This study outlines key aspects of professional development among health professionals in low- and middle-income countries (LMIC). LMICs need support in developing their continuing medical education, and non-technical skills (NTS) that have been neglected in this respect. Given the nature of NTS, educational methods should be used experientially. This study aims to explore an interactive educational approach to increase NTS among health care professionals in an LMIC setting.A design-based research approach was applied to develop an educational method. Key NTS concepts were identified, which directed the selection of research-based surveys. A series of workshops was designed in which a survey-based experiential approach was developed. The educational process followed a pattern of individual reflection, small group discussion and relating the concepts to the local practice in a wider group.An approach to increase NTS in LMIC settings emerged in iterative development through conducting workshops with health care teams in the Balkans. The topics could be grouped into individual, team, and organisational dimensions. The approach can be described as survey-based experiential learning involving steps in recurring interaction with participants. The steps include identifying concepts in individual, team and organization dimensions and contextualising them using experiential learning on the individual and group levels.An overarching approach has been developed that addresses NTS in an LMIC setting. The survey-based experiential learning approach can be beneficial for raising professional awareness and the development of sustainable healthcare settings in LMICs. Low-and middle-income countries (LMICs) need support in developing their continuing medical education. This study presents an interactive educational method aiming to strengthen non-technical skills (NTS) in health care teams. Foreign Aid and donor organisations focus primarily on technical skills and equipment in LMIC. However, they are rarely adapted to the local context and thus miss the aim of long term validity for sustainable health care development This study addresses the need to develop strategies for learning NTS in continuing medical education in the context of LMICs.To improve health care results and meet the Millennium Development Goals  suitableClinical skills usually focus on technical aspects and practical procedures, requiring specialised training and practice. These are necessary skills for health care professionals. However, in order for these skills to be used in an optimal way, NTS are fundamental . In settNTS are defined as cognitive and social skills, such as decision-making, planning, situation awareness, leadership, teamwork, and communication . BetweenDespite the importance of NTS in these settings little research is available, and no context specific NTS educational tools have been found in a literature review . Given tThis educational approach was developed using the process of design-based research (DBR), which aims to improve practice and contribute to theory , 13. TheTwo two-day workshops were conducted between May 2018 and March 2019, including participants from three regions. The first workshop was conducted in Montenegro and the second in Bosnia and Herzegovina. The workshops were planned in collaboration with the participants, based on their perceived needs, to ensure that they are adapted to the local organizational cultural context.We decided not to lecture but instead to provide an active collaborative contextualisation of the content in interaction with the participants, based on surveys as educational tools. We planned for consecutive workshops to deepen the understanding of aspects of NTS in order to support health care settings in the developmental phase in LMIC. Before and after every workshop, the research team refined and analysed the contextualised concepts in preparation for the following workshop, seeking to strike a balance between concepts and the needs and development of the participants. This iterative process formed the core of development of the approach.Twenty-nine participants with different professions from the three university hospitals in Sarajevo (Bosnia and Hercegovina), Pristina (Kosovo) and Podgorica (Montenegro) participated in the workshops. The participants were part of a long-term regional training programme  previousThe surveys were used as educational tools to emphasize and process NTS concepts such as situation awareness, decision-making, leadership, teamwork, and communication  the individual’s implicit long-term conceptual understanding of and reflection upon the concepts and experiences of each participant individually or from the work groups and ii) the researchers’ continued synthesising of the contextualised understanding, which was then presented during the next workshop.These four steps describe an iteration that was repeated for several concepts. Throughout the workshops interaction between participants and researchers supported a shared understanding.Ethical approval was granted by the ethical committee Pristina University (ref nr. 4963).Data consisted of observation of discussions, team interaction, group work, field notes, post workshop conclusion, and reflection among the research team. We did not use survey outcomes per se in this study, hence no analysis was performed on survey data. The workshop content and activities were analysed and categorized into three dimensions used to provide further structure.The workshops were work-intensive, focusing on the participants’ active reflection on topics related to their contexts and sharing of experiences. Three dimensions emerged in the analysis of content and activities: the individual, team, and organisation (ITO). An overarching mapping of the different surveys in relation to ITO dimensions is presented in , each participant shared his or her understanding of the concepts on a personal level. Individuals reflected on the possible use and wording of LSQ and Johari’s exercise, and it was evident that the nurses were eager to reflect on and interpret their perceptions of the concepts. The participants became aware of how their personal strengths and limitations related to teamwork and patient care.The individual’s role and responsibility were addressed through three surveys: individual development plan, interprofessional education collaborative (IPEC) domain descriptions and the TMX scale. These surveys focused on the individual’s role, one’s role in a team, perspectives on working as a team and working in a multi-professional team. In general, individuals shared the same view that working as a team is much easier and safer for both the patient and the professionals. The concepts of role and responsibility led to exchanges of ideas, which, according to the participants, clarified individual roles and responsibilities.The team dimension was observed both in topics and activities. An important setting for developing the participants’ awareness of the concepts was the small group with familiar colleagues. Once the participants’ individual professional awareness on the topics was addressed, they shared experiences and understanding with colleagues in the small group setting. This interaction led to reflections in the small group on how the subject was perceived. Communication, teamwork, and reflection were important skills for professional and competent clinical practice. Sharing opinions with participants with the same profession was favoured, even if they belonged to different organisations. Both nurses and doctors were eager to discuss the concepts with colleagues of the same profession. Senior colleagues led the discussions.TeamSTEPPS, TMX scale and IPEC addressed the team level of professional development. Concepts were related to changing health care needs and optimisation of the knowledge available in the organisation. According to the participants, traditional individual-oriented teaching should be extended by problem-based learning. Statements from IPEC domains were related to the professionals’ roles and responsibilities and sharing of responsibilities related to patient treatment. The team should be considered a safe zone since mutual agreement on the patient’s treatment is reached by the group, and the responsibility should be shared by the team. Discussion on the readiness to take over colleagues’ responsibilities in the case of emergency and to organise the work according to the available resources included several ideas, such as regular meetings to discuss tasks and engage patients and families in the treatment.The concept of communication was evident in most of the surveys. Here, both content and interaction patterns were addressed: nurse–nurse, nurse–physician, physician–physician and communication directly with the patient.The organisational dimension was expressed in topics and in discussions in which the participants’ various settings were compared. In the first workshop, the participants were introduced to an organisational example from Swedish health care. It was emphasised that change processes require time and adjustments. This information allowed the research team to adjust the curriculum for the workshops. Specifically, more emphasis was given to the practical application of NTS in the participants’ local contexts. For example, the participants were invited to contrast their own experiences with the presented Swedish health care setting.In the second workshop, three managers presented their organisational settings in more detail. The presentation focused on history, the current situation, and changes since the last workshop. In addition, a site visit was planned, but unfortunately it had to be cancelled. Following the organisation presentation, participants discussed organisation and management in the full group setting. According to some group discussions, hierarchies in the workplaces was a challenging factor when establishing teamwork practices. This included both the organisation structure as well as informal roles and gender structures. In some cases, the organisation and political management structures were not supportive of interprofessional teamwork. While the participants expressed an interest in collaborating with other clinics/institutions, they lacked organisational support in the form of formal policies.To support the long-term contextualisation, the second workshop started with a recapitulation and discussion of NTS concepts. Both understandings of the concepts and explicit observations of the concepts in one’s own workplace were addressed. The participants had developed awareness of the concepts and provided numerous examples and experiences. Some of the participants’ ideas were transformed to examples: establishing protocols and guidelines, having regular meetings and support group discussions with the members of the multi-professional team. Another aspect of long-term contextualisation was the research groups’ increased awareness of the participants’ understandings of interprofessional teamwork and challenges in the clinics.The presentations from the three local organisations (above) were an important part of the long-term contextualisation. To further emphasise the concepts of communication and shared understanding of the local organisations, the participants were divided into three groups and asked to present their understanding of the organisations. Variations in understandings of the same organisations contributed to increased organisational awareness.Overall, the findings suggest that NTS are important for professional sustainable development. Through a deeper understanding, individual reflection and team discussions, the participants saw ways this could be seen and introduced into the local organisation. Previous efforts to introduce NTS concepts in LMICs have often been developed in high-income countries and not adjusted to the context of LMICs . To the The health care services in LMICs are increasingly interested in creating possibilities for continuing education so that the services that are offered are efficient and reliable . EffortsWe sought to ensure that a broad range of relevant professions were represented in the workshops, as this was found to be important in other contexts when teaching professional awareness and skills. This was in line with DBR, where collaborative and multidisciplinary interventions between practitioners and researchers are developed in iterative and cyclic processes .The identified way of structuring the range of NTS concepts into ITO dimensions proved to be supportive for organising the content into a meaningful workshop discussion. We did not seek to adjust NTS to any of the specific ITO dimensions but rather to motivate importance of understanding the dynamics of multi-professional development in an organization. The individuals in this study processed concepts by using surveys in an experiential learning manner. The Johari exercise challenged the participants into an increased individual awareness both on personal and professional levels. This awareness provided a foundation and catalysed following activities. Differences in individuals’ understandings of the concepts brought different perspectives to the multi-professional team discussions.In the small group setting, the interactive reflections on the content of the surveys and topics were supported by the research team to facilitate the understanding of how they could be applied to the local context. According to Kolb’s learning theory, small group reflection is important for trustful communication in a group . The disA lack of financing and human resources in LMIC health care might hinder the implementation of NTS practices . This stIn the larger setting, the participants applied their achieved awareness to the organisational level. Individuals’ own interpretations of NTS were distributed among the three ITO dimensions. A shared view on NTS can support a collective organizational awareness, and this can be reached through experiential learning activities . The manThe participants’ knowledge on NTS developed between and after the workshops, based on their work practice. Consequently, the SBEL approach encouraged the individuals’ implicit conceptual understandings of and reflection upon NTS in relation to their experiences. According to Kolb & Kolb  the longThe overall goal of the SBEL approach was to increase the awareness of NTS as an important part of professional development. It was considered an appropriate educational intervention providing holistic health care education to improve patient safety.In this study we developed an interactive educational framework for NTS to support professional awareness in an LMIC setting. The SBEL approach was inspired by Kolb’s learning theory, where the learning cycle begins with any particular action and experience, which is analysed, followed by reflection and feedback, as part of the learning experience. Kolb’s theory provides a framework for planning, implementing, and managing education actions . The appWhen organisations are invited to participate, it is important that the full spectrum of team members is included, as diversity creates a challenging and interactive learning experience. Thus, this diversity should be retained in the SBEL activities. All experiences and participant contributions should be considered equally important and should be encouraged to be articulated. An overall awareness of the cultural context and differences is needed to ensure a successful process and implementation. A future step would be to apply and evaluate the SBEL approach in other LMICs in order to evaluate its general application in other contexts.The SBEL approach can be used to support professional development and NTS in LMIC settings through research-based surveys. This approach can be applied to stimulate experimental learning in order to develop NTS and increase professional awareness of the individual, team and organisational levels in LMIC settings. It could also be used for teaching other concepts and skills of continuous medical education. The approach can encourage the development of a robust and safe health care organisation. However, it is important that considerations at the individual–team–organisation levels are taken into account among participants so that selected concepts can be tailored for the local needs.


Anseriformes order, are the main carrier of lentogenic (non-pathogenic) variants of Newcastle disease virus (NDV) in nature. But the question of the reservoir of velogenic (highly pathogenic) NDV in nature still remains open. In the 1970s, 1990s, and 2000s in North America during epizootics among cormorants, velogenic NDV strains were isolated. It was later concluded that cormorants play an important role in the maintenance and circulation of NDV in North America. New data have been obtained on the circulation of velogenic NDV strains in wild birds in Central Asia: VIIb and XIII genotype strains were isolated from cormorants for the first time in Kazakhstan. Interestingly, outbreaks of NDV registered in poultry in Central and Southern Asia were phylogenetically close to the viruses from cormorants that support the idea that cormorants can serve as the potential reservoir of velogenic NDV in developing countries of Asia. The seasonal migrations of cormorants may contribute to the distribution of the virus throughout Asia but more evidence must be obtained to confirm this hypothesis. There is increasing evidence of the introduction of NDV into the poultry farms from wild nature worldwide. This article continues the discussion on the likelihood of cormorants to serve as a reservoir and carrier of NDV on the Asian continent.Despite numerous disease prevention measures and control programs, Newcastle disease (ND) remains one of the most significant infections in poultry worldwide, especially in developing countries. It is known that wild birds, mainly of the  Anseriformes order are the reservoir of lentogenic NDV in nature  birds with signs of ocular opacity, partial paralysis, and extreme weakness . Then, aIt was noted that isolation of NDV from sick or dead birds was not always possible in North America. Several factors were suggested that may have contributed to the failure to isolate NDV from many of the birds examined. The virus does not persist for more than 3 and 5 weeks in intestine and brain of sick birds, respectively, while neurological disorders may persist longer. Presumably, some of the cormorants examined may have had residual signs and lesions but have been free of virus .Outbreaks with mortality among cormorants in the United States continued in 1995 and 1997. It was determined that the mortality rate was ~32–64% and recorded only among juveniles under 3 weeks of age. After 4 weeks of age, juveniles left the nest and disseminated the infection . ExperimIn the 21st century outbreaks of NDV among cormorants were recorded in North America in 2005, 2008, and 2010. Phylogenetic studies have shown their relatedness to each other . They weAll the authors that described NDV epizootics in North America in 1975–2010 underline that despite over two decades of NDV in cormorants of North America, many aspects of the epidemiology of this disease remained unknown . EpizootThe history of the study of NDV among cormorants in Eurasia began with the mass mortality among domestic chickens in Scotland in 1949. Macpherson  made obsMK423875), where outbreaks with massive mortality of domestic chickens occurred in poultry farms, caused by 99% phylogenetically close NDV strains of sub-genotype VIIb  during 2003–2013 despite extensive vaccination efforts , 25.Unlike in North America, no isolates very similar to those from nesting sites have been found in the wintering areas of cormorants in South Asia. Below is a comparative analysis between North American and Asian epizootics.Similar points:- Mortality occurred only among juveniles up to 3–4 weeks of age, adults shed the virus but did not get sick.- NDV outbreaks with mortality were recorded during the nesting period in the summer.- Besides the cormorants, mortality was observed among sympatric gulls and pelicans , 9.- Highly pathogenic for domestic birds- Outbreaks do not occur every year, but after two or more years.- In North America, it was unable to isolate the virus during each outbreak. In Kazakhstan, mortality among juvenile cormorants has been reported at Lake Alakol in 2020, but the virus has not been isolated then.- There is a specific G110R amino acid substitution in cormorants of North America, but in Asia, in addition to cormorants, it has also been found in gulls, pigeons, and domestic chickens.Differences:- In North America, NDV from cormorants belonged to genotype V but in Asia, they belong to genotypes VII and XIII. Interestingly, NDV isolated in 2014 belonged to genotype VII but in 2016, belonged to genotype XIII. Both were found in the same location of Alakol Lake in Asia. Genotype V viruses likely emerged in Central and/or South America in 1970s and subsequently introduced into Europe , 27 and - NDV was found on cormorant wintering grounds in southern USA. Such findings were not registered in Southern Asia where cormorants from Central Asia winter.As we can see, there are more points making similar North American and Asian epizootics among cormorants than distinguishing, and we can talk about the same phenomenon on both continents.Based on the available data, we can see that in Asia, as well as in North America, cormorants pose a significant threat to poultry industry. They pose the greatest threat mainly in nesting places, where massive infection of juveniles occurs, followed by dissemination of the surrounding territories.However, we cannot exclude the possibility that infected cormorants transfer NDV from northern breeding areas to wintering grounds in Asia. It was shown that the virus in North American wintering grounds continually circulates subclinically among susceptible adult and older juvenile birds, which then further reinitiate the cycle during spring migration .To date, there is no information on the isolation of velogenic strains from cormorants in their wintering areas in South Asia, so it is still impossible to consider them a source of a distant transmitter within the continent. There are only assumptions about an indirect relationship between the viruses of cormorants and poultry, when, during an outbreak of NDV in India, a specific amino acid substitution G110R was identified, which was considered inherent only in cormorants. It should also be noted that in Asia this substitution was found not in all cormorants, but only in one out of 10 studied. An important task is to examine the populations of wintering cormorants in the countries of South Asia for NDV. If found, compare them with strains causing mass mortality among poultry in adjacent territories.Commercial flocks in developed countries are protected from any contact with domesticated poultry or wild birds or any pet birds. So, only sporadic epizootics occur in Europe and North America. The greatest impact of ND may be on village or backyard chicken production that is widely spread in developing countries of Asia. ND is frequently responsible for devastating losses in village poultry. There are many restraints making the control of ND in village chickens in developing countries extremely difficult or even impossible . The intThere are still many questions such as whether cormorants or gulls are the primary reservoir of infection, where is the virus being maintained in nature because outbreaks in cormorants and sympatric gulls occur not every year, why the virus cannot be isolated during every outbreak, cormorants can disseminate the virus within a few weeks and is this sufficient to deliver NDV to the southern wintering grounds? The answers are yet to be found but in any case, cormorants, as a massive species distributed in all corners of the globe, living in huge colonies, is the most important link in the epizootic of velogenic NDV in the wild. An indisputable fact is that cormorants are a species, with the course of evolution, adapted to live with velogenic NDV. Mortality is observed only among young birds and it does not reach 100%, adult birds are not susceptible to the virus, which also increases the likelihood of this species as a reservoir in nature.It has been shown that the circulation of velogenic strains among cormorants in North America and Asia is of a very similar nature. Meanwhile, in North America, the circulation of phylogenetically close strains has been established both in nesting and wintering colonies, which are very distant from each other. In Asia, this phenomenon has not yet been identified. In the case of the occurrence of similar cases in Asia, we can talk about the existence of a real possibility of the introduction of velogenic strains from the wild into the domestic flocks.Unfortunately, the production and management for disease control measures are not sufficient in Asia. Poultry farms are concentrated in close proximity to backyard flocks  facilitaCirculation of virulent viruses in vaccinated birds in commercial farms of Asia and their continuous evolution over time suggest the existence of a high environmental viral load of unknown nature . This arAll 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.


Deterrence by punishment aims to prevent a crime; however, it is not always successful. Restrictive deterrence explains the continuous criminal activities that occur despite deterrence; offenders enact various strategies to avoid detection, which is more typical among drug offenders given that they have a high frequency of offending and exposure to punishment. This systematic review provides an in-depth understanding of restrictive deterrence of drug offenders. Two prominent themes, “restrictive deterrence strategy” and “deterrability and restrictive deterrence,” depict drug offenders' restrictive deterrence and effectively fit within the certainty–severity framework of punishment. Future studies should investigate restrictive deterrence strategies in the after-arrest context, the facilitative effect of perception of risk on strategy development, and facilitators or inhibitors affecting the diffusion of restrictive deterrence strategies. For decades, researchers, and theorists in criminology have investigated punishment and its deterrent effect. A large portion of deterrence research has focused on how punishment exerts an influence on people's determination to engage in or refrain from illegal behavior. Two elements of punishment, certainty, and severity, are the most commonly cited and explored, and are considered to be influential factors in motivating people to avoid committing crimes. Although punishment aims to deter people from crime altogether (absolute deterrence), it has a chance of encouraging people to commit crimes in insidious ways, which echoes the concept of restrictive deterrence  Gibbs, , p. 33.The distinction between absolute and restrictive deterrence is the extent to which people adjust their criminal behavior in reaction to risks. As Gibbs , p. 32 dJacobs  expandedDrug offenders, referring to those who use, deal/traffic, or cultivate/manufacture illegal drugs, are of particular relevance in the theoretical development of restrictive deterrence. Since Gibbs , p. 33 iLikewise, restrictive deterrence is of particular relevance in shaping the character of drug offenders. First, the high recidivism levels of drug offenders . Punishment is a system of conditional probabilities  representing successfully avoiding detection, and exploring the potential prerequisite for strategy implementation.In the present study, meta-synthesis of mixed studies is adopted. Meta-synthesis is an analytical technique used to combine and compare the outcomes or metaphors of various qualitative studies to create interpretations, ground narratives, or theories   approach  version 2018 was used to evaluate the methodological quality of the included studies. The MMAT contains 27 methodological quality criteria for appraising qualitative, quantitative and mixed-methods studies. Each criterion in the tool would be labeled with one asterisk if a requirement was met and would be labeled without asterisk if a requirement was not met or “cannot tell.” There are two comprehensive screening questions for all types of studies, namely “Are there clear research questions?” and “Do the collected data allow to address the research questions?” A further appraisal may not be feasible when the answer is “no” or “cannot tell” to one or both screening questions. Of the remaining 25 questions, 5 of them are expressly set up for appraising the qualitative study, 15 of them for quantitative study , and 5 of them for mixed-methods study. Accordingly, for each study, it will be labeled with 5 asterisks, or scored 100%, if it meets all criteria for the type of study. By analogy, a study that meets 4 criteria will be labeled with 4 asterisks (or scored 80%). The MMAT does not have a specific standard cut-off value. However, two categories (low and high) or three categories  can be adopted. The crucial aspect is to carefully utilize the results of the appraisal in the review. One author of the present study analyzed the methodological quality of each included study and verified its final score. Studies with at least 3 asterisks (or scored 60%) were kept.A data extraction table was developed to report a full description of each included study, including its purpose, sample size, design, participants, research setting, and the drug crime type reported by the author.Themes were extracted and grouped from individual studies into wider themes and subthemes before being synthesized. A thematic analysis and meta-synthesis were performed rather than a meta-analysis since meta-analyses are not feasible when there is considerable heterogeneity among qualitative studies.n = 373) (n = 10) or high quality (score of 100%) (n = 24).Based on the search strategy, 1,237 individual titles were retrieved and 864 studies remained after removing any identified duplicates (n = 373) . A totaln = 373) . FinallyThe 34 studies were published from 1984 to 2019: 18 studies focused mainly on factors that affect the action of restrictive deterrence; 15 of them depicted restrictive deterrence strategies; and only one literature review discussed restrictive deterrence with respect to multiple crimes. Studies were carried out mostly in the United States and other Western countries. Nine studies used a quantitative design (surveys/questionnaires/systematic observations), whilst 22 used qualitative designs , and three were designed using mixed methods (interviews and surveys/systematic observation).Based on the systematic review and meta-synthesis of mixed studies, the characteristics of the included studies were summarized in Offenders are risk-respondents rather than risk-takers  are likely to reconsider risk before the crime. They fear losing the investment they have made in prosocial domains, leading them to commit crimes less frequently and a longer time before re-arrests DeJong, . ComparePsychological status is another relevant individual characteristic that affects drug offenders' perception of risk and subsequent behavior. Drug offenders with experience in avoiding detection undermine risk sensitivity, as they reckon that they are more capable of escaping detection than anyone else and they become overly confident and reckless when carrying out crimes  and “how” (severity mitigation) drug offenders will be punished. The parity of discussion between the severity and the certainty of punishment is uncommon in prior deterrence studies. The imbalanced topic distribution, specifically that most of the studies focused on the certainty of punishment, may be due to the different deterrent effects of certainty and severity of punishment. Firstly, it is generally accepted that the certainty of punishment exerts a significantly stronger and more stable deterrent effect on offenders than the severity of the punishment DeJong, . SecondlAlthough the severity of punishment has been devalued compared to the certainty of punishment, it acts as a significant catalyst that stimulates the whole deterrence process. Roche et al.  revealedUnder the terrain of restrictive deterrence, drug offenders are no less apprehensive about the severity of punishment than its certainty. This could be due to the strategy of severity mitigation, which influences the extent of using the strategy of certainty reduction. To illustrate, a marijuana seller is less concerned about the timing and location of sales than a heroin dealer. A drug dealer with 0.01 grams of heroin on their person is less likely to care if they dress or behave in a way that will attract the attention of the police than a dealer with 100 grams of heroin. Theoretically, this echoes the aforementioned idea that the perception of the severity of punishment sets an anchor for that of certainty Nagin, . AnotherIt is worth noting that the severity of punishment is primarily examined in quantitative studies and certainty of punishment is usually discussed in qualitative studies. These two observations may reveal the difference in design between qualitative and quantitative studies. Qualitative studies, using mainly semi-structured interviews, usually design interviews with a relatively broad range of questions and do not strictly separate the severity of punishment from the certainty of punishment. In conjunction with what has been mentioned earlier that the certainty of punishment has a higher profile in deterrence research overall, it is easy to attribute the role, effect, or importance of severity of punishment to the certainty of punishment when interpreting drug offenders' responses to punishment. In contrast, quantitative research can clearly separate the two elements through questionnaire design and examine and demonstrate the role of severity of punishment while controlling for the role of certainty of punishment. The severity of punishment can also be explored interactively with other variables, which facilitates the identification of the role of severity of punishment in a given population or a given situation and tap into its once-overlooked position. Therefore, the qualitative study tends to examine the role of certainty of punishment, while the quantitative study is better equipped to uncover the role of severity of punishment.The second key conclusion from this review is that the perception of risk is not only an inhibitor in using restrictive deterrence strategies, but also a facilitation of strategy differentiation. First, we found that due to the psychology of self-serving bias, drug offenders with less perception of risk implement restrictive deterrence strategies with confidence. This is consistent with the literature on the perceptual risk, which states that the lower the perception of risk, the more significant the crime (e.g., Pratt et al., The final conclusion of this review is that the formation of crime skill relies on a combination of the slow internalization of self-reflection and the rapid input of collective wisdom. Self-reflection leads to nuanced adjustments of restrictive deterrence strategies. At the same time, collective wisdom accelerates the progress of skill learning because it reduces the individual's cost of trial and error. Perhaps because of the two different contributions to the speed and magnitude of crime skill learning, crime skill formed through self-reflection is not considered a learning process and is thus classified as an intuition. This echoes the findings of offenders' Bayesian learning based on personal experience. Bayesian learning is a way in which individuals incorporate newly learned information to update subjective prior beliefs. Anwar and Loughran  found thWhile the reviewed research revealed fruitful restrictive deterrence strategies and their potential prerequisites, it still leaves room to explore uncharted topics that can promote our understanding of the issues. First, restrictive deterrence strategies were mainly discussed in the pre-arrest context, and future research could further explore strategies used during and after arrest. Before the arrest, by the use of proactive situational control over the context, offenders can minimize their chances of being arrested. However, this much focuses on the context of pre-arrest, delivers an incorrect presumption that drug offenders do not respond to risk once they are arrested. An arrest does not equate with the final sentence, e.g., imprisonment. Punishment is a system of conditional probabilities: restrictive deterrence strategies before an arrest can influence the outcome of punishment, and restrictive deterrence strategies after an arrest can achieve this effect as well. Between arrest and the final sentence, a series of judicial proceedings can affect the outcome, such as prosecution, conviction, and the dismissal of charges. As the “Cooperating with police” section of the current review shows, drug offenders beg or cooperate with the police to mitigate the expected severity of punishment. It is an evidence of the restrictive deterrence strategy adopted during and after arrested. Similar restrictive deterrence strategy has also been found in the study of other offenders. Sex worker, for example, might be very polite and compliant with police during arrest in the hope that they would be charged with a less severe crime (Dewey and Germain, Second, determining the facilitative effect of the perception of risk on the innovation of restrictive deterrence strategies is an area for future research. While much of the broader deterrence literature has quantified the role of the perception of risk in curbing crime or an individual's intention to commit a crime (e.g., Pratt et al., Another future research line for exploration is to look into the impact of collective wisdom on crime skill learning and strategy use. The influence of collective wisdom on offenders' crime skills is more significant than individual reflection regarding speed and quantity. However, the effectiveness of collective wisdom highly depends on the offender's closeness to other offenders or crime organizations. It is noted that the connection to criminal groups is beneficial for drug offenders to obtain advanced and effective strategies (Ekland-Olson et al., Interpretation of our results should be tempered by several limitations. First, although the literature search was comprehensive, only a small number of studies could be included compared to previous literature reviews focusing on deterrence or drug criminality (e.g., Pratt et al., The original contributions presented in the study are included in the article/XG organized the database and wrote the first draft of the manuscript. TWL contributed to reviewing and editing the manuscript. Both authors contributed to manuscript revision, read, and approved the submitted version.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.


Herniated cervical intervertebral disc  with radiculopathy is known to occur in seven or eight out of 100 people worldwide. This disease causes movement limitation, loss of strength, and pain of upper extremity. The aim of this study is the effect of conventional physiotherapy agents on predetermined parameters in patients with cervical radiculopathy and to compare the results with healthy controls.A total of 102 patients with CDH with radiculopathy and 98 healthy controls were included in the study. Visual reaction time (VRT) and auditory reaction time (ART) measurements were evaluated with reaction timer, while the pain was assessed with visual analog scale (VAS) and handgrip strength (HGS) assessed with hand dynamometer, respectively. Conventional physiotherapy  agents were applied 5 days/week for 3 weeks as treatment protocol.As a result, VAS, VRT, and ART scores were significantly decreased, and HGS scores increased significantly in both female and male patients post-treatment measures (p<0.05). There was no statistically significant difference between patient group and control group measurements in post-treatment evaluations (p>0.05).This study presents the conclusion to literature that conventional physiotherapy agents have the effect of decreasing pain and regaining motor function and also a therapeutic effect on VRT and ART in the treatment of patients with CDH with radiculopathy. Chronic pain is an emotional, effective, and undesired situation which negatively influences daily life activities and quality of life. In chronic pain grading, neck aches come the second after backaches. One out of three people in the general population complains about neck pain that develops due to various reasons in some part of their lives. One of the most common reasons for neck pain is cervical disc herniation (CDH) . It was found that evidence about the effect of conventional physiotherapy agents, which are found to have positive effects on pain, motor performance, functional attainments, and daily life activities in literature frequently used in clinics, on VRT and ART in patients with CDH with radiculopathy, were very insufficient.When situations such as pain paresthesia resulting from cervical radiculopathy disappear, the individual can show his/her real performance. In this study, the pain that appeared to be reduced on post-treatment evaluations probably led to the emergence of the muscle strength of the individuals. This situation was reflected in post-treatment results as a significant increase in HGS scores. It is thought that radiculopathy with disc hernia can also influence reaction time due to its adverse effects on individuals’ muscle strength and motor performance . HGS is In their study, Egwu et al.  stated tReaction time is also influenced by pain. In terms of analyzing the effectiveness of conventional physiotherapy agents on the musculoskeletal system, the improvement in reaction time can be an important indicator . In thisWhile the association between chronic backache and the lower extremity reaction time is one of the studied subjects in the literature, the number of studies on the association between CDH patients and VRT, ART, pain, and muscle strength is very limited , 26. In These results support that despite innovative treatment alternatives, conventional physiotherapy agents continue to be used frequently and they are effective methods that should be preferred in the treatment of patients of CDH with radiculopathy in terms of causing a decrease in the pain which has a negative influence on the patients’ daily life activities, regaining motoric function and improving reaction time.Difficulty of patients coming to attend 3-week physiotherapy sessions due to their living conditions limited the work and created limitation. Although the fact that this study is the first in this area creates a limitation for the discussion section, it will form the basis of new studies in this area.


Multiple sclerosis is a neuroinflammatory and neurodegenerative disease causing several psychosocial problems that significantly impairs quality of life. The most common physical and mental symptoms are anxiety, depression, stress, fatigue, and pain. Several studies investigated the effectiveness of non-pharmacological approaches in improving psychological well-being. This review focused on the impact of mindfulness interventions in patients with multiple sclerosis to reduce psychopathological symptoms and improve well-being. We searched on PubMed database and screening references of included studies and review articles for additional citations. From initial 107 studies, only 8 met search criteria. Our studies showed the efficacy of mindfulness treatment with a reduction in depressive symptoms, a better quality of life , and a decreased level of fatigue. Findings demonstrated that mindfulness is useful for the improvement of psychological symptoms and pain management and this improvement has also been shown to have a positive impact on the quality of life and coping and adaptation strategies. However, according to the poor available clinics evidence, on cannot conclude that mindfulness interventions are superior to other active interventions in the treatment of psychological symptoms of SM. Multiple sclerosis (MS) is a neuroinflammatory and neurodegenerative disease characterized by an unpredictable development that can be relapsing or progressive. Its estimated incidence is over 2.5 million people worldwide, classifying it as a major cause of non-traumatic disability in young adults in many countries .People with MS have several psychosocial problems because of the disease that significantly impair their quality of life .The most common physical and mental symptoms are anxiety, depression, stress, fatigue, and pain. The study by Nauta et al.  shows thFor this reason, many studies in recent years have focused on approaches that can improve psychological well-being .Several studies have shown, for example, that psychopharmacological treatments using selective serotonin, although effective in treating depression, have several side effects and a high dropout level , 12. On Mindfulness interventions have been shown to be useful for the improvement of psychological symptoms and pain management . This imMindfulness is a technique that involves awareness-oriented meditation with attention to the present moment. This involves the recognition of thoughts, emotions, and sensory experiences, using a non-judgmental attitude of openness and receptivity . During the last 10 years, a strong interest has developed in the empirical investigation of the application of mindfulness  as a possibility to deal with various psychological and physical disorders , 18. ThiThis descriptive review focused on literature studies that investigated the impact of mindfulness interventions in patients with MS on reduce psychopathological symptoms and improve well-being.The studies have been selected from the PubMed database   and “Multiple Sclerosis” (All Fields).The research terms were identified in the title and abstract, and only studies published in English were considered.After examining the selected studies by removing those that differed from the criteria, we selected due to the characteristics of the methodologies used, the articles were evaluated according to the title, the abstract, and the research methodologies used.The selection of studies was related to the study design, participants, interventions, and outcomes.Studies already completed at the time of the research;Sample composed of patients with MS;Studies that assessed the psychological well-being of patients;Studies which deepen mindfulness-based intervention;Case studies were excluded.Specifically, studies were selected according to the following criteria:Only 8 studies met the inclusion criteria. The number of subjects involved in the research was 416 MS patients .All patients included in the different research designs were affected by MS and followed by several outpatient clinics in Italy and abroad. Participation in the study was on a voluntary basis and assignment to the experimental or random control group. None of the participants had a history of psychiatric disorders. The samples were made up of subjects belonging to different sexes distributed randomly, except for one study that focused on a sample of women only . The selThe aims and results for each study are summarized in Table Anxiety, depression, psychological distress, and fatigue are common comorbidity  among people with MS, with estimation prevalence variable and largely dependent on the variable measurement tool used in the different studies . These sIn the study by Simpson et al. , the perOther authors have more specifically investigated the effect of mindfulness on psychiatric symptoms in MS patients.Blankespoor et al.  used a mThe results obtained by this research group suggested that following the mindfulness sessions, patients experienced a reduction in depressive symptoms, a better quality of life , and a lower level of fatigue than before starting the sessions. They also showed that after the sessions, the patients were more tolerant with themselves and able not to identify with negative thoughts and emotions all the time. Mindfulness, indeed, was effective in improving the way we observe and describe emotional experiences by learning to control reactions to them.Also Crescentini et al. evaluated the influence of mindfulness on depressive symptoms and personality profiles, taking into account interventions oriented towards awareness on character scales  and on personality traits . The authors found increased awareness and decreased anxiety-depressive symptoms after the meditation training were observed. In line with this study was the results showed by Carletto et al.  that useRachel et al.  using miConscious yoga program and mindfulness were used in the study by Nejati et al.  to evaluOnly one study  assessedMS is a chronic autoimmune demyelinating disorder that affects the central nervous system and damages the myelin sheaths around the nerves, causing inflammation, loss of myelin, and axonal destruction. Clinical manifestations in MS vary according to the area of the central nervous system affected by demyelination and include sensorimotor, cerebellar, psychiatric, and cognitive alterations. Understanding the influence of these symptoms in a patient’s quality of life and their multifactorial nature seems to be fundamental to the development of new psychosocial interventions.Mindfulness is a process that helps to develop a mental awareness oriented to the present of one’s feelings or body states , and it The studies reviewed suggested that mindfulness improves psychiatric symptoms regardless of severity, even when these symptoms are associated with other medical conditions. An only study focused on MS pain showing a strong and significant association between mindfulness and lower levels of pain interference.It is possible that the effect of mindfulness on reduce SM symptoms is due to better stress management, since the patients begin to relate differently to their physical symptoms and are better prepared to cope with them. Howells et al.  have, inA small number of works were included in this review since only six studies met the inclusion criteria. A meta-analysis was unable to be performed because quantitative information was not reported in the included studies.In addition, excepting for Simpson et al.  and CarlAll studies, indeed, were based on self-report; therefore, the negative mood of the person with MS may have affected their responses and their perception of well-being after the interventions. Only Carletto et al.  involvedMindfulness allows to intervene in a complete way on the person, focusing both on the physical and mental aspect, promoting a better knowledge of their body. Therefore, through a path of greater awareness seems to be possible to effectively manage symptoms of anxiety-depressive or physical fatigue. Mindfulness is well known to have positive effects on mental health among different clinical populations; however, recommendations cannot be made based on current evidence due to limited research and inadequate methodological rigor of published literature –37. The From a clinical standpoint, according to the poor available evidence, we cannot conclude that mindfulness interventions are superior to other active interventions in ameliorating all the considered outcomes, suggesting a role as complementation and not as replacement of the treatment of psychological symptoms in SM.


Against the background of the growing burden associated with diabetes mellitus, the German Federal Ministry of Health commissioned the Robert Koch Institute to develop a national diabetes surveillance. The periodic publication of up-to-date data needed by diverse target audiences (dissemination) to develop subsequent public health measures is a crucial aspect of disease surveillance. The study produced an overview of diabetes surveillance in various countries with the intention of developing a dissemination strategy. This involved a two-stage process beginning with an online survey of public health experts from 46 countries. Structured Internet research was then carried out for countries that did not provide a response (19 out of 46). The majority of countries  include diabetes in their health reporting; three quarters  of these countries rely on an indicator-based reporting system. The study found that the most common formats used to publish information about diabetes and other noncommunicable diseases were topic-specific reports  and national health reports , followed by online formats such as websites or databases . Moreover, health reporting primarily targets politicians  as well as the media and the press . The study found that both printed and online publications form part of a comprehensive dissemination strategy, however address different audiences. The burden associated with diabetes mellitus and other noncommunicable diseases (NCDs) is steadily increasing in Germany as it is throughout the world , 2. In 2Public health surveillance is defined as the continuous, systematic collection, analysis and interpretation of health-related data that is needed for the implementation of public health measures aimed at protecting and promoting the health of the population (‘data for action’) . This deIn order for health reporting data to be used in this manner, target audiences must be provided with up-to-date information (dissemination). In public health sciences, as in other fields, a gap exists between the production of new knowledge and its translation into practice and policy . This unThe WHO identifies four target audiences as part of its Global Monitoring Framework for the surveillance of non-communicable diseases: (1) healthcare providers, (2) policy makers, (3) service providers, and (4) the general population . In addiIn addition to building on the experience gained by other public health institutes, best practice examples from other countries are to be used as a model to develop a dissemination strategy for diabetes surveillance at the RKI. An international workshop was held in this context at the RKI in June 2018 that also involved the presentation of innovative formats . FurtherThe study used a two-step approach to collect data about national health reporting of diabetes and noncommunicable diseases . The firAn international comparison of noncommunicable disease reporting: the case of diabetes mellitusData owner: Robert Koch InstituteAim: To develop an overview of the strategy, content, formats and target audiences of the health reporting of noncommunicable diseases conducted in OECD and EU countries.Geographical focus: 46 OECD or EU member states, as well as other selected European countriesStudy design: Two-stage process► Online survey of public health experts► Structured Internet research into countries that did not participate in the online surveyParticipants:► Experts from 27 countries participated in the study► Structured Internet research was carried out for 19 countriesStudy period: April to September 2018The survey was limited to OECD and EU member states and other selected European countries; 46 countries were included in the study .The online survey of public health experts took place between April and July 2018. The survey used a questionnaire created with the Acuity4 survey software (version 5.5.1.205) from Voxco®. In order to recruit suitable participants, the RKI’s network was used to contact EU and OECD public health institutes as well as those from other European countries. The aim was to ensure that people with expertise in diabetes and health reporting participated in the study. In cases where it was impossible to find someone suitable to answer the questionnaire, a request to participate in the survey was sent to health ministries and national statistical offices. Other institutions were only contacted if they had been named by a member of one of these institutions.The online survey comprised 39 questions and was divided into two subject areas . On the Between August and September 2018, structured Internet research was conducted into countries that had not supplied any data by the end of the online survey period (July 2018). The analysis focused on the country’s framework, indicators, and the formats used for diabetes and NCD-specific health reporting. The Internet research was carried out in the following manner: first, a search was conducted of the websites of the respective national public health institutes, health ministries and statistical offices for keywords linked to diabetes and noncommunicable diseases. The Google search engine was then used to search for a combination of terms. In each case, the search term consisted of either diabetes, noncommunicable disease or NCD, alongside surveillance, monitoring, strategy, report, health reporting or indicators. Lastly, the respective country name (in English) was added to the search term. The study then examined the first 30 search results. Public health institutes, ministries of health or statistical institutes do not always provide relevant information in English, German or French. In these cases, their websites were translated into English using Google Translate and the resulting translations were searched for the keywords mentioned above.The research was limited to the framework  and formats  used by the country for health reporting. Furthermore, only reports and formats published in or after 2000 were included in the study. Unfortunately, it was impossible to identify the reports’ target audiences as the websites that published them provided no relevant information about this issue.Of the 46 countries included in the overall study, 27 (59%) participated in the online survey . The majThe first part of the study focused on the framework employed for diabetes health reporting and the indicators used to depict developments in the course of the disease. In total, four out of five countries include diabetes mellitus in their national health reporting . Of thesThe evaluation of the indicators determined by the study led to the identification of 142 different indicators or indicator clusters that are used in diabetes surveillance. These were divided into the following six areas: epidemiology, disease burden, complications and comorbidities, risk factors, quality of care, and public health measures. The 15 most common indicators are shown in In addition to questions about the framework governing diabetes surveillance, the study focused on the formats used and the intended audience of diabetes-specific health reporting. The study found that different formats were being used to deliver the results . These cReports, flyers, websites and online databases are generally made available in a country’s own language. In about half of the cases , they are also available in English. However, English is an official language in seven of these countries. Most formats  are published or updated regularly. The majority of reports, websites and databases are updated once a year  or within two to five years .The public health experts were also asked about the target audiences that diabetes-specific health reporting was seeking to address . Almost Different formats are used to address different audiences and, as such, they were evaluated with respect to their intended audience . HoweverThis results in a clear picture: whereas political decision-makers are particularly targeted by interdisciplinary and topic-specific health reports, online formats, flyers and fact sheets are mainly used to address the general population. The media and the press, as the second most commonly mentioned target audiences, are addressed via both more traditional printed publications and more modern online formats.The study also sought to select examples of best practices from the formats identified by the online survey and the Internet research . UltimatThe online survey of public health experts and the Internet research enabled a structured overview of diabetes-specific health reporting in the EU and OECD countries to be developed. The majority of countries under study include diabetes mellitus in their national health reporting and have established indicators for disease surveillance. Health reports that were either printed or typeset and published online were the most commonly used formats. Online formats such as websites and databases are used in more than half of the countries under study, some of which also provide innovative visualisation tools. All of the countries principally targeted policy makers, followed by the media and press, individuals and institutions involved in public health research, and the general population.The literature provides very little information that could offer an overview of the surveillance systems used to collect data on noncommunicable diseases in various countries. However, as part of its action plan for the prevention and control of NCDs, the WHO regularly reports on the progress that each member state is making towards reaching the action plan’s objectives, and also publishes relevant documents . The proSocial inequality and diabetes mellitus and secondary data in diabetes surveillance.Although the WHO Framework  recommenAt the same time, the literature also provides very few recommendations or reviews of the formats and communication channels that are used for health reporting in the context of diabetes and other NCDs. As part of its framework, the WHO recommends the publication of fact sheets and data books (comprehensive volumes containing tables) that are entirely focused on the data  and thatThe study found that traditional printed reports are the most common publications used to provide information from disease surveillance. However, websites and online databases also offer a variety of options for data visualisation and are already being used by some countries to present the results from the surveillance of noncommunicable diseases. These tools are already being used to a greater extent in the surveillance of infectious diseases . For exaThe online survey found that diabetes reporting primarily seeks to address policymakers and health-care decision-makers, followed by the media and press. The WHO also identifies policymakers and health-care decision-makers as two of its four target audiences for information from NCD surveillance in addition to service providers and the general population . The litThe two-step approach and the use of two different methods to collect data on diabetes-specific health reporting means the study faces a number of limitations. As some countries did not participate in the online survey, the only information and documents available in these cases were those that were found on the Internet. These were available in English, German or French or via Google Translate. Moreover, as data about target audiences are not freely available and can only be supplied by public health experts, the Internet research was unable to provide information about the intended target audiences in these cases. Similarly, as no information was available about the people who were actually using the respective formats, it was impossible to judge whether the intended audiences were actually being reached. Furthermore, the study was limited to publications by state institutions and ministries; publications by non-governmental organisations, such as patient associations or professional associations, were not included in the analyses. Equally, the study’s focus on national health reporting meant that regional reports or other regional formats were not considered. Finally, it is unclear whether the results of the study can be applied to all noncommunicable diseases, as diabetes receives greater attention than other diseases.Public health surveillance systems provide the data required to make health policy decisions and to establish public health policies. The growing complexity caused by the increasing number of data sources and findings from scientific research means that information needs to be provided transparently and understandably. In addition to more traditional formats, such as reports, new tools for visualisation and interactive databases can enable data to be depicted in a manner that is understandable and which facilitates access to different target audiences.Health reports about NCDs primarily address politicians and health policy decision-makers. However, these individuals can be reached in different ways. In addition to reports, established communication tools and social media also provide appropriate communication channels that can raise the priority and awareness of specific public health challenges. Discussions and symposia also constitute an important aspect of dissemination strategies.The study’s findings are to be used to develop a dissemination strategy for diabetes surveillance at the RKI. Diabetes surveillance particularly targets politicians and decision-makers in the healthcare sector. In line with the results of this study, a diabetes report is to be drawn up for this target audience. In addition, information is also to be provided to the general public and the media with the aim of raising awareness about the growing challenges posed by noncommunicable diseases. In order to address these audiences, a website is to be developed to provide visual representation of the results of diabetes surveillance; social media, such as Twitter and YouTube, are also to be used more regularly. The examples of best practices, which were collected during the survey and Internet research, will provide an important basis for the further development of these formats.83% of countries include diabetes in their national health reporting.77% of countries use an indicator-based surveillance system for health reporting on diabetes.Topic-specific and general health reports (67%) are the most commonly used formats to publish information about diabetes.56% of countries use websites or online databases to provide information about diabetes.The study’s participants maintained that policy and decision-makers in the healthcare sector were the most important target audiences of diabetes health reporting.


Persons with chronic pain experience a lack of support after completing rehabilitation and the responsibility for the return-to-work (RTW) process is taken over by the employer. In addition, employers describe not knowing how to support their employees. Smartphone apps have been increasingly used for self-management, but there is a lack of available eHealth apps with evidence-based content providing digital support for persons with chronic pain and their employers when they return to work.This study aims to describe the development of a digital support application with evidence-based content that includes a biopsychosocial perspective on chronic pain for sustainable RTW for persons with chronic pain and their employers .A user-centered agile design approach was applied. The multidisciplinary project team consisted of health care researchers, a user representative, and a software team. A total of 2 reference groups of 7 persons with chronic pain and 4 employers participated in the development process and usability testing. Mixed methods were used for data collection. The design was revised using feedback from the reference groups. The content of SWEPPE was developed based on existing evidence and input from the reference groups.The reference groups identified the following as important characteristics to include in SWEPPE: keeping users motivated, tracking health status and work situation, and following progress. SWEPPE was developed as a smartphone app for the persons with chronic pain and as a web application for their employers. SWEPPE consists of six modules: the action plan, daily self-rating, self-monitoring graphs, the coach, the library, and shared information with the employer. The employers found the following functions in SWEPPE to be the most useful: employees’ goals related to RTW, barriers to RTW, support wanted from the employer, and the ability to follow employees’ progress. The persons with chronic pain found the following functions in SWEPPE to be the most useful: setting a goal related to RTW, identifying barriers and strategies, and self-monitoring. Usability testing revealed that SWEPPE was safe, useful , logical, and easy to use with an appealing interface.This study reports the development of a digital support application for persons with chronic pain and their employers. SWEPPE fulfilled the need of support after an interdisciplinary pain rehabilitation program with useful functions such as setting a goal related to RTW, identification of barriers and strategies for RTW, self-monitoring, and sharing information between the employee and the employer. The user-centered agile design approach contributed to creating SWEPPE as a relevant and easy-to-use eHealth intervention. Further studies are needed to examine the effectiveness of SWEPPE in a clinical setting. Chronic musculoskeletal pain, which affects 10% to 20% of the European population and negatively impacts functioning, quality of life, and the ability to work, comes with significant individual and societal expenses, including costs associated with sick leave and loss of productivity . A recenDigital support (web-based applications or smartphone apps) is a growing intervention for persons with chronic pain and a useful tool for quality of learning -16. The Digital applications can be valuable tools for persons with chronic pain, especially when used in an outclinic setting , and canWeb-based support for RTW has shown to be successful and cost-effective for persons with musculoskeletal disorders . HoweverIn this study, a user-centered agile design  was usedThe multidisciplinary project team consisted of health care researchers, a user representative, and a software team .The development process was led by a senior researcher (MB) with extensive experience with RTW, chronic pain, and occupational therapy. Two reference groups representing the end users—patients with chronic pain and their employers—were recruited for the development process. The initial product discovery phase consisted of exploring the users’ needs and wishes about the functions and contents of SWEPPE. The second product creation phase involved design, development, and usability testing of SWEPPE. Mixed methods were applied to collect quantitative and qualitative data for early input and feedback from the users throughout the process.The Swedish Ethical Review Board approved the study (Dnr 2020-01593).Participants in the reference groups were recruited using a relevance sampling strategy  conducteThe mean time since participation in IPRP was 10  months. Of the 7 participants, 1 (14%) had experienced a large degree of support during RTW after IPRP, and 6 (86%) had experienced some support from different stakeholders . A total of 10 employers who previously had been involved in an RTW process for an employee with chronic pain at the rehabilitation clinic were invited to the study in a similar way as the persons with chronic pain. Of these 10 employers, 3 (30%) were not possible to reach and 3 (30%) declined participation in the study owing to lack of time. Finally, of the 10 employers invited, the 4 (40%)—3 men and 1 woman—who agreed to participate in the study were from private and public areas of the labor market .Practices such as workshop and usability testing were applied during the different phases of the development of SWEPPE . The refusing SWEPPE and being back at work) were developed based on previous research and clinical expertise with persons with chronic pain and other stakeholders. The user personas and scenarios were used in a workshop where 2 health care researchers and the software team verbally and visually presented information about different types of users [User personas and two scenarios  to 10 (very important). The proposed functions were based on aspects identified as strengths in previous research, such as setting a goal related to RTW -44, the During the web-based usability test with the persons with chronic pain (P1), data were collected in several steps. First, notes were taken by the first author (CT) and 2 or 3 members of the project team during the think-aloud process regarding what the person said and did when performing the assignments in the SWEPPE prototype. If the test persons were silent, they were prompted by the test leader with questions such as “What are you thinking right now?” Second, at the end of each usability test, the participants were asked open-ended questions regarding the overall impression of SWEPPE: positive or negative functions and content of SWEPPE, what was missing or could be improved, how they would describe SWEPPE to a colleague or friend, and their opinion on how the SWEPPE prototype would be helpful in RTW. Third, after the usability tests, the participants were asked to fill out the System Usability Scale (SUS) questionnaire ,47 for tAfter usability tests P2 and E1, both reference groups received the SUS questionnaire and follow-up questions regarding the functions in SWEPPE. The participants were asked to rate the perceived usefulness of different parts of SWEPPE as a support on a scale ranging from 0 (no support) to 100 (maximum support). They were also given the opportunity to comment on the functions and content of SWEPPE—for example, what was missing or could be improved and how they would describe SWEPPE to a colleague or friend.Quantitative data from the surveys and the SUS questionnaire were summarized and analyzed using descriptive statistics. The qualitative data gathered in the empathy maps were summarized and grouped based on topics, questions, and needs to address in the development of SWEPPE.The notes collected during the think-aloud methodology and data from the open questions in the first usability test with the reference group of persons with chronic pain were analyzed using Instant data analysis . InstantThe workshop with the project group generated topics, questions, or needs considered during the development process of SWEPPE .Results from the questionnaire about the desired content and functions of SWEPPE showed that maintaining motivation and following progress were of great importance for both reference groups  and 5.For the persons with chronic pain, the opportunity to keep track of their health status and work situation was also important. Employers wanted information about their responsibility and suggestions for adapting the work situation. Both reference groups preferred getting feedback through graphs showing changes over time. Persons with chronic pain wanted to use SWEPPE on their smartphone, and most 4/7, 57%) reported wanting to use SWEPPE daily. The employers had a diverse view of how often they would use SWEPPE. An employer wanted to use SWEPPE when needed, another weekly, and another monthly. Most of the persons with chronic pain preferred recording pain  and sleep  daily and physical activity , balanced life situation , and work situation  weekly. The opinion among the persons with chronic pain about push notifications was mixed: push notifications were rated as an important function  and 5, b7% reportThe initial development of SWEPPE, based on the first survey of persons with chronic pain, focused on three aspects: (1) the action plan, where the users assess their work ability, set a goal related to RTW, identify barriers to RTW, develop strategies to handle barriers, and identify support wanted from the employer; (2) self-rating, where the users register daily health status and work situation; and (3) self-monitoring graphs, where the users follow their progress and receive feedback to keep them motivated.These 3 aspects were developed and tested along with the overall design  in the first usability test (P1). The participants in usability test P1 were in general positive to the prototype and experienced it as relevant, quick, and easy to use. They stressed the importance of SWEPPE not demanding too much of them cognitively. They described SWEPPE as a tool to help them stay motivated and learn more about themselves and their pain. The task performance rate was high .Some usability problems were identified using the think-aloud methodology and were addressed in the continued development process .The process of setting a goal related to RTW and creating the action plan was simplified, and questions for assessment of goal fulfillment were added: further improvements of self-rating of health aspects were made with addition and development of items, and separate graphs for self-monitoring of health aspects and goals were developed. Continuous adjustments and refinements of the functions based on the usability test P1 were made, and further parts of SWEPPE  were developed.The version of SWEPPE evaluated in usability tests E1 and P2 consisted of a fully functioning web application for the employers and a smartphone app for the persons with chronic pain. The employers perceived receiving information about the employee’s goal related to RTW, barriers for RTW, support wanted from the employer, and the graph to follow the employee’s progress as the most useful functions in SWEPPE . The perThe final version of SWEPPE consisted of all the modules presented in This study describes the development of SWEPPE, a digital support application for sustainable RTW for persons with chronic pain and their employers. SWEPPE was developed with a UCD agile approach , where tSWEPPE was developed by a multidisciplinary project team using a combination of the 5 principles of UCD agile design . First, This study shows that SWEPPE has the potential to be a valuable tool for supporting the individual in self-management of chronic pain during the RTW process. Web-based applications or smartphone apps can be easily accessed and enable persons with chronic pain manage their condition  and reduPain education is also a common part of self-management and can be related to the neuroscience of pain, medication, stress, depression, and sleep management . In SWEPRegarding the dynamics of the employee-employer relationship, the participants in both reference groups were in general positive to the function of sharing information in SWEPPE to facilitate collaboration and communication between the employee and the employer. SWEPPE was built to be al tool for providing the employer with information but without the employee having to educate the employer regarding chronic pain and its consequences for work. Instead, by using SWEPPE, the employee can invite the employer and give access to the library and decide what information to share from their action plan. If the employer is willing to engage in the process and use the provided information, this could increase the employer’s ability to support the employee. The issue of employees not wanting or daring to share information with their employer was raised by some of the persons with chronic pain during usability testing. An important feature of SWEPPE was to make the employee in charge of what information to share, when and with whom to avoid the employer from using the app for control or pressure. In this study, usability tests P2 and E1 revealed the persons with chronic pain perceived the function sharing information as slightly less useful compared with the employers and compared with other functions in SWEPPE. This was due to the participating persons with chronic pain having come too far in their RTW process and commented on this function as being more useful earlier in the process. This stresses the importance of getting the user’s context correct in the development of digital solutions . TherefoThere are some limitations of this study that need to be considered. SWEPPE was developed in Sweden, where the employers are prescribed by law to take actions to adapt the workplace to the individual’s capacity and thereby enable the employee to RTW or stay at work. However, the rights and responsibilities of employees and employers vary among countries, and the usefulness of an app such as SWEPPE may depend on the societal system.The number of persons in the reference group of persons with chronic pain was small and might not be representative of the whole population of persons with chronic pain. However, the participants are representative of the targeted users of SWEPPE . The persons with chronic pain participating in this study had come further in their RTW process than the intended users of SWEPPE. This was regarded as a strength of the study, as the participants had the experience and possibility to reflect on their needs during the RTW process and could acknowledge that SWEPPE had been useful for them earlier in the RTW process. As a result, there were lower ratings of some of the functions , as these were not needed in the participants’ present situation. There were also few employers participating in this study, and recruitment of employers to the reference group was more difficult, as they were experiencing a lot of time pressure. However, having employers involved in the development of SWEPPE was crucial and is a strength of this study, as they play an important role in the RTW process . OverallAnother strength of this study was having a user representative as part of the multidisciplinary project team, as the experience-based knowledge provided by a research partner complemented the professional knowledge . The useA strength of this study is also the use of both qualitative and quantitative methods for evaluation and feedback during the development process , which gUsability testing requires advanced planning and involves several decisions such as selecting the setting, the tasks the user should perform, and the type of data to be collected. In this study, 3 persons with chronic pain participated in the initial usability test (P1) of the low-fidelity prototype. This may have been too few to identify all possible usability issues. It has been suggested that 5 participants are sufficient for usability testing and finding 80% of the usability problems . Still, The results of the development of SWEPPE are positive and highly usable because of the UCD agile approach. However, to investigate its effectiveness, SWEPPE needs to be tested in a clinical setting, initially in a pilot study and then in a randomized clinical trial.This study reports the development of a digital support application for persons with chronic pain and their employers. SWEPPE fulfilled the need of support after IPRP with useful functions such as setting a goal related to RTW, identifying barriers and strategies for RTW, self-monitoring, and sharing information between employee and employer. The UCD agile design approach contributed to creating SWEPPE as a relevant and easy-to-use eHealth intervention. Further studies are needed to examine the effectiveness of SWEPPE in a clinical setting.