for the Balkan area would be more appropriate due to the local specificities and different level of genetic services. On the contrary, the representatives of North Macedonia and Slovenia believe that there should be a common framework, although adapted to national health systems, which would enable common standards of knowledge for the European Union health systems, whereas the representative of Bosnia and Herzegovina thinks that a single uniform curriculum for all compulsory courses internationally would lead to better optimization of the scientific plan. Finally, all representatives agree that variations and freedom should be allowed to each course coordinator.Of the six included countries, medical genetics is offered as a medical specialty only in North Macedonia (from 2015) and Slovenia (from 2002). In Montenegro and Serbia, clinical genetics is offered as a sub-specialist education after a previously completed specialty . Neither of the previously mentioned opportunities are offered in Bosnia and Herzegovina and Croatia.Similar to the opportunities for medical genetics training, laboratory genetics is available as a medical specialty in North Macedonia and Slovenia. In the case of North Macedonia, training in medical genetics was previously available only for biologists at the Medical faculty, University in Skopje; however, a new specialty—Clinical laboratory genetics, was introduced in 2012, which is open to health professionals, including medical doctors. In Montenegro, training in laboratory genetics is recognized in terms of the necessary conditions for work in genetic laboratories but residents need to perform their training in other countries considering that it is not available in their country. Neither of the previously mentioned opportunities are offered in Bosnia and Herzegovina and Croatia.In the final question, the representatives were asked to share their opinion on the main obstacles for optimization of the courses in their respective countries.The representative of Bosnia and Herzegovina shared a detailed evaluation on the current situation in their country, including that knowledge of medical genetics among teaching staff is very limited considering that there are no specialists in medical and laboratory genetics. In addition, financial challenges are obvious, especially in organizing laboratory work, such as demonstrations. Finally, the representative emphasises the inconsistencies of the entire education system as a separate issue.The representative of Croatia believes that the fact that mandatory clinical courses in medical genetics are even offered in Croatia is a success of its own considering there is no training in medical or laboratory genetics. The biggest issue for their optimization is the lack of sufficient awareness of clinical decision makers about the importance of medical genetics and its place in modern medicine, which contrasts with great agility among medical faculty teachers towards the introduction of medical genetics in clinical practice, especially at the Faculty of Medicine, University of Rijeka. The fact that clinicians underestimate the necessity that medical students learn about medical genetics and do not integrate genetic contents or discuss patients with genetic disorders with their students represents the greatest obstacle for proper implementation of medical genetics in clinical practice in Croatia. One of the possible reasons for this is the low level of genetic literacy among different specialists. The representative of Montenegro, who believes that the small population of the country does not enable the sustainability of all types of education and that there is insufficient awareness of decision makers about the importance of medical genetics and its place in modern medicine, shared a similar opinion. In addition, the representative of Serbia thinks that better synchronization is needed between basic, laboratory and clinical aspects of medical genetics, both in education and in practice in their country. Finally, the Slovenian representative believes that there is a disconnection between medical faculties, which are dominated by non-medical scientists involved in teaching and decision making, and clinical centres, which are the seats of actual genetic medical practice.In the present study, we evaluated the current state of compulsory basic and clinical courses in genetics for medical students offered at medical faculties in six countries associated by Slavic languages, including Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia, Serbia, and Slovenia. With the help of representative authorities in both human and medical genetics from each country, we performed the first such study in the Balkan peninsula, which was of the utmost importance for gaining insight into the present situation, as well as planning for future directions in mandatory genetics education at medical faculties for medical students in this area. A detailed analysis of each country revealed that Bosnia and Herzegovina and Serbia precede in the number of medical faculties (six in each country), and are followed by Croatia (4), North Macedonia (3), Slovenia (2), and Montenegro (1). Except for Slovenia, all other countries offer some sort of compulsory courses in genetics for medical students: either courses in basic education in human genetics  or both basic education in human genetics and clinical education in medical genetics (Croatia and Montenegro). However, in the case of Croatia, basic education in human genetics is offered at just one medical faculty, whereas clinical education in medical genetics is offered at three different medical faculties. Therefore, currently the best example for an integrative approach to medical students’ comprehensive education in genetics is represented by the Faculty of Medicine, University of Podgorica in Montenegro, which offers basic education in human genetics in the first year of study and clinical education in medical genetics at the fifth year of study.Compulsory basic courses in human genetics are offered at 17 medical faculties in five countries . Interestingly, except for Croatia, which represents a special case, and Slovenia, which does not offer any type of basic education in human genetics, this result indicates that mandatory education in human genetics is offered at every medical faculty in Bosnia and Herzegovina, Montenegro, North Macedonia, and Serbia. Most of the courses (15) are offered in the first year of study, with highly similar aims, learning outcomes and course content. Although the mandatory literature is also similar, commendably, certain course coordinators also have their own accredited handbooks, emphasising and encouraging the importance of allowing freedom to each course coordinator. All these results indicate high awareness of the importance of basic sciences in modern medicine in these countries and represents an excellent basis for the introduction of clinical courses in medical genetics in the later years of study, like in Montenegro.As indicated, Croatia represents a special case because although a compulsory course “Medical biology” is offered at all four medical faculties in the country, covering certain topics of the basics of human genetics, this is not reflected in the title of the course and was therefore excluded from further analysis. However, an initiative might be launched at the national level to rename the courses to reflect their contents in a more accurate manner . We also encountered certain illogicality at the Faculty of Medicine, University of Split, where the title of the basic course “Immunology and Medical Genetics” does not reflect the content and should therefore be renamed and separated from immunology. In addition, after the modification of the course aims, learning outcomes and contents, the course should be moved to a higher year of study, as is the case with the remainder of medical faculties in the country. It is unclear how this artificial merging of two highly diverse courses occurred considering that this not in line with the Croatian national curriculum.Although the representatives of Bosnia and Herzegovina, Montenegro and North Macedonia believe that the position of the courses are too low in the study year, the representative of Serbia considers that the position is appropriate and that an additional clinical course should be introduced at the higher years of study.The current situation regarding compulsory clinical courses in medical genetics is completely different than for basic courses in human genetics. Generally, clinical courses in medical genetics are highly underrepresented in Balkan countries. Specifically, only four compulsory clinical courses are offered in just two countries—at three medical faculties in Croatia and one in Montenegro. Interestingly, neither country offers medical or laboratory genetics as a medical specialty. In addition, although these courses are similar with regards to study year position (fifth or sixth year), number of contact hours (45–60), ECTS (3–4) and contents, they vary considerably with respect to the aims, learning outcomes, types of classes, ratio of types of classes, teaching methods and methods for student evaluation. Not only do the courses vary between Croatia and Montenegro, but they also vary substantially between the medical faculties in Croatia. For example, students attend practicals only at the pediatrics departments at the Faculty of medicine, University in Zagreb, whereas at the Faculty of medicine, University of Osijek, students do not have practicals at all. On the other hand, at the Faculty of medicine, University of Rijeka, the course is based on clinical reasoning and is aligned with key competencies according to Core Competences in Genetics for Health Professionals in Europe published by the European Society of Human Genetics specifically for physicians who are not specialists in medical genetics , confirmThe reasons for such low integration of compulsory clinical courses in medical genetics at the medical faculties for medical students in Balkan countries are numerous. The Balkan area is a highly specific geographic area in Southeast Europe and is sometimes associated with different cultural and historical explanations. First, this is an area which is synonymous with conflict and violent confrontation, which undoubtedly slowed down the progress and development of certain Balkan countries. The best evidence for this is Slovenia, which is the only country that did not suffer substantial war consequences and was the first of the Balkan countries included in this study to introduce both medical and laboratory genetics specialties and experience profound progress in the application of the most modern technologies in genetic testing to everyday clinical practice. In fact, specialists in medical and laboratory geneticists from Slovenia are the ones who are nowadays helping professionals in other Balkan countries develop medical and laboratory genetics with their knowledge, experience, and clinical services. Second, a direct consequence of the afore-mentioned concerns are economic issues of the Balkan countries, which are still evident in the present time (emphasised by the representatives of Bosnia and Herzegovina and Croatia) and does not allow for the same opportunities for the procurement of expensive modern genomic technologies as in the Central and West European countries. Third and final, considering the substantial delay in medical genetics in comparison with West European countries, most diagnostic genetic laboratories were led by non-medical professionals, especially biologists and molecular biologists, who were consequently also the first course coordinators of clinical courses in medical genetics . Considering that non-medical professionals did not associate the contents in their courses with clinical practice, future physicians did not see the benefits of medical genetics in clinical practice. When these students became physicians, they could not integrate medical genetics into their clinical teachings, leading to a consequently huge gap and a vicious circle between basic scientists and clinicians, which is still ongoing.In this study, the representative of each country shared their opinion on this topic for their country and these are in line with the afore-mentioned issues. With certain specificities in their answers, all representatives agree that the biggest issue in each country is insufficient awareness of decision makers  about the importance of medical genetics and its place in modern medicine.In terms of the basic courses in human genetics, although they are highly similar on paper , further research would require the analysis of course performance. Therefore, future research would require peer-review and attendance of all courses to evaluate the transfer of content to students, especially in the context of analysing the achievement of course aims and learning outcomes, as well as applied teaching and learning methods . Future studies should also analyse vertical integration with clinical courses to allow for updates in the curricula. Also, feedback from student evaluation of the courses must be considered because student opinion is crucial for advancing any curriculum or syllabus.For the clinical courses, Balkan countries are in desperate need of introducing these to higher years of study consequent to the rapid development of medical genetics and its integration into all fields of modern medicine. However, course coordinators should bear in mind that it is crucial that their courses are aligned with the minimum core competencies for future physicians and that the education is needs-based. Otherwise, if medical students do not see usefulness, purposefulness, and application of the course contents in their future clinical practice, opposite, unwanted effects might be achieved. Therefore, it would be important to follow the rules of adult-learning theory and apply active learning methods  and critical thinking to the maximum extent . AlthougAdditionally, vertical and horizontal integration of medical genetics with other clinical courses would be of the utmost importance and continuous emphasis on the importance of genetics through other medical specialties to medical students is indispensable for their understanding of the importance genetics has in modern medicine. Thus, genetic education of clinicians of other specialties might help prevail this obstacle.Finally, only two countries offer medical and laboratory genetics as a medical specialty (North Macedonia and Slovenia), and in addition to introducing mandatory genetic education for medical students and clinicians, the remaining countries should focus on the introduction of both specialties for postgraduate students.In the present study, we performed the first research on the current state of basic and clinical courses in genetics for medical students offered at medical faculties in six Balkan countries with Slavic languages . Except for Slovenia, all other countries offer some sort of compulsory courses in genetics for medical students at a total of 20 medical faculties: either courses in basic education in human genetics  or both basic education in human genetics and clinical education in medical genetics (Croatia and Montenegro). Most of the basic courses in human genetics are similar concerning their aims, learning outcomes and course content. On the other hand, clinical courses in medical genetics are offered only at three medical faculties in Croatia and one in Montenegro. In addition, although these courses are similar with regards to study year position, number of contact hours, ECTS and contents, they vary considerably with respect to the aims, learning outcomes, ratio of types of classes, teaching methods and student evaluation. Further research warrants the analysis of performance of basic courses, as well as introducing clinical courses in medical genetics to higher years of study across Balkan countries. Increasing genetic literacy in medical genetics in clinicians of other medical specialties is also crucial. Finally, this study emphasises the need for collaboration and is the first step towards breaking the years-long barriers that have prevented the consensus on medical genetics education in Balkan countries with Slavic languages, all for the benefit of future physicians and their patients.


The advent of the COVID-19 pandemic saw the introduction of many unprecedent actions occurring within our communities and by extension our country. Whilst many of us may have heard the term pandemic before, few would have had the knowledge or experience of the measures that were taken to contain coronavirus in our country. The introduction of lockdown measures such as the closure of public places like bars restaurants, malls, places of worship, gyms, spas and beauty services, casinos, cinemas  highlights individual, relational, community and societal risk factors for domestic violence. These risk factors include common themes such as heavy alcohol and drug use, economic stress , having few friends, being isolated from other people and a desire for power and control in relationships . AlcoholThe power and control wheel can also be turned through isolation and economic abuse. Isolation of the victim is further enhanced by stay-at-home measures aimed at preventing the spread of COVID-19, but also trapping victims of domestic violence with their abusers. Notwithstanding communication technologies, there are also physical constraints on the victim preventing them from accessing direct in person support and retreat to the safety of family, friends and shelters. Behaviours such as constant surveillance and enforcement of rigid rules by perpetrators serve to fuel the isolation and propagate acts of violence in the home. The potential for economic abuse has also increased since the pandemic due to the effects of job-losses, furloughs, reduced working hours and general declines in economic activity. Consequently perpetrators' financial stresses coupled with the propensity to consume alcohol as an escape, create a highly charged home environment with acts of violence becoming likely possibilities. In addition, some victims of domestic violence are financially dependent on their abusers, therefore making it difficult for them to leave these home environments. Local data reported by UN Women suggests that as of December 2020, only 39.3% of indicators needed to monitor the sustainable developmental goals (SDGs) from a gender perspective were available. There were gaps in key areas such as unpaid care and domestic work, and information on the gender pay gap. However, it can be noted that the unemployment rate among women over 15 years of age was found to be 6.3% compared to 4.6% of men in the same age range .The concept of male privilege may have also been strengthened during the COVID-19 pandemic as men occupying supervisory and managerial roles at their workplaces have become day to day bosses at home thereby increasing their tendency to act like masters of the castle and relegating the woman's role to that of a servant. Indeed, this domination and control through the use of male privilege plays a significant role in male abusers who often consider abusive behaviour as a right and a privilege. A Trinidadian qualitative report revealed that male dominance in the family is a key factor creating a risk of violence. Controlling behaviours such as isolation tactics, accusations, threats and stalking also highlight the relationship between male dominance in the family and multiple, intersecting forms of violence. Accusation by partners is common, repetitive and used to precipitate threatening, hitting, slapping, cursing and choking .Tactics used to maintain power and control through the use of male privilege in the context of COVID-19 were highlighted by the Battered Women's Justice Project. These tactics include violation of others' personal space, using all the work and study areas in the home, disrupting routines and refusing to share the computer .The COVID-19 pandemic in itself can be leveraged by perpetrators. Indeed those suffering from domestic violence may be less inclined to go to the hospital on account of fear of infection. Ultimately, the social distancing, albeit essential to contain COVID-19, may exacerbate the violence and maintain it less visible .Increased acts of sexual violence have also been documented during this pandemic. A UK and Kenyan based study reported that Sexual and gender-based violence (SGBV), and particularly intimate partner violence (IPV), had spiked dramatically during the COVID-19 pandemic . India nAs a family physician, it is my view that we make the best use of the limited resources available to us to protect our population from the scourge of domestic violence that is accompanying the COVID-19 pandemic. Now more than ever comes the time for innovation and tact in the implementation of measures to screen, guide and act definitively to protect the victims of domestic violence. Toward this end, the WHO's ALIVES framework for inquiring and responding to a disclosure of domestic violence serves as a primer for facilitating disclosure, validating concerns and enhancing safety and support .This framework can perhaps best be implemented through the use of telehealth which has now become a standard of care in order to mitigate against COVID-19. It is well-documented that women and children are the main seekers of health care. As health care providers, we must capitalise on that by tactfully screening for domestic violence during virtual encounters through the use of safe words or even advice on the wearing of certain colours of clothing as a signal that a survivor is concerned about their risk .As a society we must never condone acts of domestic violence. Rather, we should seek to educate the victims about avenues for relief and try our best to dissuade perpetrators by creating a supportive environment especially in the era of COVID-19.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.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.


Background: Stomach cancer (SC) is one of the most common cancers in the world. Dietary risk factors of SC are not fully understood. This study aimed to investigate the association between macronutrient intakes and the risk of SC.Study design: A hospital-based case-control study.Methods: The data were obtained from a hospital-based case-control study conducted at the Cancer Institute of Iran from 2010 to 2012. Patients were 40 years or older and were diagnosed with SC in less than one year with no history of any cancers. On the other hand, the controls were healthy subjects who were caregivers or visitors of the patients. Demographic characteristics were collected using a structured questionnaire through face to face interviews by trained interviewers. Dietary data were obtained using a validated Diet History Questionnaire. The age and gender-adjusted odds ratios (ORs), as well as the adjusted ORs of age, gender, energy, education, smoking, and body mass index, were reported for continuous and tertiles of intakes.Results: Totally, 207 SC patients and 217 controls participated in this study. In the full adjusted model, after comparing the highest tertiles to the lowest ones, the intake of sucrose , protein , cholesterol , and percent of calories from protein  showed a positive significant association with SC. Moreover, a significantly negative association was found between the percent of calories obtained from carbohydrates and SC .Conclusion: The findings in this study showed that macronutrient intakes might be associated with the etiology of SC in Iran. Its incidence rate is double in males and increases by aging in both genders . The SC incidence is high in Iran and is the most common cancer in males. The Age Standard Rates of SC were estimated at 20.6 and 9.7 per 100,000 populations in males and females, respectively . Approximately, 80% of patients are diagnosed in advanced stages and do not benefit from therapeutic strategies . Therefore, prevention strategies could play an important role in SC control.Stomach cancer (SC) is one of the most common cancers in the world. Although its incidence is decreasing in most developed countries, it is known as the fifth common cancer and the third cause of cancer death worldwideHelicobacter Pylori infection has been recognized as the main risk factor in this regard, along with genetic factors, gender, tobacco smoking, heavy alcohol consumption, and body fatness . Furthermore, dietary factors are considered to have an important role in the etiology of SC. Several studies have investigated the association between dietary factors and SC leading to controversial results. Some studies found a direct association of risk of SC with the intake of protein , fat, saturated fat, and carbohydrate. However, other studies reported negative or null association with protein , as well as monounsaturated and polyunsaturated fats . The World Cancer Research Fund International in its latest report recognized obesity and foods preserved by salt as probable nutritional risk factors for SC . Additionally, it declared there is limited evidence on the association between SC and other nutritional factors, followed by no conclusion on the effect of nutrients intake on SC. Given the inconsistent results of previous studies, this study aimed to investigate the association of SC with energy and macronutrients intake in Iran.Several risk factors have been studied concerning stomach cancer. . The SC is rare in people younger than 40 years of age; and if it occurs, it is mainly due to genetic factors. Therefore, this study recruited 210 patients who were 40 years old or over and were diagnosed with SC in less than one year with no history of any cancers. An experienced pathologist assessed gastroscopic or surgical biopsy of the patients.The data were obtained from a hospital-based case-control study conducted at the Cancer Institute of Iran from 2010 to 2012. It is noteworthy to mention that this institute is the most comprehensive cancer center located in Tehran, capital city of Iran that admits cancer patients from all parts of this country Accordingly, the patients with histologically confirmed stomach cancer  were included in this study. The controls consisted of 223 healthy relatives of patients who were referred to the hospital to visit or take care of their relatives. The healthy controls were enrolled since the dietary intakes of the patients were usually changed due to their disease. The controls were matched with the cases regarding number, residential place, and age (±5 years). As mentioned, the inclusion criteria were 1) age of older than 40 years, 2) lack of no chronic diseases (except GS in patients), and 3) willingness to participate in the study. On the other hand, the pregnant or breastfeeding female patients, as well as those who were diagnosed with cancer more than a year or being affected by SC as a second cancer were excluded from the study. Written informed consent was obtained from all participants after oral and face to face explanation of the study protocol and objectives. The study protocol was approved by the Ethical Committee of Tehran University of Medical Sciences, Tehran, Iran (no.17198).. This questionnaire was previously modified according to Iranian food habits, and its validity was confirmed in a previously conducted study . This questionnaire includes 146 questions related to the consumption of foods and Iranian mixed dishes during the last 12 months. The cases were asked to recall their intake before the appearance of disease symptoms (one year before the diagnosis).Demographic characteristics of the participants were collected through a structured questionnaire by a face to face interview conducted by trained interviewers. Following that, trained nutritionists conducted face to face interviews to complete the Diet History Questionnaire (DHQ). This questionnaire is a kind of Food Frequency Questionnaire (FFQ), which developed by the American Cancer Institute to study the nutritional factors associated with cancers  Moreover, the interviewers reminded the patients several times through the interviews that they should answer the questions based on their dietary habits before the onset of the cancer symptoms. They used Iranian portions of food to help subjects remember their food intake properly. If it seems that subjects are over- or under-reporting, the interviewer asked how much food was usually served on that occasion and how many people ate these portions of foods to help them recall more preciously. Since bread is the staple food of Iranian population, interviewers initially asked how much bread was eaten in a day. Subsequently, they asked about the consumption of different kinds of bread, and if there were wide range of differences, they attempted to help them recall the correct amount of consumption. The DHQ contained questions about dietary supplement consumption in order to dismiss people who take supplements. However, it was not common in our study population, and no one was dismissed by this reason. An experienced nutritionist checked all questionnaires, and the missing data were obtained through telephone calls., McCance and Widdowson's tables of Food composition  were utilized and supplemented by Iranian ones  for some special foods that are consumed in Iran. The procedure is explained in detail elsewhere .The data obtained from the DHQ were converted to gram/day in separated programs made by the authors in STATA statistical software. Daily food intakes were inverted to energy and nutrient intakes using a food composition table. As the Iranian food composition table covers only raw foods and limited nutrients  The Body Mass Index (BMI) was calculated as weight in kilograms divided by height in squared meters. As SC affects the weight of patients, they were requested to recall their usual weights rather than the recent weight. Smoking status was defined through self-reporting and classified by ever smoking and non-smoking at any time in the last year.. As one gram of nutrient intake could not make any significant differences to cancer risk, it was suggested to the group subjects based on their classification of intakes, followed by a comparison between the higher and lower intakes . Therefore, the multivariate unconditional logistic regression model was employed to estimate Odds Ratios (OR) and 95% confidence intervals of SC according to raw and tertiles of energy and macronutrient intakes. Furthermore, the residual method explained by W. Willet was used to adjust for energy intakes. The model A was adjusted for age, gender and energy and the model B was further adjusted for education, smoking and BMI. The P for trend were estimated putting continues form of nutrients intake in models.The sample size was estimated in Stata software (version14) using a power of 90%, a significance level of 0.05, and an OR of 1.8 to investigate the association between macronutrient intake and risk of SC. Accordingly, the sample size was estimated at a minimum of 192 cases to study this association in the Iranian population P<0.01) and older  than the controls. Moreover, they consumed less energy , compared to the controls -1 by the inhibition of IGF-binding protein production . The IGF-1 stimulates cell proliferation and inhibits apoptosis through a series of downstream pathways activated by phosphoinositide3-kinase/protein kinase B and Ras/mitogen-activated protein kinase pathways . On the other hand, total carbohydrate intake is associated with a higher intake of fruit and vegetables and a lower intake of protein and fat which could lower the risk of SC.High dietary intake of sugar increases blood glucose and insulin , which was consistent with the results of this study. Moreover, another study in the USA showed a positive association between SC and total intake of protein or intake of protein from animal sources. However, in a report by the World Cancer Research Fund and American Institute for Cancer Research in 2016, all investigations on SC and nutrient intakes reached unconvincing results about protein, carbohydrate, and fat intakes .The results of this study also demonstrated that a higher intake of protein and a higher percent of calories from protein were associated with a higher risk of SC. Palli et al. suggested that SC was associated with protein intake in Italy. Cholesterol intake showed a positive association with the risk of SC in this study, which supports the findings of several studies that reported the association between intake of cholesterol and risk of SC ; however, there are also conflicting results in other studies . Although the mechanisms are not clear, high cholesterol intake is associated with alterations in apo-lipoproteins and lipids, which may contribute to inflammation .The mechanism of the effect of protein restriction on cancer prevention is not fully understood. A decrease in protein intake affects cellular metabolism significantly. Moreover, it changes the energy and amino acids metabolisms, autophagy, immune responses, inflammation, and signaling pathways. It is clear that all these modifications could alter cancer risk. Moreover, protein restriction could modify gut microbiota, which is considered a new way to control cancer . However, since all epidemiological studies apply FFQ, the misclassification of the study participants was unavoidable based on their dietary intakes . Although several confounders were under control in this study, the possibility of residual confounding variables could not be excluded. Given the case-control design of the study, the inherent limitations of recall and selection bias should also be considered in this study.Regarding the strength of the present study, one can name the high rates of participation, same socioeconomic status of patients and controls, as well as the use of a validated DHQ. Since the participants were recruited from all parts of the country, the results could be generalized to the whole population across Iran. Moreover, since SC is most prevalent in low- and middle-income countries the risk factors of which are similar to those in Iran, the results could be generalized to these countries This study indicated a potential role of some macronutrients intake in the risk of SC, including intake of sucrose, cholesterol, and protein. Further research with a larger sample size is required to confirm these findings and evaluate the above findings in the cardia and non-cardia SC exclusively. The authors are grateful to all participants who responded to the questions patiently. Moreover, this study was supported by nurses in the cancer institute of Iran. There is no potential conflict of interest. This study was financially supported by the Cancer Research Center in Tehran University of Medical Sciences, Tehran, Iran (no.17198). FT and KZ designed the study, BS and MH supervised data collection and cleaning. FT analyzed the data and wrote the draft under the supervision of KZ and AH. All authors reviewed the final version of the manuscript. Written informed consent was taken from all participants after a face-to-face explanation of the study protocol. This study was approved by the Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran (no.17198).Stomach cancer is known as the fourth-common cancer in males.Unhealthy dietary intake is a modifiable risk factor for gastric cancer.Sucrose, cholesterol, and protein intakes could be associated with increased risk of SC


One of the key challenges of community health worker (CHW) programmes across the globe is inadequate supervision. Evidence on effective approaches to CHW supervision is limited and intervention research has up to now focused primarily on outcomes and less on intervention development processes. This paper reports on participatory and iterative research on the supervision of CHWs, conducted in several phases and culminating in a co-produced district level supportive supervision framework for Ward Based Outreach Teams in a South African district.Drawing on a conceptual framework of domains of co-production, the paper reflects on the implications of the research process adopted for participants, generation of research knowledge and recommendations for practice, as well as lessons for research on the supervision of CHWs.Through the research process, participants reflected and engaged meaningfully, honestly and productively across hierarchies, and were able to forge new, dialogic relationships. The iterative, back forth feedback, involving a core group of participants across phases, enabled additions and validations, and informed further data collection. The culmination of the process was consensus on the key issues facing the programme and the generation of a set of recommendations for a local, context-specific framework of supportive supervision. The process of engagement, relationships built and consensus forged proved to be more significant than the framework itself.The co-production approach can enable local impact of research findings by providing a bottom-up collaborative platform of active participation, iterative feedback, knowledge generation and mutual learning that can complement guidance and frameworks from above. Although time consuming and not without its limitations, this approach to research has much to offer in advancing understanding of CHW supervision. South Africa, like many other low and middle income countries, has adopted community health worker (CHW) programmes in the face of high chronic communicable and non-communicable disease burdens and human resources for health shortages , 2. The Despite their promise, community health worker programmes across the globe have experienced challenges that include limited training and resources, low trust with other primary health care workers and inadequate supervision –8. SuppoResearch on interventions to strengthen the supervision of CHWs has traditionally favoured experimental methodologies and systematic reviews of trials –18. SupeFurthermore, intervention research on CHW supervision has up till now focused primarily on the outcomes of the interventions and less on their development processes. The literature is silent on how to develop CHW supportive supervision interventions that are participatory, and involve mobilisation of local tacit knowledge that can complement guidance and frameworks from research and policies; or how local stakeholders can be brought into research processes to develop and improve supervision interventions for CHWs.This paper reports on 4 years of research engagement by the first author (as part of her PhD) in a South African district, culminating in a co-produced district level supportive supervision framework for Ward Based Outreach Teams (WBOTs - South Africa’s CHW Programme). Based on a deliberate research design, this process involved working in a participatory and iterative manner over time with relevant stakeholders at strategic and functional levels that can best be described as a co-production approach.Co-production is a process of working together and building relationships between different groups of people to generate knowledge that coherently incorporates different viewpoints, as well as a ‘collaborative model of research that includes stakeholders in the research process’. , 27 RefeLangley et al.  propose Supervision is a deeply relational process, embedded in social and professional contexts in the health system, that involves supervisors and supervisees at different levels of hierarchies across a range of functions and interactions . A co-prThe paper begins by describing the setting of the research, then lays out the conceptual framework of co-production as domains of influence adopted for the analysis and how the research unfolded in phases. This is followed by an exploration of the co-production process through the lens of domains of influence, and a discussion of the lessons for research on supportive supervision in CHW programmes.The study was conducted in Ngaka Modiri Molema (NMM) district, North West Province. The South African ward-based PHC outreach team (WBOT) functions at a ward level, where a group of six to ten CHWs provide basic preventive and promotive services on non-communicable diseases, HIV/TB and mother and child health at household and community level, supported and supervised by a professional nurse, called a team leader, and reporting to a PHC facility .The North West Province was an early adopter of the WBOT programme after its launch in 2011, and recognised for its many achievements , 34. Howit is key in the early stages of building trust between diverse stakeholders and helps banish myths that constrain contextually sensitive solutions being developed” [Drawing on theoretical understandings in the literature , a qualitative, descriptive study that combined a document review of five available policy and guideline documents , and focus group discussions (FGDs) was conducted in NMM and a neighbouring district. A total of 41 PHC facility managers, team leaders and CHWs, purposefully sampled, participated in the FGDs. Themes and sub-themes that emerged from coded text in both the document review and the FGDs were thematically analysed, alignment across documents and practices analysed and strengths, weaknesses and gaps identified. The second part of phase 1 was a cross-sectional, quantitative study using social network analysis (SNA) in one sub-district of NMM district with the longest experience of WBOTs. Two of the three local areas in the sub-district with participants who had been associated with WBOTs since the early phases of the programme, were purposefully selected. The 48 participants in this phase were provided with feedback of the findings from the document review and preceding FGDs to validate and comment on the policies and practices of the WBOT supervision system  after the workshop were also recorded.In sum, the co-production process framed questions in a manner that got participants to think in a certain way about the supervision of WBOTs and encouraged reflection at every stage, where researchers and participants learnt from each other in a dialogic process in iterative, back and forth engagements.Participants gave written consent to participate in all the studies, with attention paid to privacy and confidentiality. Information was also provided about the possibility of withdrawing from the study if they wished before the data were analysed. The study was approved by the University of the Western Cape’s Senate Research Committee and Ethics Committee, reference number BM17/3/3.In this research, a sequential approach to participant groupings was adopted. In the first and second phases, FGDs were mostly conducted in separate categories: six with CHWs, four with team leaders and four with facility managers. Middle managers were interviewed individually in the second phase to avoid frontline health workers feeling intimidated by their supervisors.The idea of connecting personally, this is something we take for granted and never thought about. It is an opportunity to dig deep”. Participants who appeared sceptical were specifically encouraged to express contrary views based on their experiences and observations. As one team leader commented, “It has helped me grow emotionally and be sensitive to others”.However, one FGD in the second phase was deliberately set up as a mixed group of participants  across dI do not trust my workplace. I am not supported, not developed, intimidated, bullied”. Such honest opinions were enabled by the iterative processes of presenting feedback on findings of previous phases to the same participants over time, and facilitating repeated reflections of their own local experiences. These sessions were a platform of learning and critical questioning of local practices on supervision and the WBOT programme. As one team leader reflected “It just opened our eyes about things we were not taking seriously. It helped us a lot. We can see our gaps and what we are going to do to improve.”In the final phase, an introductory session invited participants to reflect on their attitudes, hopes and challenges in the workplace, by responding anonymously to six questions on sticky notes. In this way participants were encouraged to provide open responses and voice opinions they would otherwise hold back if said verbally. For example, one participant in the workshop, sitting next to their supervisor, wrote “how does this (research) benefit us in the challenges we have?”. Another group of CHWs, which had been a pilot team for the sub-district since the beginning of the programme expressed frustration at the lack of movement on career pathing or absorption into the health system. As the process unfolded, the CHWs from the two teams who participated in all the three phases were observed to express their challenges in a non-confrontational manner, and generally had good engagements with officials and managers from the district and the province. The ‘safe spaces’ of the research enabled useful and meaningful dialogue, with maximum participation by all players across hierarchies. By removing ‘social desirability’ constraints, more honest and productive reflections from a variety of perspectives were made possible. The participants were observed to mix comfortably in the breakaway groups, where everyone was given a chance to comment. CHWs led the feedback to the plenary workshop on behalf of some of the groups.The researcher (TA) observed and kept notes of people’s reactions and participation through-out the research process. In the early stages of phase 1, CHWs were hostile and appeared angry with the process, the team leaders and the researcher. One team that had experienced difficulties with their payments, and had been without a team leader for some time, asked the researcher “You cannot nurture a relationship if you are not constantly in contact with one another. The PHC facility managers do not support team leaders”. This serves as an example of how main points of discussion were carried through all the phases.Inputs and comments that participants provided in the feedback sessions were treated as additions and validations of the findings. Moreover, they were used to inform data collection in the phases that followed, ensuring participants’ reflections were correctly captured while demonstrating that the knowledge generated was important and recognised. One manager, commenting on the SNA findings of limited communication between key individuals, acknowledged that “Phases 1 and 2 documented a number of weaknesses in both the design and practices of the supervisory system of the WBOTs. These are summarised in Fig. With regards to the development of WBOTs, supervisors (team leaders and PHC facility managers) lacked adequate orientation on the programme and supervision. Feedback on decisions relating to the programme, referrals from PHC facilities and general feedback on CHW performance was poor in many settings. In-service training for CHWs beyond the formal training was informal and infrequent. While there was a general sense of cohesion and support among CHWs themselves and with their team leaders, the interactions and relationships between WBOTs and PHC facilities workers was often strained. Because of poor engagement from management beyond PHC facilities, facilities had little support and encouragement in supervising WBOTs.Drawing on these findings, four key themes were identified for the discussion in the final workshop: leadership, development of CHWs, allocation of roles and resources. Using the knowledge that was generated iteratively, and involving some participants in all the three phases, meant that by the time of the workshop there was general consensus on the key issues facing the WBOTs. This fed naturally into the development of a local framework that all could own.The culmination of the co-production process was the generation of a set of recommendations for a framework of supportive supervision as set out in Table While some of the strategies of the framework remained at a fairly general level, the fact that these were collectively generated and owned, led to a discussion of implementation. The most significant output of the co-production process was thus not the framework itself, but rather the dialogue that enabled consensus on the problem and solutions. The process produced recommendations that were contextually relevant and tailored for the district, drawing from different perspectives, and which identified systemic issues and local opportunities. In addition, the process was able to model a supervisory approach that is supportive and inclusive.Interventions, guidelines and reports on supervision of CHWs are typically designed or developed using an evidence-based approach, as reflected in the 2018 WHO guideline on health policy and system support to optimize community health worker programmes . This paThis research experience offers a number of lessons on co-production as an approach to supervision research.Firstly, the time and effort that participants invest in generating knowledge makes ownership and uptake of recommendations for practice more likely . HoweverSecondly, supportive supervision is a complex phenomenon that involves multiple actors and relationships and which therefore requires a systems perspective. The study involved participants at both functional and strategic levels in the WBOT supervision system. It demonstrated that co-production can be beneficial for social interactions as relationships across different hierarchies and functional levels are equalised and placed on a new footing , 25, 38.Thirdly, the research showed the importance of integrating and translating generic knowledge and recommendations on supervision within specific sets of relationships and context by mobilising tacit understandings and knowledge. The recommendations arising from the research cannot be regarded as an evidence based universal framework but rather the best fit for the local context. In this regard, the processes of engagement are more important as generalisable knowledge than the specific elements of the research product .Finally, the role and positionality of the researcher in the co-production process is key, and requires a high degree of reflexivity, and in some instances, resilience. Researchers may have to navigate reluctant participants, and entrenched ways of seeing, doing and engaging. It is also important to recognise that power relationships, priorities and expectations of researchers and policy makers inevitably “shape and direct these processes” , 26. LinThe study had some limitations that should be acknowledged. In particular, the wider provincial crisis, including civil servant protests and strikes in the Province during the study period delayed data collection process and affected the momentum of the co-production process. Despite these delays, a degree of stability was maintained, participation was secured over time and the planned data collection was eventually all completed. As indicated, the first author has had a prolonged engagement in the study site, and built on prior relationships during the research. This may have posed a potential bias in understanding and analysing findings. On the other hand, the author’s long association with the WBOTs programme enabled her to negotiate entry and participation and contextualise findings in trends over time. Another limitation was that the study was confined to supportive supervision in the formal PHC and the district health system and excluded communities where the services are rendered. The inclusion of communities in the study population and their contribution in the participatory process would have broadened knowledge generation and added valuable recommendations to the development of the framework.This research adopted a co-production approach to developing a district level framework for supportive supervision of CHWs, recognising that the phenomenon is fundamentally a system of relationships. Rather than seeking to develop technical recommendations using ‘evidence-based’ methodologies, it drew on the tacit knowledge of practitioners, modelling different behaviours, encouraging dialogic approaches, and working within and across groups to flatten hierarchies. Co-production can enable local impact of research findings by providing a bottom-up, collaborative platform of active participation, iterative feedback and mutual learning that can complement guidance and frameworks from above. However, this form of research is time consuming and not always feasible or without its limitations.