Most of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings.Healthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources.54 participants from 24 hospitals  were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking , and where it was present, it was perceived as a barrier . Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, one hospital in India provided the best example of interdisciplinary ASP, championed through organisational leadership.ASP initiatives in this study were restricted by professional boundaries and hierarchies, with lack of engagement with the wider healthcare workforce. There needs to be promotion of interdisciplinary team work including pharmacists and nurses, depending on the available healthcare workforce in different countries, in ASP. The surgical pathway remains a hard to reach, but critical target for ASP globally. There is a need to develop contextually driven ASP targeting the surgical pathway in different resource settings. Research in tackling antimicrobial resistance (AMR) and implementing antimicrobial stewardship is necessary from different cultures, economies and healthcare organisations. There are increasing calls for identifying global solutions to the threat of AMR ,2. It isASP interventions are designed, implemented and expected to be adopted with little insight on the culture and context in which they are to function sustainably. Culture is defined as the knowledge that people use to develop shared beliefs, practices and norms that distinguish one group of people from another, e.g., the culture across different specialties, organisations or countries can influence and shape behaviours and intervention outcomes. We repoPrior to selecting the countries in this study, a search of the grey literature was conducted to assess the state of the healthcare system in each of the countries. This search was undertaken to identify the existing stewardship programmes in each country, together with the key indicators in relation to antimicrobial resistance and ASP. This data helped provide contextual background knowledge for each country and helped the analysis of the qualitative data by providing background detail. We used the Centre for Disease Control (CDC) components for stewardship to assess the existing ASP activities in each country. The CDCThe study interview guide was piloted in England and in India (via telephone interviews before commencing the study). Data collection from the field was carried out in Norway (May 2015), France (December 2016), England (March 2017), Burkina Faso (June 2017), and India (April 2017). The duration of data collection in each country was two weeks. The key collaborators in each country were invited to participate in this study because of their existing work in ASP. Through snowballing and purposive sampling, the key collaborators in each country nominated healthcare professionals with roles in ASP. Individuals showing an interest were contacted by the collaborators and a mutually convenient time arranged for face-to-face interviews. Informed consent from participants was obtained prior to each interview. The key themes emerging during the interviews were investigated in more depth through further questioning during the interviews. Methodological triangulation was achieved through respondent validation and reflexivity. Data triangulation was achieved through collecting the data over different periods of time, from different persons, across different hospitals, teams, and specialties. This approach of combining data from different sources, and persons helped increase the validity and reliability of the data collected, and reduced observer bias.In Burkina Faso, AP conducted the interviews in the local language (French). The interview guide had been translated to French . The following ethical committees granted approval for this study: Comité d’Ethique de Recherche en Santé (CERS) du Burkina Faso (Burkina Faso); Imperial College Joint Research Office Ethical Board (England); Amrita Institute of Medical Sciences Ethics Committee in Ponekarra (PO), Kochi (India); Comité d’Evaluation de l’Ethique des projets de Recherche Biomédicale (CEERB) (France); The Data Protection Officer at Haukeland University Hospital, representing the Norwegian Data Protection Authority (Norway). Prior to interviews, verbal and written informed consent was obtained from all participants. The participants were emailed the study information sheet prior to the interview. On the day of the interview the interviewer verbally described the study to the participants. An informed consent sheet was signed by the participant prior to starting the interview.Familiarisation with the data began by conducting the interviews , listening to the recordings of the interviews and reading the transcripts . Nvivo 11 software  was used for analysis of all the qualitative data from field note observations and the transcripts.The analysis and data collection were simultaneous using established methods of grounded theory –28. AnalEscherichia coli isolates in inpatients  or hospital level  antimicrobial prescribing guidelines . The leaAcross the five countries, 61 individuals from 33 hospitals were invited to participate in the study. Nine individuals , refused to participate or did not respond to the two emails that were sent. In total 52 participants from 24 hospitals were interviewed . The malAnalysis of the interviews, and the observational data identified key insights into the determinants of ASP in these different settings. These insights are summarised in In India and Burkina Faso, there is great disparity in the level of access to healthcare, and the quality of healthcare provided. There is variation in the availability and type ASP models in secondary care. Bureaucracy and inefficient systems force individuals to seek private healthcare. Government hospitals often have limited budgets for patient services. The diagnostic capability of the microbiology laboratories of the government hospitals is often technologically 10–15 years behind. In addition, due to the relaxed regulations and no mandatory accreditation for hospitals there are a variety of hospitals and healthcare providers which serve the population at different costs. Often, by the time patients are hospitalised they have already taken several different over the counter antimicrobials (ranging from a single tablet to a full course), and the lack of access to or availability of medical records makes it impossible to know the full past medical history  for individual patients, The regulation is very poor. Companies making generic antimicrobials make two formulations, one for export, one for use in India, in one study on cephalosporins, the Indian generic version had 15% less potency. We had a case of aspergillosis. The drug of choice is voriconazole. In the Indian market, there are voriconazole from 200 rupees to 2,000 rupees. We gave the patient the option. He chose the cheapest one, the Indian generic one. We gave the correct dose of voriconazole, the infection did not respond. Then we did the therapeutic drug monitoring, we found that the concentration was at least five to six time less than the original drug … so we had to give five to six times the dose of the generic drug.’ Medical Microbiologist, India Hospital N‘In the UK, resource is limited in a different way. The National Health Service (NHS) is under pressure to save money year on year, both in staff resourcing and in consumables such as drug expenditures. At the same time the healthcare system is subject to regular disruptions in the form of restructuring of the workforce and management teams. During this study, NHS England launched the Commissioning for Quality and Innovation (CQUIN) initiative for reducing the burden of AMR and sepsis. In secoThe English experience is at odds with the India and Burkina Faso experience. In these countries, central government involvement is lacking but is attributed a high value by healthcare professionals, whereas in the UK it is attributed a low value by healthcare professionals, though it is an active driver of ASP. In India and Burkina Faso healthcare professionals consider ASP to be the responsibility of central government. Unless driven by central government and mandated by law, ASP initiatives will not take root in hospitals , T1 Q10.In many parts of the world, including France, Norway and India ASP is still predominantly led by doctors . The role of the wider healthcare workforce in ASP is undefined and limited. France has a long history of ASP in its secondary healthcare. Traditionally the treatment of infections has been the remit of intensive care physicians and the intensive care units still play a pivotal role in ASP, and in infection management of patients , T2 Q13.The study participants reported an awareness of the different practices in relation to antimicrobial prescribing amongst different specialties. One finding across the countries was the challenges facing ASP teams in engaging with and optimising antimicrobial use across surgical teams. Generally, it was reported that surgical specialties are the least likely to adhere to antimicrobial prescribing guidelines, whereas ICU teams being protocol driven and used to multidisciplinary input are the most likely to adhere to them  in ASP have not been fully investigated. Whilst a degree of state (top down) reinforcement and support is essential, e.g. to ensure an adequate healthcare service accessible by all, too much intervention and micro-management can have negative and disruptive effects.This study found that despite the expectation of multidisciplinary collaboration in ASP from WHO and other international bodies, it is only still practiced in a limited number of countries. In the context of this work, across India, France, and Norway doctors remain the sole profession involved in ASP efforts. The reasons for this are manifold. The entrenched hierarchies within the medical profession  that impThis study reports that surgery specialties remain universally difficult to engage with regarding ASP. The lack of adherence to ASP principles by the surgical teams also affects the medical care of the patients. Historically ASP efforts have mainly targeted medical specialties. This isThe key learning from the findings in this paper are focused on workforce development, identifying key champions to drive stewardship locally and to engage with governments and policy makers to ensure effective support for and scale up of interventions. Research on the implementation of ASP from low resource settings remains critical. By focusing within LMICs and addressing these questions in the least resourced settings, we will maximise the opportunities for bi-directional learning and the potential for scale up to any resource setting. There is a much wider workforce, including pharmacists and nurses, within healthcare that can take forward stewardship interventions in different settings.There are several limitations to the methods, and interpretation of this study. First and foremost, In India, France and Norway access to the pool of potential participants was gained via key informants who were national leaders in ASP in their own countries. This may have introduced selection bias. The fact that they were identified by the key informants was intentional as the aim was to include individuals who had a role in ASP. There may have been bias in the participants feeling obliged, coerced, or under undue influence to participate due to the key informants having invited them. Having spent time in each of the lead institutions however, and observing how the teams operate, coercion is not a plausible bias in this study. One of the most advanced examples of interdisciplinary teamwork in this study is from India, a country historically considered to be extremely patriarchal and hierarchical. Another cause for selection bias and limitation in this study was language. The need to speak English (France in Burkina Faso) may have been a selection bias for the participants. In Norway and India, all university graduates are fluent in English, therefore language was not a bias for selection.At the macro level government and state infrastructures determine ASP. There is a recognised need for legislation and investment in resources to support ASP locally, however too much government involvement can lead to disruptions in ASP and redirection of limited resources. A culture of hierarchies dominates the effectiveness and reach of ASP, with professional boundaries limiting the involvement of nursing and pharmacy staff and doctors remain the key stakeholders. ASP champions and local leadership can be used to overcome hierarchical and rigid national and organisational cultures. There are opportunities for shared learning from the interdisciplinary model adopted by key study hospital in India, which could break through entrenched hierarchies. Across all the countries in this study the surgical specialties were identified as being the least likely specialty in acute care to adhere to ASP. To tackle AMR, the surgical specialties in secondary care need to be included in ASP initiatives. It is critical to develop contextually driven ASP targeting the surgical pathway in different resource settings. There needs to be a complete and transparent, shared understanding of the principles of optimised antimicrobial prescribing across the entire healthcare work force in acute care, including across surgical teams.S1 File(PDF)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


Globally, three billion working people have daily occupational health needs that can only be met by providing occupational health services, such as those to support sick workers and to ensure that workplaces are safe and healthy . Each yeDespite being disproportionately affected, it is difficult to get an accurate picture of the occupationally-related morbidity and mortality being experienced in the poorest countries of the world. One of the greatest challenges encountered while conducting occupational health research in less economically developed countries (LEDCs), is a lack of local or even regional data to describe the extent of the problem. This includes information on exposure in general and in the form of exposure measurements, and information about the industry and population under study.http://www.oecd.org/dac/financing-sustainable-development/development-finance-standards/DAC_List_ODA_Recipients2018to2020_flows_En.pdf).A search of the Scopus bibliographic database was used to identify the number of papers on occupational health across the world. Papers were searched with “occupational health” in the title, abstract or article key words. There were 76,443 documents listed; the earliest publication appeared in 1928, with around 2,500 papers published annually in recent years. A search was conducted within these to identify those where the affiliation country was within the Least Developed Countries (LDCs) as defined by the United Nations, or the Lower or Upper Middle Income Countries and Territories (LMIC and UMIC) on the Organisation for Economic Co-operation and Development's (OECD) Development Assistance Committee (DAC) list for Official Development Assistance (In the LDCs there were between zero (34% of countries had not published a paper) and 43 papers published cumulatively between 1928 and the present; the largest number from Bangladesh, which is the most populous of this group of countries. In the LMIC and UMIC countries the range was larger: zero to 1,730 (Brazil). Unsurprisingly, the most populous countries generally published more papers related to occupational health.Although only one bibliographic database was used to illustrate the distribution of publications between countries, we consider the distribution of publications is unlikely to be markedly different from a more comprehensive search of the literature. Clearly, the stage of development, which to a large extent is defined by the per capita gross national income, determines the ability of a country to undertake research on occupational health problems. Ninety-four of the countries in this sample of developing nations (66%) have published fewer than 10 papers on occupational health problems in the scientific literature. These data illustrate the enormous absence of knowledge about the occupational health conditions in the developing world.In many cases, when conducting research studies in LEDCs, relevant data and knowledge of comparable industries from more economically developed nations are used as a proxy for local conditions and assumptions are made about the comparability of the data. Many health impact assessments take this approach as well as original research .However, work situations can differ vastly between LEDCs and more industrialised nations. A larger proportion of total employment in LEDCs consists of an informal workforce comprising self-employed, household-based unpaid labour and other cottage industries or small to medium sized enterprises (fewer than 50 employees). Informal employment can be up to 70% of the total workforce compared to 10% in more industrialised nations . InformaAssumptions about the comparability of data can lead to uncertainties and biases in the estimates of the health impacts of work exposures in LEDCs and there is a need for further intelligence, particularly in the form of exposure measurements to overcome this. If exposure is higher than that assumed from proxy data then studies of the global burden of disease may underestimate the burden from work. However, industrial development will probably have happened later in LEDCs and there would be a corresponding delay in the subsequent exposures being characterised, which could result in morbidity and mortality being overestimated. This potential for both underestimation and overestimation was described recently for the global burden of mesothelioma deaths . In the The lack of exposure measurements from LEDCs is likely a symptom of a greater systemic problem of a lack of occupational health expertise and resources in these countries. They generally lack the resources, knowledge and technology to identify and control workplace exposure to disease-causing agents . MentorsLEDCs must be assisted to improve their occupational health services and accessibility to these services. We believe there is an obligation for more economically developed nations to assist LEDCs in accordance with the UN Sustainable Development Goals (SDGs). These consist of 17 broad-based goals addressing issues related to poverty, inequality, climate, environmental degradation, prosperity, and peace and justice. Several of the goals support the right to healthy workplaces:Goal #3 Good Health and Well-Being:By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination.Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks.Goal #8 Decent Work and Economic Growth:Protect labour rights and promote safe and secure working environments of all workers, including migrant workers, particularly women migrants, and those in precarious employment.Goal #16 Peace, Justice and Strong Institutions:Develop effective, accountable and transparent institutions at all levels.Goal #17 Partnerships for the Goals.Strengthen the means of implementation and revitalize the global partnership for sustainable development.When attempting to quantify the burden of death and disease being experienced globally as a result of workplace exposures, as we have discussed, it is commonplace to use research from more industrialised nations to represent conditions in LEDCs. These efforts should not be dismissed as much thought and effort can go into accounting for differences between the two study locations and any assumptions made will have been clearly defined. However, the absence of knowledge about workplace exposures in LEDCs is vast and must lead to imprecise and perhaps underestimation of occupational disease burden. LEDCs should be encouraged to increase their capacity for occupational health research. More economically developed countries have a responsibility to assist LEDCs to improve their occupational health services in accordance with the UN SDGs, to provide healthy and safe workplaces for all, by 2030. We recommend supporting mentorship initiatives that use a grassroots approach to connect experienced occupational health professionals with key local stakeholders in LEDCs. We consider that developed countries should prioritise some of their official development aid to help improve capability to assess and control workplace exposures, improve occupational health, and support research.Where authors are identified as personnel of the International Agency for Research on Cancer/World Health Organization, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer/World Health Organization.MC, JC, and AO contributed to the text throughout the manuscript. JC provided the figure.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.


One hundred years ago, a pandemic of unprecedented size and scope afflicted the human population. This pandemic was caused by an H1N1 influenza virus of avian origin. Over the course of 1918–1919, this virus infected approximately one-third of the nearly 2 billion people living on Earth at the time, resulting in at least 50 million deaths. The pandemic caused massive economic disruptions, severely strained many of the public health infrastructures that were designed to contain disease, and spread to the farthest and most isolated corners of the globe, often with especially deadly consequences in remote areas. The disease caused by this virus had several unusual characteristics that remain incompletely understood, including high mortality in previously healthy, young adults . Questions also remain about the geographic origin of the pandemic, and the underlying drivers that led to emergence from avian hosts. The 1918 influenza pandemic remains one of the most feared epidemics in world history, and a rallying cry for more effective preparedness for future outbreaks of influenza and other viruses. It is well worth reflecting on this pandemic, including with an evolutionary lens.In this special collection of papers, we present new evolutionary perspectives on the history of the 1918 influenza pandemic. Our collection includes a review by Dr. Margaret Humphreys that weaves together historical and evolutionary perspectives, providing a broad overview of the pandemic for those interested in evolutionary medicine. Dr. Michael Worobey and colleagues provide new perspectives on the geographic origins and timing of the first cases of the 1918 influenza pandemic, including insights from phylogenetic analyses and the causes of young adult mortality. In the time since the 1918 pandemic, a greater appreciation for the cross-species spread of viruses has emerged. To provide some of these new insights from a One Health perspective, Dr. Emily Bailey and her colleagues review new knowledge on influenza viruses. Lastly, as a provocative and forward-looking Commentary, Dr. David Fedson provides new insights to the causes of young adult mortality and proposes how this knowledge can be used to reduce mortality in future pandemics. He also outlines approaches for future testing of these proposals. In addition to these four papers, we have other papers that are in the works for this collection over the next year, and we welcome additional submissions.Evolution, Medicine and Public Health, I am excited to help orchestrate this highly interdisciplinary collection of papers. I would like to see other topical collections emerge on the pages of the journal, especially those that present different viewpoints based on rigorous science that move evolutionary medicine research forward. If you have ideas for other collections—including sets of papers from organized symposia—please contact me about the possibilities for publishing those papers at EMPH. As Editor-in-Chief of Conflict of interest: None declared.


Numerous epidemiological reports have found that adolescent, young adult, and middle-aged adult girls and women are more likely to be diagnosed with unipolar depression and report greater symptoms of depression when compared to boys and men of similar ages. What is less well-known is whether this gender difference persists into late life. This literature review examines whether the well-known gender difference in unipolar depression continues into old age, and, if it does, whether the variables that are known to contribute to the gender difference in unipolar depression from adolescence through adulthood continue to contribute to the gender difference in the elderly, and/or whether there are new variables that arise in old age and contribute to the gender difference in the elderly. In this review of 85 empirical studies from every continent except for Antarctica, we find substantial support for the gender difference in depression in individuals who are 60 and older. More research is necessary to determine which factors are the strongest predictors of the gender difference in depression in late life, and particularly whether the factors that seem to be responsible for the gender difference in depression in earlier life stages continue to predict the gender difference in the elderly, and/or whether new factors come into play in late life. Longitudinal research, meta-analyses, and model-based investigations of predictors of the gender difference in depression are needed to provide insights into how and why the gender difference in depression persists in older age. It is well-known that females are more likely to be depressed than males, both in terms of unipolar depressive episodes and in terms of depressive symptoms ,2. HowevSo far, a thorough discussion of the gender difference in unipolar depression in older adults is largely missing from major reviews of the gender difference in depression. There are several reasons for this. First, reviews of the gender difference in depression tend to focus on the emergence of the gender difference during adolescence and subsequently focus more on empirical studies of adolescent, college, and middle adult groups e.g., ,2,7). Wh,7. Wh2,7In this paper, we will review what is known about the gender difference in unipolar depression in old age (age 60 and older). The primary question we will try to answer is whether there is sufficient empirical data to support the existence of a gender difference in depression in older adults. If the gender difference in depression does exist in older adults, we will examine whether the major psychosocial variables that are thought to be responsible, at least in part, for the gender difference in depression in teenagers, young adults, and middle-aged adults play a similar role in depression in older adults, and/or whether there are new psychosocial variables that are responsible for a gender difference in depression in older adults. Finally, we will try to specify the most important research questions that remain to be answered in order to develop a reasonably complete picture of the gender difference in depression throughout the life course.The first goal was to answer the following question: Is there a gender difference in depression in older adults who are at least 60 years old? We conducted a literature search in March 2017, using the Academic Search Complete, PsycINFO, and MedLine (ProQuest) databases. For each database, the search terms “gender difference”, AND “depression”, AND “elderly or aged or older or elder or geriatric” were used. This returned 713 abstracts from Academic Search Complete, 3788 abstracts from PsycINFO, and 3155 abstracts from MedLine. Full articles were retrieved and included in our review if they met the following inclusion criteria: empirical research articles published in peer-reviewed journals; participants aged 60 or aged 50 and above with the mean age of the participants at least age 70; both women and men as participants; and, a report of unipolar depression by gender. Lifespan studies were only included in our review if depression data was reported by gender for the group of participants who were 60 and above. Duplicate abstracts were consolidated. These criteria were met by 85 articles that were published between 1980 and 2017. In these 85 articles, the most commonly used measures of depression were the well-validated Center for Epidemiologic Studies Depression scale (CES-D) , which wIn 69 (81%) of the 85 studies, older women, as compared to older men, had a significantly greater likelihood of a depression diagnosis based on clinical interviews or cut-off scores, or significantly more depressive symptoms on standard measures. Of the 69 studies, four found a significant gender difference in some groups but not others. In 14 of the 85 studies (16%) there was no significant difference in depression scores or diagnoses between women and men. In two of the 85 studies (2%), men had significantly greater depression scores than women. Taken altogether, this answers the central question of this paper: the gender difference in depression, with women more likely to be depressed than men, is found in people over the age of 60. (See Only 16 (18%) of the 85 studies that met the criteria for inclusion in this review did not find a significant gender difference in depression, in which women scored higher than men. In these 16 studies, the characteristics of the samples and the ways in which depression was assessed did not seem to differ in any significant way from the 69 studies in which a gender difference in depression was found. Furthermore, these 16 studies reported data on samples from 11 different countries .In summary, 69 of 85 81%) studies that reported on the gender difference in depression in the elderly found that older women were more likely to have a diagnosis of depression or a greater number of depressive symptoms when compared to older men. Although interpretation of the epidemiological findings is made somewhat more difficult because only a comparatively small percentage (29%) of the studies excluded participants based on conditions such as dementia, cognitive function, chronic illness, disability, and co-morbid psychological disorders, the consistency of the basic finding of a gender difference in depression in the elderly extends the consistent epidemiological finding that there is a gender difference in depression among adolescents, younger adults, and middle-aged adults . Some empirical studies have asked whether the gender difference in depression changes across development stages from adolescence and young adulthood into late life. Our screening process returned 10 studies with participants from 18 different countries that addressed the question of whether the gender difference in depression changes in magnitude across the life span. The results of these analyses were mixed. Three of the studies reported that the gender difference in depression, while remaining significant, was narrower in elderly adults as compared with young- and middle-aged adults ,73,74. TOne possible reason for the mixed results is the differences in the age groups that were analyzed in the various studies. In the studies that found no change in the gender difference in depression over age, one compared all of the participants under age 55 with all of the participants over age 55 , a seconIn general, the studies that explored the possibility of changes in the gender difference in depression across the life span used a cross-sectional approach, with different participants at different ages. As a result, cohort effects cannot be ruled out. Large-scale epidemiological studies have revealed that a cohort effect is present for depression, with more recent cohorts reporting higher rates of depression when compared with older cohorts ,10,82. IAll in all, the currently available data are clearly mixed on whether and how the gender difference in depression changes across the life span. There is no readily perceivable pattern based on the sampling procedures (or the depression measure) used in those studies that have tried to examine this question. Two studies examined the incidence of the initial depressive episode between the ages of 18 and 65, and asked whether more women than men experienced an initial depressive episode at each age ,84. In bWhile the psychosocial predictors of depression have been extensively studied in people of all ages, the psychosocial predictors of the gender difference in depression have been studied much less, and almost not at all in older adults. What research there is on the psychosocial predictors of the gender difference in depression has generally focused on adolescents and young adults, and utilized diathesis-stress models. In this research, the diatheses are vulnerabilities that make individuals more susceptible to depression when stressors occur in their lives, and the question is which stressors and which vulnerabilities are more prevalent in the lives of females than in the lives of males . The resIn addition, many researchers have looked separately at which variables predict depression in older women and which variables predict depression in older men. These studies rarely ask whether there are gender differences in the psychosocial variables that predict depression in each gender (and whether any gender differences in those variables might lead to women being more negatively affected than men). There are very few studies that look at whether there is a gender difference in a predictor variable that predicts the gender difference in depression. This is unfortunate because only with such studies can we conclude that that variable can, at least in part, explain the gender difference in depression in the elderly. In this section, we will examine the results of the studies that have looked at gender differences in psychosocial variables that might predict the gender difference in depression in older adults. First we will consider whether there is evidence that the variables that predict the gender difference in depression in adolescents and younger adults might also predict the gender difference in depression in older adults, and then we will consider whether there are additional variables that arise in old age that might be responsible at least in part for the gender difference in the elderly. This section combines studies that were done in many different countries. In some studies, data from several different countries were examined. The results were quite consistent across countries, and so the results are reported without considering the countries in which the data were gathered. In adolescents and younger adults, the predictors of the gender difference in depression that have been identified include: stressors, coping styles ; depressogenic personality styles ; social support; the physiological changes of puberty; gender role intensification, sexual abuse and assault; and, negative body image ,7,86. ThThere are many different kinds of stressors. The most commonly measured stressors in the depression literature generally are negative life events that occurred within the previous year. However, very few studies have asked whether there are gender differences in negative life events in the elderly that are related to the gender difference in depression in this age group, despite the fact that negative life events occur frequently in the lives of the elderly. In the few studies that have examined this question, it is not clear whether older women experience more negative life events than older men: in two studies they did ,88 and iCognitive coping skills are commonly considered to be predictors of the gender difference in depression in adolescents and younger adults  and avoidance styles  . Two stuSome depressogenic personality characteristics that are quite commonly assessed in younger samples have not been examined in older samples. For example, dependency and sociotropy are interpersonal orientations that have been proposed to contribute variance to the gender difference in depression in younger samples ,99,100. On the face of it, social support looks like a potentially important variable when considering the predictors of depression. In general, social support is seen as buffering against depression; that is, it is assumed that social support protects a person against depression . InsofarOne of the reasons for the mixed results may be that there are many different ways of defining social support, and it is difficult to figure out whether there is any comparability among them. For example, social support can be either instrumental or emotional. It can be defined as the size of a person’s social network or as whether a person has a best friend or confidante. It can be seen as coming from family or from friends. One or more of these kinds of social support could have more of an effect on one gender or the other, and these effects could be positive or negative. For example, it is possible that elderly women are more vulnerable to the absence of social support than elderly men and that this difference in vulnerability could account in part for the gender difference in depression.The psychosocial variables that are more prevalent in old age than in younger age groups can best be characterized as new stressors that are more likely to arise or intensify in old age. These include: widowhood/living alone; illness; cognitive decline; financial strain/poverty; and, caregiving. Each of these variables increases in old age, and the question then becomes: are there gender differences in these variables in old age and, if so, do these gender differences predict the gender difference in depression in old age?Marital status and living arrangements are the most studied psychosocial variables in the literature on depression in the elderly. These are not exactly the same variables although they certainly overlap; for example, it is possible for an elderly person who is widowed or divorced to be living alone or to be living as part of an extended family. We will first examine the literature on marital status, and then we will explore the literature on living arrangements. The data consistently show that elderly women are less likely to be married and more likely to be widowed than elderly men ,113,114.Other investigators have proposed that a gender difference in living alone might be a predictor of the gender difference in depression. Many more elderly women live alone than elderly men ,87,116. Health status seems to be an obvious variable to examine in relation to the gender difference in depression in the elderly since health tends to decline as people age. Health can be measured in a number of ways: number of chronic conditions, ability to do the tasks of daily life, and self-ratings of health are the approaches that have been used most frequently in studies of the elderly. The first question, however, is whether there is a gender difference in health. Do elderly women have poorer health and more chronic conditions than elderly men? In general, the answer to this question seems to be yes. There is a gender difference in health status in the elderly, with women experiencing more chronic conditions, demonstrating less ability to perform daily tasks, and subjectively reporting poor health ,112,120.The studies of the relationship between cognitive decline/dementia and depression in the elderly differ from studies of the relationship between other variables and depression in the elderly in an important way. Whereas, studies of other variables generally ask whether the variable predicts depression, studies of cognitive decline/dementia ask whether depression predicts cognitive decline. While the reason(s) for this is not explicitly discussed in the literature, it seems likely that it reflects the difficulty of assessing depression in individuals with dementia. There are considerable data that older women are not only more likely to be depressed than older men, but also are more likely to be diagnosed with dementia, especially over age 85 ,123,124,The data on whether depression is a risk factor for or a correlate of cognitive decline are mixed, and gender differences have rarely been reported. In the studies reviewed by Sevick, Rolih, and Pahor (2000), the data on depression as a predictor or correlate of dementia or cognitive decline were mixed, with no gender differences being reported . In the Although financial strain and poverty are thought to be more prevalent in women than in men throughout the life span, perhaps surprisingly, we found very few studies in the depression literature that reported whether elderly women experience more financial strain and poverty than elderly men. Those studies that have examined whether elderly women are more likely to be poor than elderly men have found this to be the case ,130. MosCaregiving is by no means unique to older adulthood, but it is certainly a demand placed on many older adults. Pinquart and Sorenson (2006) conducted a meta-analysis that found higher rates of depressive symptoms in female caregivers than in male caregivers, with women reporting higher levels of burden, more hours of care, more caregiving tasks, and more personal care than male caregivers . This meThe Pinquart and Sorenson (2006) meta-analysis examined studies in which those receiving care might be debilitated in various ways . Other sThe present review found strong empirical evidence for the gender difference in depression among older adults aged 60 and above. Older women scored higher than older men on dimensional measures of depressive symptoms and older women have higher rates of diagnosis of unipolar depression compared to older men. This pattern was observed in 69 (81%) of 85 studies. The majority of studies included in this review assessed depression using dimensional self-report instruments of depressive symptoms. Although self-report instruments, such as the CES-D and GDS, are not the same as a diagnostic clinical interview, they nevertheless are valuable tools for depression screening and assessment of symptom severity, are highly predictive of well-being, and are valid assessments in older adults ,14,15. Although subclinical levels of depressive symptoms are more commonly experienced in geriatric samples than major depressive disorder , subclinThe literature reviewed for this paper was impressive in its geographic and cultural diversity, with every continent except for Antarctica being represented in the papers reviewed. The majority of the papers reported data from North America, Asia, and Europe, with fewer studies taking place in South America, Africa, and Australia. Population-based samples predominated in the studies reviewed, with remarkably little dependence on convenience samples. Taken altogether, the existence of a gender difference in depression in the elderly, with women being more likely to be depressed, appears to be a very robust finding. While the existence of the gender difference in depression in the elderly seems to be solidly established, we know much less about why this gender difference occurs in the elderly, the magnitude of this effect over ages, or whether this effect occurs in the elderly for the same reasons that it occurs at earlier life stages. In particular, we were unable to ascertain whether the data were similar for older adults age 60–80) and for very old adults (older than age 80). Those studies that explored the gender difference in depression across a broader age range in order to examine whether the gender difference in depression changed in magnitude across the life span provided mixed data, perhaps because most of these studies used different age ranges ,79,80,81 and for In general, the vast majority of the studies that explored predictors of depression in the elderly looked at what predicted depression in women and men separately. There were relatively few studies that reported gender differences in potential predictor variables, and an even smaller number of studies that actually tested whether the gender differences in predictor variables accounted for a significant part of the variance in the gender difference in depression. In addition, most of the studies focused on stressors that increase dramatically in old age, such as widowhood/living alone, poor health/chronic illness, cognitive decline, financial strain/poverty, and caregiving. There were relatively few studies with elderly participants that explored predictors, such as negative life events, coping styles, and interpersonal orientation, which have been extensively researched in adolescents and adults. The only predictor of the gender difference in depression that has been studied extensively throughout the life span is social support, but the data on the role of social support are very mixed and difficult to interpret, probably because there are so many different ways to define social support (and its absence).There does seem to be some indication that dysfunctional coping styles, such as rumination and avoidance coping, are more prevalent in elderly women than in elderly men ,81,96,97Although particular stressors—widowhood/living alone, poor health/chronic illness, cognitive decline, financial strain/poverty, and caregiving—have been extensively studied in the elderly, the broader range of negative life events that have been studied in adolescents and adults, and that generally represent the stressors in diathesis-stress models of depression, are notably absent from the literature on gender differences in old age. More research on the broad range of negative events in the lives of the elderly might prove informative for understanding the gender difference in depression in this age group.Although we know more about the particular negative events of old age than we do about negative life events in general, we do not know nearly enough about any of them to be able to specify whether a particular negative event makes a contribution to the gender difference in depression in the elderly. People who are not married  are more likely to be depressed than people who are married, and elderly women are much less likely to be married than elderly men ,117,118.It seems clear that there is a new set of stressors that arise in old age. Unfortunately, there is not sufficient research to be certain whether any of these new stressors contributes to the gender difference in depression in the elderly. There is, however, a hint in the literature that the risk factors for a depression diagnosis in the elderly may be different from the risk factors at younger ages. Studies have documented a U-shaped function for the gender difference in initial diagnosis of depression between the ages of 18 and 65, with essentially no gender difference at the youngest and oldest ages ,84. HoweSevere and moderate (but not mild) depression is also associated with increased mortality in older adults ,140, andWe designed this review of the literature on the gender difference in depression in the elderly to examine, first, whether the well-known gender difference in depression among adolescents, young adults, and middle-aged adults, was also consistently found in the elderly and, second, to examine what was known about risk factors for depression in the elderly. The present review establishes the existence of the gender difference in depression among the elderly and reveals important gaps in the literature about what factors are responsible for this gender difference. Below, we describe ways to address these gaps through empirical research. We also briefly touch on applications of these findings for clinical practice, especially as the applications pertain to depression screening of senior populations.Although the general literature on the gender difference in depression, which is almost entirely based on samples of adolescents and young adults, has examined and compared various models designed to explain the gender difference , model-dThe emergence of the gender difference in depression in adolescence is likely overdetermined: there is empirical support for many of the variables, as well as all of the models that have been proposed . Given tWe strongly recommend that a comprehensive meta-analytic review of the empirical literature on the gender difference in depression, including the empirical literature on the gender difference in older adults, be conducted as the next step towards understanding gender and depression over the lifespan. Some meta-analyses have already been conducted on subsets of older adults . HoweveA critical issue that needs to be addressed in future research on gender, depression, and aging, is stratification by age group in individuals over the age of 60. Most studies included in the present review lumped all of the individuals over the age of 60 together in their analyses. This can be contrasted with research on adolescents and young adults where narrow cross-sectional cohorts are carefully defined. In addition, given the expected life span, at least in developed countries, individuals at age 60 can expect to live for approximately 20 more years. Thus, research that combines together participants over age 60 would be similar to research that combines individuals between the ages of 20 and 40. There are important changes in health, ability, and marital status that take place in the decades following age 60. Ideally, research on gender differences and depression in older adults should stratify findings by age in order to examine the correlates of developmental changes that are particular to different decades. Future studies on gender differences in late life depression should stratify by age, examine interactions between gender and age, and identify predictors that particularly affect individuals in different age categories.The studies in the empirical literature that examined the gender difference in depression across large parts of the life span used cross-sectional designs ,73,75. SSome of the studies included in this review followed multiple cohorts longitudinally for a number of years, but none of them followed the cohorts long enough to collect life span developmental data e.g., ,111). It. It111])Using self-report data with elderly participants, several studies have found that the gender difference in first-onset of depression follows an inverted U-shaped function across the lifespan, with the gender difference converging in adolescence and around age 65, and widening from adolescence to middle adulthood ,84,150. The majority of studies included in the present review did not report on screening for comorbid psychological disorders, dementia, or health problems, and those that did screen for these issues usually did not exclude participants based on that screening. As a result, it is difficult to determine whether the reported gender difference in depression is due, at least in part, to other health-related factors. Older adults may present with depression as a symptom or as a consequence of an underlying health problem or cognitive decline ,152,153.The higher prevalence of depression in women than in men highlights the need for mental health professionals to target women in depression screenings and interventions. Women’s health initiatives would benefit from including depression as a target for educational, prevention, and treatment interventions. Since elderly men who live alone are also at a high risk for depression, they could be targeted by primary care physicians for depression screening during medical visits or in community-based depression screening programs. Increasing our understanding of the predictors of the gender differences in depression can help practitioners select more appropriate interventions. With women who are ruminating and using avoidance coping skills, cognitive-behavioral interventions might be best suited to treat depression. Interpersonal psychotherapy would also be an appropriate intervention for individuals for whom social support, or the lack thereof, is impacting depressive symptoms. Since women who are married are more susceptible to depression than men who are married, couple interventions may be more appropriate for married women than married men.Depression in older adults is a serious concern. The experience of depression can lead to personal distress and disability, and pose a significant impediment to successful aging. Generally speaking, successful aging is a multidimensional construct that includes psychological health, physical health, social support, and the ability to carry out the tasks of everyday life . Unsurpr


The field of education has experienced a profound change following the introduction of mobile technology over the last decades, and nursing education is not an exception. This study explored the experiences of nursing students about the ethical concerns regarding the use of mobile devices for learning purposes, that is, mobile learning, in educational and clinical contexts. A qualitative phenomenological study was carried out on nursing students (n = 19) in Saveh University of Medical Sciences of Iran between December 2017 and April 2018. Data were collected through semi-structured interviews with open-ended questions. Data analysis was done using Colaizzi’s 7-step method, revealing four themes and nine sub-themes including: 1) preserving professional dignity ; 2) securing informed consent and respecting personal (the patient’s and teachers) autonomy; 3) proper and efficient use ; and 4) avoiding harm (responsible use of class and patient data). It was revealed that using mobile technology in education could raise ethical concerns for nursing students, and this should be emphasized in nursing educational programs.  Mobile devises have emerged as new learning tools with a notable potential both in classrooms and outdoor learning environments . Mobile Mobile devices such as smartphones can be integrated into health profession education , 9. StudEvery day a new technological innovation is introduced in the field of higher education. The advancements have also affected nursing education. The integration of mobile technology has revolutionized learning over the past decades and it is widely incorporated into nursing education . M-learning has not only brought about deep changes in education, but it has also created new issues in the field of ethics. With the expansion of various aspects of nursing education, the dimensions of ethical concerns have also expanded. Use of mobile technologies by students in the educational context is not free of ethical concerns. While some studies have concentrated on ethical issued in m-learning, there is a paucity of studies to recommend ethical ways of using m-learning . The divAlthough several studies have been conducted to determine the effectiveness of m-learning in students’ academic achievements, there are no published study on the lived experiences of students about the ethical concerns surrounding the issue. There are universal ethical principles and values such as trustfulness, veracity, intrinsic dignity, respecting others’ privacy, freedom, honesty and the like; however, these concepts have different definitions in each situation. For instance trustfulness in business is different from trustfulness in education. All research projects start with a clear question that dictates the path and stages of the study. Thus, the research method is a function of the question. In this work, the question was “How do nurses experience the ethical concerns related to using m-learning in educational and clinical contexts?” As the question indicates, methodology should represent the nature of the phenomenon in a natural context along with the structures and factors that affect its development. Indeed, the authors expected to find the reality in its natural form as experienced by the students. In other words, the authors tried to perceive the experience instead of measuring it. Thereby, a qualitative method was the best option to illustrate the nature of the phenomenon in its natural context. There has been a paucity of qualitative studies on the lived experiences of nursing students about the ethical concerns regarding m-learning in educational and clinical contexts. Thus, the present study was an attempt to examine nursing students’ lived experiences about the ethical concerns related to the use of mobile devices for learning purposes in such contexts.A qualitative study was carried out using the phenomenological method of inquiry in Saveh University of Medical Sciences in Iran between December 2017 and April 2018.Purposive sampling was used to identify and choose well-informed individuals in order to select the participants. Study inclusion criteria consisted of being an undergraduate nursing student, having passed at least two academic terms, and willingness to participate in the study. Given that nursing students entered the clinical setting starting the 2nd semester, all participants had at least 20 days of clinical experience. Nursing students with different demographic characteristics and clinical experiences (maximum variation) were included in the research for enhancing transferability of the results. However, to make sure that the participants were familiar with mobile technology, the research population was limited to undergraduate nursing students. These students were mostly at the same age group and could be recognized as the “digital native” generation. On the other hand, adding graduate nursing students could create unique landscapes.Sampling was continued until data saturation was achieved and no new code was found. Data gathering was done using semi-structured interviews with open-ended questions . Given that the author is a research instrument in qualitative studies, guided questions were also obtained from the interview texts and used in subsequent interviews. Probing questions were used based on the information offered by the participations to gain deeper insight into the issue. To improve trustworthiness and rigor of the data, Guba (1981) was followed including the four criteria for credibility, transferability, conformability, and dependability .To ensure creditability, the authors tried to create an intimate interaction with the subjects, win their trust by creating a relaxed and unstressed environment, and assign adequate time for data collection. In this way, the authors made sure that the participants could recount their experiences without tension. In addition, field notes, memos, member-check, and reviewing codes and themes by external reviewers (extended check) were used to guarantee the credibility of the data. To ensure conformability of the study, details of the study procedure including data collection, analysis, and extraction of codes and themes were elaborated so that the readers could form a judgment by reading the report. To support dependability, the whole procedure was extensively described to make it easy for readers to audit the study. With regard to transferability, a detailed account of the location of the research, interactions, and the processes observed during the study was also provided to facilitate judging the transferability of the study. The results were analyzed using Colaizzi’s 7-step method .At first, the statements in the interviews were transcribed verbatim, and the transcriptions were read several times to obtain a common perspective with the participants. At the second stage, the key meanings and concepts were extracted and critical points were determined. At the third stage, the important themes were formulated and the authors tried to find the meaning of each extraction and the related concepts. The themes were clustered at the fourth stage, and the concepts were studied in detail and classified based on their similarity to the subject categories or the main concepts. As the fifth step, the results were used to achieve a comprehensive explanation of the subject. At this point, different subject categories of the same meaning were placed in larger categories to find the concepts of the main description. Afterward and as the sixth stage, the explanation of the intrinsic structure of the phenomenon under study was presented as an explicit statement of its basic structure. As the final step, creditability of the findings was ensured by carrying out a private interview with each participant. In the interview, each participant was asked to comment on the findings, and the results were then finalized. In observance of ethical codes, the subjects were informed at the start about research objectives, interview method, and confidentiality of their information, and were also assured that they could leave the study whenever they wanted. In addition, they were asked to sign an informed letter of consent. To ensure convenience of participation, the interviews were arranged in a way so as not to interfere with the daily routines and educational programs of participants. The author secured a permit from the Ethics Committee of Saveh University of Medical Science as well (IR.SAVEHUMS.REC1396.33). The students expressed their consent to participate in the study both orally and in written form. They were informed about the study purposes, interview method, confidentiality of information, and their right to participate in or leave the research at any point.rd, five in the 6th, and six in the 8th semester. Among the 19 subjects in this study, 63.15% (n = 12) were female, and the average age of the participants was 20.57 ± 0.53. Moreover, three students were in the 3Data analyses yielded 352 primary codes, which were then truncated based on overlaps and merged into 167 primary codes. After comparing the codes and their similarities, nine sub-themes and four themes were extracted , which a1.Preserving professional dignityPreserving professional dignity in front of the patient The findings showed that it was very important for the students to preserve their professional prestige before patients. For this reason, while interviewing the patient or providing care, they would try to keep eye contact and refrain from using their mobile phones in any way that might be construed as disrespectful. In addition, some of the respondents said that using phones during care provision might interrupt the nurse-patient relationship and negatively affect the quality of rapport. One participant said: Using any technology entails a specific code of conduct; for instance, I would never use my mobile phone while interviewing a patient, not even for educational or academic purposes. If I do so, it might be interpreted as disrespectful, and would be degrading to my professional prestige.”] (Participant No. 11)  (Participant No. 8)  (Participant No. 12)[“Another student said:Not all teachers are familiar with the advantages of smartphones for educational purposes. Many of them are aged and follow traditional methods so they reject the idea of using mobile phones for educational purposes. Respecting the teacher’s way is important for me and I would rather not use my phone before these teachers even for educational purposes.] (Participant No. 2)  (Participant No. 4)  (Participant No. 19)  (Participant No. 17) (Participant No. 9)  (Participant No. 14) (Participant No. 13)  (Participant No. 6)  (Participant No. 1) (Participant No. 3) (Participant No. 11) (Participant No. 18) (Participant No. 5)  (Participant No. 10)[While new technologies, including mobile technology, can act as a positive force to facilitate change, they can also be a source of new ethical challenges. The findings showed that using mobile technology in clinical and educational contexts causes ethical issues, and it is critical for nursing students all around the world to ponder on these issues in their daily education. The rapid growth of mobile device use over the recent years has led to conflicts with the accepted standards of behaviors . Still, Four themes were extracted from the students’ experiences with regard to the ethical concerns associated with m-learning: preserving professional dignity, securing informed consent and respecting personal autonomy, proper and efficient use, and avoiding harm. To the best of the authors’ knowledge, the present research was the first qualitative study on the lived experiences of nursing students about the ethical concerns related to m-learning. It is notable, however, that m-learning has been qualitatively and quantitatively examined in some studies as a general issue to determine the effective factors in accepting the technology or its learning effect on students. For instance, Xiao et al. 2017) reported that nursing students had a positive attitude and understanding about m-learning. They concluded that the use of m-learning by students should be promoted by providing suitable conditions 17 report. Yoo andDeveloping one’s knowledge is an essential part of learning, and in clinical settings, students tend to use mobile devices for rapid acquisition of information. Still, some of the participants said that they did not use their phones before patients, as they perceived it a rude action. This concern was also mentioned by patients and hospital personnel .Respecting patients’ autonomy and gaining their informed consent was another theme extracted from the students’ experiences. Capturing digital content about patients without prior consent  and sharing it on the Internet may create serious ethical challenges, even if done unintentionally. The purpose of securing permission beforehand is to make sure that the patient or surrogate is given the chance to accept or reject the action or treatment under no duress. Otherwise, autonomy and dignity of the subjects is neglected .Therefore and as mentioned by the majority of the students, recording information and content about patients should be done only after obtaining their free and informed consent. Irresponsible use of patients’ electronic information and digital educational content was another ethical concern extracted from the experiences of the participants. One ethical concern with regard to the risk of information accessible only for a limited audience was public distribution of that information. Although most of the participants agreed that publishing such information without permission was unethical, some had experienced ethical challenges in this regard. Other studies have demonstrated that irresponsible and unethical use of information and educational materials may be an ethical concern with regard to m-learning . The findings indicated that one consequence of using patients’ information irresponsibly was rooted in capturing and disseminating videos that might go viral. Some students film their teachers or classmates and publish the videos on the web, which in most of the cases is done to humiliate them. Therefore, along with providing a supportive environment for mobile phone use in class, teachers should play as ethical role models to prevent cyber-bullying. Mobile learning is widely practiced in universities as a sort of educational method , 8; howeOne probable problem is the lag between the rapidly advancing technology and the slow evolution process of the rules on its use. Mobile devices have become a part of students’ daily lives, nursing students included. Teachers are required to adapt to the technology and modify their teaching techniques to facilitate ethical m-learning. Likewise, students should be equipped with the knowledge that using mobile devices may have negative effects on their professional prestige before teachers and patients. Ethics is an ambiguous concept  and the In our path toward a more ethical approach to m-learning, our focus must be shifted from mobile devices to the issues that are the real concerns. The main question is how to use mobile devices in learning. Therefore, rather the prohibiting their use, we need approaches to limit bad behaviors and empower the students with efficient ways to deal with inappropriate behaviors of others. Like other fields of education, improvement of student-teacher-patient relationship in terms of observing the ethics of m-learning leads to an enhanced quality of nursing education. By relying on the principles of ethics and extending their knowledge in this regard, students can use m-learning in a more intelligent, purposeful and informed manner. University teachers also need to pay special attention to ethical codes on using mobile devices both in the real and online world.As a qualitative research, the findings cannot be generalized to a larger population, but may be transferable to similar environments. However, our research was the first of its kind to explore nursing students’ experiences regarding the ethical concerns related to using mobile devices for learning purposes in educational and clinical contexts. Future studies with different students, schools and countries are needed to investigate the role of additional constructs in the issue.Using mobile technology in clinical and educational contexts can raise ethical concerns for nursing students. Rather than prohibiting the use of mobile devices, we must devise approaches to restrict unacceptable behaviors and help the students develop strategies to deal with others’ inappropriate behaviors. This should be emphasized in nursing educational programs. Additionally, it is necessary to adjust teaching and education and allow the students to use their mobile devices in a more appropriate manner.