Applying the concepts of technological ecosystems to the care and assistance domain is an emerging field that has gained interest during the last years, as they allow to describe the complex relationships between actors in a technologically boosted care domain. In that context, this paper presents a systematic review and mapping of the literature to identify, analyse and classify the published research carried out to provide care and assistance services under a technological ecosystems’ perspective. Thirty-seven papers were identified in the literature as relevant and analysed in detail (between 2003–2018). The main findings show that it is indeed an emerging field, as few of the found ecosystem proposals have been developed in the real world nor have they been tested with real users. In addition, a lot of research to date reports the proposal of platform-centric architectures developed over existing platforms not specifically developed for care and services provision. Employed sensor technologies for providing services have very diverse natures depending on the intended services to be provided. However, many of these technologies do not take into account medical standards. The degree of the ecosystems’ openness to adding new devices greatly depends on the approach followed, such as the type of middleware considered. Thus, there is still much work to be done in order to equate other more established ecosystems such as business or software ecosystems. Providing care and assistance services to people with special care needs  is a complex task. Different actors such as health organizations, health and care workers, regulators and governing bodies, and even IT solution providers may be involved with the provision of a single service. According to the World Health Organization , many exIn this sense, although recent advances in sensor technologies have spurred the care and assistance field, expanding the possibilities of providing better and more reliable technological solutions for assisting people with disabilities , many ofDuring the last decade, however, there has been an increasing interest in the development of different types of solutions that allow the interaction between the different actors in the health and care sector, in order to deliver integrated and age-friendly care and assistance services ,9,10,11.Thus, the current trend in IT solution providers  is to move from fragmented services to progressively more integrated services, which are likely to be provided by multiple stakeholders through well-elaborated collaboration mechanisms .As such, the field of technological ecosystems has emerged as the study of the complex interaction between technological devices  and extensible technological frameworks and architectures on the one hand, and organizations, users, customers, developers, and businesses on the other ,12.The definition of a technological ecosystem has evolved throughout the years , in order to obtain an overview of the needs of the rest of the ecosystem actors involved  and identify the strengths and weaknesses of the research presented to date, which in turn will point out the possible future research directions along with their potential applications, stakeholders and market. In this sense, there have been different systematic reviews related to the Ambient Assisted Living (AAL) domain such as ,4,30,31 As care and assistance technological ecosystems are an open and new research area, which involves evolution capabilities and actors’ inter-relationships and added value, going beyond specific solutions for health or AAL, in this paper we want to provide an overview of the research work reported in the field by means of a Systematic Literature Review (SLR). To sum it up, the purpose of this systematic literature review is to obtain an overview of the research reported in the field of technological ecosystems aimed to provide services to people with special care needs.The rest of the paper is organized as follows: Following the recommendations of ,33, prio AND (“state of the art” OR “SLR” OR “review” OR “systematic mapping” OR “systematic literature review”).http://bit.ly/2Pfr9xT). Next, we analyzed the title and abstract of the resultant papers and applied the following inclusion criteria:The papers were written in English ANDThe papers were published in peer reviewed Journals, Books, Conferences or Workshops ANDThe papers performed a systematic review of the existing literature ANDThe systematic review focused on digital/technological/software ecosystems ANDThe technological ecosystems are within the care, assistance or health sector ANDAs a result of this search, we obtained a total of 1335 results, from which we removed all duplicates across the databases and stored them in a spreadsheet , obtaining a total of 24 candidate papers. It has to be noted that also during the assessment of this criteria three cases were detected with missing abstracts that could be candidates for full paper reading based just on the paper title, so they were also included in the next step.After these first two rounds the resultant candidate papers were labeled as “Candidate for full paper reading” in the spreadsheet : the target group for the investigation. As we are interested in two areas simultaneously—technological ecosystems and care—, our population is, in fact, a conjunction of those two populations.Intervention (I): specifies the investigation aspects or issues of interest for the researchers. In our case the design, implementations, components, performance evaluations, etc. of technological ecosystems proposals.Comparison (C): refers to aspect of the investigation with which the intervention is being compared to. No comparison intervention has been planned in our study.Outcomes (O): the effect of the intervention. We seek ecosystem proposals related to care and assistance as well as real implementationsContext (C): the setting or environment of the investigation. In our case, they are those environments related to care and assistance .As part of the planning stage, we have formulated three main research questions which have been broken down into a set of several sub-questions that will drive the review method. In order to contextualize, frame and answer these questions, and explain our review scope, we started by defining the PICOC items proposed by Petticrew and Roberts . The PICTaking the PICOC model into account, we translated our research goals into the following main research questions (RQs):How are care and assistance technological ecosystems considered in the literature? During the last years many different fields have employed the ecosystem metaphor to different extents. When compared to those other communities, we want to explore if the care and assistance ecosystems have any particularity in terms of their definition, scope, evolution over time, etc.RQ1 What are the main distinctive characteristics of this type of ecosystems? As described in our PICOC model, our population is comprised by two very different research fields: one is related to care and assistance whereas the other has to do mainly with technology. In terms of the first field, we are interested in investigating who are the principal actors participating in the care and assistance ecosystems, how does each actor contribute to the ecosystem, what are the barriers that complicate or hinder those contributions and what is the maturity of the proposals found in the literature.RQ2 How are sensor technologies integrated in the care ecosystem proposals? In ecology terms, an ecosystem is a unit of interdependent organisms which share the same habitat [RQ3  habitat , so it wThe above main questions have been broken down into a set of mapping questions (MQs) that will help to explore and analyze the current state of the art in the field. The considered mapping questions were:MQ1.1 What definitions of care and assistance ecosystems are given in the literature?MQ1.2 How has the research field of care and assistance ecosystems evolved over time? I.e., number of publications per year.MQ1.3 What are the main publication venues?MQ1.4 Who are the most active authors in the area?Regarding RQ1:MQ2.1 What is the ecosystem goal in terms of care and assistance?MQ2.2 What care and assistance services are provided?MQ2.3 Who are the main actors and what are their value propositions?MQ2.4 How can actors enhance the ecosystem functionalities?MQ2.5 What is the ecosystem maturity? I.e., have proposals been deployed in real world conditions or only conceptual architectures?Regarding RQ2:MQ3.1 What type of ecosystem architectures have been proposed in the literature?MQ3.2 What modelling notation and guidelines have been employed for describing the ecosystem architecture?MQ3.3 What sensor technologies are employed for providing care and assistance services?MQ3.4 How are sensors integrated in those architectures?MQ3.5 How do sensor technologies take into account the care and assistance environment? I.e., do they follow medical standards?MQ3.6 Are there complementary training actions considered in the ecosystem? E.g., in terms of technology usage, devices integration, etc.Regarding RQ3:The database is available for us through our institution.The database is capable of using logical expressions or a similar mechanism.The database allows full-length searches or searches only in specific fields of the works.The database allows additional filtering options such as publication year or publication language.The database is one of the most relevant in the research areas of interest in this review process: engineering, computer science, and care and assistance technologies.After defining the research and mapping questions , we selected the information sources of the papers to be included in the search process. The search was conducted in the following electronic databases: Web of Science and Scopus. The databases were chosen accordingly to the following requirements:As stated in , buildinFrom here, a common approach for building the search string is to manually choose the search terms, taking the researchers’ knowledge of the field as a basis, and refining the chosen terms by performing pilot searches until a search string that produces adequate results is found. However, as stated in As such, our final search string was:(ecosystem OR SECO OR platform) AND (elderly OR “older people” OR care OR “Ambient Assisted Living” OR AAL OR dependent OR dependant)Due to the broad scope of our review population and therefore of our search string, we made use of the databases search tools in order to delimit the number of obtained results. We limited the search to the engineering and computer sciences fields, as we were interested in ecosystems of technological nature. In addition, we limited the results from 2003 to date, because it can be considered the year where the concept of business ecosystem adopted the digital component which later originated other concepts such as technological ecosystem or software ecosystem .http://bit.ly/2PwL37v), we are able to compute the similarity (in terms of cosine distance) between two document abstracts. By using this approach, we have computed the distance between all the abstracts in the corpus of results and three selected prototype abstracts that we considered that resemble the topic of interest  to assess the correctness of the obtained results. Following this methodology, we considered that a threshold of 0.96 was adequate, both for producing a manageable number of relevant studies and for providing an adequate threshold to eliminate many that were not relevant according to the classifier.It has to be noted that the set of tools used are not intended to fully automate the process of paper selection; they are decision support tools. The final decision is always in the hands of the researchers’ criteria which are reflected in the quality criteria described in Papers should address technological ecosystems related to care and assistance technologies.Only papers published between 2003 and 2018.Papers published in peer reviewed Journals, Books, Conferences or Workshops.Papers written in English.Papers that have a document body that is more than three pages long.Papers’ abstract cosine distance to any of the three prototype abstracts is less than 0.96.Taking the above into account, our final inclusion criteria were:Assessing the quality of a primary study is a challenging task while performing a systematic literature. Thus, as shown in the guidelines proposed by Kitchenham and Charters , a qualiIn this case we refer to the maturity level of the ecosystem, ranging from just a proposal to having been implemented in the real world. That is, we evaluate the closeness of the ecosystem to be running real conditions. If the ecosystem is just a proposal, it is labelled as No. If it has been piloted to some extent it is labelled as Partially, and if it has been deployed and running it is labelled as Yes.The search was conducted in the databases indicated in http://bit.ly/2BpCxV0).The inclusion criteria was then applied to the downloaded list of candidate papers. In order to reduce the number of results to be manually analyzed, the automated abstract similarity inclusion criteria was first applied, restricting the list of candidate papers to 809. Results from this first selection are shown in (http://bit.ly/2Mkfujv).The resultant papers were then assessed for complying the rest of the inclusion criteria of http://bit.ly/2xXUxRu). In addition, during this assessment we considered papers collected within the references of those ones that potentially could be interesting for the review and mapping process, and the same quality assessment was performed over them. This last step provided the authors with another 5 papers to review.The papers were then read in detail and analyzed based on the quality assessment checklist described in The protocol followed for the review process consisted of the following main steps:Following the above steps, the obtained results are shown in The different steps and outputs are summarized in For each research question, a qualitative data analysis approach was followed to extract relevant data from the selected studies. The conducted process followed three major stages:http://bit.ly/2Pjo7bQ) following the coding created during stage 2.1. Papers were first read in detail localizing chunks of text related to each research question and were highlighted for further analysis. 2. Pattern codes and labels to assign symbolic meaning to the highlighted information were created. Related patterns were grouped in order to quickly find, extract, and categorize the segments relating to a particular research question. 3. A second in depth read of the text was performed and data was retrieved and stored in a spreadsheet  Independent Living; (OL) Occupation in Life; (R) Recreation; (HC) Health and Care; (O) OtherCare and assistance services provided: (R) Reminder and information services ; (S) Social interaction and support ; (HC) Health or Care services ; (EM) Environmental Monitoring  (RH) Rehabilitation and maintenance services ; (O) Other. In those cases where a described top-level service involved two or more of these categories  both service labels were considered.Who are the patient end users: (E) Elder users; (D) Disabled users, (CD) Patients with Chronic Diseases; (O) Others.Which actors that contribute to value co-creation are pointed out in the ecosystem: (HC) Health Care related actors ; (P) Patients (patients and their next-of-kin); (F) Funders ; (R) Regulatory parties; (SP) Software/technology Providers  (GP) Goods Providers ; (ED) Educational / research institutions.How can actors add/modify ecosystem functionalities: (ID) Including new Devices; (ISO) Including new SOftware (MSO) Modifying existing Software; (NS) adding New Services; (MS) Modifying existing Services  conceptualization ; (P) Piloted without real users; (PU) Piloted with real Users; (D) Deployed in real worldType of ecosystem architectures: We use the classification proposed by : (C) CorSoftware structure model notation and guidelines. Here we use the same notation as the one employed in : (A) Ad Sensor technologies employed for providing services: (A) Ambient sensors ; (L) Localization and presence sensors ; (B) Body sensors/medical devices ; (M) smart/Mobile technologies ; (C) Cameras; (O) OtherSensors integration approaches: (N) not described; (P) Point-to-point; (M) Middleware based; (SO) Service Oriented;Do these technologies follow standards or are they ad hoc solutions: (S) Standards; (A) Ad hoc solutionsComplementary training actions: (SD) on Software Development of new functionalities; (SI) on Systems Integration ; (TU) on Technology Usage  on Health Education ; (O) OtherAs a result, for each research question the following data extraction groups and labels were considered:http://bit.ly/2Pjo7bQ:In this section we present the results for each of the mapping and research subquestions obtained from analyzing the papers that resulted from the systematic process described in In terms of the definitions given in the literature for technological ecosystems in health and care, nine studies were found which try to provide a definition at least related to the concept. The proposed definitions are summarized in Regarding the temporal distribution of works dealing with technological ecosystems in care and assistance, the evolution of selected works over time is shown in It can be observed from the evolution of the number of publications that the topic of technological ecosystems focused in providing care and assistance services for people with special care needs is indeed an emerging field, as the only papers found before 2010 are . It has To answer this question we identified the authors from the selected papers. Only one researcher appears more than one time in the results, one as main author and the other as co-author of the paper. We have to note that this author also appeared in other excluded papers during our mapping process  due to tIndependent living—assist in normal daily life activities e.g., tasks at home, mobility, safety, agenda management (memory help), etc.Health and care—health monitoring, disease prevention, and compensation for disabilities.Occupation in life—the continuation of professional activities along the aging process.Recreation—facilitate socialization and participation in leisure activities.Regarding the ecosystem goal, we tried to evaluate how the different proposals approached the objective of providing care and assistance services to the end users. As such, results were grouped in terms of the four goals identified by  as the mIn terms of the care and assistance services provided, Provided services are distributed in the papers as: health or care related services 28 papers (75%), environmental monitoring 22 papers (59%), reminder and information services 17 papers (46%), social interaction and support 17 papers (46%), rehabilitation and maintenance services 10 papers (27%). Examples of the different services are shown in We have identified three main groups of patient end users: older people, users with any type of disability, and patients with chronic diseases. Results show that older users are mentioned in 76% of the studies (28 papers), disabled users are referred in 35% of the studies (13 papers) and patients with chronic diseases are identified in 14% (5 papers). In terms of the rest of the actors involved in value co-creation within the ecosystems, results are shown in http://bit.ly/2Pjo7bQ for further information. It has to be noted that, in this case, patients are included in the patient and/or relatives group if they make use of the ecosystem to actively provide benefits in the value co-creation chain .Regarding the specific value propositions identified in the papers for the different actors, we refer the reader to The obtained results shown in Cornerstone Ecosystems: where actors interact on top of a common software platform and usually extend the platform’s functionality. Thus the existence of a technological platform is of central importance for an ecosystem of this type. The structure and governance of this type of ecosystem is usually centralized. Examples of this type of ecosystem are Android or the AppStore.Standard-based Ecosystems: where instead of a common platform, the compliance to standards is the key requirement for contributing in the ecosystem. Usually, compliance to standards is set above the functionalities and concrete realization of the contributions.Protocol-based Ecosystems: where a protocol API is shared among all actors, providing more flexibility over technical contributions to the ecosystem. Protocols are a less restrictive and more flexible technical linchpin of ecosystems. They provide a predefined specification of interaction of contributions with each other .Infrastructure-based Ecosystems: where a common technology is shared among all actors, providing tools at development time but at the same time maintaining independence on the contributions. Usually, the interaction among actors are on a social level. Examples of this type of ecosystem are Gnome or Github.Regarding the ecosystem architectures proposed in the papers, we follow the ecosystem architecture classification proposal described in , and disTo answer this question, we followed a similar approach for classifying the different approaches as the one described in  for openAs such, in  differenDifferent modeling techniques were found, being the ad hoc notation the predominant one as present in 23 papers ,The objective of this question is to explore which are the main types of devices mentioned in the literature as to provide health and care services to the objective end users. We have grouped the technologies that compound the technological infrastructure of the ecosystems mentioned in the reviewed papers into five categories: ambient sensors, localization and presence sensors, body sensors or medical devices, smart or mobile technologies and cameras. Body sensors and medical devices: ECG devices ,47,63; bAmbient sensors: temperature ,7,66; huSmart technologies: smartTV ,53 PDAs Cameras: ,57,67,72Localization and presence sensors: infrareds ; RFID 77Examples of the different technologies described in the studies include:In terms of the integration of sensor devices in the ecosystem architecture, it is of particular interest to investigate the approaches followed to obtain and manage the information gathered from the different devices. The current trend in IT solution providers for health (including the care and assistance environment) is to move from fragmented services to progressively more integrated ones, which are likely to be provided by multiple stakeholders through well-elaborated collaboration mechanisms . Thus, pOn the other hand, middleware based approaches mainly follow a service oriented architecture as 80% of those papers refer to a service oriented middleware (SOM) . Other middleware approaches include agent-based , fog nodTechnologies involved in care or assistance solutions require a degree of regulation to ensure that they are safe, and that the data is shared and processed in a uniform, consistent and safe manner. The degree of regulation required depends on the level of risk associated with the technology. Although the list of regulations is broad, and in many cases they are geographical and domain-specific , with thHealth Level-7 or HL7  refers tXDS.b  is an stFor medical records:CEN ISO/IEEE 11073 —to enablFor sensors or medical devices:ISO 13940:2015 —covers tHIPAA   and which have been surveyed in In this section we discuss the findings related to our main research questions described in In order to explore how technological ecosystems for care and assistance are considered in the literature, we must first consider what a care and assistance technological ecosystem is in terms of its definition. As stated in , “there Considering this definition of digital health ecosystems, which includes those devoted to care and assistance services but also other health related areas, we can follow a similar approach as the one described in , and looResearch in new technologies for care and assistance is a growing research area and the domain has evolved at a fast pace during the last two decades in various directions . This teIn terms of the scope of the publications, until 2011 the topic of the research was clearly focused on developing software platforms for providing integrated care services ,53,62,73Apart from analyzing how care and assistance technological ecosystems are approached in the reviewed literature, the purpose of our second and third research questions is to have a notion of the main components that compound this type of ecosystem and how the reviewed papers approach them. The main structures that are comprised by a technological ecosystem have been proposed by Christensen : softwarIn the care and assistance domain, earlier proposals focused on techno-centric solutions that aimed to provide specific healthcare related services to senior citizens or disabled persons . HoweverObtained results are correlated with other systematic reviews such as , focusedAs defined in : “A careFor example, in terms of a health and care focused ecosystem, in  they depAs shown in In contrast with this finding, in the systematic review performed in  they claHowever, as discussed in Value co-creation is a fundamental aspect in the development of ecosystems of any nature which has gained importance through the years. This tendency is shown in  where thAs stated in : “the moHowever, as the goal of the searched technological ecosystems is to provide services to people with special care needs, it is evident that the value offered by these ecosystem actors will always be present in the interaction with other actors as found in , so we hHowever, in spite of the observed tendency towards broadening the scope of the ecosystems ,91, thisDuring the first steps of technological ecosystem design and planning, it is important to take into account which are the potential ecosystem actors, along with which could be their main interests in taking part in the ecosystem community. The main problem is not considering which values or benefits are sought or offered to the ecosystem community by the ecosystem actors by means, for example, of performing a previous exploratory study. For example, in terms of value co-creation, the core value sought by medical and technological companies from a care and assistance ecosystem is business growth. Another example could be non-profit organizations that already provide certain care services offered by the ecosystem but may be reluctant to incorporate certain technologies to provide those services if the benefits of doing so are not clearly stated. Therefore, even if a medical application or device could improve individuals’ lives significantly, if the value proposition is not mutually beneficial it might not be feasible to develop or include into the ecosystem due to a lack of interest of the stakeholders. This type of stakeholder exploratory study in the revised papers is only found in ,47,54.Not considering the actor’s value propositions during the ecosystem design stage is a flaw that has been reported in the literature ,92,93. IIn terms of adding new functionalities to the ecosystem, the three main considered groups of actors found in the studies  conform the main group of ecosystem stakeholders on which the development of new functionalities depends see . As suchObtained results differ from other areas of ecosystem development, for instance in software ecosystems, where including new software is one of the main goals in ecosystem evolution and sustainability  or eLearOn the other hand, research institutions and regulatory parties are barely mentioned in the reviewed literature as ecosystem complementors who could include real enhancements to the ecosystem (27% and 10% respectively). This also happens in other systematic literature reviews regarding ecosystems in other fields such as ,13,36,95In the particular case of care and assistance ecosystems, the reviewed literature shows that the capacity of adding new functionalities to the ecosystem, that comes from health care related actors and patients or relatives, is mainly reduced to assessing or complementing the existing services, providing new service ideas or generating new necessities for the creation of new services or the modification of existing ones. Technology and software providers are the main actors in charge of implementing those necessities into real enhancements in the ecosystem, provided that the ecosystem is open to new functionalities. However, as stated in  regardinAlthough from the obtained results, the fact that many proposals (which mainly describe platform-centric or infrastructure-based solutions) state that they are open to include new technologies , does nOn the other hand, in terms of the openness of the proposals to include new software enhancements, it has to be noted that as cornerstone architectures and infrastructure based ecosystems are the main types of ecosystems found, so the degree of ecosystem openness mainly depends on the development of new services over existing infrastructures, such as providing new applications to a mobile based care ecosystem. This is reflected in our results as only 5% of the reviewed papers provide means to modify the existing software.This contrasts with purely software ecosystems, where the recent systematic review carried out in  found 87Regarding this ecosystem maturity, These results are correlated with the ones obtained by , where tThe lack of real world deployed ecosystems described in the reviewed papers may be due to the fact that many of them are recent ecosystem proposals; no additional scientific work has been done after the papers were published or efforts were redirected to the real ecosystem deployment. In this sense, a further online search was performed and we found that some of the conceptual proposals have in fact been partially or completely deployed such as the univerSAAL platform described in , which iFirst of all, it has to be noted that there is a lack of concrete classifications in the literature in terms of technological ecosystems’ architecture no matter what their scope is ,13,34. TIn terms of care and assistance related solutions, the need for common software platforms has also been denoted. For example, in a recent survey of secondary studies on AAL platforms published between 2013 to 2017, they highlight the absence of a reference architecture that can be used to create a standard for AAL platforms .Related to those conclusions, our results in On the other hand, as  affirms,It has to be noted that although the ecosystem typification proposed by  is well This lack of standard-based ecosystems studies in the scientific literature can also be found in other application domains such as ,36,95.In terms of the modelling techniques employed in the literature, we observed in In terms of the employed technologies, we observe a wide range of technologies which have been considered in the selected studies see , and almIn addition, as reflected in the literature , employeIt has to be taken into account, however, that many proposals are conceptual models  based onIn terms of how these technologies take into account the care and assistance environment they are supposed to operate in, we have to note that only 35% of the papers take medical standards into account in some way or another see . The neeIt has to be considered that technologies that are intended to operate in close relation with humans, and particularly those involved in health, care or assistance solutions, require a degree of regulation to ensure that they are electrically, chemically, biologically, and physically safe for the patient, and that the data is shared and processed in a uniform, consistent and safe manner . We see a lack of concern in standard acceptance in the studied papers, which could be related to the ecosystem maturity of the proposed solutions. This issue has also been addressed in other studies related to devices in care technologies such as , where tIn terms of the integration of sensor technologies into the ecosystem, results presented in The constraints of the ad hoc integration are reflected in the studied papers that follow a point to point integration approach where, although a specific middleware is not used for the integration of devices, researchers are compelled to employ different kinds of dedicated gateways so the data obtained from the sensors are accessible by the rest of the ecosystem components to provide aggregated services. Although these gateways serve as an abstraction from the specific protocols and standards of the interconnected devices to the upper layers, data gathering and aggregation must be done by the gateway device by means of protocol-dependent software and applications. This causes the whole service provision chain to be subject to the specifications of the sensors employed, and also the incorporation of new devices that could enhance existing services or provide with new ones is restricted.For example, in ,64 they The importance of employing a middleware approach in complex scenarios is a matter that has been widely addressed in the sensor-related literature ,105,106.Results described in Within the SOM approaches, the use of the OSGi framework is widely spread in the papers, as 50% of them make use of OSGi  for servThe importance of training actions, which include documentation, wikis, forums, etc. is of great importance in terms of technological development and is well known in technological fields like computer science . In factIn terms of care and assistance, it has been shown in many studies over the years that senior users and persons with any type of disability face serious problems when it comes to interacting with the technology ,109,110,For that reason, training actions should be a major concern in order to overcome their reluctance to be part of any type of technological ecosystem. As stated in one of the reviewed papers which carried out piloted studies with real users : “Due toThis issue has also been addressed by other authors in other ecosystem fields, not only in terms of end-user usability but also in terms of the easiness of developing new functionalities into the ecosystem. For example, in a recently published systematic mapping , they stIt has to be noted that, as with any research method, there could be threats to its validity and limitations in the current systematic review. The first threat is that the inclusion of all the relevant projects in the field of ecosystems in care and assistance is not guaranteed. This threat was mitigated by piloting different searches and combining different databases and manual searches. However, as can be depicted from the results, the number of papers that have reached the final stage after applying the quality criteria is quite low if compared with the number of papers retrieved from the search. The main reason for this is that, even though we have developed specific tools for aiding in the search string construction, the research field of technological ecosystems in care and assistance is an emerging field, so scarce information can be retrieved. For that reason, the search scope was broadened so as to capture as much information as possible within the limits of the review scope, and tools for fast abstract screening have also been developed for that purpose as described in A limitation of the proposed methodology and tools relies in employing only the retrieved abstract from each study. As the abstracts of publications contain way less information than is contained in the full paper, this could lead to a bias in the search results. In addition, as there could be different configurations of the parameters involved in the proposed stages  the set of parameters could introduce new threats to validity. It has to be noted, however, that the employed methodology for search string construction and abstract screening is not intended to fully automate the process of document search and retrieval, but to be combined with the researchers’ knowledge of the field. These stages were peer-reviewed so as to ensure the fulfilment of the research goals, and searches were first piloted to ensure that relevant terms were employed that produced enough results related to the topic of interest.http://bit.ly/2Pjo7bQ) that contain the results from databases as well as the results of the different stages of the review process were intended to reduce or remove any kind of bias, and also to make the whole process reproducible for the reviewers and readers.There are also two threats to internal validity in this systematic review. The first threat is that, due to the wide scope of the ecosystems described in the papers that include not only many different technologies, layers and components , most of the papers do not provide detailed descriptions or references for all the research and mapping questions. The second threat is related to the identification of values for classification criteria which again was not obvious in many cases, as many papers contained vague or fuzzy descriptions for the grouping terms employed for data extraction. In this case, some strategies  were used to mitigate this effect. In addition, the different resources provided  participation in the care process. Increasing the communication amongst different ecosystem actors not only allows doctors, hospitals and care institutions to be more accessible to patients, but also helps patients to connect with other patients. Furthermore, it allows patients and carers to be aware of treatment options along with preventive measures.Stats and management information which are a product of the care process. The information extracted from the ecosystem information exchange (taking into account privacy and security issues) allows the establishment of new business models that could attract other stakeholders even not directly related to the care provision.Taking into account the propositions of added value found in the proposals, the opportunities of delivering care innovations through technological ecosystems include:However, results show that there are still many challenges and gaps that need to be fulfilled for developing technological ecosystems in care and assistance mature enough to provide the above opportunities in a consistent way. The ideal would be to follow a path to a single solution set, evolving from innovative solutions into a single ecosystem solution that involves all the ecosystem stakeholders. In this sense, one of the main gaps in the reviewed literature lies the maturity of the solutions found. As stated before, this could be related to the delay in indexing new developments in the selected sources. In any case, as a result of this lack of maturity there exist numerous ongoing initiatives for example at a European level such as the projects ACTIVAGE, Sofia2, SeniorSome, OneM2M, BigIOT, or MONICA focused on developing ecosystems in the health and care sector. The fact that they have not been found in the current search may be due to the fact that some of the proposals are either ongoing projects, they are not specific to the care sector or they do not have published research papers in relevant databases, but are rather found through communities and fora. Nevertheless, the existence of these initiatives denotes there is still much work to be done in the field.Focusing on the obtained results, from the point of view of the software and technology structure there is still a great margin of development. For example, in terms of the openness of the proposals to include new software enhancements, only 5% of the reviewed papers provide means to modify the existing software. Including new software developments not only benefits from the point of view of ecosystem openness and expandability of the platform but also allows the inclusion of third-party software developers into the value chain. The fact that cornerstone and infrastructure based ecosystem architectures are the main types of ecosystems found makes the governance of the ecosystems highly centralized. This causes the existing software technologies, although modular and able to accept the inclusion of new software, in many cases to not be specifically designed for a care and assistance environment, and it is difficult to take into account aspects such as the privacy of the data or the interoperability between medical information systems. This results in a general lack of means to model and standardize the inclusion of new software developments, again hindering the incorporation of new potential stakeholders. In the same sense, although many proposals make reference to the possibilities of new device integration through different kinds of middleware, few of them take into account medical standards for connecting new sensors and medical devices. Not considering medical standards makes potential medical device developers back down when it comes to being part of the ecosystem.It seems evident that the above gaps have a direct influence on the ecosystem business model. In this sense, the business structure is generally omitted in the found literature, along with the lack of involvement of the potential stakeholders in the development of the ecosystem since the first stages of technological development. In general terms, the approach taken to provide services is to make measurements of clinical information or environmental monitoring in the patient’s home and then share it through a centralized platform in which doctors or caregivers can make decisions about care provision. This user-centric model, rather than stakeholder-centric, makes it complicated to develop business models once the platform has been implemented and to attract other ecosystem actors. In this way, business models are reduced to patients and families care providers  using the ecosystem services. However, scarce attention is given to other business models such as: IT support and maintenance, providing training for end users or third party developers, develop ecosystem data and analysis tools (such as dashboards) and even to third parties incorporating or publishing other non-care-related services such as amenities for the dependant end users.Due to the above, there is also a lack of an organizational structure in order to govern the ecosystem proposals, which in fact has a negative impact when it comes to attracting health authorities and governmental organizations. Although the process of delivering care is quite generic, and its complexity varies due to different factors such as geography, different patients health conditions, etc. found ecosystems rarely take into account this variability from an organizational perspective. To achieve this claim, platforms should feature a high degree of modularity while using established standards, and also consider other aspects such as data ownership, security, privacy etc., which in many cases vary depending on the country or even region. Although some of the found proposals take these issues into account, they lack the organizational structure necessary to apply them in practice. Thus, they do not provide the necessary links between the software and business structures, and also they lack an adequate organizational structure to govern the different technological solutions from a global  perspective.All the above gaps can be seen as opportunities for developing future lines of research. To understand and model care providing ecosystems, different paradigms still need to be applied in order to capture a more realistic view, bridging the gap between the ecosystem model and the ecosystem that needs modelling. For example, in terms of establishing well founded software and business organizational links, more effort should be made in characterizing the different ecosystem components from the very beginning. As such, incorporating the organizational and business structures during meta-modelling the ecosystem software structure and taking them into account in the data ontologies could help to reduce these gaps. An example of efforts in this direction can be found in . On the There is not a single concrete definition that encompasses all the characteristics of a care and assistance ecosystem. However, most definitions share common characteristics in terms of providing technological means to a community of users  in order to involve all of them in providing better care and assistance related services.The field of technological ecosystems in care and assistance is indeed an emerging field, as most publications found date from 2011 onwards.Most of the papers’ main efforts are focused on developing ecosystems where actors interact on top of a common technological platform, either developed from scratch or adapted from existing infrastructures and where the governance is usually centralized.The maturity of the ecosystems found in the literature is mainly conceptual, however, some of these conceptualizations have been evolved to concrete solutions.Ecosystems are usually user-centred rather than stakeholder-centred, where aggregated services and architectures are mainly focused on the patient end users. Few ecosystems take stakeholders into account during the designing stage.Employed devices for providing services are of a very diverse nature depending on the intended services, but many of them do not take into account medical standards.As platform or infrastructure centred ecosystems, the degree of the ecosystems’ openness to new devices greatly depends on the followed methodology for device integration within the service chain. Service oriented middleware (SOM) is the preferred approach in the studied papers.There is a lack of training actions considered in order to facilitate or even create the relationship between the different ecosystem actors and the underlying technological components.In this paper we have presented a systematic review and mapping of the literature to identify, analyze and classify the published research carried out to provide care and assistance services from a technological ecosystems’ perspective. The research was conducted using systematic review and mapping in accordance with the guidelines proposed by Kitchenham and other authors in the field of software engineering. After applying the developed systematic search and review protocol, 37 papers that described technological ecosystems in care and assistance were obtained, data was extracted and results were analysed to give answers to our main research questions: how are these types of ecosystems considered in the literature, what are their distinctive characteristics from technological, care and assistance points of view. The main findings obtained from this process can be surveyed as:


The approaches and tools of health promotion can be useful for civil society groups, local and national governments and multilateral organizations that are working to operationalize the 2030 agenda for sustainable development. Health promotion and sustainable development share several core priorities, such as equity, intersectoral approaches and sustainability, that help maximize their impact across traditional sectoral boundaries. In the Region of the Americas, each of these priorities has strong resonance because of prominent and long-standing health inequities that are proving resistant to interventions driven solely by the health sector. We describe several cases from the World Health Organization’s (WHO) Region of the Americas in which the approaches and tools of health promotion, with a focus on cities, healthy settings and multisectoral collaboration, have been used to put the agenda into practice. We highlight areas where such approaches and tools can be applied effectively and provide evidence of the transformative potential of health promotion in efforts to achieve the sustainable development goals. Transforming our world: the 2030 agenda for sustainable developmentThe scale of the transformation required to achieve all of the SDGs is considerable. Historically, in general, sector-specific commitments have driven the actions of the key players in international development. The millennium development goals (MDGs)Box 11. Intersectoral action by multiple stakeholders2. Health systems strengthening for universal health coverage3. Respect for equity and human rights4. Sustainable financing5. Scientific research and innovation6. Monitoring and evaluationHealth promotion has a fundamental role to play in realizing the entire agenda. In contrast to the MDGs, the agenda highlights health as a component of all the SDGs and a critical element of the process of developing an equitable and sustainable future. Compared with the MDGs, SDG 3, which aims to “ensure healthy lives and promote well-being for all at all ages”, applies a much more expansive view of health. The direct or indirect links of health to all 17 SDGs highlight both the complex role and the importance of health promotion in achieving equity, empowering communities and people and protecting human rights.It has been argued that the agenda places too much focus on relatively narrow measures of economic performance, e.g. economic productivity, gross domestic products and job creation, and too little focus on sustainable environmental and social measures.Realizing the future we want for all.The vision for the agenda was outlined in a document that the United Nations published in 2012: Measurement of progress towards the MDGs was mostly reported as aggregated means that failed to illustrate the contributions that various subgroups of the population made towards a specific outcome. As the MDGs did not effectively address the differentials in health status associated with educational, ethnic, gender, socioeconomic and other differences, they often allowed health inequities to persist. However, they also led to much success. Within the Region of the Americas, for example, many countries reached or surpassed the MDGs relating to access to education, improved water and sanitation.The Region of the Americas faces several challenges. While rapid economic development has opened the window to many health gains, socioeconomic inequalities combined with other important determinants of health, e.g. education, ethnicity and gender, are associated with considerable gaps in health outcomes and unacceptable health inequities. For example, life expectancy at birth in Canada is nearly 20 years longer than that in Haiti and infant mortality rates in Canada and Cuba are about a tenth of those in the Plurinational State of Bolivia and Haiti.In addition to the need to address health inequities, the gains under the MDGs also call for changes in priority health areas. For example, during attempts to achieve the MDGs, the Region of the Americas saw a substantial increase in the proportional contribution that neonatal mortality made to mortality among children younger than 5 years. This observation indicates the need for a greater focus on neonatal mortality and its associated risk factors. Although the development of enhanced immunization programmes has led to substantial increases in coverage of three doses of diphtheria–pertussis–tetanus vaccine, about one million children are still unvaccinated in the region, many of them difficult to reach and living in situations of vulnerability.,Over the last few decades, several new approaches to health promotion have been developed. Most have involved the integration of multilevel interventions. There has been an emphasis on enabling healthy environments, reorienting health services and promoting well-being and healthy choices via community involvement, public policies and the strengthening of individual capacity to control the determinants of health.The Ninth Global Conference on Health Promotion highlighted various approaches to health promotion, based on public policy, that were predicted to facilitate achievement of the SDGs. These approaches included action across sectors, the development of so-called healthy cities and social mobilization.–,The development of healthy settings represents a currently widespread strategy for putting health promotion into practice at the country level with important ties to universal health coverage and access to key health and social interventions.The Shanghai Declaration also recognized the need for more promotion of health literacy. By strengthening health literacy at local and national levels, it should be possible to increase each person’s control over their own health and their capacity to engage with the broader determinants of health.A growing number of initiatives, spearheaded by national and local policy-makers, highlight how the approaches we have discussed can be translated into action in the Region of the Americas. Mexico’s National Agreement for Healthy Food represents a notable example of successful intersectoral action in the region.The movement for healthy cities, communities and municipalities has also attracted considerable enthusiasm. The Shanghai Consensus on healthy cities, which was adopted at the Ninth Global Conference on Health Promotion in 2016, highlights the strong links between sustainable urban development and health.There have also been encouraging initiatives at the local level. For example, the Colombian city of Medellín underwent a process of citizen and urban transformation in 2004 and has since been increasingly recognized as a hub for civic engagement, equity, social and technological innovation and sustainability.In 2013, Chile established a healthy cities, communities and municipalities strategy, with the goal of promoting intersectoral collaborations to address pressing local health needs. Since then, several national ministries have coordinated with over 300 municipalities to implement programmes that address inequities in access to healthy food and public health services.The observations made in Chile and Colombia highlight some of the important contributions that cities and municipalities are making towards health and the SDGs. There is a powerful link between the health-related SDG 3 and SDG 11, which promotes sustainable cities and communities. The substantive leadership role played by mayors and municipal leaders, both individually and in formal and informal networks, appears to be critical to the success of healthy-city initiatives. Mayors can play a defining role in creating healthy urban environments through determined political action and are also often able to lead in the delivery of SDG-related activities.The ultimate aims of the agenda are to safeguard the planet and improve people’s lives. The agenda’s goals, indicators and targets should reflect the efforts that each country, local community and individual are making to improve global health and not, simply, the ability of a single sector to achieve a few specific outcomes.–There are several obstacles facing the achievement of the SDGs. Given the substantial financial backing and resources required for implementing SDG-related strategies and policies, sustainable development requires action from a broad range of investors.Once each country decides on which SDGs and targets they will focus on, a core challenge will be the establishment of a strong framework to monitor progress in addressing those goals and targets, especially those related to health and inequalities. We need improvements in our understanding of successful interventions and in the identification of populations with the greatest needs. As a basic requirement for pursuing effective action under the SDGs, we also need to use existing data to build the evidence base for health-promotion actions and interventions that address determinants of health.In many low- and middle-income countries, there are extreme shortages of relevant disaggregated data on educational level, ethnicity, socioeconomic status and other important health determinants.The health-promotion and sustainable-development movements can each be more successful if they build on their shared priorities, exploit the pool of mutually relevant knowledge and capitalize on growing global interest. Open and inclusive channels of communication need to be established among all of the groups that are devoting resources to accelerate the implementation of the agenda. Given the overlap of the goals, methods and priorities associated with the SDGs with those associated with health promotion, progress made on the SDGs has great potential to advance health promotion simultaneously and vice versa. Approaches that promote health are key to achieving the SDGs. Health equity comprises a core shared value that should, according to recent global commitments such as the Shanghai Consensus,Several challenges remain, particularly the dearth of frameworks for effective monitoring and evaluation and the dearth of evidence on the impacts of complex social actions on health determinants and systems. If the field of health promotion is to embrace its full potential role in responding to these challenges and achieving the SDGs, we need to build a solid evidence base and document and disseminate the relevant evidence that is already in existence. For health-promotion interventions, we need more data on the impact of multisectoral collaborations designed to support health and healthy settings and on the conditions that promote equity effectively.By applying the tools and principles of these converging agendas, in systematic, targeted and measurable ways that reflect the mandates of recent global and regional commitments, it should be possible to make dramatic strides towards our shared vision of an equitable, healthy and sustainable future in which no one is left behind.


It has long been recognized that health and its determinants are stronglyinfluenced by policies, programs, and projects outside of the health caresector. Few countries have introduced health impact assessments (HIA) to try andensure that probable impacts on health are considered. An appropriate healthimpact assessment regime will identify negative and positive impacts of proposedhealth policies and programs on health, enable the interpretation of health riskand potential health gain, and present the information to assist in decisionmaking. These HIAs are often generic and rapid desk–based appraisalscharacterized by the use of information and evidence that is already availableor easily accessible and generally undertaken by administrators in anorganization to gain a snapshot of the health impacts to inform proposaldirection. Rapid and generic desk–based assessments require less-intensiveeffort and resources and draws on existing data sources from scientificpeer-reviewed and gray literature to analyze potential health impacts. However,both sources can also be used to determining whether a more detailed review isnecessary. The Community HIA model proposed by this work departs from thegeneric and rapid desk–based appraisals and is intended to provide practicalevidence to give higher priority to people’s viewpoints, promote participation,understanding and incorporate community voices to help shape future policy,programs, and practice. A comprehensive review of Ghana’s National HealthInsurance Scheme (NHIS) was carried out using the generic desk–based HIAapproach. This was followed by a practical qualitative community field work. Inthis research, we have demonstrated how community HIA is to be conducted throughan actual case study in the Ghanaian West African context. The scope of thiswork is wide and incorporates the consideration of key concepts and possiblemethods for carrying out HIA at the community level. Health impact assessment (HIA) is a fast-emerging contemporary process. This articleaims to contribute to an understanding of community HIA in Ghana and also todemonstrate how impact assessment might be practically conducted in such anenvironment of limited health development and scarce resources. The scope of thiswork covers some of the key concepts related to impact assessment and possiblemethods that may be more appropriately and effectively applied at the communitylevel. It also analyzes how community participation may be promoted based onunderstanding the voices of ordinary people in making informed policy decisions. Inshort, how best to recognize community perspectives in policy planning andimplementation to achieve maximum impact at the affordable cost.This work is aimed primarily at policymakers and attempts to provide an approach thatdeparts from the standard generic desk–based HIA because of its limitations, infavor of a more practical and pragmatic approach of community HIA, better suited toAfrican, or indeed, developing countries generally.1 Howard and Gunther2 noted that community actions lie outside the mainstream health sectors andgovernment policy development objectives are best achieved when all sectorsincluding community actions are collaborative. This is because, by definition,health issues intersect all aspects of social existence. The effective use ofhealthy public policy approaches therefore relies strongly on HIA.3The public health challenges of the 21st century are extremely complex. Thus, thesolutions require sophisticated and comprehensive approaches that transcend thenarrow bounds of the health sector itself, bringing together partners across otherpolicy sectors and also community action.4The HIA process advocated by this article is embracive and therefore, when assessinga proposal, takes on board relevant evidence that includes the views of thepublic/community which is considered alongside expert opinion and scientific data,with each source of information being valued equally within the HIA.5 In this context, it is important to point out that an HIA does not makedecisions; it is a methodological approach by which the best information ispresented to decision makers in a clear and transparent way.6 Unfortunately, as indicated above, most HIAs have been solely desk-based withno lay community perspectives. Even more serious is the lack of evidence of the useof any kind of HIA in policy assessments in Sub-Saharan Africa, despite theundoubted flexibility, simplicity, transparency and cost-effectiveness, acceptanceand explicit success in carrying out local, regional, national, and internationalpolicy analyses in developed countries.7 The aim of this article, therefore, is to contribute to meeting this gap andfocuses on HIA concepts and practical methods using an example from a studyconducted in Ghana, West Africa. The study used HIA framework to examine a NationalHealth Insurance Scheme (NHIS) in Ghana. This article describes the methods used anddiscusses how HIA is a useful tool for ensuring progressive understanding andavoiding retrogression in pro-poor policies such as the national health insurancefinancing policy in Ghana.This embracive approach is argued to be so critical to HIA that it is advanced as thefoundation upon which the HIA approach advocated by this work has been based. HIAsare good tools to assess health policies in terms of impact on health. Communitiesmust therefore be part of HIAs and this fact is now internationally accepted as theframework used in policy evaluations.Most policy procedures are prepared in the framework of methods or approaches thatmay be more or less specific in a given population and at a given period. It isvital that such approaches or methods are taken into account, otherwise communityHIA runs the peril of being a non-natural process, separated from the realism of thepolicy contexts in which it is being executed. This proposed method suggests that inaddition to promoting the utmost health of communities, 5 determinants arepredominantly essential for community HIA as detailed in 8The concept of health promoted by advocates of HIA is a broad one. Sustainability isregarded as necessary conditions for health and development, as exemplified by theSustainable Development Goals. Sustainability may be defined as meeting the needs ofdemand of communities without compromising the ability of future communities to meettheir own needs.12 WHO provides the following cogent justification:13Understanding health as a human right creates a legal obligation on states toensure access to timely, acceptable, and affordable health care ofappropriate quality as well as to providing for the underlying determinantsof health, such as safe and potable water, sanitation, food, housing,health-related information and education, and gender equality.It is contended that any contemporary discourse on health policy promotion mustnecessarily engage human rights. The Constitution of the World Health Organization(WHO) envisages “ . . . the highest attainable standard of health as a fundamentalright of every human being.”9 the International Covenant on Civil and Political Rights (ICCPR),14 and the International Covenant on Economic. International Covenant onEconomic Social and Cultural Rights (ICESCR)15 must be read together as an interlocking normative system in which rights are“ . . . universal, indivisible and interdependent and interrelated” .16 Since human rights are not meaningful to a person who is afflicted by poorhealth, if occasioned by want of the material necessities of life as affirmed by theICESCR. This is the reason why Krieger et al17 highlight that HIA and human rights are both associated with the promotion ofhealth and well-being. In addition, the principle that human rights are universaland inherent in all human beings as propagated by the UDHR and the ViennaDeclaration and the WHO principles indicated above are the reasons why effective HIAis essential in ensuring the institution of good health policies and programs tofacilitate at least, the minimum well-being of all without reference to theirsocioeconomic status in a world in which the health outcomes for the rich and poorare poles apart—according to United Nations research statistics, the average lifeexpectancy in the highest developed economies is 80 years and 59 years in the lowestdeveloped countries.18The foundation instruments of the United Nations system for the internationalprotection of rights are the Universal Declaration of Human Rights (UDHR),19 Thus, for HIA, equality or equity in well-being is a core value and manyspecialists have employed HIA to advance equity in decision-makingprocesses.21 However, as the field becomes better known, there is a dangerthat the concentration on equity will diminish without explicit attention, care, andguidance regarding its role in HIA practice.22 Inequity has a moral and ethical dimension, resulting from avoidable andunjust differentials in health status.23 Equity in health entails that ideally everybody should have a fairopportunity to attain their full health potential and, more plausibly, that no oneshould be disadvantaged from achieving this potential if it can be avoided.10Health impact assessment is an essential tool for understanding health inequality asit is able to assess the community impact of proposed policies, plans, or projectson communities.11 It needs the involvement of local leaders who govern by proximity and ensurethe implementation of social policies, the transportation sector builds reliableroads that can decrease transit time for ambulances and cars to reach hospitals, thecommunications sector helps promote the existence of new health care services, andso forth.11 This means that improving inter-sector cooperation can support programs thatpromote working together across various sectors.Intersectoral actions within and outside public and private sectors and communityviews are emphasized. For example, the health sector cannot achieve health-relatedgoals as an isolated, stand-alone system.24 The FGDs and key informant interviews present the actualperspectives.26 The community HIA being proposed used key informants and focusgroup participants and are discussed as part of how to carry out a community HIApractically using the NHIS in Ghana as a case study.Depending on the type of HIA being undertaken, either community participatoryapproaches, qualitative or quantitative methods or both can fit within HIAframework. This article is focused on how lay community views fit within the HIAframework. In other words, it discusses how focus group discussions (FGDs) and keyinformant interviews can be an integral part of HIA framework to bring the views ofpeople at the community level.27 The findings are reported elsewhere, but the methodological concepts ofcarrying out a community HIA are recounted. Health impact assessment is acombination of procedures, methods, and tools by which a policy, program, or projectmay be judged as to its potential effects on the health of a population, and thedistribution of those effects within the population.28 The practical application ofHIA to the NHIS followed the conventional desk–based HIA processes with modificationand additions.The ideas presented in this section were part of a PhD project where HIA was used tostudy the NHIS in Ghana practically.Initially, there was a need to search whether the NHIS policy or program in Ghana hadan influence on health and what kind of influence. At the screening phase of the HIAprocess, it was learnt that additional evidence was needed, so a scoping process wascarried out to ascertain what auxiliary work ought to be carried out, by whom, andhow. Second, methods established were followed by impact identifications of the HIAprocess by reporting on community processes including results, then appraisal ofappropriateness of the report, and finally by action to modify the proposed policy,program, or project. The outcomes of any of these phases needed reassessment offormer phases see .A comprehensive review of the NHIS literature was identified at the screening phaseby the desk-based HIA. This was followed by a community field work as part ofqualitative research. The qualitative study of the NHIS in Ghana brought to bear thecommunity perspectives of HIA. The results of the desk-based HIA are reportedelsewhere, but the processes are found in 30 Community involvement isdiscussed below.An extensive and systematic search of the literature was conducted on variousacademic databases to locate literature on HIA and NHIS at the screening phase. The sea31 Thus, engaging the community in the qualitative research process wasessential and therefore the opinions, experiences, or expectations of thecommunities were considered through consultations in FGDs and interviews with keyinformants.After the screening phase suggested potential impacts of the NHIS policy on theGhanaian population, it became essential to engage the community in FGDs and KeyInformant interviews to listen to personal experiences and opinions of NHIS. Thesediscussions then supported data obtained from the literature. The FGDs and keyinformant interviews were done as part of the qualitative research process.Community involvement is essential in the development of policies that impact on thehealth of a society.32The primary aim of the study was to analyze the NHIS using HIA and the purpose of thefocus groups and interviews was to facilitate community involvement as part of thequalitative study. First, grassroots Ghanaians were engaged in an FGD (considered inthe data collection section). The FGDs allowed engagement with the community andlistened to people’s experiences and opinions of NHIS policy to support data fromthe literature. The FGDs were chosen for this study because of the brainstormingformat that continues to be one of the best means of gaining in-depth opinions andfeedback on a broad range of issues.33 note that qualitative interviews are appropriate for seeking access torespondents’ understanding of their social world. Interviews are one of thegenerally accepted, identified, and indispensable mechanisms for collecting evidenceor data for social science research.34 As the topic on NHIS is about studying human affairs, the interviews providea useful source of information and they stand the chance of obtaining richinformation from their informants.35Second, community leaders, the elite and key informants on the NHIS policy, wereengaged through face-to-face interviews. From an epistemological viewpoint, Moss and ShankIn total, the FGDs and the interviews were for the grassroots Ghanaians and keyinformants to explore their experiences, thoughts, and feelings because they are atthe receiving end of NHIS services with direct and indirect impact. The datacollection processes including sampling of the FGDs and interviews respondents aredetailed below as part of the impact identification process in HIA .20 note that qualitative methods within HIA dwell on community involvement andcomprise a range of activities such as interviews and focus groups. Qualitativemethods have been reported to be distinctive to individual experiences, perceptions,beliefs, and understandings and also answer the primary research questions, thusjustified. The qualitative data collection processes then followed are narratedbelow.As indicated in The community selection processes are discussed first, followed by selection ofhousehold processes. The sample strategy aimed to select communities that wouldbring out variations in the findings. We chose the areas that could offerinteresting findings such as those towns and villages that had varied economy andgeography. We deliberately selected 7 differing communities from the Ghanaiancommunities in the Ashanti region areas. The 7 communities selected were justifiedbecause they were based on their distinctive geographic characteristics, portrayingcharacteristics of the rural areas. Two communities were well developed andaffluent. Another 2 communities were both slightly undeveloped and developed andwere popularly known as middle-class areas. The remaining 3 communities, on theother hand, were overpopulated and underdeveloped communities. They are deprived andmarginalized communities with serious socioeconomic problems—in short, these werevery poor communities. Local authorities  ofthese communities were approached to introduce ourselves and explain the purpose ofthe study. The authorities of the hospital in the town were also informed about theproject and the recruitment of participants. When permission was given to recruitfrom households for the focus groups, invitation letters were distributed to varioushouseholds from urban to rural communities as described below. For each selectedcommunity, on approaching the first house, a coin was tossed. A head meant thishouse was taken as the first in the counting process and then the fifth house wasselected for inclusion. A tail meant that the second house was considered as numberone in the counting process. The fifth house from this was then selected forinclusion. This was systematic random sampling. Therefore, every fifth house wasselected with the view of inclusion and this continued until saturation. Informationabout the nature, purpose, and objectives of the study were provided to the inviteesin the selected households and their verbal/signature consent was obtained duringthe FGD.36Data were collected between July and October 2015 from residents of the Ghanaiancommunities in the Ashanti Region. Participants in the focus groups were aged over18 years and were from the sample households within the communities of the district.The sampling unit of the focus groups was the household, which is defined as “aperson or group of persons living together in the same house or compound, sharingthe same housekeeping arrangements.”37 averred that having such a close-knit group is useful, because people who arealready acquainted through living, working, or socializing might normally discuss(or evade) the sorts of issues likely to be raised in the FGD sessions. Thus, anaturally occurring group is one of the most important settings in which ideas areformed and decisions made. Study participants were free to terminate theirparticipation at any time, even after the focus group had started. Participants inthe focus groups were engaged in the discussions via an open-ended semi-structuredquestionnaire in a local language. The questions were reviewed occasionally to marrythe aim and objectives of the project. The FGDs were conducted in parallel with theface-to-face interviews of key informants during the data collection period. Theinterview methods are discussed below.The sampling unit of the FGD was household and most of the participants in each groupdiscussion were quite familiar with each other and were living together in a largecompound house, in a small family house, or in the community. Krueger38 key informants are used to gather detailed and rich evidence in a relativelyeasy and inexpensive way. Denzin and Lincoln39 suggest that such interviews look like a normal everyday conversation,allowing for a free flow of ideas and information. Morris40 explains that key informant interviews also allow the investigator toestablish relationships with the respondents and to clarify questions, thusproviding an opportunity to build or strengthen relationships with importantcommunity informants and stakeholders. Overall, all the 9 face-to-face key and eliteinformant interviews provided a free exchange of ideas, with more complex questionsasked and detailed responses of impact of the NHIS received.Nine key informant interviews  enabled what is the impact of the NHIS policy on the people of Ghana?Semi-structured interviews were determined to be suitable methods because they allowdiscussions of the concepts in depth and they accommodate changes in the interviewprotocol in line with the emergence of new themes and the specific areas ofexpertise of participants. A semi-structured interview guide that varied slightlydepending on the category of stakeholder was used. In general, it included questionson the impact of the NHIS on the population of Ghana and health care finance and theinformants’ role in development, implementation, and decision-making pertaining topolicy. Forty-five-minute to 1-hour face-to-face interviews were conducted with allthe agreed participants. Interviews were held in either homes or offices and no onewas coerced to participate. All participants were promised confidentiality andanonymity, and everyone provided oral/written consent.The specific research question that guided the qualitative component of the studywas: The study was approved by the ethics committees of our Ghanaian and United Kingdom’sinstitutions respectively.A tape recorder was used to document both the key informant interviews and the FGDs.The tape recording approach allowed us to engage freely in the conversation withoutworrying about note-taking. The recorded information helped when we weretranscribing the data. Brief notes were also taken during the interview, writtendown, and organized at the end of the interview. These notes were used to fill ininformation gaps as well as to supplement the recorded conversation. Consents wereobtained from the key informant and the focus group participants to audiotape theinterview/FGDs. The audio taping was discussed with all the participants beforescheduling the interview appointments.27 but it should be noted that this article is focused on the processes and themethods of carrying out Community HIA; hence, the appraised results is not discussed.This is in line with the 5 fundamental principles of HIA described in HIAliterature—sustainability, human rights, equity, ethical application of evidence,and collaboration see .Community HIA is concerned with the health impacts of future, as well as present, andtakes into account lay views to support the health, development, and well-being ofpopulations in decision-making see . People 23 Countries that are part of this agreement appreciate the rights of citizensto enjoy the highest attainable standard of mental and physical health. In anyevent, the special status of the UDHR as the premier human rights instrument incontent and authority allows us to assert that its core principles have crystallizedinto jus cogens principles or peremptory norms of customaryinternational binding on all states.41Community HIA is concerned with human rights as discussed above and most nations haveendorsed at least one global accord that comprises the right to health see . The Uni42 argue that the health determinants that underpin the right to the highestattainable standard of mental and physical health are food, community participation,transportation, and equity. According to Scott-Samuel and O’Keefe,10 it is a right to influence choices that affect a person’s health. In recentyears, Marmot et al6 and CSDH22 have expanded human rights with progressive understanding to mean thatcountries must take obvious steps toward recognizing the right of health for all andretrogressive steps are acknowledged as not acceptable in health. Thus, communityHIA are good tools for guaranteeing progressive understanding in policyimprovements.Hunt and MacNaughton42 The World Health Assembly according to Marmot et al43 accepted a declaration to address health inequalities that was influenced bythe CSDH report.22 This, however, gave the WHO a better obligation to promote HIA.Community HIA is also underpinned by an explicit value system and a focus on socialjustice in which equity plays a major role so that not only both health inequalitiesand inequities in health are explored and addressed wherever possible.44 Focus groups and key interviews fit most closely within community HIA, withthe conception of community HIA to be consultative.11 It is most appropriate to undertake this approach when community involvementis only one aspect of a wider information strategy within the HIA, where eachcomponent is valued equally. This type of HIA seeks only to consult and does notraise community expectations as to the outcome of their involvement but can raisecommunity awareness around certain issues and increase confidence in understandingthe policy. Lay community views have been reported to be distinctive to individualexperiences, perceptions, beliefs, and understandings.11 Focus groups and key informants’ views within community HIA enhanceparticipation and use similar methods to the consultative HIA, while seeking todistribute some degree of power to members of the community or a specific group,usually through workshops, steering committees, and advisory groups.Moreover, community HIA can foster collaboration as indicated in the concepts andmethods discussion above. Joining synergies across sectors and the importance ofinvesting in health beyond the narrow health services sector is crucial in communityHIA. The opinions and views of experts should not be the sole consideration indecisions about planned interventions. This is probably the main area whereCommunity HIA can help to maximize multisectoral approaches by incorporating layviews. Involving communities in practices in methods within HIA help make policyinitiatives more practical because it makes community HIA processes engage with boththe people who are affected by the policy and the key stakeholders within the community.45 Recognizing lay views with community HIAs demonstrate the significance ofactivities for health and well-being of communities as well as providing flexibilityby representing, responding, and adjusting to decision-making. Last, but by no meansthe least, community HIA provides for inclusiveness by involving and including layviews of people from certain groups of society or provides a platform forcommunities to be part of decisions that shape their lives and influence theirhealth and well-being. Community HIA looks at unintended consequences, spin-offs, orside-effects and can practically incorporate lay and expert views as demonstratedthroughout the article. Community HIA can be conducted in other settings aside fromAfrica to continuously measure its success, effect or influence and estimation ofsize, quality, and value.The main purpose of this article was to show how community HIA might be conducted inthe African context using a case study of NHIS project in Ghana. HIA has notprogressed in Africa and specifically in Ghana at the same level as in othercountries, eg, in Europe, America, or Australia. In future, detailed quantitativework can confirm and refine our proposed method and concepts of incorporating layperspectives in HIA both in Ghana and in other contexts and countries response todevelop an international HIA consensus that moves the field forward. In summary,focus groups and interviews via involving community respondents and key informantswithin HIA are clearly linked to the principles underpinning health promotion andthe broader community development field.


What is the topic of this review?In this symposium report, we review the glymphatic clearance from the brain.What advances does it highlight?Evaluation of the evidence indicates that cerebrospinal fluid flows along paravascular spaces at the surface of the brain. However, bulk flow along penetrating arteries into the brain, followed by exit along veins, requires further confirmation. Clearance from the brain, based on mixing, might provide an alternative explanation for experimental findings.The interstitial fluid of the brain provides the environment for proper neuronal function. Maintenance of the volume and composition of interstitial fluid requires regulation of the influx and removal of water, ions, nutritive and waste products. The recently described glymphatic pathway might contribute to some of these functions. It is proposed that cerebrospinal fluid enters the brain via paravascular spaces along arteries, mixes with interstitial fluid, and leaves the brain via paravascular spaces along veins. In this symposium report, we review the glymphatic concept, its concerns, and alternative views on interstitial fluid–cerebrospinal fluid exchange. It does so by the delivery of oxygen and nutrients from nearby capillaries and by the elimination of waste products in the opposite direction. Not all waste, however, can be eliminated via diffusion or specific transporters across the blood–brain barrier (BBB) into the bloodstream. Therefore, there is a need for additional mechanisms of ISF refreshment. In peripheral tissues, ISF is continuously renewed through transport of water and solutes from blood vessels. Most of the fluid is recycled back into the vessels at the venous side of the circulation, while the remainder is taken up by lymph vessels. The brain is different in this respect because far less fluid extravasates because of hydrostatic forces. This is a consequence of the very low permeability for ions such as sodium  and appears as a widening created by meningeal blood vessels. This widening of the SAS is particularly large around arteries, probably because of the rounded shape in comparison to the more flattened veins, and can be observed in both humans and rodents  of the animals, might interfere. In addition, the role of AQ4 is perhaps misinterpreted, because Aqp4 knockout mice can develop astrocyte endfoot swelling  net flow herein is unclear. If net flow is absent or very low, mixing could facilitate CSF–ISF exchange in these extensions of the CSF compartment. Paravascular spaces around veins are present on the brain surface, but the evidence for paravenous efflux from the brain lacks confirmation. We speculate that leakage and/or secretion of water and solutes from capillaries contributes to the formation of ISF. The quantity of this fluid is likely to be relatively small in comparison to other tissues, owing to the restrictions provided by the BBB. Nonetheless, in the case of BBB dysfunction, this could provide a net outflow of ISF from the brain parenchyma to the CSF with sieving of larger solutes, such as amyloid‐β, at barriers formed by astrocytes, including those formed by astrocyte endfeet around arteries.None declared.