Planning to transition from the Minimum Initial Service Package for Sexual and Reproductive Health (SRH) toward comprehensive SRH services has been a challenge in humanitarian settings. To bridge this gap, a workshop toolkit for SRH coordinators was designed to support effective planning. This article aims to describe the toolkit design, piloting, and final product.Anchored in the Health System Building Blocks Framework of the World Health Organization, the design entailed two complementary and participatory strategies. First, a collaborative design phase with iterative feedback loops involved global partners with extensive operational experience in the initial toolkit conception. The second phase engaged stakeholders from three major humanitarian crises to participate in pilot workshops to contextualize, evaluate, validate, and improve the toolkit using qualitative interviews and end-of-workshop evaluations. The aim of this two-phase design process was to finalize a planning toolkit that can be utilized in and adapted to diverse humanitarian contexts, and efficiently and effectively meet its objectives. Pilots occurred in the Democratic Republic of Congo for the Kasai region crisis, Bangladesh for the Rohingya humanitarian response in Cox’s Bazar, and Yemen for selected Governorates.Results suggest that the toolkit enabled facilitators to foster a systematic, participatory, interactive, and inclusive planning process among participants over a two-day workshop. The approach was reportedly effective and time-efficient in producing a joint work plan. The main planning priorities cutting across settings included improving comprehensive SRH services in general, healthcare workforce strengthening, such as midwifery capacity development, increasing community mobilization and engagement, focusing on adolescent SRH, and enhancing maternal and newborn health services in terms of quality, coverage, and referral pathways. Recommendations for improvement included a dedicated and adequately anticipated pre-workshop preparation to gather relevant data, encouraging participants to undertake preliminary study to equalize knowledge to partake fully in the workshop, and enlisting participants from marginalized and underserved populations.Collaborative design and piloting efforts resulted in a workshop toolkit that could support a systematic and efficient identification of priority activities and services related to comprehensive SRH. Such priorities could help meet the SRH needs of communities emerging from acute humanitarian situations while strengthening the overall health system. The implementation of comprehensive SRH services follows the planning process and falls outside of the MISP. Here, integration – the terminology used in the MISP guidance – refers to the inclusion of comprehensive SRH services into a package of primary healthcare services rather than integrating services, such as integrating postpartum family planning with child immunization programs. The MISP also notes the importance of ensuring that safe abortion care is available to the full extent of the law, as another priority.The Minimum Initial Service Package (MISP) for Sexual and Reproductive Health (SRH) is a priority set of life-saving interventions to be implemented at the onset of every humanitarian crisis . The firPlanning for comprehensive SRH should occur as soon as possible and in close coordination with the health sector or cluster partners at the national or subnational level according to the humanitarian and country contexts. Strengthening the six health system building blocks as defined by the World Health Organization (WHO) offers a useful planning framework to inform the inclusion of comprehensive SRH services into a primary healthcare package and reinforcement of other comprehensive SRH services at the higher levels of care . These bSince the conception of the MISP in the mid-1990s, progress has been made in scaling up SRH services in crisis-affected settings . For exathe clinical services of the MISP should be sustained, improved in quality, and expanded upon with other comprehensive SRH services and programming throughout protracted crises and the recovery and reconstruction phases  for re-activating reproductive health services through their support. — Participant in Yemen.By following the step-by-step approach outlined in the toolkit, facilitators enabled participants to produce a work plan at the end of each of the pilot workshops, suggesting that the toolkit was effective in reaching its primary objective. Additionally, results in Yemen suggested that the workshop contributed to raising the importance of SRH, which was perceived to be neglected among decision-makers and health managers and overshadowed by other sectors.In addition to improving comprehensive SRH services in general, the main recurrent themes in work plans were strengthening the healthcare workforce, which was common to all countries ; increasing community mobilization and engagement as well as focusing on adolescent SRH in the Kasai region and Cox’s Bazar; ensuring a sustainable supply chain in the Kasai region and the all three Yemeni Governorates; and expanding maternal and newborn health services in Cox’s Bazar and all three Yemeni Governorates, with an emphasis on quality, coverage, and referral pathways. Priorities specifically highlighted in the Kasai region included renovating health centers, strengthening the health information system, advocating to the government to harmonize the fees for SRH services, and advocating to donors for additional funding. Priorities specifically reported in Cox’s Bazar were expanding the availability of contraceptive services, enhancing demand for and supply of gender-based violence services, and improving the quality of neonatal health services. The capacity development of midwives was a specific concern in Yemen.The methodology was great. It helped us define the priorities we need and how to divide the activities among the six WHO building blocks...It ensured everyone’s participation in planning. – Participant in Yemen.I would like to say that this methodology is more simplified, practical, and participatory in the sense that it was not a colossal and very complex methodology. Everyone had the opportunity to participate in the exchanges. The added value in this workshop is that we started on reliable bases that reflect the real needs in the field … It was the record time that made the biggest impression on me. What impressed me the most was the time that was allotted folks. The whole team came together to identify needs and opportunities in record time. That’s what emergency coordination is all about: responding quickly. You don’t have to take a lot of time while there is an [urgent] need. – Participants in DR Congo.Participants across settings appeared to welcome the methodology and its efficiency in producing results. Participants reported the methodology to be practical and simple and underscored the relevance of using the framework of the WHO Health System Building Blocks. Participants appreciated that a two-day workshop could produce specific and achievable planning priorities within a short time. Most participants across settings found that the workshop duration was adequate; none found it too long. In Sana’a, simultaneous translation added pressure on the available time, and participants felt that the workshop could be longer.Participants found all the successive steps to be useful and complementary. Nonetheless, they proposed concrete changes to enhance the methodology , rebuilding and restoring destroyed and looted health facilities in the Kasai region, and enhancing human resources for health .The emphasis on common themes, such as strengthening the overall provision of comprehensive SRH services, capacity development of the health workforce, community mobilization, adolescent SRH, and maternal and newborn health services is somehow unsurprising, albeit critical. Trained, motivated, and retained staff form an essential building block of the health system as they enable access to a wide range of information and services . For insThe MISP objectives focus mostly on the supply side of health services, which must complement activities that generate demand, such as community mobilization and involvement . AlthougOther priorities, such as family planning or gender-based violence, were subsumed under the overall plan to enhance a comprehensive SRH service package or specifically underscored, or both. For instance, the highlight in Cox’s Bazar’s plan to increase awareness on gender-based violence and the quality of related services reflected the high needs in this context .The collective work plans for comprehensive SRH that participants developed at the end of the workshops are multipurpose. They could help strengthen the implementation of comprehensive SRH information and services and focus attention on key problem areas. If used to feed into an advocacy and resource-mobilization strategy, they could garner support and funding for programs that feed into the overall reproductive, maternal, newborn, child, and adolescent health program.Initial planning for comprehensive SRH should start at the onset of the acute response, and the participatory process proposed in this toolkit should begin as soon as the MISP clinical services are available and accessible and progress towards reaching Objectives 1 to 5 and other priorities of the MISP are underway. This participatory process could also take place when agencies begin longer-term planning with new funding cycles and in preparation for humanitarian appeal processes. The integration of comprehensive SRH services into these mechanisms could contribute to avoiding service delays and ensuring their sustainability.Operations research is needed to examine, whenever possible, the implementation of the toolkit in a real-time transition from an acute response toward recovery and health system strengthening. Researching the implementation of the toolkit in protracted situations is equally important. In both cases, the question remains whether and how a work plan with priority activities developed in a participatory manner would translate into the concrete implementation of these priorities and contribute to health system strengthening efforts.The bigger question will be whether and how each of the settings will implement the prioritized activities in terms of advocacy, identification of sustainable resources, and eventually expanded access to quality services that the community will utilize. The toolkit preempted the possible challenge of seeing the work plans remaining without follow-up and implementation by participating stakeholders. Therefore, it included an important step: a post-workshop follow-up process that participants would conduct to ensure that plans are followed through and challenges addressed—seed funding, even if limited as it was the case in the three countries, could help with the initial operationalization of identified priorities. This review and synthesis of the workshop pilots are limited to the toolkit. However, the IAWG community needs to continue learning about the follow-up to the workshops in DR Congo, Bangladesh, and Yemen. For example, who in the three countries led their operationalization? What was the process undertaken? How useful was the process in advancing the implementation of the work plans? How did it strengthen the health system? What were the challenges, breakthroughs, and recommendations to improve the continuum from planning to implementation?Several factors may have contributed to the success of this toolkit, including the framing by the WHO Health System Building Blocks, which directly focused participants on interventions that could strengthen the health system. However, it is the participatory nature of the two-pronged design process that likely made the toolkit relevant to local specificities and global needs in terms of developing capacity for comprehensive SRH planning. However, do interventions based on participatory design work in healthcare?The multiphase participation-centered design of the toolkit was likely a critical component in producing anticipated results with efficiency. Our findings contribute to the current evidence, as illustrated by a synthesis of the effect of community-based participation in various settings . The synThe pilots were a product of strong international and national partnerships based on valued and respected collaboration. This multi-level support and investment in the initiative likely contributed to the success in the design and implementation of the workshop toolkit. Moreover, the partners involved in this project had both overlapping and differing objectives and delivery timelines. The funding and programmatic synergies through their partnerships allowed better use of funding with consequently more seed funding for actual program implementation and building buy-in for this effort.To adhere to different timelines and opportunities, the planning for the pre-workshop preparation and workshop implementation was felt to be limited. The time constraints could have compromised the thorough mapping of the situation in preparation of the workshop, as well as limited the members of priority communities whom the planning process could have engaged—resulting planning priorities could have been different. However, local participating stakeholders came from organizations responsible for direct service and implementation and had a sound knowledge of their settings and awareness of the needs of their community, which could have minimized the risk of producing a work plan of less relevance. Further, in humanitarian contexts, actors must be nimble and responsive to varying limitations and opportunities. The rollout of the workshops was reflective of this reality and still shown to be effective in meeting its objectives.Future rollouts of the toolkit need to consider the high staff turnover in crisis-affected contexts and factor it into the planning process and strategy for work plan implementation. For example, participants in the workshops in DR Congo and Bangladesh who participated in the planning transitioned out of the response by the time the work plan implementation began. For this reason, it is recommended that there be a clear and consistent sharing of information and knowledge about the planned transition towards comprehensive SRH programming and to ensure work plans move forward and responsibility and accountability are shared.The facilitators of the workshop were those who conducted structured discussions with the participants in Kinshasa and Sana’a. Therefore, social desirability could have been a potential source of bias in the qualitative inputs. Further, there were no structured discussions in Cox’s Bazaar and Aden. However, results from the qualitative interviews appeared to converge overall with those from the written end-of-workshop evaluation, which took place in all settings.Finally, it would be naive to believe that thanks to this toolkit, the planning for comprehensive SRH will be straightforward, including the implementation of the planned activities. The relief-to-development continuum is complex and often non-linear, with Yemen and the COVID-19 pandemic providing humbling and eye-opening examples. Technical solutions, including this toolkit, even those embracing participatory principles in design and implementation, will often not work unless major determinants could find roots in the settings . Such deAlmost 25 years after the creation of the IAWG and conception of the MISP, the IAWG Training Partnership Initiative, in collaboration with the WHO Global Health Cluster, has developed and equipped the global SRH community with the first toolkit to support the implementation of Objective 6 of the MISP, as well as training resources on its use. The collaborative efforts in designing the toolkit with combined bottom-up and global contributions will hopefully render the planning process for comprehensive SRH more systematic and efficient. Consequently, affected communities emerging from acute humanitarian situations or living in protracted settings could have sustained access to quality comprehensive SRH information and services that meet their needs.


Participation of children and adolescents in extracurricular sports activities seems to be associated with their immediate environment. It is therefore essential to emphasize the importance of establishing physical activity habits from an early age in family and school environments.Extracurricular physical activity in children and adolescents can help achieve compliance with the World Health Organization (WHO) recommendations for physical activity. The purpose of this study was to evaluate factors in school and family environments of children and adolescents in Spain that could be related to the practice of extracurricular physical activity. Multistage random cluster sampling was conducted to include 128 schools with the participation of 10,096 students between the ages of 7 and 16. Participants completed the survey of sports habits designed by the National Sports Council. The results revealed a higher participation in extracurricular sports activities among boys (OR: 1.67 (1.5–1.9)) and students in primary education (up to 12 years old) (OR: 1.8 (1.7–2.0)). Likewise, a statistically significant relationship ( Extracurricular activities are very common among children and adolescents. Those related to physical activity can improve health outcomes ,2 and heThe latest report on Spanish children and adolescents  shows thParticipation in extracurricular sports activities has been evaluated as a possible protective factor for overweight among children . In SpaiAdherence to physical activity has been inversely related to factors such as age, female sex, perceived effort, and overweight; however, it is necessary to note that we cannot isolate these aspects from socioeconomic and physical contexts of children as well as genetic aspects, which also condition the practice of physical activity . The SpaTherefore, this study aimed to investigate the extracurricular activities of children and adolescents and to determine the multiple components of school and family environments that may be related to the practice of extracurricular physical activity.This study was carried out in Castilla-La Mancha, a region in central Spain comprising five provinces. Multistage random cluster sampling was carried out and adjusted by province. The first units were the educational centers, where the online version of the questionnaire was administered to all students in the randomly assigned class.The sample was made up of a total of 10,096 schoolchildren, aged between 7 and 16 years old, of whom a total of 5003 were boys and 5093 girls (representing 50.4% girls and 49.6% boys). The study comprised students from public, private, and subsidized schools, equaling a total of 128 participating schools distributed among the different provinces as follows: Toledo (2251 students), Ciudad Real (2704 students), Albacete (2427 students), Cuenca (1460 students), and Guadalajara (1254 students).Participating schools were recruited by sending invitation letters detailing the purpose of the study. A total of 128 schools agreed to participate and were sent an explanatory letter with instructions for the study procedure.The questionnaire used was the one of Sports Habits promoted by the National Sports Council in Spain in 2011.The questionnaire gathered the following information: sociodemographic variables  and information on the extracurricular activities they carried out as well as their parents’ physical activity practice . In addition, they were also asked about their academic performance, their activity during recess, their screen time, their means of transport to school, and their self-perceived health.The variables featured on the questionnaire were dichotomized as Yes/No responses except for the number of hours of screen time  and academic performance .p < 0.005.The SPSS 23.0  statistical package was used. A descriptive statistical analysis of the variables was performed with the absolute and relative frequency distribution. A bivariate analysis was performed for the different factors related to the practice of extracurricular physical activity using the Pearson’s Chi-square test. Gross odds ratios (OR) were estimated with a 95% confidence interval (95% CI) related to the practice of extracurricular physical activity and educational level. The significance level was set at The sample comprised a total of 10,096 students, between the ages of 7 and 16 years old. The students belonged to public, private, and subsidized schools in the Autonomous Community of Castilla-La Mancha, with a total of 128 schools participating in the study.p = 0.054)), where boys showed more after-school physical activity than girls. The greatest increase in physical activity was observed around the age of 9–11 years where nearly 80% of boys practiced sport, dropping to just over 50% at 15–16 years; in the case of girls, the highest percentage of sports practice was at 11 years of age with 65.8% versus 41% at 16 years of age.The practice of extracurricular sports was analyzed in association with gender both on a global level and by age . StatistSubsequently, the performance of extracurricular physical activity was analyzed by the two educational levels studied: primary education (from 7 to 12 years old) and secondary education (from 12 to 16 years old). Finally, the factors associated with both the school and the family environments in terms of extracurricular physical activity were studied at both educational levels. Statistically significant differences were found in almost all variables analyzed, both in primary  and secoWhen analyzing the relationship between the type of transportation to and from the school and the practice of extracurricular sports, no significant differences were found, i.e., no relationship was found between active transport to school  and the practice of sports. This null relationship was verified in terms of both the age of the student and the gender.For the remaining variables, statistically significant relationships were obtained. Thus, relationships were observed with gender, age, types of activity during recess periods, sport practiced by the family environment , hours of screen time, school performance, and perceived health status. Being a boy and having a physically active family member  was a statistically significant situation among those enrolled in extracurricular sports. Additionally, being active during recess periods, doing other non-sports extracurricular activities, and spending less than two hours a day screen time were significantly associated with being enrolled in extracurricular sports. Positive associations were also seen in perceived higher academic performance in students who were enrolled in extracurricular sports when compared to their peers; inverse associations were also observed when students considered themselves as not being academically behind their peers.The analyses were carried out distinguishing by gender, and no changes were observed in the results obtained.The students who most practiced extracurricular sports activities were males aged between 10–11 years who were also active during recess time. They were living in a family environment where other members also practiced sports, spending less time daily using computers and watching television, with a higher academic performance than their peers, and who considered they were in a better state of health.This study aimed to evaluate the extracurricular activities of primary and secondary school students and to analyze school and family factors that could be associated with participation in extracurricular physical activities in a sample of 10,096 schoolchildren from Castilla-La Mancha, Spain.Our findings revealed that the practice of extracurricular physical activity among Spanish students in the region of Castilla-La Mancha was related to the practice of sports activities by their parents, good academic performance, participation in other non-sports extracurricular activities, more active recess time, and less screen time. Furthermore, relationships were found in relation to age and gender, with the practice of extracurricular sports activities being more common in male children around the age of 10.In this study, we proposed an analysis of extracurricular sports activities according to three main topics; first, the analysis by the two educational levels; second, the analysis by factors related to family environment; and finally, the analyses of factors that could be related to the school environment.Regarding the first topic, results showed a greater dedication to extracurricular activities at primary education level than at the secondary level. Previous studies have shown a decrease in physical activity levels from childhood to adolescence ,8,16; hoThis study highlights the positive correlation of a supportive family environment on the practice of extracurricular sports. Thus, we analyzed whether the father, the mother, or the sibling(s) practiced sports as well as their screen time. Numerous studies have analyzed the influence of the family environment on the activities carried out by children during childhood and adolescence ,20,21, rIn regard to screen time, considering the study sample participants’ ages, it is up to the parents and therefore the family environment to determine how permissive they are in terms of the number of hours that the children watch television or use a computer, tablet, or video game console. Regarding the time dedicated to screens , in this study, we observed, especially at the secondary education level, that students who carried out extracurricular physical activity spent less screen time than the ones who did not. The number of screen time hours has been positively related to body mass index (BMI) and adiposity ,23; likeOther extracurricular activities were also included in the topic dedicated to the family environment, since, as minors, it is the parents who have to sign up and consent (or not) to their children attending to these activities. The benefits of sports practice on academic performance has been demonstrated previously , raisingFinally, we evaluated the effect of certain elements of the school environment on extracurricular physical activity participation. Commuting to school was considered as well as activity time during breaks and perceived academic performance. No statistically significant differences were observed between participating in extracurricular sports activities and active commuting to school. It appears that the factor most strongly associated with active commuting to school is the distance from home to the educational center,  althoughAs for recess time, we asked whether students performed any kind of sport or exercise during these periods or whether they mostly spent their time sitting down and talking to their classmates. Relationships between active recess time and extracurricular sport activity participation were observed in primary school, however, many of the secondary school students did not answer this question, and therefore no clear relationship could be established between this parameter in secondary school students. In a review by Ridgers  of physiConcerning academic performance, students were asked whether their academic results were superior, inferior, or the same as those of their classmates. Both direct and inverse associations were obtained. Thus, students who played extracurricular sports reported to perform better academically than those who did not. This is in line with previous studies where they have associated sports participation with a beneficial effect on academic performance .Finally, we asked about self-perceived health status, which was greater among those who practiced extracurricular sports. The benefits of physical exercise on health are unquestionable , and stuThe Spanish regions manage the promotion of school sport in a very different way. In the region of Castilla-La Mancha, teachers receive bonuses for the promotion of sport, thus results may differ from other regions in our country .The type of study carried out does not enable the establishment of causal relationships. Thus, solely associations can be observed, although one would expect school and family environments to condition the students’ habits and not vice versa.This study has a number of limitations. First, the effect of experimental mortality, as some questions were not answered, and more detailed statistical analyses could not be carried out. On the other hand, it would have been interesting to assess the number of hours dedicated to each of the extracurricular activities and to verify whether the results are maintained or whether different effects are observed because of an excess of hours. These data would help us understand the number of hours that is considered most healthy and whether these correspond with the amount of time spent on physical activity recommended by the World Health Organization.It would be interesting to carry out a study that can also research causal relations. In future research, it would be also interesting to analyze active commuting to school and associated factors.In conclusion, the practice of extracurricular sports activities was positively associated with having family members who practiced sports on a regular basis, less use of screens, a perceived high academic performance, and an active recess time. A greater amount of extracurricular sports practice was observed in boys and in primary education. Conversely, no relationship was found in relation to active commuting to school.The pattern of associations found provides a guide for future efforts towards encouraging greater participation to extracurricular activities that may have an impact on the biopsychosocial health of children and adolescents.These data, analyzed using a cross-sectional design, show that participation in extracurricular physical activities is favored when the child/adolescent has proactive physical and social environments in both the close family and school. For this reason, it is necessary to develop policies aimed at educating parents that emphasize the importance of helping to establish physical activity habits from an early age. In addition, schools should encourage active recess time and recreation opportunities, especially for girls.


Background: Mental health research output in the Arab region is increasing, yet little is known about its recent landscape. This study provides a bibliometric analysis of mental health research in all 22 Arab countries over the past decade.Method: We used 760 journals and numerous keywords to search for articles published between 2009 and 2018 by individuals affiliated with institutions located in the Arab region. We analyzed data within Arab countries and between Arab and non-Arab countries.Results: We found that research output in the Arab world has increased by almost 160% in the past ten years, in comparison to 57% for the rest of the world. The quality of publications has also steadily improved, and so did international collaboration. Despite the progress, the number of articles per capita remains remarkably lower for the Arab world compared to the rest of the world. Also, the majority of articles continue to emanate from a limited number of countries  and institutions within these countries. Mental health research topics in the Arab region are similar to those found in low- and middle-income countries of Africa, Asia, Latin America, and the Caribbean.Conclusion: The region needs to invest more in mental health research to close the gap with other medical and healthcare research areas and with the rest of the world. The region also needs to increase its international collaboration and research training to produce higher-quality studies, attract more funding, and publish more in top journals. As the region's population continues to face increasing trauma as a result of war and terrorism, among others, the field is afforded an opportunity to establish a major standing in the healthcare domain. Researchers are uniquely poised to use their body of research evidence to effectively help people reengage with their environments and return to daily life activities. Over the last decade, many Arab countries have witnessed wars, conflicts, and major social and geopolitical changes that have negatively influenced the mental health of their people , 2. As aHow many journal articles were published during this period in the Arab region and globally?Which countries and institutions in the region contributed substantially to this body of quantitative evidence?In which journals were the articles published?What are the impact and use of these journal articles as measured by citations?To what extent mental health researchers in the Arab region collaborate locally and internationally, and what is the impact of this collaboration as measured by citations?What are the research topics mostly published by local mental health researchers?What challenges do local researchers encounter in carrying out mental health research? What to do about these challenges?The Arab world consists of 22 countries, including Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen. From here on, we refer to these countries cumulatively as “Arab countries,” “Arab region,” and “Arab world.” Bibliometric analyses of mental health research in the Arab region are important for several reasons. First, when making funding allocations, agencies consider variables such as research impact, quality, and collaboration potential of academic institutions, which bibliometric analyses provide . Second,The results of this study can be useful in many specialties, including, but not limited to psychiatry, psychology, health sciences, sociology, anthropology, and cultural studies. In addition to helping researchers, clinicians, government officials, and decision-makers understand the overall intellectual structure of the mental health research field in the region, the insights offered by this study are instrumental in ensuring that guidelines, direction, or an action-oriented agenda for future research on mental health are accurately articulated. In the absence of a holistic and comprehensive view of the research field, outstanding issues can remain undetected. This study builds on research carried out by Jaalouk et al.  and Karawithin Arab countries . Then, we used the same methodology to compare data between Arab countries and the rest of the world for four key indicators .We conducted a comparative analysis of bibliometric indicators within Arab countries and between Arab and other countries. First, we extracted data on Arab countries alone and analyzed nine bibliometric indicators, which we used to describe trends We included articles written in any language, which met the following criteria:Country affiliation of authors: We included articles published by individuals affiliated with any of the 22 Arab countries.Time-period: We selected the period between 2009 and 2018 to examine recent trends. We conducted the searches on January 1, 2019.Types of documents: Unlike Jaalouk et al. and Karam and Itani who included all document types in their studies , we included only peer-reviewed journal and review articles, as these are the document types generally accepted as the main instruments for communicating research , 18. We https://www.scopus.com/), indexes more than 25,000 journals , sleep-wake disorders, somatoform disorders, substance-related disorders, and trauma and stressor-related disorders. This strategy uniquely identified about 17.5% of the final tally of articles used in this study.To be further inclusive, we additionally searched Scopus for articles that included in their To provide both a broad overview and a detailed analysis of mental health research in the Arab region, we considered the following indicators:Number of articles by country: This indicates the number of peer-reviewed articles produced by a country. We determined the country(ies) for a given article by examining the address(es) of the author(s) in that article. When authors of the same article were from different countries, we gave full credit for each country. We calculated this for Arab countries and other world countries, using the filter by “Country” option in Scopus.Number of articles relative to country population: To understand the output of a country relative to its population size, we divided the total number of articles produced by that country by the number of its inhabitants as reported by the United Nations (2018). We calculated this for all countries.Number of articles by institution: This refers to the number of peer-reviewed articles produced by an institution in the Arab region. We determined the institution(s) for a given article by referring to the institutional affiliation(s) of the author(s) as listed in that study. Again, we gave full credit for each listed institution.Number of articles by year: We assigned a given article to the year during which it was published in the journal. We calculated this for Arab countries individually and for remaining world countries as a whole.Research quality: We examined research quality by calculating the percentage of articles from the Arab region published in journals whose impact factor was ranked in the top quartile.Collaboration: This refers to the extent of scientific collaboration between an Arab country and other countries. We measured it as the number of articles credited to a given country/region with at least one other credited country/region, divided by the country's total number of articles.Research reach: This refers to the extent to which articles from the Arab region are published in international journal outlets, calculated as the number of articles published in non-Arab journals.Number of citations: This indicator is calculated as the number of times an article is cited, according to Scopus. This number serves as a preliminary indicator of the impact of research produced in the Arab region.Research themes: To identify the areas of greatest interest among mental health researchers in the Arab region, we used Elsevier's SciVal to examine all keywords and phrases used within all abstracts and titles of articles published in 2013–2018 .The data were exported and analyzed using Microsoft Excel and Access 2016. In the first set of analyses, we used frequency analysis and cross-tabulations to produce figures for all indicators and compared them across the 22 Arab countries. In the second set of analyses, we compared key indicators between Arab countries and other world countries. We also produced a social network analysis showing the patterns of collaboration within Arab countries and between Arab and non-Arab countries.Our search identified a total of 4,506 unique eligible peer-reviewed journal articles published by all 22 Arab countries in the past decade. Considering the 467,533 mental health articles published by non-Arab countries, the Arab region contributed to about 1% of mental health publications globally in 2009–2018. By cross-tabulating the number of articles with the year of publication, we found that the number increased from 279 articles in 2009 to 728 articles in 2018 across the 22 Arab countries. As seen in We examined research quality by calculating the percentage of articles from the Arab region published in journals whose impact factor was ranked in the top quartile. Unlike collaboration among institutions within the same country, which according to data collected here, remained relatively the same in the past 10 years , research collaboration between authors from the Arab region and other countries has increased significantly in the last 10 years. In 2009, the proportion of articles with international collaboration out of all articles published by Arab countries was at 29%, but this number steadily increased to 50% by 2018.M = 3.8) than articles published in collaboration with authors from European countries (M = 19.6) and the United States and Canada (M = 18.3).Interestingly, articles without international collaboration showed fewer citations on average , followed by the Saudi-based Neurosciences (278 articles), and the Egyptian Middle East Current Psychiatry (259 articles). If Scopus had more comprehensive literature coverage from the Arab world, there might have been more local journals featuring among the most popular outlets for publishing local research on mental health. These results highlight the need for both the establishment of national journals and for having these journals indexed in international databases. These steps will increase the visibility of the Arab countries' work and would most likely help improve the quality as well as the quantity of the published work.To understand the reach of Arab mental health research, we looked at the journal venues in which investigators in the Arab region have published their work and whether these venues were local or international . The thrA surrogate to important research themes are keywords and phrases that appear most frequently in the title and abstracts fields of examined articles. The frequencies show the popularity of the general term “mental health” as well as depression, schizophrenia, child development disorders, anxiety, Autism, Post-Traumatic Stress Disorder (PTSD), bipolar disorder, and Attention Deficit Hyperactivity Disorder (ADHD), among others, in regional literature  and institutions within these countries.The increase in mental health research output in the Arab region is clear. Although it is difficult to contrast our results with other bibliometric studies because of different methodologies, it is possible to draw some tentative comparisons. For instance, Jaalouk et al.  found thInterestingly, the increase in publications over the last decade is driven by some countries more than others. For example, according to data from Jaalouk et al. , the UniWhat seems to have changed significantly over the years is the landscape of journal outlets. Afifi  found thIt is interesting to compare results not only to previous data from the Arab region, but also to current global trends in mental health publications, and to Arab trends in comparable areas of research. In terms of productivity, the Arab region contributes only 1.2% of global mental health research, despite comprising almost 6% of the world's population. Compared to overall medical research in the region, mental health research is lagging. While we found that mental health research increased from 0.7% of global output in 2009 to 1.2% in 2018, El Rassi et al.  reportedmore local collaboration because there are many collaborators within their national boundaries (Finally, there are noted similarities between the Arab countries and non-Arab countries. Particularly, Arab countries, like many others, have become increasingly collaborative in research. For example, while international collaboration in general increased from 3 to 20% between 1980 and 2008 , collaboundaries . We may In terms of commonly researched topics, there is a continued interest in depression, and anxiety, consistent with earlier findings , and a pDevelopmental and Educational Psychology and Neuropsychology and Physiological Psychology, which may have included entries relevant to mental health. However, when designing the methodology of this study, we informally tested whether these categories would have added incremental value to the data, and we found that they yielded many false-positive articles that were not relevant to mental health. Another limitation of this study is that it included articles from journals covered in Scopus only. Many researchers in the Arab world publish their work in local or national journals not covered in Scopus. Future studies should consider covering such databases as Al-Manhal, Dar Almandumah, and Iraqi Academic Scientific Journals, which index hundreds of journals published in Arab countries.Unlike previous bibliometric studies on mental health in the Arab region, this is the only study that looked at indicators of collaboration and quality of research. Additionally, its comprehensive search strategy and use of MeSH headings captured additional articles published in multidisciplinary journals. One possible limitation of this study, however, may have been its selection of four out of 11 possible journal subject categories within the Scopus database. This selection excluded categories like In the past 50 years, mental health research in the Arab region has been steadily on the rise , 21. UnlThese issues are congruent with the implications of this study, which highlight the gap between the current research output and the documented need for mental health studies in the region. Researchers need to design better studies that are locally relevant yet also contribute to the international literature and therefore have higher chances of being funded and published in highly visible journals. At the level of institutional support and policy, Arab researchers would also benefit from additional funding that targets under-researched themes, and encourages cross-Arab collaboration. Technical support in the form of advanced research training, and copyediting in English, can also improve the chances of producing studies of publishable quality. Although the process may be more complex than stated, we hope that Arab mental health researchers would build on such initiatives to further develop their research portfolios in a way that is impactful locally, regionally, and internationally –28. As tThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.All authors contributed to the conception and design of the work as well as the acquisition, analysis and interpretation of the data. All authors also contributed to drafting the work and revising it critically for important intellectual content.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.


Diario Oficial da União  on February 6, 2019.1 This new policy, aimed at defining telemedicine as a way of providing medical services by means of technology, is much more aggressive than the previous one published in 2002, which limited the use of telemedicine to medical consultations made by telephone or internet, and implied the presence of a health professional at both ends of the communication channel. The current resolution expanded the concept of telemedicine in providing technological solutions for remote patient monitoring and treatment , and analysis of laboratory results. However, soon after its release, the new document caused an intense public debate on the theme dividing stakeholders for and against the incorporation of telemedicine into practice nationwide. The debate was so intense that the Federal Medical Council revoked the resolution, as published in the DOU on March 6, 2019.2The Federal Medical Council (CFM) has recently published a new resolution on telemedicine in Brazil. The 2227/2018 resolution, establishing the criteria for the use of telemedicine, was published in 3The revocation of the policy after intense societal debate indicates the significant challenges regarding the implementation of technology-enabled care in Brazil. Such debate should not be the end, but rather, the beginning of a social mobilization to reframe the use of connected technology in healthcare in the country. To tackle the barriers to the uptake of technology-enabled care in Brazil, one should better understand the stakeholder positions, and consider the political and cultural environment, the ethical and legal apparatus and the available technology infrastructure.A more comprehensive understanding of the contemporary scenario where technology-enabled care may fit into Brazilians’ needs is critical to suggest approaches that might lead to societal benefit while being acceptable by physicians and other stakeholders.This is an exploratory paper, aiming to provide a personal overview of potential barriers to the incorporation and dissemination of telemedicine in Brazil. It is also an objective to discuss potential approaches to overcome these barriers.From the political point of view, government initiatives concerning telemedicine have been led primarily by the Brazilian Ministry of Health and were designed to promote the use of telemedicine in the expansion and improvement of health services. The dimensions involved, however, are beyond the limits established by the Ministry of Health. An effective inter-ministerial action would be required to foster the economy (innovation and economic efficiency) and the social dimension  to leverage telemedicine towards the expansion and improvement of healthcare.4 and uncertainties that are commonly related to the introduction of a "new way of doing things". On the one hand, technology-enabled care may help overcome the obstacle of access posed by the distance  with expected gains with the information and communication technologies, i.e., by increasing access and reducing costs. However, the interdependence between telemedicine and health services organization in guiding new investments may cause a shift in the arena of power. These complexities and uncertainties pose a substantial barrier to the dissemination of the new technologies.Culture is another limiting factor in the dissemination of telemedicine from the perspective of institutions, physicians and other practitioners. From the need for adjusting to the new working process, to the challenging relationship between power structure and professional structure, the adoption of the latest technology may generate significant resistance. The resistance to change is strengthened by the risk aversion2 Telemedicine involves multidisciplinary players, encompassing health practitioners of diverse disciplines, information and communication technology experts, managers and policy makers. The adoption of this technology requires the redesigning of work processes in their multiple aspects that generate tensions and conflicts. Physicians, in general, are not trained to be part of a “real team" and tend to behave more like a chairperson, which can increase the tension among team members. Moreover, telemedicine changes the typical doctor-patient relationship, requiring a process of acceptance, by all, of the technological mediation. Beyond that, physicians believe that these technologies may constitute an unsafe medical practice, in part due to the infeasibility in performing a remote physical examination. Overcoming institutional and professional cultural barriers is an essential step in the process of telemedicine dissemination and consolidation. Finally, reimbursement is another issue; physicians feel they will be pressured to care for more patients, dedicating less time to each patient, with lower reimbursement rates.Likewise, telemedicine faces resistances from practitioners.5 Although it may be cheaper in financial terms, there are psychological costs associated with behavior changes: people irrationally overvalue benefits they currently possess relative to those they do not.6From the patient perspective, although telemedicine may add distinct value to their needs and cheaper access to healthcare, as a health consumer, they may fail to buy the "innovative product" because it may require them to change their behavior.status quo bias, and the endowment effect,6 associated with why the adoption of innovation fails5 may help propose specific solutions where telemedicine may be acceptable by providers and wanted by patients.7 Examples of approaches regarding telemedicine that might lead to societal benefit while being fair to physicians are described below:The understanding of the psychology of gains and loss, and more deeply, the concepts of loss aversion, B.1) To make behaviorally compatible products: the development and incorporation of mobile health sensors may offer a sense of safety that is missing to remote physicians. If one can rely on such type of device for feedback of a "remote” physical examination, physicians would feel more secure in guiding and discussing about a patient’s condition using technology mediation. This may minimize physicians’ resistance to telemedicine.B.2) Seek out the deprived individuals : telemedicine has the potential of solving significant current health challenges. In addition to the Brazilian territorial extension, there are thousands of isolated, difficult-to-access locations where healthcare services are extremely scarce, and physicians are lacking. Some physicians are mandated to serve in remote areas (military physicians). Fostering the development of the required infrastructure for the establishment of telemedicine in remote areas will open the doors for communities to have access not only to healthcare but also to other resources (like education). This will promote secondary gains as enhancing local and regional economic progress and may attract physicians and their families to places that otherwise would not be the first choice to live.B.3) Find believers : According to Ripton,8 millennial generation has been changing healthcare by forcing a greater emphasis on technology solutions for healthcare delivery. The development of technology-enabled solutions targeting this population may speed up and sustain the adoption of telemedicine not only in Brazil but also in other countries. The millennials’ demand will force physicians to adapt (and incorporate) to technology-enabled care, to be competitive in the market.B.4) Strive for 10x improvements5: telemedicine benefits should be so great that it would overcome physicians and patients’ overweighing of potential losses. Besides adding efficiency and reducing costs, telemedicine has the potential to expand the actions of health practitioners, integrating them into healthcare services and systems. Also, one can explore the potential savings and share them with practitioners in a new type of employment relationship and reimbursement model that may improve acceptance of telemedicine among physicians while promoting societal benefits.3 Even though a single instrument would hardly reach these goals, the fragmentation is one more hurdle to overcome to achieve the potential of telemedicine.Besides what has been discussed above, there is also a lack of synchronization between the vast potential of these technologies and the prevailing ethical and legal apparatus. Contrary to a comprehensive national policy, there is a general scenario of fragmentation, characterized by different norms and standards issued by various bodies and with distinct focuses.3 This means the infrastructure of the broadband data network is one of the most limiting factors to the expansion of telemedicine, particularly, in the countryside of Brazil.Also, mention should be made of the scarcity of resources and technical expertise, as well as infrastructure issues. Brazil has unequal geographic distribution concerning broadband availability.3 Therefore, even with the implementation of all technological infrastructure required for telemedicine, which is typically an interdisciplinary activity, it would not guarantee an improved and more expanded access to healthcare.Finally, it should be mentioned the precariousness of health services in Brazil, including primary care facilities, outpatient clinics, and even specialized hospital services. Scarce resources, management problems, lack of practitioners, inadequate compensation, outdated facilities, lack of equipment and consumables, among many other aspects, are repeatedly mentioned as the leading causes of such precariousness, witnessed by health professionals and users. This is even worse in remote and peripheral areas and is a significant barrier to the dissemination and consolidation of telemedicine in Brazil.The primary characteristic of telemedicine is its ability to make access to health services democratic. To accomplish that, legislative initiatives  that support and encourage the use of this technology, a regulatory apparatus, mobilization of a core group of companies, and development of scientific capability are required. From the healthcare perspective, telemedicine is capable of promoting higher integration of the healthcare system, overcoming the still existing and deleterious fragmentation that prevents the access to full healthcare rights. Investments in infrastructure are mandatory to widespread adoption of telemedicine. Beyond that, other challenges that limit its development are most related to the stakeholder’s conflicts, interdependence, and demands. In this regard, understanding some of the concepts related to behavioral economy and innovation uptake failure may increase or create opportunities and approaches where the use of technology-enabled care might lead to societal benefit while being acceptable to physicians and other stakeholders.


Substance use disorders pose a significant global social and economic burden. Although effective interventions exist, treatment coverage remains limited. The lack of an adequately trained workforce is one of the prominent reasons. Recent initiatives have been taken worldwide to improve training, but further efforts are required to build curricula that are internationally applicable. We believe that the training needs of professionals in the area have not yet been explored in sufficient detail. We propose that a peer-led survey to assess those needs, using a standardised structured tool, would help to overcome this deficiency. The findings from such a survey could be used to develop a core set of competencies which is sufficiently flexible in its implementation to address the specific needs of the wide range of professionals working in addiction medicine worldwide. A systematic analysis of the global burden of disease (1990–2016) concluded that 4.2% and 1.3% of all disability-adjusted life years (DALYs) were attributable to alcohol and drug use respectively.3 Such trends have been of increasing concern to public health services. Strengthening the workforce in the field of addiction medicine would contribute to addressing these challenges.Substance use and substance use disorders (SUDs) are major contributory factors to global morbidity and mortality. According to recent reports, 43% (2.3 billion) of the global adult population have consumed alcohol during past 12 months.4 In addition to cultural, political and legal impediments, stigma and a self-perceived lack of competence in handling SUDs have been cited as important factors that contribute to negative professional attitudes, such as having a low regard for persons with SUDs and a reluctance to work with them.Effective pharmacological and psychosocial strategies exist for treatment of SUDs. Although improving access to treatment requires multifaceted approaches at all levels of the system, increasing the size of an adequately trained workforce can potentially improve treatment outcomes. Despite SUDs being a common public health problem, there seems to be a reluctance among general practitioners, physicians and psychiatrists to treat and manage these conditions.5 There are several barriers to developing addiction training in the medical education curriculum. These include the limited availability of curricular time, poor interdepartmental coordination, insufficient faculty members qualified to teach addiction medicine and a lack of addiction treatment facilities that can be used as education sites for clinical experience.5A review of the organisation and effectiveness of addiction medicine training across the globe highlighted a lack of standardised training programmes at both graduate and postgraduate levels of medical education, with the exception of few psychiatry and family medicine courses.6 highlighted the deficiencies in training programmes on SUDs globally. Almost one-third of all countries surveyed reported that they had no training programmes for their workforce in the management of SUDs; that figure increased to 60% of low-income countries. Worldwide, the greatest availability of postgraduate training exists for psychiatrists (52% of countries) and other doctors (49%). The lowest availability of courses for those specialising in addiction medicine were for counsellors (23%) and community health workers (19%).The World Health Organization (WHO) ATLAS-SU survey on resources for the prevention and treatment of SUDs, conducted in 162 countries,7 Over the past decade, efforts have been made to create a specialist training pathway in the field of addiction medicine. Numerous training programmes have been initiated in high-income countries.8 For example, countries such as Canada, The Netherlands, the USA and Australia have initiated Fellowships in Addiction Medicine, and some  have extended these schemes to non-physicians. Most low- and middle-income countries do not have such fellowships and access to quality education at the undergraduate/medical school level remains a problem. It is beyond doubt that programmes aimed at increasing the number of professionals specialising in this field will improve the overall quality of care for SUDs, and the lack of such programmes in low-resource settings, which have a higher burden of SUDs and poorer access to treatment, remains a problem.The WHO, in laying out its global strategy on human resources for health, has emphasised the importance of building the capacity and capability of the workforce in order to achieve a range of sustainable development goals.ad libitum approach. Instead of having a well laid-out plan for training, the provision of care (and related training in the field) has often been provided on ad hoc basis and is often inadequate. Such programmes are usually short- term, focus on a narrow set of aims and are often planned with limited consideration of future training needs. In our opinion, an approach is required which is not as resource intensive as specialised training, but which targets professionals' needs by taking into account their views and providing clear goals and flexibility in implementation.Traditionally, training in SUDs in the majority of low- and middle-income countries has followed an 5 Five of these studies were from the USA. They evaluated faculty perceptions about existing services available for residents in addiction training. One German study assessed the services available for undergraduates. Only one study aimed to develop a curriculum in addiction medicine for healthcare professionals and explored training needs from their perspective. This study proposed a number of core competencies, including screening, assessment and diagnosis, management and treatment, and management and referral of medical comorbidities.9Although there is a substantial literature highlighting the deficiencies in training courses on SUDs for undergraduates and postgraduates, the format and content of professional training courses has not been fully characterised. In particular, there is little information available about the way in which low-income countries could fulfil the training needs of medical and other professionals. As a result, it is difficult to make recommendations on the basis of existing evidence. For example, a 2015 review of the organisation and effectiveness of addiction medicine training across the world could find only nine studies in the previous 15 years that provided information about training needs.10 Although relevant, these recommendations cannot be assumed to be representative of the competencies required in day-to-day practice. As members of the international Network of Early Career Professionals in Addiction Medicine (NECPAM), we call for a web-based survey to enable systematic assessment of the training needs of the professionals working in addiction medicine, at various educational levels and in a wide variety of countries. This proposed assessment will be peer-led, it will use structured, validated instruments to gather data and it will focus in particularly on early career professionals working in addiction medicine across many countries.In the absence of scientific evidence, recommendations have been made by international scholars that highlight a core set of competencies to be covered at undergraduate and postgraduate levels, as well in continued medical education.Professionals who manage SUDs include psychiatrists, specialist physicians, general practitioners, nurses, psychologists, social workers and counsellors. Each has a specific range of training needs. Furthermore, these health professionals are expected to provide different aspects of SUD service requirements. There are significant sociodemographic, cultural and political characteristics that influence the management of SUDs in different regions. As discussed, there are vast differences in the training in SUD management that is provided in different parts of the world, with specialist courses in some regions but a complete lack of basic health workers in all medical fields in others. The globally distributed training-needs survey would help highlight basic deficits in skills and knowledge. Those needs could subsequently be addressed by the development of a peer-led learning model that yields itself to being adapted for use in any region.11 Investing in early career professionals will serve as a timely replacement for an ageing workforce in addiction medicine.12Apart from focusing on training needs among a wide variety of professions, the emphasis of such a survey must also be on those professionals who are at an early career stage. These are the individuals who are likely to be the leaders and stakeholders in the field of addiction medicine in the future. Therefore, addressing the issues most pertinent to them will empower and enhance their capabilities.Worldwide, addiction medicine training programmes differ significantly in their content and duration . Because of such heterogeneity, the clinical skills that are taught by such programmes vary in quality and are usually insufficient. As early career professionals from different countries we feel that better training is required to handle SUD prevention and management. There should be an enhanced focus on the identification of the specific training needs of the early career health professionals engaged in providing SUD services.We are advocating that a core set of competencies be developed and that particular attention be paid to the views of those already working in the field. The recommendations should be sufficiently flexible in their implementation to be sensitive to a variety of specific needs, depending on the culture and characteristics of the country in which those professionals are working. There should be a structured set of objectives with appropriate flexibility in terms of their implementation. To achieve our goal, we suggest that professionals are asked about what they really need to know. As a starting point, we aim to assess the training needs of addiction professionals worldwide. We believe that combining these evidence-based findings on perceived training needs with a modified and flexible educational programme for healthcare workers would help to make existing programmes more relevant, effective and acceptable to treatment providers and patients alike.


In 2013, a change in copayment rate was introduced in the Basque Country (one year later than in the other regions in Spain), and improvements were made to drug packaging. In 2014, a National Program Against Bacterial Resistance (Spanish abbreviation: PRAN) was approved. The aim of this study is to analyze the impact of change to the copayment rate, the adjustment of drug packaging, and the approval of PRAN on the consumption of antibiotics. Raw monthly data on the consumption of antibiotics ) were collected from January 2009 to December 2018 in the Basque Country. Counterfactual and intervention analysis (Autoregressive integrated moving average (ARIMA) model) was performed for the total series, disaggregated by group of antibiotics  Classification) and active substances with the highest cost per prescription (cefditoren and moxifloxacin), the lowest cost per prescription (doxycycline and cloxacillin), and the most prescribed active ingredients . Introduction of copayment led to a ‘stockpiling effect’ one month before its implementation, equal to 8% in the three consumption series analyzed. Only the adjustment of drug packaging significantly reduced the number of packages dispensed (−12.19%). PRAN approval reduced consumption by 0.779 DID (−4.51%), representing a significant decrease for both ’access’ and ’watch’ group antibiotics. Despite the delay in implementing changes to copayment, there was a ‘stockpiling effect’. With the adjustment of packaging, fewer packs were prescribed but with a higher drug load and price. PRAN approval reduced both the consumption of ’access group antibiotics’ (first-line treatment) and ’watch group antibiotics’ (second-line treatment). The indiscriminate use of antibiotics accelerates the process of selection and dissemination of bacterial resistance, estimated by the Spanish Society of Infectious Diseases and Clinical Microbiology to lead to 26,000 deaths every year in Spain  and to cTo improve the public health deficit, worsened by the economic crisis of 2008, Royal Decree-Law (RDL) no. 16/2012 was introduced in Spain, containing urgent measures to guarantee the sustainability of the National Health System and the quality and safety of its services . PharmacThe RDL not only made pharmaceutical copayment income-based, but it also introduced regulations to adjust drug packaging to fit the actual duration of the treatment. During the process to approve new medicines, AEMPS, a state agency working as part of the Spanish Ministry of Health since 1999, also evaluates the format in which it is administered. For previously introduced drugs, adjustments were made to the number of units per package . With thTo reduce the risk of selection and spread of antibiotic resistance, in June 2014, the Inter-territorial Council of the National Health System approved PRAN . This prIn July 2013, an economic policy, based on changes in copayment rates, and a health policy, based on the adjustment of drug packaging, were applied in the Basque Country. A year later, an additional national program to monitor the consumption of antibiotics was also approved. This study focuses on the Regional Health Service of the Basque Country, following the recommendation by AEMPS to ensure the exploitation and analysis of data on antibiotics consumption at regional level . The objThe database containing all monthly antibiotic prescriptions (therapeutic group J01) in Primary Care from January 2009 to December 2018 in the Basque Country was available. The Basque Government Pharmacy Department provided the data, disaggregated by date of prescription (month and year), active ingredient administered , and patient data . The doses were given in defined daily doses (DDD). As indicated in the World Health Organization (WHO) methodology, this unit of measurement is subject to continuous variations in order to ensure its representativeness, as it seeks to indicate the maintenance dose in the main indication for a route of administration . DDDs arIt is important  to perfoAs time series were available, analysis was performed according to the Box-Jenkins methodology, frequently ,29 appliBox-Jenkins analysis was performed using different packages of R, a software environment for statistical computing and graphics, in order to: represent and break down the variables according to season; obtain the autocorrelation function (ACF) and partial autocorrelation function (PACF), select the best ARIMA model (Autoregressive integrated moving average) according to the Akaike information criterion (AIC), chosen for this study out of the others available (BIC or AICc); and make forecasts for various periods with a confidence level and verify with the Ljung-Box test whether the model adequately captured the information of the observed values and to check that there was no information in the residuals that could be used to make the predictions.To understand the impact of RDL no. 16/2012, counterfactual analysis was performed, which examined the first 53 observations, from January 2009 to May 2013 . The preThe analysis by active substance showed that, for ’watch’ group drugs, whether they were included in the regulations (azithromycin and levofloxacin) or not (cefditoren and moxifloxacin), there was no significant decrease in the number of packages prescribed. With regard to the active substance of the ’access’ group, on the other hand, the regulation had a significant effect in reducing the number of packages prescribed , amoxicillin and inhibitors (−0.193 DID) and azithromycin (−0.174 DID), with the latter belonging to the ’surveillance antibiotics‘ group . Despite this, antibiotic prescriptions are the closest proxy variable to actual consumption. Another limitation is the use of DDD, which is recommended to monitor consumption in adults, but it has also been applied to pediatric prescriptions as there are no exact values for this group. However, this study included pediatric use as the Basque Health Authority already had internal estimations and provided us with this information.As a conclusion of this study, it may be pointed out that, despite the delay in applying the copayment, the characteristic stockpiling effect of this type of policy follows the same trend as for the rest of the country. In addition, the adjustment of prescription formats reduced the number of packages, by 12.19%, but did not reduce the trend in either the dose or the expenditure. Finally, the approval of the PRAN effectively reduced the consumption of antibiotics, by 4.51%, not only for those indicated as first-line treatment but also for ’watch group antibiotics’.


E–mental health (EMH) offers various possibilities for mental health care delivery, with many studies demonstrating its clinical efficacy. However, the uptake of EMH technologies by mental health care professionals remains to be low. One of the reasons for this is the lack of knowledge and skills in using these technologies. Skill enhancement by means of serious gaming has been shown to be effective in other areas but has not yet been applied to the development of EMH skills of mental health care professionals.The aim of this paper is to describe a study protocol for the user requirements analysis for the design of a game-based training environment for mental health care professionals to enhance their skills in EMH.The user requirements are formulated using three complementary outputs: personas , scenarios (situations that require EMH skills), and prerequisites . We collected the data using a questionnaire, co-design sessions, and interviews. The questionnaire was used to determine mental health care professionals’ characteristics, attitudes, and skill levels regarding EMH and was distributed among mental health care professionals in the Netherlands. This led to a number of recognizable subuser groups as the basis for personas. Co-design sessions with mental health care professionals resulted in further specification of the personas and an identification of different user scenarios for the game-based training environment. Interviews with mental health care professionals helped to determine the preferences of mental health care professionals regarding training in EMH and the technical and organizational conditions required for the prospective game-based training environment to be used in practice. This combination of requirement elicitation methods allows for a good representation of the target population in terms of both a broad view of user needs (through the large N questionnaire) and an in-depth understanding of specific design requirements (through interviews and co-design).The questionnaire was filled by 432 respondents; three co-design sessions with mental health care professionals and 17 interviews were conducted. The data have been analyzed, and a full paper on the results is expected to be submitted in the first half of 2021.To develop an environment that can effectively support professionals’ EMH skill development, it is important to offer training possibilities that address the specific needs of mental health care professionals. The approach described in this protocol incorporates elements that enable the design of a playful training environment that is user driven and flexible and considers the technical and organizational prerequisites that influence its implementation in practice. It describes a protocol that is replicable and provides a methodology for user requirements analyses in other projects and health care areas.RR1-10.2196/18815 Technology can offer significant benefits to mental health care delivery. This includes lowering the threshold to seek help, the possibility of more time- and place-independent health care delivery, and the enhancement of patients’ autonomy -3. DespiGames are usually seen as a leisure activity in which the main aim is to entertain the user. Serious games are  games that are applied for purposes other than entertainment -20. TherTo address such a design challenge, the first step is to identify the user requirements that such an environment should meet. By addressing these needs, professionals are more likely to engage in and benefit from the game-based training possibilities that are offered . Having This study protocol describes research to define the user requirements for a serious game–based training environment for mental health care professionals to train their EMH skills. The user requirements analysis resulted in three complementary outputs: personas , scenarios (a detailed description of situations that require EMH skills), and prerequisites . This protocol describes the methods used to deliver these 3 outputs and can be used for similar projects in  health care by providing a detailed description of the procedures in a user requirements analysis.This study entails an explorative research design using quantitative and qualitative methods: a questionnaire, co-design sessions, and interviews. The multiple methods approach adopted here incorporates the use of two or more different methods in one study. Unlike a mixed methods design, it does not depend on the integration of data gathered from the different methods, rather provides space to a variety of methodological combinations -39. In tThe Inmates Are Running the Asylum, Alan Cooper [The use of both quantitative and qualitative methods for identifying user requirements is grounded in the literature about the development of personas within the context of interaction design ,41. In hn Cooper  introducn Cooper  used a mn Cooper . Howevern Cooper ,43. TherThe multiple methods design generates a specification of the requirements in terms of personas, scenarios, and technological and organizational prerequisites , which apersonas, designers try to understand the different types of users and what drives them, in order to truly empathize with them and connect to their needs in the design process [scenarios, designers are able to create story lines, related to the personas, for the content development of a game-based training environment [walks through [technical and organizational prerequisites that influence users’  intention to actually make use of a game-based training environment. This offers a more holistic perspective on the process by not only focusing on the end user but by also considering what is needed from other stakeholders, such as managers and Information and Communication Technology departments [By developing  process -48. Pers process ,48,49. I process ,47-51. Iironment ,53. Thes through . This enartments ,45. ThisTo ensure a good representation of the target user group for each data collection method, professionals from various disciplines that are involved in the direct care delivery process within mental health care were included in the research. The structure of mental health care professions that was officially acknowledged by the Dutch Health Care Authority was used to determine these disciplines, leading to the following clusters of professionals: medical professionals, psychotherapists, psychologists, nursing professionals, social workers, expressive therapists, and paramedical professionals in mental health care. Professionals working in mental health care that are not directly involved in client care  are not likely to use EMH and are therefore not included in this study. The research population that was approached represents the primary users of EMH and therefore the users of the anticipated training environment. This enhances the accessibility of the intended training environment for professionals from multiple disciplines within mental health care with a variety of skill levels and subsequent training needs. In the following sections, the recruitment strategy for each data collection method is specified.Respondents for the questionnaire were recruited directly at 5 large mental health care organizations in the Netherlands. Furthermore, respondents were recruited through web-based communication platforms of professional associations from different disciplines in mental health care specified earlier. Owing to the explorative nature of this questionnaire, we were not able to execute a statistical power analysis to define a sample size aim. According to Daniel , the samprofession to maximize the variation. This led to the inclusion of mental health care professionals from a broad range of mental health care disciplines in the sample  with various levels of adoption of EMH [To contribute to the description of users and ideas about a game-based training environment from multiple viewpoints, a co-design session was organized involving 9 participants, including mental health care professionals, EMH supporting staff, designers, and researchers. In recruiting participants for this first co-design session, maximum variation purposive sampling was applied using n of EMH  and subsn of EMH . AlthougThe interviewees were also selected using a maximum variation purposive sampling strategy and were also recruited at GGzE. We aimed to recruit between 15 and 20 interviewees to guarantee maximum variation in profession and level of adoption of EMH. The interviewees were approached through email. Upon written confirmation of their intended participation, an interview was scheduled. The interview started with a short explanation of the purpose and procedure of the interview and the interviewees were asked if they agreed to the recording of the interview. Upon confirmation, the interviewees were asked to fill in an informed consent form. After 17 interviews, we found that no new data were collected and that data saturation was reached.To determine mental health care professionals’ characteristics, attitude, use, and skill levels on different EMH tools, a questionnaire was developed that uses the current state of the art in EMH and relevant literature on EMH adoption, literacy, and skills ,12-14. Tdrawing a client journey. Following this, scoring cards were used on which participants could indicate in which situations EMH tools could be valuable. Finally, the participants were asked to use drawing and crafting materials to visualize their ideal game-based training environment. The 2 co-design sessions that were aimed at developing scenarios (December 2019) took place after analyzing the data from the questionnaire, interviews, and the first co-design session, which means that information about the potential users of the game-based training environment, or the persona, was available. In the 2 co-design sessions aimed at scenario development, further elaboration took place regarding story lines that could serve as a basis in a skill-developing game. The session was led by a facilitator, and participants were asked to brainstorm in small groups about different story lines in which a mental health care professional treats a fictional client. Afterward, the different results of the 3 groups were discussed and used by the design team to create 2 story lines. These 2 story lines were refined in a second co-design session in which mental health care practitioners were asked to reflect in detail on the stories that were drawn by the designers.In the first co-design session (March 2018), the aim was to generate a common understanding about mental health care professionals’ work context and detailed descriptions of the client trajectories that they encounter. Furthermore, the possibilities of applying EMH in this context and their need for knowledge and skill enhancement regarding EMH were identified and discussed. Participants were asked to jointly reflect on these insights and translate this in to ideas for a game-based training environment. This co-design session took 3 hours and demanded no preparation time for the participants. During the session, cards were used to reflect different possible treatment situations, to support participants in The interviews consisted of 2 parts. The first part of the interview was used to gather in-depth information about the specific needs and preferences of mental health care professionals regarding skill enhancement in EMH. This in-depth information was added to the questionnaire data by making more elaborate descriptions of the user groups resulting in personas. These detailed descriptions of the users of the envisioned game-based training environments enable designers to make choices that strongly align with the needs of mental health care professionals. The second part was aimed at identifying the technical and organizational prerequisites to use this environment. The interviews were semistructured to allow for exploring different views on what is needed to develop and implement the envisioned training environment. The topic list was based on the literature on technology acceptance  and gameOn the basis of the data gathered through the questionnaire, the users could be clustered into a number of subgroups based on shared characteristics that were found in the data. From the literature, we know that there are differences in the perceived drivers and barriers to using innovations . It is tThe co-design sessions were recorded using a video camera, microphone, and live note-taking. The recordings and observations were organized and analyzed using thematic coding . Thematiperceived ease of use  and affinity with computers . The analysis in different coding rounds was conducted by a junior researcher, after which the codes were checked by a senior researcher.The interviews were recorded (only with explicit permission from the respondent) and were transcribed verbatim. The transcripts were then coded using a thematic coding method and appropriate software for qualitative data analysis . This isThe data analysis resulted in 3 outputs: personas, scenarios, and prerequisites. These were used to describe the user requirements of the game-based training environment in the design documents. Personas were developed based on data from all 3 sources, scenarios were developed based on co-design sessions, and the prerequisites were based on data from the interviews.The research protocol was approved by the Ethical Review Board of Tilburg University in April 2018. At the time of writing this paper, the questionnaire was distributed, 432 people had responded, and the results were available for the design process. A co-design session was conducted to define specific contextual information (n=9) and 2 co-design sessions (n=10) were held to develop the scenarios. The interviews (n=17) were conducted, and the data were analyzed. We aim to report these findings elaborately in a scientific paper describing the results of the user requirements analysis in 2021. The unpublished results are currently used to inform the design process of a game-based training environment.Digital tools are currently underused in mental health care. This is because, in part, of a lack of knowledge, skills, and sense of self-efficacy of mental health care professionals when engaging with a wide variety of available EMH tools. To address this challenge, we are in the process of developing a game-based training environment that offers safe and engaging ways to explore digital tools and become more proficient at their use.This protocol describes the research and design methods and processes aimed at developing the requirements for such a game-based training environment. This study protocol contributes to an understanding of how user requirements analysis for a game-based training environment in mental health care can be carried out using synthesized expertise from social sciences, clinical practice, and design sciences. To establish this study protocol, researchers from these different disciplines are needed to closely interact to create common ground about the purpose and approach of the project. Knowledge about design thinking -29 yieldWhile a user requirements analysis in itself is more common in design research, in this protocol, it describes how to approach such an analysis in a health care area where such approaches are rather novel. This has led to a more specific approach that also reflects on the elaborate interactions between researchers in different areas. Although this protocol describes a user requirements analysis for mental health care, it may also be very useful in other projects in mental health care and in health care areas where similar research and design questions may be at hand.This protocol is particularly valuable because of its holistic approach, in which complementary outputs are proposed. In this multioutput approach, the development of personas and scenarios play an important role in describing users’ needs. More traditional ways of describing user needs are often too generic to fit a variety of potential users of a product . Personawhy of a product in an environment where design thinking is not commonly applied [Furthermore, this line of thinking can support multidisciplinary teams in understanding user needs early on in the design process ,29,31. A applied . Owing t applied -65. With applied -65 and aThe envisioned game-based training environment offers an approach that is simultaneously safe, challenging, and engaging. It particularly aims to enhance a number of relevant 21st-century skills that mental health care professionals increasingly need, in addition to their clinical skill set: media and technology literacy, web-based communication skills, flexibility, collaboration, and technology self-efficacy. To develop an environment that can lead to a significant improvement in professionals’ EMH skills, it is important to (1) address real-world issues that mental health care professionals experience and (2) offer training possibilities that address their specific  needs. The approach described in this protocol incorporates elements that enable the design of a product that satisfies these needs. It is user driven and flexible; at the same time, it considers contextual factors that influence its implementation in practice.