There is a renewed global interest in improving community health worker (CHW) programmes. For CHW programmes to be effective, key intervention design factors which contribute to the performance of CHWs need to be identified. The recent WHO guidelines recommends the combination of financial and non-financial incentives to improve CHW performance. However, evidence gaps remain as to what package of incentives will improve their performance in different country contexts. This study aims to evaluate CHW incentive preferences to improve performance and retention which will strengthen CHW programmes and help governments leverage limited resources appropriately.A discrete choice experiment (DCE) will be conducted with CHWs in Bangladesh, Haiti, Kenya and Uganda with different levels of maturity of CHWs programmes. This will be carried out in two phases. Phase 1 will involve preliminary qualitative research including focus group discussions (FGDs) and key informant interviews to develop the DCE design which will include attributes relevant to the CHW country settings. Phase 2 will involve a DCE survey with CHWs, presenting them with a series of job choices with varying attribute levels. An orthogonal design will be used to generate the choice sets for the surveys. The surveys will be administered in locally-appropriate languages to at least 150 CHWs from each of the cadres in each country. Conditional and mixed multinomial logit (MMNL) models will be used for the estimation of stated preferences.This study has been reviewed and approved by the Population Council’s Institutional Review Board in New York, and appropriate ethics review boards in Kenya, Uganda, Bangladesh and Haiti. The results of the study will be disseminated through in-country dissemination workshops, meetings with country-level stakeholders and policy working groups, print media, online blogs and peer-reviewed journals. Assessment of multistakeholder perspectives to identify important job attributes will provide policy-relevant and actionable choice options to be tested in the study.Draws evidence from multiple countries with strong country-level stakeholder involvement including ministries of health, non-governmental organisations and donor agencies.In countries with multiple cadres of community health workers (CHWs), the study includes formative interviews with at least two cadres of CHWs to understand their perspectives.As with other discrete choice experiments, a key limitation is that the job alternatives presented to the CHWs are hypothetical.The results have limited generalisability across the countries given the variation that tends to exist in the needs of CHWs across cadres, terrain and job responsibilities.The dearth of health workers, especially in areas where they are most needed, continues to be an ongoing challenge for health systems globally. The WHO forecasted a global shortage of approximately 18 million health workers by 2030.et al conducted a systematic review of evidence to recommend several behavioural and promotional interventions which can be effectively delivered by CHWs with limited training or trained CHWs along the continuum of maternal healthcare. These include the promotion of reproductive health services and family planning, appropriate care seeking and antenatal care during pregnancy, and skilled care for childbirth.As governments respond to this wave of renewed enthusiasm for CHW programmes, it is critical to be responsive to the lessons from the past. Evidence from studies conducted over the past five decades have identified significant contributions as well as challenges of CHW programmes. Bhutta In many low/middle-income countries (LMICs), CHWs are often funded by government or donors.However, barriers to instituting these recommendations in practice remain. First, there is no agreement on strategies that would best support adequate incentivisation of CHWs. Second, with respect to health worker compensation, the health sector human resource policies and practices vary considerably across countries. Third, given the optimal ratio of CHW to population, the question of affordability of scaled CHW programmes to governments remains. A study of CHW programme costs in 37 sub-Saharan African countries estimated that when CHWs are paid an equivalent of US$80/month by existing central government healthcare budgets, the median relative cost of a CHW programme would be 27% of the national healthcare budget.This study aims to address this critical gap in understanding the combination of financial and non-financial incentives that will support CHWs, improve their work satisfaction and retention, and consequently influence the performance of CHW programmes. The proposed study is being conducted by Frontline Health Project through Population Council, and Johns Hopkins Bloomberg School of Public Health, supported by Bill & Melinda Gates Foundation, in partnership with United States Agency for International Development, UNICEF and Integrating Community Health non-governmental organisation (NGO) partners in Bangladesh, Uganda, Kenya and Haiti. The Frontline Health Project works with global stakeholders to contribute to the objective of advancing evidence for community health. Given the active leadership and participation of donors, NGOs and governments for this study, we expect that the results will aid donors and national policy-makers to develop training and remuneration policies that are conducive to high performance of CHW programmes, as well as maximise the effective use of limited resources.The theoretical underpinning of our approach comes from evidence that suggests that the context within which CHW work—including sociocultural factors, support from the health system, relationship with the community, respect and recognition, among others—all contribute to their motivation to work as CHWs, and subsequently their performance.DCEs are based on Lancaster’s consumer demand theory and random utility theory (RUT). According to Lancaster’s theory, individuals derive benefit or value (utility) from the attributes of a good or service under consideration rather than the good/service itself.This approach has been used in comparable studies involving CHWs in India and healthcare workers in LMICs.We will use a DCE to examine the job attributes that influence the overall satisfaction and motivation of CHWs in Bangladesh, Haiti, Kenya and Uganda. For the study, we focus on a set of factors that are amenable to national policy and programmatic changes. The study will be conducted in two phases. In the phase 1, we aim to identify a set of attributes that are realistic, pragmatic and meaningful to CHWs and policy-makers, and in the phase 2, we will prioritise critical attributes associated with job satisfaction from the CHWs’ point of view. The study design considers the varying context across the four countries, as well as the multiple cadres and roles of the CHWs in each country. The study will be conducted between June 2019 and October 2020.Bangladesh has 8 administrative divisions, 64 districts and 491 subdistricts (upazilas). Each rural area within an upazila is divided into union parishads and mouzas, which are further divided into villages. An urban area in an upazila is divided into wards, and mohallas within each ward.Shasthya Shebikas, which has been one of the largest cadres of CHWs in Bangladesh. However, currently the scale and function of the Shasthya Shebikas is being revised owing to the high attrition rate of these workers.Based on discussions with the Directorate General of Family Planning (DGFP) and Directorate General of Health Services (DGHS), the focus of the study will be on the two government-supported CHW cadres: FWAs (supported by the DGFP) and HAs (supported by the DGHS). The study will be conducted in the four divisions of Sylhet, Rajshahi and Khulna, as well as in Chittagong Division’s Cox’s Bazaar area. The upazilas within each division will be identified through further discussions with the DGFP and DGHS.Haiti is divided into 10 geopolitical regions and subdivided into 42 states (arrondissements).This study will take place in three communes located in two arrondissements: one in Artibonite region and the other in Centre region. In Centre region, the study will occur in Mirebalais commune, Mirebalais arrondissement. In Artibonite region, the study will occur in Petite Riviere de L’Artibonite commune and Verettes commune. Study sites and communal sections were selected in collaboration with Zanmi Lasante who have a strong collaboration and presence with the ASCPs in Haiti as well as the MSPP.Kenya is made up of 47 counties with a population projection of more than 40 million. The healthcare system in Kenya is based on the 2010 Kenyan Constitution,In Kenya, the study will take place in Bungoma and Kilifi counties. For phase 1, CHVs, CHEW’s county level community focal person and the national stakeholders who works closely with CHV will be interviewed. For phase 2, CHVs will be the primary survey respondent in the two counties. Kilifi is a coastal county with mixed rural urban populations, and Bungoma is an agrarian county in Western Kenya. These counties represent a set of diverse vulnerabilities within which CHWs operate. Within each of these counties, two subcounties will be selected in consultation with the county health management teams.In Uganda, the Health Sector Development Plan highlights the critical shortage of health workers, with a ratio of 1.55 health workers per 1000, compared with the WHO recommendations of 2.28 per 1000.In the phase 1, an initial set of policy-relevant, realistic and actionable attributes will be identified based on a review of secondary literature, as well as primary research involving FGDs with a sample of CHWs, their supervisors and national-level stakeholders involved in making decisions about CHW programmes in the country. The attributes and attribute levels will be established separately for each country, based on information collected through the literature review and this formative phase. Discussion topics will include, but not be limited to, expected remuneration, working conditions, availability of supplies and equipment, amount of training, supervision, job role and expected support from the health system and community. Participants will be probed to identify additional priority areas. The FGD will use a nominal group technique where the facilitator will ask the participants to think about aspects of the job that are most important to CHWs as well as actionable by policy-makers. Participants will silently generate a list of attributes, and then be asked to state a single attribute to the group.An estimated number of four FGDs with five to seven national and county/subcounty level policy-makers, four to six FGDs with CHW supervisors and approximately six to eight FGDs with CHWs (each cadre) will be conducted in each country. These numbers will vary with the context in each country with the categories of actors involved with community health system as well as the subregional levels where the study will be conducted. Additionally, for policy-makers who cannot be convened in a group setting, the same set of interview questions will be asked to them as key informants in an in-depth interview format. All participants must be aged 18 years and/or with the ability to provide consent. There are no eligibility criteria related to gender or marital status. Policy-makers will be identified by the study team and other relevant partners and CHWs and their supervisors will be recruited through CHUs/PHC facilities in select counties/districts. To ensure that the study takes a ground-up approach, the first set of interviews will be conducted with CHWs and supervisors. The study team will review the results of these interviews to then align the discussion with the policy-makers and other stakeholders to reflect the priorities of the CHWs.Attributes and levels identified in phase 1 across all the interviews will be finalised by the study team based on the discussion transcripts. To ensure that the final set of attributes and levels represents a pragmatic and desirable set, they will be further vetted with external stakeholders such as ministry representatives and NGO leaders working in the CHW space. Efforts will be made to have clear definitions of each attributes and avoid conceptual overlaps across attributes and levels.A fractional factorial design, which only takes a subset of choice sets, will be generated as too many choice sets place cognitive burden on respondents.Sawtooth Software Inc. To generate the experiment will be unlabelled, full profiles and consist of three alternatives, that is, two job alternatives and an opt-out option.The DCE questionnaire will include questions about respondent demographics, content and years of training as a CHW, socioeconomic status, and current level and quality of supervision. The order of the choice sets will be randomised to avoid positional bias. In each questionnaire, a dominant alternative will be included where one job option is superior to the other on all characteristics so that internal consistency and rationality of the responses can be considered during analysis.In each country, the questionnaire will be translated into local language(s). The survey will be administered face-to-face to the CHWs by trained data collectors on tablets using the Open Data Kit software.N needed to detect differences in the preferences is dependent on the number of analysis cells c, number of choice sets t and number of alternatives a as shown in the following equation:Sample size calculation in DCE studies mostly rely on rule-of-thumb estimates.c will be equal to the largest number of levels for any of the attributes.Assuming a main effects model, then If we assume that respondents will face a maximum of 18 choice sets, the largest number of levels of any attribute in a main effects model is four, and that each task has two alternatives (excluding the opt-out), then using the above equation, we derive a minimum sample size of 56. Therefore, we estimate that recruiting a minimum of 150 CHWs per cadre per country to be more than sufficient to detect differences in preferences. A total of approximately 900 respondents across the four countries will be recruited for phase 2 . Based on the total sample size, an equal number of CHWs will be recruited per geographic area in discussion with the county/district health management teams to get broad representation of the types of CHWs.Phase 1 of the study is structured to formally gather feedback from the broader community that supports CHWs, including national and international stakeholders and donors, other health officials, CHW supervisors and CHWs themselves. Opinions and experiences of these stakeholders are critical to shaping the questionnaire design and approach for the phase 2 of the study. Health officials at the facilities will be involved in the identification and recruitment of the CHWs in phase 2 of the study. Study results will be disseminated through in-country workshops where health officials involved during the design and recruitment phase will be invited to participate.Conditional logit model will be used as the base model as it is congruous with RUT.However, one of the shortcomings of the conditional logit model is that the assumption of the independence of irrelevant alternatives (IIAs) must hold. This is as a result of the error terms being assumed to be independently and identically distributed following extreme value type 1 (Gumbel) distribution. To relax IIA and further explore preference heterogeneity, a MMNL model will be used. MMNL presumes that some or all the parameters are randomly distributed with a particular probability distribution.Intrinsic and extrinsic factors influencing CHW incentive preferences are diverse and real-life decisions change over time; therefore, the relative importance of job preferences may vary with time and this needs to be considered when designing CHW programmes and policy interventions. We also recognise that CHW preferences can be different based on their organisational affiliations and prior experiences working as CHWs. While the study aims to capture a sample of CHWs across few areas in each country, the sample is not nationally representative of the preferences of all CHWs. We recognise that a comprehensive job package for CHWs may comprise many more factors that can be adequately captured by this study design. Finally, the results of this study will constitute stated preferences, reflecting responses to hypothetical scenarios. Decision makers will need to consider information from DCEs on CHW as part of the inputs to improved CHW performance and retention while making policies.This study has been reviewed and approved by the Population Council’s Institutional Review Board (IRB) in New York, the AMREF-Health Africa Ethics and Scientific Review Committee in Kenya, Zanmi Lasante’s IRB (Haiti) and the Higher Degrees Research Ethics Committee at Makerere University College of Health Sciences in Uganda, and the Bangladesh Medical Research Council. Dissemination activities will include sharing of findings through policy briefs, workshops, online blogs in community fora and peer-reviewed journal articles. The research approach is inherently designed around the need for research uptake by policy-makers. Involvement in the research from the beginning is the overarching strategy for promoting research uptake. To ensure there is significant demand for the final study findings, we will debrief policy-makers and other health system stakeholders at pivotal points in the initial stages as well as at the end of the study. We will share non-technical summaries of research results with all the partners for dissemination including the study’s key partners in the MoH. If there is enough interest, appropriate dissemination will be conducted with policy-makers in half-day workshops and to facilitate translation of the research findings in national CHW agenda.


Parents have a major impact on the outcome of health care of preterm infants. Parents’ engagement in meaningful activities could have an impact on their own health and wellbeing and therefore be relevant in neonatal intensive care. The aim of this study was to explore meaningful activities of parents of very low birth weight (VLBW) preterm infants with the purpose to further the understanding of their clinical relevance and to foster their consideration in clinical practice and research of neonatal intensive care.A total of 36 parents of preterm infants born prior to complete 37 weeks of gestation with VLBW (≤1.500 grams) were asked to participate in a focus group interview. Interview transcripts were used to analyse the content of the focus group interviews using meaning condensation method by Steinar Kvale.Thirty-six parents participated in a total of twelve focus groups. Parents reported that the meaning of certain activities changed due to preterm birth. Meaningful activities, like bathing the baby and gardening, could foster a transition from a feeling of parental immaturity to a feeling of maturity, following health care instructions to possessing health care skills, and a functioning-only state to a balance of activities.In neonatal intensive care, nurses contribute to delivering parental education and thereby facilitate experiences of being a mature parent and of possessing health care skills. Occupational therapy could be used to help re-engage in meaningful activities and maintain a balance of activities in parents of VLBW preterm infants. Eleven percent of live births worldwide (15 million per year) are preterm, defined as born prior to 37 completed weeks of gestation , 3 and nSeveral studies highlight the importance of parents’ sensitive and compassionate caregiving for a healthy development of their children , 8. MoreParental activities in the neonatal intensive care unit (NICU) have been explored previously. For example, parents of preterm infants experienced challenges of coping with anticipated versus real activities and of transforming the meaning of parental activities . HoweverHowever, parental involvement in neonatal care could be related to experiences of stress  and overPrevious studies provide initial evidence for a potential link between engagement in meaningful activities and parental and child health and wellbeing. For example, the engagement in meaningful activities was positively associated with health and wellbeing in mothers of preterm infants . FurtherConsidering these interrelations, parental engagement in personally meaningful activities could be linked to child health and wellbeing. It might be useful for professionals working in neonatal care to better understand the importance of meaningful activities of parents of preterm infants.The aim of this study was to explore meaningful activities of parents of very low birth weight (VLBW) preterm infants with the purpose to further the understanding of their clinical relevance and to foster their consideration in clinical practice and research of neonatal intensive care.The researchers employed a qualitative study design to generate knowledge and an in-depth understanding of the meaning of certain activities for parents of VLBW preterm infant. Qualitative research designs can be used to explore the experience of a certain health condition from the perspectives of patients, caregivers and health professionals , 28. TheParents who met the inclusion criteria were asked by the researchers for participation. Inclusion criteria for the study were: (1) being a parent of an infant born alive prior to complete 37 weeks of gestation and with VLBW (≤ 1.500 grams), (2) without a history of psychiatric and/ or neuro-motor disease and (3) with sufficient German reading and speaking skills. Furthermore, for inclusion, parents had to participate within six months after the discharge of their VLBW preterm infant(s). Exclusion criteria were (i) death of the preterm infant, (ii) insufficient German reading and speaking skills and iii) proven psychiatric and/ or neuro-motor disease.Potential participants were recruited from parents of VLBW preterm infants treated at the Division of Neonatology, Pediatric Intensive Care and Neuropediatrics of the Medical University of Vienna, Austria in 2015. The researchers screened the medical records of the VLBW preterm infants to identify potential participants. The first author (MD), unknown to the parents, recruited eligible parents by phone or personally in the ward. Eligible parents were informed about the study purpose and data collection and were invited for participation.Furthermore, for inclusion, parents had to participate within six months after the discharge of their VLBW preterm infant to ensure the currency of their experiences. We aimed to include a total of 36 parents following the suggestions for saturation sampling of focus group interviews . Out of The focus group interviews were conducted in a private room in the intermediate care unit at the General Hospital/Medical University of Vienna. Participants who were couples participated separately. The number of participants per focus group varied from three to five. The small group sizes resulted in less time required and therefore took into account parents’ restricted time resources. Besides, small focus group sizes have been found to enable expressions of diversity and disagreement of perspectives and viewpoints . ParticiThe focus group interviews were led by a moderator (MD) skilled and experienced in conducting and analyzing focus group interviews. Participants were informed about the study purpose and procedures. Participants were asked to talk about their experiences related to their activities. They were encouraged to describe and discuss any experience and diverse opinions, even though they would consider them as unexceptional . The focBased on a phenomenological approach, the researchers conducted meaning condensation method  to analyThe researchers obtained informed consent from all individual participants included in the study. The names, we are referring to in the original quotes at the results were changed to guarantee confidentiality of the participants. The ethical committee of the Medical University of Vienna specifically approved this study. The study is part of a larger project called “Occupational balance in informal caregivers—OBI-Care” .A total of 36 parents of VLBW preterm infants participated in one of twelve focus groups between June and November 2015. Among these, two were mixed, five were with mothers, and another five were with fathers only. The mean duration of the focus group interviews was 102 minutes (± 15). All mothers were on maternity leave at the time of the interview, two of them were students, and another two were also self-employed. The participants were parents of a total of 35 VLBW preterm infants. Seventeen parents (47%) participated in the focus group interviews during the hospital stay and nineteen parents (53%) after discharge of their VLBW preterm infants. Demographic data of parents and VLBW preterm infants are depicted in A total of seven activity-related themes were found to be important to parents of VLBW preterm infants. These were: a change in the meaning of their activities, a transition from a feeling of parental immaturity to a feeling of maturity, from following health care instructions to possessing health care skills, and a transition from a functioning-only state to a balance of activities. In the following paragraphs, the themes are described as statements and substantiated by original quotes:Small things, daily routines were very important to me. Activities such as changing the nappy, bathing [the baby]. What I didn’t expect is that nothing else really mattered to me. Even though I had to run a household and we own a company”. A 43-year-old father of a girl with a gestational age of 25+2 weeks, Thomas, described a change in the meaning of gardening in the following way: “Gardening. It’s grounding me. (…) It’s growing and green. It blossoms, grows and thrives, this is just enjoyable. It’s metaphoric also. The little one [baby] is fed also, and grows and thrives. This is certainly so lovely” . In addition, cooking and eating together with their partner began to mean nurturing the loved ones, which was also a symbol for their loving feelings while struggling with the various attempts and activities to nourish their baby.Parents reported a change in the meaning of their activities. For example, Cornelia, a 34-year-old mother of a boy born at a gestational age of 30+4 weeks said: „Furthermore, parents reported that meaningful activities had an impact on their transition of becoming a parent of a preterm infant. Meaningful activities could foster their transition from a feeling of parental immaturity to a feeling of maturity, from following health care instructions to possessing health care skills, and their transition from a functioning-only state to a balance of activities.For example, parents frequently reported that they were not parents at the beginning, and that meaningful activities could help them to develop feelings of parenting and attachment. Furthermore, parents were found to gain health care skills by engaging in meaningful activities such as talking to health care professionals, bathing and feeding the child and by requiring feedback from health professionals, especially from nurses. The possessing health care skills allowed them to act independently and self-assured, often after a long period of guidance from the health professionals. Additionally, parents described that they were in a status where they were just functioning. A status in which they just did, what had to be done and in which own needs weren’t important at all. In the functioning-only status it was most important to do everything in ones’ power to avoid further deteriorations of the current situation. Previous meaningful activities were abandoned for a while, until they started to regain a balance of activities. For example, a balance of activities which had to be done and activities which they wanted to do. The results of the study indicate that the meaning of activities for parents of VLBW preterm infants changes over time and that, meaningful activities can foster transition. More specifically, activities meaningful to parents of VLBW preterm infants were found to foster a transition from a feeling of parental immaturity to a feeling of maturity, from simply following health care instructions to possessing health care skills and from a functioning-only state to a balance of activities. Previous studies found that parents of preterm infants undergo a transition process, such as adjusting to preterm birth and to deviations from the parental role formerly imagined .In the current study, parents of VLBW preterm infants reported about a change in the meaning of certain activities, such as gardening and cooking. For example, fathers reported that gardening became a meaningful activity during the hospital stay of their preterm infant. In addition, while cooking and eating was related to still one’s hunger, it became symbolic for nurturing the loved ones. An adaptation of the meaning of certain activities was reported previously in persons who experienced a loss of meaningful activities, due to their health condition, disability or a transition phase, such as the transition from employment to retirement , 40. HowIn the current study, meaningful activities were found to foster a transition from a feeling of parental immaturity to a feeling of maturity. This effect has been reported from parents of preterm infants previously. In a recent study on parental activities in the NICU, engaging in meaningful activities helped parents to overcome their feelings of unpreparedness  and to eThe findings indicate that engaging in meaningful activities, especially in child and health care activities, such as changing diapers and feeding the child, fostered a transition from simply following health care instructions to possessing health care skills. The acquisition of health care skills through the engagement in meaningful activities of parents of preterm infants was reported recently. For example, it was found that these activities encourage parents to increasingly check, interpret and respond to their preterm infant’s temperature and oxygen saturation, and to actively engage in the health care of their preterm infant . AdditioEngaging in meaningful activities, such as having a walk or acting at an amateur theatre, was found to foster a transition from a functioning-only status to a balance of activities. Functioning, like family functioning, behavioral, cognitive, executive and motor functioning were explored in preterm infants and their parents , 43. A bThe findings of the current study highlight the importance of various activities from the perspectives of parents of VLBW preterm infants. To our knowledge, meaningful activities other than childcare activities have not been considered in neonatal clinical practice. However, as described in the introduction, initial evidence has been gathered showing a potential link between engagement in meaningful activities and parental and child health and wellbeing , 24, 45.There are no studies reporting health care interventions targeting a transition from a functioning-only status to a balance of activities in parents of preterm infants. Occupational therapists are part of the NICU team  and are Qualitative research uses small sample sizes to generate meaning and to allow in-depth analyses of each case. The number of participants per focus group varied from three to five. The small group sizes resulted in less time needed and therefore considered parents restricted time resources. Small focus group sizes were found to enable expressions of diversity and disagreement of perspectives and viewpoints . An explActivities beyond childcare activities were found to be meaningful to parents of VLBW preterm infants and to foster a transition to a feeling of parental maturity and a balance of activities. In neonatal intensive care, nurses contribute to delivering parental education and thereby facilitate experiences of being a mature parent and of possessing health care skills. Considering the link already found between meaningful activities and health and wellbeing, parents’ increased engagement in various meaningful activities could become an important objective for neonatal care and thus could become clinically relevant. Occupational therapy could be used to help re-engage in meaningful activities and maintain a balance of activities in parents of VLBW preterm infants.


Research indicates that Posttraumatic stress disorder (PTSD) has an extensive impact on family relationships. Nevertheless, there is a dearth of empirically supported interventions addressing family functioning and PTSD. In the Netherlands, it is considered good clinical practice to offer multi-family therapy (MFT) to veteran and refugee families. MFT for traumatized families aims to address the dysfunctional family patterns that have evolved to address the consequences with trauma.The aim of this study is to generate a common framework for the practical impact and active ingredients of MFT in families confronted with trauma. The Delphi method was used to study the expert opinion of 11 therapists in Dutch expert trauma institutes.The results indicate that MFT is a promising treatment for families dealing with the consequences of trauma. According to experts, positive outcomes include an increased understanding between family members, particularly visible in the de-escalation of conflicts within the family, and improved parenting. One explanation for the effectiveness of MFT with these target groups is its defining feature of therapy with several families.The findings support the importance of considering family relationships and the family context in interventions for traumatized individuals. There is a conceptual gap between the concept of posttraumatic stress disorder (PTSD), which defines a traumatized individual who experiences distress, suffering and impairment, and the significant distress, suffering and impairment of families as the result of PTSD of one family member. A review of traumatized parents and relational patterns with their children showed consistent negative associations between increased parental symptoms of PTSD, parent functioning, a reduced quality of the parent-child relationship and child functioning , 2. A prA review of the relational patterns between caregivers with PTSD and their children showed that traumatization can cause parenting limitations, and these limitations can disrupt the development of the child. To understand the complex relational patterns, many factors need to be considered . Mechanisms such as mentalization , attachment, and physiological factors offer a valuable perspective; however, to understand the impact of parental traumatization on children, the need for a transactional perspective, the inclusion of child factors, is essential . These fIn the Netherlands, it is considered good clinical practice to offer multi-family therapy (MFT) to veteran and refugee families, as the experience of trauma and violence leads to changes in multiple dimensions of individual and family functioning, and systemic approaches, such as MFT, sensitize the social and cultural context in which the meanings of individual and family functioning are shaped –12. MFT Dutch expert trauma centers dealing with veterans and refugees offer MFT. Nevertheless, evidence of the efficacy of MFT comes from studies in families dealing with severe depression, obsessive compulsive disorder, substance abuse, abuse and neglect, and eating disorders . In contComplex interventions are conventionally defined as interventions with several interacting components . MFT fitThe Medical Research Council proposes that the development and evaluation of these interventions require an understanding of its practical impact and whether it works in everyday practice, as well as a good theoretical understanding of how the intervention causes change, what the active ingredients are and how they exert their effect . Only byThe Delphi method can be particularly useful to systematically gather expert knowledge and the understanding of an intervention and, in this case, to prioritize the change mechanisms and treatment outcomes , 20. To Repeated individual questioning of the expertsAnonymityControlled feedbackPrioritizing the informationThe Delphi method  is well-The research question is formulated in a survey of open questions and is then sent to a sample of suitably qualified experts. The experts respond anonymously, and their responses are synthesized into a list that is fed back to the experts for their consideration. Issues, concepts and suggestions raised by experts are fed back to the group. The experts could adjust their response until consensus or another predetermined point in the process is reached .N = 15). These centers offer specialized and highly specialized trauma care. Specialized units deliver care to refugees and veterans, as well as their families. Care is delivered to refugees from all over the world, for example, from Afghanistan, China, Eritrea, Iraq, Iran, Somalia, and Syria. Most of these refugees have experienced multiple traumatic experiences, some examples of which are imprisonment, being wounded, combat situations, rape, murder of a relative or friend, and torture. Care is delivered to veterans who experienced traumatic events during missions, for example, in Afghanistan, Cambodia, former Yugoslavia, Iraq, and Lebanon. Most veterans experience multiple traumatic experiences as well; examples are imprisonment, being wounded, combat situations, and death of a friend or colleague.All therapists currently using MFT with refugee and veteran families in Dutch expert trauma institutes were invited to participate  negative outcomes of participating in MFT for family members.Please indicate what families believe are the  negative outcomes of participating in MFT.Please indicate why MFT can be used as an intervention to deal with problems associated with a traumatized parent.In the first round, a survey was performed among these experts to gain insight into therapeutic outcomes, change mechanisms and essential techniques. Experts were prompted to both generate knowledge on their perspective on MFT and ideas on the perspective of families using MFT. The experts were asked to generate an exhaustive list in response to the following questions:Two coders categorized the responses of the experts into themes until a consensus was reached. Duplicates and redundancies were removed. The result of this analysis was a list of anonymous expert responses to each question. In the second round, this list was fed back to the experts who responded in the first round to determine prioritization. Experts were requested to score each response on a five-point Likert scale for the criteria: relevancy and frequency . For example, each expert rated the relevancy of the increased understanding between family members and the frequency of the increased understanding between family members as a positive outcome of MFT. In addition, experts were given the opportunity to provide feedback on the generated list. In the third round, all participants in the second round were requested to respond to the anonymous feedback of individual experts. Consensus was defined as an agreement between experts of at least 75% on ‘relevancy’. The weight of an item was defined as the mean score on ‘frequency’ multiplied by the percentage of ‘relevancy’. The weight of the items is reported in this article.Eleven experts participated in the first round, ten in the second and nine in the third round . Participants were psychiatrists, clinical psychologists, family therapists or psychiatric nurses, mostly female (80%), with a mean age of 51.7 years (S.D. = 9.14) and with an average of 5.10 years of work experience in MFT (S.D. = 1.60).Table Mechanisms either supporting or withholding positive changes are shown in Table All potential negative outcomes, according to experts or families (rated by experts), were scored low in frequency but high in relevancy Table . No treaOthers with similar problems tend to understand you easier (4.7)Generating hope and multiple perspectives (4.44)Sharing and connecting with other people (4.3)Mentalization (3.8)Families become experts in their own process (3.7)Experts reached a consensus over five reasons for applying MFT with families confronted with trauma. These reasons were considered as most present in and most relevant for clinical practice:The aim of this study was to generate a common framework for the practical effect and active ingredients of MFT in families confronted with PTSD. The results show that MFT with veteran or refugee families is clearly aimed at the treatment of the consequences of PTSD on a systemic level. MFT supports families that have lost sight of each other and the environment and who got stuck in a pattern that led to the loss of hope and perspective. On a systemic level, these consequences can be conceptually linked to the consequences of complex traumatization: loss of trust in people, loss of meaning, loss of control, loss of the ability to mentalize, and loss of a future perspective. Trauma to individuals has the potential to reverberate throughout the family system.MFT is a promising treatment for veteran and refugee families dealing with the consequences of trauma. One explanation for the reported effectiveness of MFT with these target groups is its defining feature of therapy with several families. Both veterans and refugees can be particularly prone to experiencing the importance of being part of a group or the loss of being part of a group. In contrast with experts who value contact with other families as a vehicle toward change, the veteran and refugee families value this as being the most significant positive outcome of MFT. Even though belonging to a group and groupthink can become too strong and counterproductive, it is exactly this feature of belonging that can create a window of opportunity for difficult-to-reach populations, such as veterans and refugees, to open up to interventions on a systemic level.MFT was designed as a generic systemic intervention for complex family problems. Specific to using MFT with families confronted with trauma is that MFT should not be a stand-alone treatment but instead should be combined with individual trauma-focused therapy. These results are in line with a study on the efficacy of recommended treatments for veterans with PTSD, which found that group therapy alone was not effective, whereas a combination of individual trauma-focused therapy and group therapy had the highest combined effect size . A combiDespite being promising, MFT for families confronted with trauma is also in need of refinement. Due to its generic design, MFT protocols are lacking, and it is in the hand of the therapist to design a completion of MFT for the specific target group in the specific context of an institute. Considering the mechanisms that withhold positive change, the effectiveness of MFT for families confronted with trauma can be improved substantially with clear guidelines for the intervention. Active ingredients, such as working with other families, recognition and identification, mentalization and unraveling behavioral sequences, should be core treatment components in such guidelines. Research into the efficacy and effectiveness of MFT can benefit from clear guidelines as well.A strength of this study lies in the evaluation of a complex intervention using the Delphi method. Until now, no systemic studies into MFT for families confronted with PTSD are available. The generalizability of the results is, however, a limitation. This study was performed with Dutch experts only working in Dutch trauma expert institutes and using MFT with veterans and refugees. In addition, we did not ask the opinion of families directly but gathered this information via the experts. Future studies could qualitatively study the perspective of families and quantitatively focus on the effect of MFT on family functioning and more specific communication, conflict, parenting, bonding and emotion regulation, as these concepts are primary outcomes according to the experts.The aim of this study was to generate a common framework for the practical effect and active ingredients of MFT in families confronted with PTSD. The results show that MFT with veteran or refugee families is clearly aimed at the treatment of the consequences of PTSD on a systemic level and is a promising treatment for families dealing with the consequences of trauma. Increased understanding between family members, which was particularly visible in the de-escalation of conflicts within the family, and improved parenting are rated by experts as the most important outcomes. One explanation for the reported effectiveness of MFT with these target groups is its defining feature of therapy with several families. The findings support the importance of considering family relationships and the family context in interventions for traumatized individuals and could form a stepping stone for systematic studies into the efficacy and effectiveness of MFT in families confronted with PTSD.


Catastrophic health expenditure (CHE) is well established as an indicator of financial protection on which there is extensive literature. However, most works analyse mainly low to middle income countries and do not address the different distributional dimensions of CHE. We argue that, besides incidence, the latter are crucial to better grasp the scope and nature of financial protection problems. Our objectives are therefore to analyse the evolution of CHE in a high income country, considering both its incidence and distribution.Data are taken from the last three waves of the Portuguese Household Budget Survey conducted in 2005/2006, 2010/2011 and 2015/2016. To identify CHE, the approach adopted is capacity to pay/normative food spending, at the 40% threshold. To analyse distribution, concentration curves and indices (CI) are used and adjusted odds ratios are calculated.The incidence of CHE was 2.57, 1.79 and 0.46%, in 2005, 2010 and 2015, respectively. CHE became highly concentrated among the poorest (the respective CI evolved from − 0.390 in 2005 to − 0.758 in 2015) and among families with elderly people (the absolute CI evolved from 0.520 in 2005 to 0.740 in 2015). Absolute CI in geographical context also increased over time . Medicines represented by far the largest share of catastrophic payments, although, in this case concentration decreased . Contrarily, the weight of expenses incurred with consultation fees has been growing .The incidence of CHE and inequality in its distribution might progress in the same direction or not, but most importantly policy makers should pay attention to the distributional dimensions of CHE as these might provide useful insight to target households at risk. Greater concentration of CHE can actually be regarded as an opportunity for policy making, because interventions to tackle CHE become more confined. Monitoring the distribution of payments across services can also contribute to early detection of emerging  drivers of catastrophic payments. The financial protection of families, when using needed healthcare, has been long recognised as a core dimension of health system evaluation , 2, becoSince the seminal work by Xu et al. , a largePrevious evidence suggests considerable country variation of the incidence of CHE by income group. Specifically, Xu et al.  obtainedDuring the period analysed in this study, Portugal was hit by the 2008 economic crisis. The effects of the economic recession were aggravated by the public debt crisis. Following the financial rescue plan of the country, several reforms were implemented in the health sector in order to reduce costs and increase efficiency –13. FromData are taken from the 2005/2006, 2010/2011 and 2015/2016 waves of the Portuguese Household Budget Survey (PHBS). This survey contains data from a representative stratified clustered sample of households living in non-collective dwellings across the country. It is carried out by Statistics Portugal. The series of surveys on household budgets initiated in Portugal in 1967/1968, and the PHBS began in 2005/2006. Data have been collected every five years. Besides information on expenditure, the PHBS also collects demographic and income data. In 2010/2011, the nomenclature from the Classification of Individual Consumption by Purpose was adopted as well as the electronic recording during the collection of daily consumption of goods and services.The data used in this study were collected between 10 October 2005 and 8 October 2006 , betweenThe variables extracted from the databases concern: total expenditure, expenditure for food, out-of-pocket healthcare payments  and specialist visits; dental care; diagnostic tests; paramedic services; hospital services), monetary income, type of household , household size, sex and level of education  of head of household, and region of residence .To identify households with CHE, we adopt the methodology proposed by WHO researchers , 19 and Before analysing inequalities in the distribution of CHE and in order to get an idea of the wider scenarios behind catastrophic payments over the years, we start by looking at the distribution of households across different bands of shares of OOP in total capacity to pay as well as the distribution of these shares across households ranked by capacity to pay. In the latter case, we present the concentration curves for the three periods considered in our study. The concentration curve plots the cumulative percentage of, in this case, shares of OOP (y-axis) against the cumulative percentage of the population , ranked by living standards , beginning with the poorest, and ending with the richest (x-axis) .To analyse income-related inequalities in the distribution of CHE, we present also concentration curves for the three periods considered in our study. Here, we have in the vertical axis the cumulative percentage of CHE, and the horizontal axis there shows the cumulative percentage of households ranked by capacity to pay.To quantify the degree to which the distribution of CHE departs from proportionality we resort to the calculation of the concentration index (CI). CI equals twice the area between the concentration curve and the line of equality (the 45° line running from the bottom-left corner to the top-right). Where there is no inequality, the CI is zero; a negative (positive) CI indicates a disproportionate concentration of the given variable  among the worse-off (well-off) . In the In the case of the distribution of CHE according to households’ capacity to pay, we estimate the CI following the convenient regression approach , 26. In τ is the mean of the variable being analysed.Given that CHE is a binary variable, we present the results also for the corrected index suggested by Wagstaff , 28: if To better understand where concentration occurs in the case of the distribution of CHE across regions and family types, we adopt multiple logistic regression analysis. The results of the regression analysis are reported as adjusted odds ratios (AOR); the ratio of the odds of an event (CHE) occurring in one group compared to the odds of that event occurring in another group (reference category), controlling for other explanatory variables. In the geographic analysis we report AOR for all regions (Madeira is the reference) and in the case of family type we report AOR for households with at least one elder. Remainder explanatory variables included are: household size, presence of children, sex and level of education of head of household, living in rural (versus urban) area and family monetary income.To analyse the distribution of catastrophic payments across services and goods, we calculate, for the subsample of families incurring CHE, the frequencies of shares of different kinds of expenditure in total healthcare expenditure (full list of services and goods provided in previous section). When the share of a given item is 1, this means that households presenting this share incur catastrophic expenditure by spending on this item alone.Finally, with the objective of complementing the previous analysis, we assess the distribution of healthcare payments in relation to capacity to pay (now using whole samples), calculating the Kakwani index (or progressivity index) for total payments and then for medicines, consultations, dental care and exams. If healthcare payments are proportional to capacity to pay, the Kakwani index is zero; if payments are regressive (progressive) then the index is negative (positive) thus indicating a disproportionate concentration of payments among the poor (rich). The Kakwani index is also estimated with the convenient regression method , 26.All the analyses are carried out in SPSS 25.0 and Excel (2013). Sample weights provided in the databases are used.As shown in Fig. The distribution of the shares of OOP in total capacity to pay Fig.  did not The incidence of CHE in Portugal decreased over the period analysed in this study, from 2.57 to 0.46% Table . The redIn terms of the distribution of CHE across regions and across household types, we found a similar pattern to that obtained previously: inequality decreased from 2005 to 2010 and then it significantly increased . It must however be noted that, controlling for other characteristics of households, the AOR for the Centre was not statistically significant, meaning that national measures targeting vulnerable groups based on other risk factors are likely to solve the problem. Still, authorities should be aware of the situation.Another noticeable change is the growing importance of expenditure on consultations. Given the characteristics of the Portuguese health system (as described before), one would expect the expenditure on consultations to be justified mostly by the use of specialist services. However, the break down of data in 2015 shows a somewhat surprising picture. Why are poor, old people not using the NHS for their GP consultations? Is it a matter of supplier-induced demand like that which has been reported for the case of Greece ? This isNonetheless, it might be better to pay than go without needed healthcare. In fact, a limitation of the CHE approach is that a low incidence might simply mean that people are not getting the care they need . In TablThere are methods, other than the one used in this study, to calculate CHE, depending on how households’ ability to pay is interpreted . The two main approaches are either to consider that the whole budget is available for healthcare spending (budget share approach) or to consider that households must first meet basic needs (capacity to pay approach). In the latter case there might be some further nuances to what is deemed basic needs. Cylus et al.  comparedAnother possible avenue for future research is to explore the association between CHE and its distribution and macro variables such as public debt, economic growth rate, share of public health spending on total health expenditure and percentage of the population benefiting from any insurance scheme besides the NHS.This study sought to look beyond the incidence of CHE and to also analyse its distribution in a high income country. Evidence suggests that financial protection, in Portugal, measured through the incidence of CHE, has greatly improved in a decade. At the same time the concentration of CHE among the poorest and households with elderly increased. Consequently, there is the need to reinforce existing protective measures for the elderly poor, and adopt new ones. We also obtained evidence that the weight of spending on medical visits, in particular GP services, is growing. It is of utmost importance go on monitoring this to understand whether the NHS is failing or if individuals, especially elderly, are being induced to consume private services.Policy makers should pay attention to the distributional dimensions of CHE, as these might provide useful insight to target families at risk. Although inequality is generally regarded as a negative outcome per se, in the context of financial protection, it can actually be regarded as an opportunity for policy making. With greater concentration, interventions to tackle CHE become more confined. It is also important to identify which items are leading families to incur catastrophe health expenditure and monitoring changes over time can contribute to early detection of emerging  drivers of catastrophic payments.


New drug safety issues are emerging that are beyond the existing medication safety management system. To pre-empt these problems, forecasting future drug safety trends and issues is a necessity. The objective of this study was to identify issues and future trends impacting drug safety using foresight methodologies. The study started by identifying global megatrends, trends in safety management of medicines, and key issues in drug safety. A total of 25 global megatrends were selected by extracting and clustering keywords from 26 reports concerning the future. Using the text-mining method, 10 trends in drug safety were identified from 3593 news articles. This study derived 60 issues which can arise from the trends, and finally, the 20 key issues with the highest urgency and impact scores were selected. Some examples of issues with high scores were as follows: illegal distribution of medicines, lack of technology for managing and utilizing big data, change in the pharmaceutical trade environment, lack of education and safety management for specific populations, lack of artificial intelligence-based technology for the safety management of medicines, and the prevalence of drug advertisements through social network services. The key issues could be used to establish plans for medication safety management. Because a medication safety accident can cause harm to patients or death in severe cases, it is a threat to patient safety. The recent recall of antihypertension medicines due to carcinogenic substances contained in the China-sourced raw materials caused great social problems. Moreover, the number of cases in which medication is recalled or suspended in the USA and South Korea is estimated to be around 40 cases per year in both countries ,2. BecauThe Ministry of Food and Drug Safety (MFDS), like the USA Food and Drug Administration (FDA), regulates medical products in South Korea and conducts research and development (R&D) on a medication safety management. The project includes the advancement of policies and systems, scientific reviews and assessments, and guidelines for the safe use of medical products . The MFDAs the National Assembly has pointed out, issues such as the distribution of medicines through social network services, the theft and loss of 186 opioid drugs, and the lack of management of the nation’s essential drugs, show that there are holes in medication safety management . FurtherThe purpose of this study was to analyze the issues and future trends impacting drug safety using scientific foresight methodologies to timely respond to the rapidly changing global environments.The definition of terms used in this study are as follows ,14: (1) Global megatrends, trends in drug safety, and key issues in drug safety were identified using a method referring to foresight methodologies used by Ministry of Science, Information and Communication Technology (ICT) and Future Planning, and Korea Institute of Science and Technology Evaluation and Planning  was used. Other sources for text-mining were not used to limit overestimating problems due to overlapping articles on the same topic. As a search term, the terms corresponding to the global megatrend and the MFDS’s drug safety categories were used. A web crawler, using Python version 3.4 , automatically collected and stored the body of the articles which were the <div class = “bodyarea”> part of the pages published from 1 January 2014, to 28 February 2017. Afterward, the words corresponding to the nouns were extracted by conducting an impropriety, and a stem extraction and morpheme analysis from the article text were collected using the R-program’s KoNLP  package. The simultaneous occurrence probability among the nouns was calculated using the latent Dirichlet allocation (LDA). The words that appear together are grouped into a topic. The trends in drug safety were selected to represent the nouns included in each topic. Since the search terms used for text-mining are the term determined by the megatrends, we could pair megatrends to trends, which were the results of text-mining.In order to derive trends in drug safety, text-mining was conducted. Unlike qualitative conventional methods such as Delphi, expert panels, and scenarios, which rely on opinions from experts, text-mining can forecast the future in objective and quantitative ways ,44. In aIssues that may arise within five years concerning the medication safety trend were derived from a literature review and brainstorming. News articles, research papers, and regulatory agency reports from the USA, European Union, and Japan about trends in drug safety were reviewed. After that, both individual and group brainstorming sessions were conducted. Ten participants with one to more than ten years of experience in medicine performed brainstorming individually, and three of them participated in group brainstorming. Created issues were categorized. The issues were evaluated by thirteen experts from industries, universities, and research institutes assessing the urgency and impact using a 7-point Likert scale. Experts were evenly selected for industry, academia, and research institutes who had more than 20 years of experience and competence in planning research with sufficient insight into medication safety management. Urgency was defined as how quickly an issue will it be a problem or will need to be resolved. Impact was defined as how much the problem threatened people’s health or how much risk could be prevented when the problem was solved. Issues with a minimum average score of 4  were chosen as key issues in drug safety, and issues that experts disagreed (an average score of less than 4) with were excluded.A total of 517 trend keywords were extracted from 26 sources, and 25 global megatrends were derived by clustering the keywords. The 25 global megatrends are listed in The existing future reports did not describe trends for the field of drug safety, so trends in drug safety were derived using a website where medication-related news articles are posted. A total of 3593 articles related to both global megatrends and drug safety were extracted. Words extracted through text-mining were grouped into ten topics according to their probability of appearing simultaneously. Ten trends in drug safety were selected and are shown in We obtained 60 issues in the drug safety area through literature review or brainstorming. The issues derived were eventually grouped into 24 issues. The twenty-four issues and their urgency and impact scores are presented in We derived 10 trends and 20 key issues in drug safety. Foresight methodologies, which were environmental scanning and text-mining, were used in the research process. It is the first time in South Korea that text-mining has been used to forecast the future of drug safety. Planning research for medication safety management has been conducted previously. Science and Technology Policy Institute (STEPI) reports from 2001 documented safety management trends, such as the rapid development of the biological industry and the government’s will to foster it, increased investment by large companies and venture startups, the emergence of new biotechnology products, and the increase of new harmful and toxic substances . It propThe social, technological, economic, environmental, and political megatrends, such as the aging of society, advanced technologies, disasters, major countries’ low growth, and the unification of Korea affect drug safety. Unification between South and North Korea is a unique situation. North Korea has a significant gap in medicine safety management as compared to more advanced South Korea, and the terminology in drug management and disease prevalence are also different. Thus, efforts and studies are needed to narrow this gap . Some trIssues related to the recent development of information technology were particularly high in urgency and impact. This reflects the high interest in managing drug safety by applying new big data and artificial intelligence technologies. Advertising or distributing medicines over the Internet is also a new problem. The key issues in drug safety can be used to determine the direction of policy proposals or the direction of R&D by MFDS to proactively address the drug safety issues forecasted by future environmental changes ,50. For This research has derived trends and issues in drug safety using scientific foresight methodologies but has several limitations. First, because trends are chosen based on words that have emerged with a high frequency in text-mining, it is likely that emerging trends, which are currently not discussed in articles, but maybe major in the future could be omitted. Second, some issues, such as unification, are unique to Korea and thus difficult to generalize when considering other countries. However, most of the issues are relevant to global society, so are worth mentioning.Although accurate forecasting of the future of drug safety is not possible, research using foresight methodologies can proactively develop response strategies by presenting the possible future of drug safety. R&D projects to address the issues presented in this study will have to be planned in the future. For that process, it will be helpful to perform a scenario analysis. The scenario would provide a direction for the allocation of resources for problem resolution and enable the efficient use of limited resources. Continuous and periodic identification of trends and issues in drug safety will be required to determine policies proposed by government agencies for drug safety management and the direction of R&D to be carried out.Twenty key issues related to drug safety were derived using scientific foresight methodologies. ‘Illegal distribution of medicines’ and ‘Lack of technology for managing and utilizing big data’ were identified as the most important key issues. The key issues could be used to establish plans for medication safety management. To address the issues, MFDS will need to plan its R&D strategy. This will require further research such as SWOT  analysis and scenario analysis.


The increase in dairy donkey farms in Europe, as a consequence of the increasing scientific interest in donkey milk for paediatric nutrition, has led to the need for a better understanding of the welfare of dairy donkeys. Taking into account the Animal Welfare Indicator’s (AWIN) welfare assessment protocol for donkeys, the aim of this review has been to obtain insight into good feeding welfare principles, in order to identify and discuss the nutritional requirements, the farm management requirements and the animal-based indicators that may be used to achieve an overall assessment of the appropriate nutrition welfare criteria of dairy donkeys.Data are available in the scientific literature concerning the quality and usefulness of donkey milk for human consumption. However, there is a lack of studies related to the understanding of the welfare of dairy donkeys. The only attempt, at a European Union level, to assess the welfare of donkeys is that of the Animal Welfare Indicator’s (AWIN) welfare assessment protocol for donkeys, where the appropriate nutrition welfare criteria have been assessed, but only through the evaluation of the body condition score. However, several other indicators that take into account the importance of good feeding welfare principles should be considered for the correct management of dairy donkeys. Therefore, it is hoped that this review of the available scientific literature will be useful to help establish a set of appropriate welfare requirements and indicators for the management of dairy donkeys. The review is aimed at identifying and discussing other requirements and indicators, such as nutritional requirements, farm management requirements and animal-based indicators, which may be important for the correct assessment of the appropriate nutrition welfare criteria and to establish best practices for the feeding of dairy donkeys. The donkey population in Europe had been experiencing a decline over the past twenty years, due to the growing automation in agriculture, and to the depopulation of rural districts . However® principles and their welfare criteria. Among the principles, good feeding plays a crucial role for dairy donkeys, since these animals have to produce extra milk for human consumption. However, at the moment, the good feeding principle only includes the appropriate nutrition and the absence of prolonged thirst welfare criteria; these criteria are only evaluated considering three welfare indicators, that is, the body condition score, the skin tent test and water availability [(i)nutritional requirements .(ii)farm management requirements .(iii)animal-based indicators (including the body condition score (BCS), fatty neck score (FNS) and bodyweight (BW)).This new interest and increasing demand for donkey milk have stimulated the setting up of farms on which dairy donkeys are reared . Over thlability . HoweverAll these requirements and indicators are discussed in order to help optimise the welfare of donkeys used for dairy production.A precise understanding of the requirements of donkeys during lactation helps to optimise milk yields and it is important for the welfare of both the jennies and their foals. Lactation is a critical period of the breeding cycle of dairy donkeys. According to the available literature, the lactation period of dairy donkeys ranges from 180 to 350 days ,7,12. FoCurrently, there is a lack of studies that establish the energy requirements of lactating donkeys. Further work is required to determine the energy requirements for milk production. However, information is available on the growth rates of donkey foals; a study conducted by De Paolo et al.  estimateIt has been reported that 10 L of milk are required to increase the weight of a foal by one kilogram , consequThe mean energy requirement per kg of milk produced by a jenny has been estimated to be around 3 MJ of digestible energy (DE), or 2.54 MJ of net energy (NE), throughout the whole lactation period . Therefo0.75/day may be proposed, with a mean MER of 0.29 MJ of NE/kg of BW0.75/day.If the requirements are evaluated according to the French Net Energy System , a rangeA comparison of the proportional increase above the maintenance energy requirements for milk production for a 300 kg BW jenny, considering a milk production of 5 L is reported in Because of the difference in the estimated energy requirements of the two energy systems and the lack of data, here, estimation of the energy requirement taking into account the BCS of the animal and the actual energy intake supplied with the diet is proposed. It is particularly important to perform feed analyses, since forages may have different compositions and nutritional values, according to the floristic composition and the environmental growing conditions . Table 3Little information is available concerning the protein requirements of donkeys. Some studies have suggested that the protein requirements of donkeys may be lower than those of ponies and horses ,24,25. N0,75) and 33 g MADC/kg milk during lactation [INRA  expresseactation . TherefoNo specific vitamin requirements are currently known for lactating donkeys. Smith and Burden  suggesteIt may also be important to ensure sufficient levels of vitamin supplementation, especially, for those animals that are primarily fed on dried forages . PastureThe mineral requirements of lactating donkeys are unknown, and the suggestion of some authors is to use the NRC recommendations  concerniFarm management requirements include different management procedures which could affect the appropriate nutrition welfare criteria on a dairy donkey farm. Therefore, this section includes those requirements  which are believed to play a crucial role in respecting the best practices for the feeding of donkeys.In nature, donkeys are able to adapt to grazing for long periods of time, and forages are the basis of their diet . There aThe first reason is that a forage-based diet is crucial for the gastrointestinal physiology of donkeys . DonkeysThe difference in the results of the various studies may be due to a difference in the voluntary dry matter intake (VDMI), which depends on the kind of feedstuff and the physiological condition of the animals. No specific recommendations are available on the minimum forage intake for either the maintenance of donkeys or for lactating donkeys but, due to their nature, forages should be given ad libitum and the body condition of the animals should be monitored to avoid overfeeding.The second reason, as pointed out by Smith and Burden , is thatAccording to Dougal et al. , a largeThe third reason is related to the fact that a forage-based diet has an effect on milk quality. Few studies are available on this topic, but Valle et al.  reportedThe provision of water has often been overlooked in the literature. It is important to underline that, although donkeys are known for their thirst tolerance, this should not be confused with their water requirements . It appeThe amount of water a donkey needs depends on several factors: diet (fresh forages versus hay-based diets), work, physiological status and environment temperature. Lactation leads to an increase in water intake in all milk-producing animals, because the losses due to lactation represent one of the major ways by which water is lost . LactatiThe type of bedding material that is used for donkeys may be of concern for their appropriate nutrition welfare criteria, because edible bedding materials may represent a risk factor for the development of nutritional diseases. The choice and quantity of the bedding material and the bedding management (regularly changed and/or cleaned) are important factors ,38, espeEven though the intention of this section is to underline the possible risks of using specific bedding that could be ingested, it is also necessary to evaluate the hygienic quality of the bedding. The use of appropriate bedding material and its absorption capacity have been shown to be important in equine management to preserve the health of both the respiratory tract and of the hooves ,43,44.No studies are available on the adequate space and appropriate group sizes of dairy donkeys. However, this aspect could represent an important issue that should be considered for the appropriate nutrition welfare criteria of dairy donkeys. Donkeys need to receive an appropriate diet in order to maintain their milk production and right body condition, and for this reason, an appropriate group size should be organised to avoid the risk of underfeeding or overfeeding some of the animals. The design of the groups should take into account the natural structure of a donkey herd. However, few studies are available on this topic. According to McGreevy , ecologiMinimising negative social interactions and maintaining the stability of the herd may also be important factors. Moving donkeys from one group to another may have social implications that could lead to an unstable social environment. Consequently, keeping well-adapted dairy donkeys together may help to contribute towards a stable inner structure of the group. This, in turn, would promote the welfare of dairy donkeys, since a stable social interaction and psychological bond would be maintained. In this way, it is possible for the farmer to have more control over the feeding intake of the animals and to adjust the diet according to their productivity.2, while one with a height of between 120–148 cm needs an area of 7 m2. However, this protocol refers just to the shelter dimensions, and no mention is made of the dimensions of the areas where they move (such as pastures or the dry lot areas where the donkeys are kept). Moreover, no mention is made of the bunk length or feeding space. These features may be important, especially for donkeys kept on semi-extensive breeding farms where access to pasture is limited. Semi-extensive farms are characterised by a combination of both intensive and extensive husbandry methods. Dairy donkeys are partially grazed and partially fed ad libitum on these farms with on-farm produced hay [Little is known about the group sizes of dairy donkeys. The group size may have an important effect on the feeding behaviour and feed intake of donkeys. Avoiding overcrowding could also be important for dairy donkeys, because it has been shown that aggressive behaviour between donkeys might be reduced when the social groups live in an environment with an abundance of accessible resources for all ,46. The uced hay , as a coThe accessibility of each group member to feeds is important to maintain the well being of the animals and the correct VDMI.Dental care is one of the most important farm management indicators of appropriate nutrition. In a study conducted on lactating donkeys, the researchers noticed that animals with a lower BCS (a score of 1 or 2 scores out of 5) showed poorer dental conditions . In addiThere is an old saying that states “no foot, no horse”, and this is an important point as an indicator of the appropriate nutrition welfare criteria of donkeys. The pain associated with hoof disorders could lead to changes in feeding behaviour, such as a reduction in feed intake and in the number of daily visits to the feeder. No studies on the feeding behaviour of dairy donkeys, as a consequence of hoof problems, are currently available. However, it has been reported that hoof pain in horses and donkeys can lead to an increase in periods spent lying and to a lack of movement . It is kThe animal-based indicators of donkeys are evaluated directly on the animals and may mirror such effects as under and/or overfeeding and metabolic diseases. Moreover, they may be used as nutritional and management indicators.BCS is the only indicator considered in the AWIN welfare assessment protocol for the appropriate nutrition welfare criteria for donkeys . BCS is In recent years, there has been an increase in the number of studies related to the regional adiposities of horses and ponies. Particular attention was paid to the adipose tissue deposited along the crest of the neck, which has been associated with the development of metabolic problems, such as insulin resistance and an enhanced risk of laminitis ,61. SeveValle et al.  developeThe best way to evaluate the nutritional status of dairy donkeys is to monitor BCS and BW together ,57. AlthPearson and Ouassat  developeThe same authors also developed an Equation (2) to estimate the BW of adult donkeys with a BCS > 6 .The Donkey Sanctuary  developePearson and Ouassat  proposedNomograms are also available for the estimation of the BW. In this case, a line is drawn on the chart to link the heart girth to the body length measurements  or the hThis review summarises the nutritional requirements, farm management requirements and animal-based indicators that should be considered when evaluating the appropriate nutrition welfare criteria of dairy donkeys. Furthermore, this review explores the connections between animal-based indicators and appropriate nutrition welfare criteria. The evaluation of the good feeding welfare principle remains multi-faceted and complex. A wide range of requirements and indicators should be considered when assessing the welfare of lactating donkeys. The scarcity of information in the current literature highlights the need for further studies on the requirements and indicators necessary to optimise the welfare of these animals. A robust evaluation should take into account an integrated set of indicators, instead of just a single one.


To evaluate the satisfaction of patients admitted to the intensive care unitusing a diary and analyze possible points for improving this instrument.This was an observational, retrospective study, conducted between March 2014and July 2017, in a multidisciplinary intensive care unit of a districthospital. The diary was implemented in patients sedated for 3 or more days.Three months after discharge, their satisfaction was assessed using aquestionnaire. A patient who agreed with the 5 statements assessing thediary's help in clarifying the intensive care unit stay, in filling memorygaps, in recovery, in reassurance, and in the recommendation of thisintervention was defined as satisfied.A total of 110 patients were included, of whom 55 answered the questionnaire.Of these, 36 (65.5%) were classified as satisfied. Each item had a positiveresponse in more than 74% of cases. A total of 60% of the participantssuggested increasing the number of photographs. No significant differenceswere found in the subgroup analysis .Most patients were satisfied with the diary but suggested an increase in thenumber of photographs. The use of intensive care diariesdates back to the early 1980s in Denmark, during a time with longer periods ofventilation and sedation, a paradigm that has changed in recent years. Sedation withdrawal andmobilization as early as possible are increasingly advocated. This development requires theadoption of strategies for monitoring and preventing new problems to which thesepatients may be subjected. Although patients are less sedated, many still havelittle or distorted memory of their stay in the ICU, which is sometimes exacerbatedby hallucinations and nightmares, with increased risk of developing posttraumaticstress disorder (PTSD), anxiety, and depression, which are part of post-intensivecare syndrome (PICS).,5In recent years, there have been changes in the approach to patients admitted to theintensive care unit (ICU), namely, with regard to sedation and analgesia. and need help to build a complete and coherentnarrative of this phase of their lives.This lack of memory is emphasized by the fact that these patients have a strong needto know what happened during their hospitalization The presentation and content of diaries varyaccording to ICU and local/regional protocols, and they may even be included in anorganized and integrated patient rehabilitation structure. Despite thisheterogeneity, the content of the diary complies with established generalrules.,9 Questions remain as to the best way to apply thediary and the positive and negative implications for patients, family members, andhealth professionals.-15 Despite the demonstrated benefitsin reducing the incidence of PTSD, there is currently no evidence from randomizedstudies of the benefits and harms of implementing diaries in patients and theircaregivers that allows recommending their widespread use as a therapeuticstrategy. Some studieshave evaluated patient satisfaction with diaries through questionnaires or informalinterviews,-19 but there are no data on thePortuguese population, with the exception of the contribution of differentPortuguese ICUs to the multicenter study by Jones et al.The development of a diary in which photographs and facts, events, and emotionsrelated to this time period are recorded by those accompanying the patient  has been identified as one of the strategiesallowing the patient to assign meaning and coherence and to chronologically orderthe period of time when memories are absent or distorted.The objectives of the present study were to evaluate patient satisfaction with thediary and to analyze possible points of diary improvement to optimize the use ofthis instrument.Hospital Pedro Hispano (HPH), in amultidisciplinary ICU, which began implementing diaries in 2009.This is a retrospective, observational, and descriptive study conducted at theIntensive Care Unit of At the HPH ICU, a diary is started for all patients older than 18 years who aresedated for 3 or more days. The diaries are kept by nurses and doctors and byrelatives and friends of the patient. The writing is performed at least daily, andthese individuals describe what the patient is going through, write messages ofencouragement, and share feelings. The diary is kept until the date of dischargefrom the ICU, even after the sedation is discontinued. When the patient improves,they are given the diary. The patient is reassessed in person by the intensivist atthe follow-up visit (FUV) 3 months after discharge, when the development of PICS ismonitored and satisfaction with the diary is evaluated through a questionnaire. Theexclusion criteria for applying this tool are illiterate patients or those with asevere psychiatric disorder, identification of problematic families (from the pointof view of communication difficulties), lack of social support/coverage, and poorshort-term vital prognosis. Delirium was identified using the Confusion Assessment Methodfor the Intensive Care Unit (CAM-ICU) applied by ICU nurses or physicians. PICS was identifiedduring hospital stay by the patient's care team and was divided into its physicaldimensions  and nonphysical dimensions . PICS at 3 months was evaluated by the physician andnurse responsible for the FUV through clinical evaluation and application of theHospital Anxiety and Depression Scale (HADS), using a cutoff of 10 points for each subscale, and of thePost-Traumatic Stress Syndrome 14-Questions Inventory (PSSS-14).Data on all patients with a diary started between March 2014 and July 2017 werecollected. Demographic data, the presence of functional or cognitive limitations,hospital admission data  and FUV data (answers to the satisfaction questionnaireand PICS at 3 months) in the ICU's electronic database were analyzed. Regarding thepresence of functional or cognitive limitations, no validated scale was used, andthey were only defined as "present" or "absent" according to the clinicalevaluation. The main diagnoses were coded according to the World HealthOrganization's (WHO) International Statistical Classification of Diseases andRelated Health Problems (ICD-10) of 2016, with the necessary adaptations to thespecific context. The severity score calculated on admission was the SimplifiedAcute Physiology Score (SAPS) II.Follow-up ended at the FUV (3 months after discharge) or before, in case the patientdied or missed the visit. Patients who missed the FUV, who did not read the diary,and/or who did not answer the questionnaire were excluded from the study.The satisfaction with the diary questionnaire was developed by the authors. It wasthen was reviewed by experts in the field of intensive care medicine and psychiatryand modified accordingly before its application. Before its application in thepresent study, the questionnaire was tested in 5 patients to assess theirunderstanding of the questions, and changes were made in the language after thisprocess. The questionnaire included 11 questions answered on a Likert scale and aspace for suggestions for improvement. Five questionnaire items were formulated toassess patient satisfaction  . PatientTo evaluate possible improvements to the diary from the patient's point of view, theresponses to closed questions on the number of photographs, quality and quantity ofinformation, and time of diary delivery were analyzed, along with the response to anopen-ended question in which the patients could express concerns andsuggestions.The statistical software Statistical Package for the Social Sciences (SPSS)version 24 was used for statistical analysis. Continuous variables with normaldistribution were analyzed by parametric methods and the remainder bynonparametric tests. For the categorical variables, the chi-square test wasused.To evaluate the relationship between some patient characteristics and hospitalstay, several subgroups were defined a priori. Each of the variables age,duration of sedation, duration of ventilation, length of diary keeping, and SAPSII was categorized into 2 subgroups, considering the mean/median of eachvariable as the cutoff point. The variables delirium, depression, and anxiety inthe ICU were categorized into 2 subgroups according to their presence orabsence. Significance was set at p < 0.01.The questionnaires were sent to all patients with the diary, accompanied by aletter explaining the study that emphasized that participation in filling outthe questionnaire was voluntary and required authorization to use these data forthe study in question. All data were treated anonymously and confidentially. Thestudy was approved by the Ethics Committee of the HPH Knowledge ManagementService of the Local Health Unit of Matosinhos.During the study period, 1,300 patients were admitted to the ICU, and a diary wasstarted for 110. As shown in Some participant characteristics that could influence the satisfaction with the diarywere analyzed.From the demographic point of view, the hypotheses that younger patients  or female patientsvalue this intervention more and were more satisfied than older or male patientswere tested. No significant differences were found .Based on the assumption that patients with greater potential to develop memory gapswould be those who would most benefit from reading the diary, the satisfaction ofpatients sedated (> 5 days) or ventilated (> 8 days) for longer, with longerlength of diary keeping (> 9 days) and higher SAPS II (> 42), was comparedwith that of the remaining patients, and no significant differences were found amongthe various subgroups .Lastly, it was evaluated whether patients who developed psychological components ofPICS  in the ICU experienced greater or lesserbenefit from the intervention, but this did not translate into satisfaction in astatistically significant manner .Possible points for improvement of the diary in the patient's perspective wereevaluated. The responses are summarized in ,17,18,24The main objective of the present study was to evaluate satisfaction with the diaryby patients admitted to a portuguese ICU. Satisfaction was assessed by completing aquestionnaire that addressed the items clarification, filling of memory gaps, helpin recovery, reassurance, and recommendation of intervention in similar cases. Eachof the items had a positive response in at least 74.5% of cases, and the itemsummarizing the patient's opinion reached a maximum of 96.4% (recommendation of theintervention in cases similar to yours). However, the authors were more restrictedin the definition of satisfaction adopted, which considered only patients whoanswered positively to the 5 questions evaluating satisfaction, which occurred in65.5% patients. Previous studies evaluating satisfaction have always used aqualitative method, and it is therefore not possible to compare these results withthose of other cohorts.When the participants were subdivided according to demographic characteristics thatcould be associated with greater valuing of the diary or with indicators of greater severity , which could be associated withmore memory changes and therefore with a greater benefit from the diary, there wereno significant differences in the satisfaction of the different subgroups with thediary. Thus, we believe that it is beneficial to continue to start a diary for allthese patients, regardless of age or the presence or absence of these severityindicators.delirium, depression, or anxiety in the ICU. Thus, webelieve that including these patients in diary protocols remains essential.The same occurred with the development of psychological components of PICS, in whichthere was also no difference in the satisfaction of patients who did or did notdevelop There are no data in the literature on these subpopulations and on the specificapplication of the diary in these patients. Theinclusion of photographs of sedated patients who are unable to consent is among themost discussed aspects. Thebest time to deliver the diary to the patient is also controversial.There are no specific and validated guidelines that define the structure, content,and process that the diary should present, and there is a diversity of diary-keepingpractices among ICU.To help answer these concerns, the objective of this study was to analyze possiblepoints for improvement of this instrument, from the point of view of thepatient.Increasing the number of photographs was the most frequent suggestion, appearing in33 of the 55 questionnaires. In the literature, photographs appear to be one of theaspects most appreciated by patients. Studies reveal that patients usually want morephotographs and that these should depict times that are difficult to describe toindividuals who did not visit them or less comfortable situations.,16,24 In arecent study, Teece et al. warned that reading the diary can arouse feelings of fearand anxiety, highlighting the importance of maintaining continued support, which canbe provided through the FUV (as occurs in the HPH ICU) or support groups.Consistent with these data, 9 patients (16.4%) did not agree that the diary containedall the information they needed about their hospital stay. Some studies found thatpatients want detailed information, including on negative events, and thedescription of medical procedures and daily activities were some of the preferredcontents. In thepresent study, the main obstacle to information clarity was the difficulty inunderstanding the handwriting of some entries.For the narrative to be understandable, the patients included in the study byÅkerman et al. emphasized the importance of presenting the data inchronological order.More than three-quarters of the patients agreed with the time of delivery of thediary. There is still no consensus as to the best time to do so. In some places, thediary is delivered during the hospital stay; in others, at the time of discharge;and sometimes, only later by mail.There are some biases associated with the use of questionnaires, such as the socialdesirability bias and the Hawthorne effect (participants behave differently when they know they arebeing observed), that we tried to avoid by using anonymous questionnaires, whichcould be completed at home and later turned in at the FUV. The use of a classicLikert scale with 5 responses would be more appropriate to evaluate patientsatisfaction with the diary.versus 12.7%), which may have influenced their adherence.Two other biases to which this method is exposed are participation bias  and loss of follow-up . To evaluate itseffect, we thoroughly characterized individuals who did not participate in the studyor were lost to follow-up to determine how they differ from the participants. Weconcluded that in regard to the various analyzed parameters, these 2 groups do notpresent significant differences. Despite the lack of statistical significance (p =0.314), the group of nonrespondents had a larger number of depressed patients ,the instructions given to them, and the inclusion or not of clinical information. Inthis sense, there could be advantages in developing more specific recommendationsregarding the method of application of this instrument. However, some authorsbelieve that "very strict guidelines" could negatively affect or inhibit the writingand sharing of feelings by family members and health professionals.More studies are needed, especially multicenter prospective studies, given theimportance of cultural differences among countries. Only then will it be possible toimprove this instrument and develop recommendations that assist in its use inpatients admitted to the ICU and possibly extend its use to other groups ofpatients, inside and outside the ICU.The data from this study suggest that 65.5% patients were completely satisfied withthe diary. There were no differences in satisfaction when analyzing differentpatient characteristics, such as age, sex, presence of severity indicators, ordevelopment of delirium, depression, or anxiety in the intensive care unit. Based onthis study and the published literature, the authors recommend implementing diariesin all patients admitted to the intensive care unit and sedated for 3 or moredays.