The ongoing COVID-19 pandemic in Africa is an urgent public health crisis. Estimated models projected over 150,000 deaths and 4,600,000 hospitalizations in the first year of the disease in the absence of adequate interventions. Therefore, electronic contact tracing and surveillance have critical roles in decreasing COVID-19 transmission; yet, if not conducted properly, these methods can rapidly become a bottleneck for synchronized data collection, case detection, and case management. While the continent is currently reporting relatively low COVID-19 cases, digitized contact tracing mechanisms and surveillance reporting are necessary for standardizing real-time reporting of new chains of infection in order to quickly reverse growing trends and halt the pandemic.This paper aims to describe a COVID-19 contact tracing smartphone app that includes health facility surveillance with a real-time visualization platform. The app was developed by the AFRO  GIS (geographic information system) Center, in collaboration with the World Health Organization (WHO) emergency preparedness and response team. The app was developed through the expertise and experience gained from numerous digital apps that had been developed for polio surveillance and immunization via the WHO’s polio program in the African region.We repurposed the GIS infrastructures of the polio program and the database structure that relies on mobile data collection that is built on the Open Data Kit. We harnessed the technology for visualization of real-time COVID-19 data using dynamic dashboards built on Power BI, ArcGIS Online, and Tableau. The contact tracing app was developed with the pragmatic considerations of COVID-19 peculiarities. The app underwent testing by field surveillance colleagues to meet the requirements of linking contacts to cases and monitoring chains of transmission. The health facility surveillance app was developed from the knowledge and assessment of models of surveillance at the health facility level for other diseases of public health importance. The Integrated Supportive Supervision app was added as an appendage to the pre-existing paper-based surveillance form. These two mobile apps collected information on cases and contact tracing, alongside alert information on COVID-19 reports at the health facility level; the information was linked to visualization platforms in order to enable actionable insights.The contact tracing app and platform were piloted between April and June 2020; they were then put to use in Zimbabwe, Benin, Cameroon, Uganda, Nigeria, and South Sudan, and their use has generated some palpable successes with respect to COVID-19 surveillance. However, the COVID-19 health facility–based surveillance app has been used more extensively, as it has been used in 27 countries in the region.In light of the above information, this paper was written to give an overview of the app and visualization platform development, app and platform deployment, ease of replicability, and preliminary outcome evaluation of their use in the field. From a regional perspective, integration of contact tracing and surveillance data into one platform provides the AFRO with a more accurate method of monitoring countries’ efforts in their response to COVID-19, while guiding public health decisions and the assessment of risk of COVID-19. Since the confirmation of COVID-19 in Wuhan, China, in late December 2019 . ExistinContact tracing is a process that involves early case recognition, isolation, and tracking of people who have been exposed to a disease ,6. It isThe implementation of an efficient contact tracing system can vary depending on the place and the type of disease. In the case of COVID-19, for instance, controlling the epidemic with a comprehensive contact tracing system guides the type of intervention to be used , whereas those with severe active disease may be hospitalized. Additionally, in most scenarios, simple traditional and manual contact tracing methods can be effective at the beginning of outbreaks when the numbers are low; however, large-scale epidemics and pandemics require newer digital contact tracing methods. During highly infectious pandemics, such as the current COVID-19 pandemic where very large populations are affected, it is pertinent to use digital solutions to effectively locate contacts who have been exposed to people with the disease as well as to monitor them consistently, especially those currently on home care and self-isolation.Numerous types of contact tracing methods have been implemented during different pandemics and endemics, and their effectiveness largely depends on the tools used . GeograpOver the years, scientific data collated by the World Health Organization’s (WHO) emergency preparedness and response (EPR) unit showed that most countries in Africa are struggling to implement efficient contact tracing methods.This has greatly increased the number of new community-transmitted COVID-19 cases; this is a very critical situation for the continent, as it has been predicted to be the next hot spot for the coronavirus . In the Application: a program or group of programs designed for end users. Examples of an application include a word processor, a spreadsheet, an accounting application, a web browser, an email client, a media player, a file viewer, a simulator, a console game, or a photo editor .Platform: a computing platform or digital platform is the environment in which a piece of software is executed. It may be the hardware, the operating system, a web browser and its associated application programming interfaces, or other underlying software, as long as the program code is executed with it .Module: a section of an application or app that focuses on a unique set of deliverables or assessments .Surveillance: an epidemiological practice by which the spread of disease is monitored via data collection in order to establish patterns of progression. The main role of disease surveillance is to predict, observe, and minimize the harm caused by outbreak, epidemic, and pandemic situations, as well as to increase knowledge about which factors contribute to such circumstances. A key part of modern disease surveillance is the practice of disease case reporting .Tool: a programming tool or software development tool is a computer program that software developers use to create, debug, maintain, or otherwise support other programs and applications .Contact tracing is a very serious limitation in disease surveillance in Africa. As shown in Figure S1 in The WHO’s AFRO GIS Center considered different scenarios during preliminary discussions in March 2020, with the COVID-19 incident management team managing the regional response at WHO’s regional office. During these preliminary discussions, it was highlighted that the best contact tracing solution would leverage existing GIS platforms and would be deployed to fill the current gaps known in COVID-19 surveillance and to help address existing challenges with contact tracing , and the second component is used to collect and record the temperature reading of a case contact for 14 days . This form references the actual case for those contacts that could be linked to a COVID-19 case.Every contact connected to a case is expected to be registered in the COVID-19 database. A prompt is shown at the beginning of the form that allows for contact registration. The index case’s ID number is required at this stage to link the contact to an already-existing case in the database . This displays the records of the index case for confirmation and validation before registering the details of the new contact.After contact registration, the contacts are expected to have a 14-day record update of their temperature and medical condition. There is a prompt at the beginning of the form that allows for contact follow-up .This form is divided into two components: the first component is used to collect general information about a traveler entering into the country, and the second component is used to collect and record the temperature reading of the traveler for 14 days . Note that the follow-up component is linked to the traveler health questionnaire and is referenced using the case phone number of the traveler as the unique identifier.This component is responsible for the interoperability and interaction of data between platforms. The APIs link the various platforms together, facilitating data exchange in real time. This allows for seamless operations and data exchange between the data collection, hosting, analytics, and visualization tools within the polio GIS toolbox and platform.This comprises all the resources developed and deployed within the WHO AFRO infrastructure. It comprises front-end data collection tools on mobile devices and web interfaces, database servers, data visualization tools, and platforms.The AFRO GIS Center, in collaboration with the WHO EPR team, went ahead to deploy the COVID-19 Emergency Deployment Toolkit, using the ODK platform to support contact tracing through self-reporting.Data management is a very crucial aspect of surveillance, particularly when it comes to data of relevance to contact tracing. In the management of contact tracing data, database linkages, performance monitoring, visualization, and analysis are important factors to consider. How these factors were managed are discussed below.The biggest challenge of contact tracing data management is enrolling contacts and performance monitoring of the contact tracing processes . This wapulldata function from the ODK, this allows the developer to pull data from other dynamic data sets and surveys  in the same or different project, similar to pulling data from a preloaded CSV file . See pulldata function and considerations for replicating this in another situation that warrants the use of dynamically pulled data from one mobile form through a server to another mobile form.On clicking the button “Link Dataset,” the changes are saved automatically. The linked data set appears in forms on the Android device. After data set linkage to the form, data can be effectively pulled from the linked data set into the form using the Evidence-based performance monitoring of contact tracing, surveillance activities, and other health interventions by health workers was a key consideration in the repurposing of polio GIS platforms. A geotracking feature was added to our app to provide geographic evidence of a team’s visits to specific contacts. This also ensures that health workers conduct surveillance and other health interventions with the knowledge that their activities are being monitored for accountability.A one-stop dashboard that brings data from participating countries into a regional interface for COVID-19 activities was developed using connectors from the databases to ArcGIS and Power BI to develop the key performance indicators for the pillars of the COVID-19 response. The dashboard allows the incident management team to conduct an integrated and effective response to the pandemic. An example is seen in Figure S3 in A module  for repoThe module focused on the use of the ODK-based app  with the following COVID-19 assessment focuses:Awareness of the existence of a COVID-19 surveillance system.Display of COVID-19 case definition posters.Presence of a COVID-19 surveillance focal point.Number of health workers in the facility who know the definition of a suspect case.Number of people who know the COVID-19 alerting number and notification channel.Appraisal of IPC awareness in terms of handwashing, functioning of handwashing kits, availability of isolation room, use of personal protective equipment, and availability of a triage system in the health facility.Recording of details of suspected cases that fit the clinical system of COVID-19 and facilitating testing.The adoption of the solutions developed by the AFRO GIS Center in collaboration with the WHO EPR team was piloted in Zimbabwe and Benin in April 2020; the solutions were then subsequently used in Nigeria, Uganda, Cameroon, and South Sudan to conduct contact tracing or support other contact tracing data collection expeditions. See Figure S4 in A total of 27 countries in the region adopted this module, which was developed to mitigate the gaps of COVID-19 surveillance at the health facility level. Event-based surveillance is highly optimized in low- and middle-income countries at the health facility level ,31 and cThe scope of leveraging the polio GIS platform in terms of apps and visualization tools addresses the mitigation plans for contact tracing and surveillance gaps in the region regarding the following aspects:During the COVID-19 pandemic, the platform was able to support the identification of COVID-19 cases, contacts, and database consolidation gaps , helping to guide the response.During outbreaks and routine contexts alike, the platform was able to identify community transmissions that were not detected by the traditional contact and case databases.Health facility–based surveillance was built on an already-existing ISS module and was, thus, quite sustainable, as other active disease surveillance was already being conducted with the app.The chain of transmission and surveillance gaps were easily seen on the interactive visualization made possible by the real-time connection of data being submitted from the apps into Power BI; thus, faster decision-making was possible at all levels.The platform allowed ease of use of the data entry modules; there was little or no training, as surveillance teams at the country level were already used to similar technologies as a result of using mobile phones for other interventions.The platform was developed with interoperability being given the highest consideration so that other countries’ contact tracing efforts and facility-based surveillance systems, such as DHIS2, KoBoTool, and SORMAS , could be easily connected to share data.This platform offers an additional dimension to the existing platforms that are being used in supporting the COVID-19 response ,33, withThe use of the GIS platform has been shown to provide adequate support and promote care of individuals across different thematic areas of health. Documented evidence exists that has demonstrated its capability to identify high-priority areas that require maternal care . In addiMany questions with regard to information sensitivity and privacy regarding COVID-19 cases and contacts have been answered by the security features of the app and the platform. However, there still exists the possibility of intrusion, careless handling of passwords, and hacking that may lead to compromised information if countries do not adequately manage their access and control. Also, the app and platform deployment involves users having phones for data entry and visualization; thus, a lot of phones are required for implementation of all aspects of surveillance and contact tracing.The solutions outlined can easily be implemented with the procedural steps that were enumerated and explained in the data collection and visualization sections. The use of technology stacks via ODK and Power BI to collect data and to visualize them in real time can easily be replicated by technical users who are familiar with these tools. However, it is important to note that early engagement and meetings with all stakeholders was crucial to ensure ownership, increase coordination, and gain a better understanding of the existing surveillance landscape . Good liHealth facility–based surveillance and effective contact tracing management tools outlined here will provide valuable information that can strengthen the use of data by national surveillance systems during the pandemic. Evidence from the global pandemic thus far clearly presents three challenges in controlling COVID-19: its lasting pandemic potential, high fatality due to its infectivity, and its ability to disrupt health systems. Similarly, in the absence of vaccines and therapeutics, the only available tools for control include contact tracing, social distancing, and quarantine. The African region must, therefore, adopt a variety of methods to minimize the above challenges and adapt the response to the specific needs of each country as the outbreak evolves.Digital contact tracing and surveillance at the facility level will be paramount at some point for every country to stay a step ahead of the virus. The applications and apps that have been developed for COVID-19 surveillance and contact tracing are not standalone interventions but should be implemented together with social distancing measures and quarantine, depending on the size of the outbreak.In the African region, COVID-19 testing capacity varies widely. Countries with limited testing capacities and large outbreaks will need more advanced comprehensive contact tracing solutions, such as the one described herein, to suppress the virus to lower transmission rates. However, those with smaller outbreaks can use traditional methods with ODK or KoBoCollect platforms and simply share their APIs with the regional office to ensure that all data are available to the incident management system.As countries begin to relax public health lockdowns, traditional and advanced contact tracing methods will be necessary to highlight areas of ongoing transmission; these data will be needed not only in their respective countries but also on a regional level to enable a better understanding of the pandemic and optimal decision-making in managing the risks and responses.If widely adopted in the region, this innovation, alongside existing data collection tools , will help countries respond effectively and efficiently to the pandemic. Other benefits to countries using this tool include real-time monitoring of the epidemic and their response, timeliness and completeness of contact tracing, and staff accountability. These factors are the cornerstone of surveillance during epidemics. During the Ebola outbreak in West Africa from 2014 to 2016, it was well-documented that a major contributor fueling the epidemic was the lack of standardized and synchronized contact tracing. Once adopted and implemented, a significant decrease in cases was observed across the affected countries, even though, at the time, the solutions were not as advanced as they are today.With the high penetration rate of mobile phones across the African region, mobile-based monitoring of COVID-19, from traditional methods to voluntary self-reporting and remote follow-up of contacts, will greatly improve the identification of suspected cases and contacts; these are important resources to help in the region’s fight against this debilitating disease. Additionally, the use of this tool should reduce the burden on health systems, allowing for the provision of essential health services and minimizing mortalities from COVID-19 and neglected secondary diseases, which can result from a system overwhelmed by the pandemic.From a regional perspective, integration of contact tracing and surveillance data into one platform provides the AFRO with a more accurate method of monitoring country efforts in their response to COVID-19, while guiding public health decisions and the assessment of risk for COVID-19.


Relevance to Practice. This study provides a baseline of data that could facilitate further investigations in the future to improve the quality of services delivered to such patients and thus their QoL and satisfaction.Depression, anxiety, and stress (DAS) are common symptoms of multiple sclerosis (MS) patients and are highly correlated with poor quality of life. Managing DAS among such patients can improve their quality of life (QoL), empowering them with improved autonomy, self-care, independency, and ability to perform daily activities. This study is aimed at examining the effectiveness of the Benson Relaxation Technique (BRT) on reducing DAS among patients diagnosed with MS in Jordan. This quasiexperimental study of 105 Jordanian patients diagnosed with multiple sclerosis tested an intervention group (60 patients) who received BRT and a control group (45 patients) who received normal treatment. Data were collected from January 2021 to April 2021, using the Arabic version of the Depression Anxiety Stress Scale (DASS21). The intervention group was instructed to perform the BRT two times a day for 10 minutes at home for eight weeks at two specific times, with 7-8-hour intervals between each episode. STROBE guidelines were followed in reporting the review. At the baseline comparison, there was no statistical difference between the interventional and control groups with regard to DAS. The levels of DAS between the two groups after three months of the last sessions of the intervention (postintervention) were compared. The results showed that the intervention group had significantly lower levels of DAS compared to the control group. The levels of the DAS were significantly lower for the intervention group postintervention. Adding relaxation techniques to the therapeutic routine is a cost-effective complementary treatment to decrease DAS among MS patients and improve their QoL.  Multiple sclerosis (MS) is a chronic disease affecting a patient's central nervous system. Epidemiological data on MS prevalence indicates that approximately 2.8 million people live with MS worldwide, which is equal to 35.9 per 100,000 population [Symptoms of MS can affect the physical, cognitive, and emotional status of patients –6. The mEmotional symptoms such as DAS are highly correlated with poor quality of life (QoL) among MSPs . The samPrevious literature applied different methods aimed at minimizing the emotional impact of MS on patients , 17. RelDoes the Benson Relaxation Technique reduce the depression, anxiety, and stress of patients diagnosed with MS?Although BRT seems to be effective in reducing the emotional symptoms of patients with chronic diseases, the effect of BRT on DAS symptoms has never been studied among MSPs in Jordan. Therefore, this study is aimed at examining the effectiveness of BRT on reducing DAS among patients diagnosed with MS in Jordan. The study answered the following research question:This is a pre-post quasiexperimental study, involving two groups of MSPs: the interventional and control groups. The control group acted as a placebo group. This review is reported according to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE)  having a confirmed medical diagnosis of MS by a neurologist and (b) being able to understand, read, and write Arabic. Exclusion criteria were (a) having a psychotic disorder , (b) receiving psychotherapy during the last six months, and (c) attending any intervention targeting psychological mental health during the previous six months. In the intervention group, those who were absent for any of the Benson interventional sessions were excluded from the study. Data were collected from June 2020 to December 2020.t-test and paired t-test) and assuming a power of 80%, an α level of 0.05, and medium effect size, a total of 102 patients was deemed sufficient to detect any statistically significant difference between the two groups according to their demographics and was enough to detect the effect of BRT on the DAS of patients.The sample size was calculated using G power software . Taking Of 145 patients approached and invited to voluntarily participate, 132 consented, representing 91%. Of those who consented, 105 completed and returned the questionnaire, representing a final response rate of 80%. They were divided into two groups, all of whom attended the two phases of the study: 60 patients received the intervention  and 45 had treatment as usual .The following information was collected for sociodemographic characteristics: age, gender, level of education, employment status, financial status, marital status, duration of disease, and frequency of relapse during the previous two years.The Depression Anxiety Stress Scale (DASS21) is a set of self-reported items used to measure the intensity of DAS over the week prior to administration. DASS21 is the short version of the basic 42-item questionnaire DAS S-42, developed by Lovibond and Lovibond . It consThe reliability of DASS21 was measured using Cronbach's alpha and was reported to be good; it was 0.91 for the depression scale, 0.80 for the anxiety scale, and 0.84 for the stress scale . The relSit quietly in a comfortable positionClose your eyesDeeply relax all your muscles, beginning at your feet, progressing up to your face, and keep them deeply relaxedBreath through your nose. Become aware of your breathing. As you breathe out, say the word “one” silently to yourself. Do deep breathing; inhale for three seconds, pause three seconds, and exhale over a three-second periodContinue for 10 minutes. You may open your eyes to check the time but do not use an alarmWhen you finish, sit quietly for several minutes at first with closed eyes and later with opened eyesDo not worry about whether you are successful in achieving a deep level of relaxation. Maintain a passive attitude and permit relaxation to occur at its own pace. When distracting thoughts occur, ignore them and continue repeating “one.” With practice, the response should come with little effort. Practice the technique twice a day, but not within two hours after any meal, as the digestive processes seem to interfere with the elicitation of anticipated changesBRT was given to the intervention group by one of the research team (interventionist) who is qualified in relaxation techniques. Participants in this group received two sessions of the Benson technique; one hour for each session in a warm quite room with efficient light, temperature, and ventilation was provided by the selected hospitals/clinics, and the technique was repeated twice. Participants then performed it in the presence of the interventionist, who provided feedback by evaluating participants' skills in performing the technique and ensured that they had acquired sufficient skills to do it alone. A video of BRT was displayed to participants during the sessions. Moreover, a CD of the Benson relaxation technique was provided with handout copies about the performance of BRT, so participants could watch the video and read the instructions when needed. Participants were instructed to perform the BRT as follows:The intervention group was instructed to perform the BRT two times a day for 10 minutes at home for eight weeks at two specific times, 7-8-hour intervals between each episode. It was emphasized to participants that they should endeavour not to forget to perform the technique. However, if they forget to do it they were asked to do it as soon as possible.There was a self-reported Performance Record Form, which was filled out daily by the participants to ensure their compliance with the BRT. Every week, the interventionist met the participants to encourage them to perform the technique, and at the same time, their Performance Record Form was collected. Moreover, to ensure that the participants underwent the intervention appropriately, the participants performed the technique again in the presence of the interventionist.The interventionist established a WhatsApp group for all the participants and sent them the BRT video twice a day at specific times, to remind them to perform the technique. Furthermore, an identification card with the interventionist's contact information was given to the participants, and they were asked to contact the interventionist if they had any questions regarding the technique.Before starting with the data collection process, ethical approvals were gained from the Institutional Review Board of the Applied Science Private University and the Jordanian Ministry of Health to collect data from governmental hospitals. These were also presented to the private sector, and access was gained to all hospitals/clinics involved in the study. Participants' rights, such as voluntary participation, privacy, confidentiality, and the right to withdraw at any time without giving a reason, were guaranteed and explained to all participants. Participants were informed that all collected data were securely stored , accessible only to the research team.An invitation letter and an information sheet were sent to potential participants. The researchers' contact details were provided on the information sheet for those who wanted to participate or who had any enquiries about the study. An informed consent form was signed by those who agreed to participate. There was an option in the information sheet and the consent form to determine the patient's willingness to attend the intervention. Those who were willing to attend the program became the intervention group, and those who were unwilling to attend the program became the control. The participants then filled out the sociodemographic questionnaire and the DASS21 before the implementation of the program, and primary analysis was done. The course was then implemented over eight weeks. After that, participants were given three months before the second round of data collection was conducted, and DASS21 was filled out again.p value below 0.05 was considered significant. Descriptive statistics were used to describe the sociodemographic characteristics. Depending on the level of measurement of the variable, analysis tests were conducted. Due to the fact that DASS21 is a continuous dependent variable and there were two groups included in the study over two periods of time, chi square and t-test are the most suitable analysis techniques attending to the aim of the study. Chi square and independent t-test were conducted to compare the control group with the intervention group. A paired t-test was conducted to check any differences in DASS21 before and after implementing the course.Data were analysed using SPSS version 25 . All numt-test and chi square were used to examine any difference between the intervention and control groups. Results showed that there were no statistically significant differences in any of these characteristics between the two groups. Both groups were young, with a mean age of 33 years. Nearly two-thirds of the sample were females, and half of them were married. The majority of the sample had a bachelor's degree and were employed. Exactly half of the intervention group was single, and 32.4 of the patients reported one time of relapse in the last two years. On the other hand, the highest percentage for the duration of the disease for both groups was between 1 and 2 years  were compared using independent samples o groups . The levol group .t-test compared the preintervention and postintervention levels of the outcome variables for the intervention and control groups. The results showed that there were significant reductions in DAS levels postintervention for the intervention group and no significant reductions for the control group  on DAS with equal numbers of experimental and control groups found that the intervention group receiving relaxation techniques exhibited significantly decreased DAS scores after the intervention, while the control group receiving routine care had no significant decrease .Moreover, a study of 60 MSPs to determine the effects of BRT on MSPs' general health assigned patients equally to experimental and control groups and found that the mean scores of patients' general health scores before and after the intervention improved significantly in the experimental group but not in the control group . FurtherAdditionally, Mirhosseini et al.  investigOther relaxation techniques were found to improve the QoL of patients diagnosed with MS. An earlier study suggested that exercise training programs such as yoga and aquatic exercises should be integrated into the standard treatment of MS, as they have been shown to reduce fatigue, depression, and paraesthesia significantly in exercise groups compared to nonexercise control groups. In fact, those who did not exercise were 35 times more likely to report moderate to severe depression than those who did such exercises . SimilarPrevious studies have shown that BRT is more effective in managing DAS than comparable relaxation techniques , 50–52. BRT is a behavioural method designed to cope with DAS. Improving the levels of DAS is extremely important for the treatment of MSPs, as these conditions often present with various other comorbidities that can affect patients' QoL. The implications of this study include the importance of adding BRT to therapeutic routine treatments. This technique is a useful and cost-effective complementary therapy to alleviate MSPs' DAS. Since the effect of BRT on DAS symptoms has never been studied among MSPs in Jordan, this study provides a baseline of data that could facilitate further investigations in the future to improve the quality of services delivered to such patients and thus their QoL and satisfaction.The major limitation of this study was the inclusion of only one city in Jordan; it would have been more representative of the national picture to include participants from other cities. However, the capital includes more than one-third of the whole Jordanian population, making it generally representative in itself, and MS prevalence is slightly higher than the national average in Amman, as mentioned previously. Furthermore, MSPs come from all Jordanian cities to seek health services in this city. A more fundamental limitation was the relatively small sample size used in this current study as a result of convenience sampling. While adequate for the purposes of this research, the inclusion of more participants would have strengthened the conclusions drawn from the results. This study implements a quaziexperimental design; a randomized control trial may add more and can better predict the effect of the intervention.Improving the levels of depression, anxiety, and stress (DAS) is extremely important for the treatment of multiple sclerosis patients (MSPs), as these conditions often present with various other comorbidities that can affect patients' QoLThis study highlights the importance of adding the Benson Relaxation Technique (BRT) to therapeutic routine treatments. This technique is a useful and cost-effective complementary therapy to alleviate MSPs' DASThe effect of BRT on DAS symptoms has never been studied among MSPs in JordanThis study provides a baseline of data that could facilitate further investigations in the future to improve the quality of services delivered to such patients and thus their QoL and satisfaction


However, Indigenous peoples who form 5 % of the population of the country and include First Nations, Metis, and Inuit, still face, as a group, challenges not faced by the settler majority. They continue to be confronted with systematically worse determinants of health including housing, job prospects and income, and educational attainment than the rest of the population, a legacy of a paternalistic system that systematically provided inferior services and care. Consequently, Indigenous children and adults face a higher prevalence of obesity and nutrition and lifestyle-related chronic disease and live more frequently in food-insecure households–7. In addition, rates of injury and violent deaths, suicide, and infectious diseases continue to be higher for this population–11. Meanwhile, communities are striving to build on their strengths, reverse the unfavourable trends and build resilience through health and wellness programming that aim to revitalise the traditional food systems, as well as through the transmission of culturally foundational knowledge about the land, and the skills needed for the continued access to traditional food through hunting, fishing, gathering, and cultivating–15. These programmes are often based on holistic Indigenous worldviews that consider human health as a continuation of the health of the ecosystem and all living and non-living things,17.Canada is a prosperous country and member of the G7, with an enviable track record in public safety nets, including child support and public medical care, it was found that the diet of First Nations was often inadequate, particularly since many barriers  prevent community members from accessing their ancestral territory, thus affecting food supply and limiting their enjoyment of traditional food, which is of much greater nutritional quality than the generally available market food, particularly in remote communities,20. In fact, on days when traditional food was consumed, intakes of key nutrients were greatly improved compared to days without any traditional food in the diet. It was also found that obesity and diabetes were very high, at 50 % and 25 %, respectively, double and three times higher than in the general Canadian population. Most disturbingly, food insecurity  was, at 48 %, four times higher in this representative sample of First Nations living on reserve in the ten Canadian provinces than the 12 % rate amongst the Canadian population, which is still considered high for a rich country like Canada. Food insecurity is also experienced at a higher rate in adults living in households with children, with parents reporting lower food insecurity for the children themselves, indicating an attempt at sheltering the children from food insecurity,21. Food security was measured using the Household Food Security Survey Module (HFSSM) with respondents categorised as living in households that were food secure, marginally food insecure, moderately food insecure, or severely food insecure. The HFSSM comprises eighteen questions about the food security situation over the previous 12 months with a section focused on children’s food security.In the recently published results of the First Nations Food, Nutrition and Environment Study (FNFNES.ca) spanning 10 years (2008–2018) conducted with 92 First Nations communities with a large sample of 6500 adult participants from territorial entities still officially named ‘reserves’ across Canada, little is known about the nutritional and food security situation for Indigenous children and youth until the publication in this issue of an important article comparing results for off-reserve Indigenous and non-Indigenous children and between 2004 and 2015 based on the Canadian Community Health Survey (CCHS) nutrition data. The article titled ‘Diet quality among Indigenous and non-Indigenous children and youth in Canada in 2004 and 2015: a repeated cross-sectional design’ explores changes in diet quality using the Healthy Eating Index (HEI), a score that measures diet quality in terms of adequacy and moderation by assessing the degree of adherence of the diet of surveyed individuals to the recommendations of the 2007 version of Canada’s Food Guide. The CCHS is a regularly conducted population survey with only the nutrition component, which includes a 24-h recall questionnaire repeated with 20 % of the sample, only administered twice in the recent past. Results from the survey are generalisable to the Canadian population thanks to its sampling framework. It is possible to identify Indigenous participants in the sample based on self-reports of Indigenous identity. However, Inuit participants are so few in CCHS that no conclusions could be drawn from the survey for Inuit living outside of the Inuit villages. It is important to note that national surveys in Canada, such as the CCHS, exclude First Nations and Metis living on reserves or communities and Inuit living in the north as well as Canadians living in remote communities,25.While these results from First Nations adults have been recently published in a special issue of the Canadian Journal of Public HealthUsing data from the 24-h recalls, the article proposes a positive reading of the nutritional situation of children and youth aged 2–17 years, pointing to a generally improved HEI for both Indigenous and non-Indigenous children and youth between 2004 and 2015 and suggesting that these improvements, which are due largely to a reduced contribution of the ‘other’ food group in the diet , are facilitated by the multiplication of food school programmes and interventions aimed at reducing consumption of junk food in this population. However, this improvement did not seem to be visible with Indigenous girls, indicating the need for a thorough investigation of gender dynamics in food distribution and consumption in that population.–28. As Canada grapples with its colonialist past’s impact on health,29 and Indigenous people are forced to deal with historic traumas recently evidenced by the gruesome discoveries of unmarked children’s burial sites close to some of the infamous residential schools, the Indigenous population continues to also pay the price of continuing discrimination with suboptimal health, social, and economic outcomes.While this is an encouraging trend, the article also notes the persistence of the great disparity between Indigenous and non-Indigenous children and youth in terms of food security as measured by the USDA Household Food Security Survey Module. In fact, food insecurity was three times higher in Indigenous than non-Indigenous children and youth in both 2004 and 2015, with only modest improvement in Indigenous food insecurity rates over the 11 years which does not consider the marginally food insecure category (from 32·8 % to 28·3 %). While the exploration of this disparity was beyond the scope of the article, it would have been useful to have this reality be made more prominent and included in the title. Food insecurity is a major determinant of diet quality (as seen in the article results) and is also associated with both mental and physical ill health and a reduced ability to manage disease. It is inexplicable that these basic human rights are still denied to a large number of Indigenous children in a wealthy country like Canada.Improvements in the diet quality of off-reserve Indigenous children and youth are welcome, but the continuing very high levels of food insecurity are troubling. The UN Convention on the Rights of the Child stipulates that every child has the right to adequate housing and adequate nutritious foods and clean drinking wateret al. allow us a glimpse into the nutritional and food security reality of Indigenous children and youth who live off-reserve. However, the situation on-reserve is very different because of a myriad of differing political, economic, and physical attributes in reserves compared to elsewhere in Canada. A new study modelled after the FNFNES but dedicated to understanding the nutrition and environmental situation of Indigenous children and youth living on-reserve is underway. The 10-year Food, Environment, Health and Nutrition of First Nations Children and Youth (FEHNCY.ca) study promises to draw a representative picture of the situation on-reserve and will allow comparisons with the general Canadian population as well as with off-reserve Indigenous children and youth. This should deepen our understanding and provide insight into changes needed and, we dare hope, track improvements as nutritional, health, education, housing, and other gaps narrow with better resources, greater self-determination, and programmes that prioritise access to traditional foods.The CCHS data and the article by Riediger


In Pakistan, the Covid-19 vaccine hesitancy is a real challenge amid all the rumors and disinformation about the vaccine , the obsWhile Pakistan has supply-side challenges, it still has procured over 40 million Covid-19 vaccine doses from the World Health Organization, China, the US, the UK, and Germany –6. AiminCompared to the first three waves , 9, the The Government of Pakistan launched the Covid-19 vaccination drive early this year initially for healthcare workers and older people . To incrThe Washington Post highlighting the impact of the program, the state recorded a 28 percent increase in the vaccination rate of those aged 16 and older in the program's first week  and the Ehsaas Cash Program. The government can encourage those who are availing benefits under such cash programs to earn additional cash if they complete their vaccination certificate. Further, relatively economical non-cash programs can also work. Under one such intervention program implemented in India by the MIT's Abdul Latif Jameel Poverty Action Lab, Noble Laureates Banerjee and Duflo demonstrated that free provision of 1 kg of lentils to people who vaccinated their children led to significant improvement in local healthcare outcomes . In PakiSimilarly, by employing the nudge approach, the Government of Pakistan should further strengthen its existing mass communication strategy by including slogans that appeal to people's self-interest and altruism. For instance, instead of “vaccinate for your life,” a revised slogan could be “vaccinate for your life and your loved ones' life.”In addition, this nudge approach should be complemented with proper legislation mandating workplaces to give breaks to their employees for completing the vaccination period. Likewise, the city government units should approach the administration of colleges and universities, ensuring that students show vaccination proof to be allowed entry to the premises of their institute.ulemas (religious scholars), to spread awareness about vaccination. Particularly, in a country where ulemas are revered and looked up to guidance, they should be engaged in squashing all the rumors around the vaccine and spreading the importance of disease prevention. They should mention the narration in which the Prophet Muhammad (PBUH) advised to prevent the spread of contagious diseases. Thus, they should remind and educate the public that prevention in the form of vaccination is obligatory for all.Lastly, the government should involve other vital stakeholders, such as non-governmental organizations, health professionals, community leaders, and Pakistan, which has a track record of slow immunization for other lethal diseases such as HBV and Polio, must also revive its memory of how it increased immunization in the past. Indeed, a collaborative approach implemented with the help of international partners and other interventions were introduced to amplify immunization rates . The GovAlongside the government's introspection into its institutional and procedural memory of combating low vaccination rates for previous non-Covid diseases, it is proposed to implement the multipronged policy approach outlined here (and summarized in MK conceptualized, analyzed, and wrote the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objective: The economic support of elderly patients with chronic diseases may affect their health status. This study assessed the impact of economic support on the health status of elderly patients with chronic diseases in China and explored the relationship between regional economic differences and the impact of economic support on health status.Methods: This study used the data of 3,416 elderly patients with chronic diseases from the China Health and Retirement Longitudinal Study (CHARLS) in 2018. Logit model and stepwise regression method were used to analyze and compare the influence of economic support on self-rated health, mental health, and activities of daily living (ADL) of elderly patients with chronic diseases. Sub-regional comparison was used for the research of regional differences in the impact of economic support on health.Results: we find that economic support has a positive effect on the health status of elderly patients with chronic diseases in China. Socioeconomic support has a positive effect on self-rated health and mental health of elderly patients with chronic diseases, and the effect on activities of daily living (ADL) is no longer significant after the gradual inclusion of control variables. Family economic support has no significant impact on the health dimensions of elderly patients with chronic diseases. With respect to regional differences, socioeconomic support can improve mental health in central China and improve self-rated health in western China, while it can improve overall health status in eastern China. The influence of family economic support on different health dimensions in different regions is still insignificant.Conclusions: The health status of elderly patients with chronic diseases is affected by socioeconomic support in China. In order to improve the health of elderly patients with chronic diseases, it is necessary to increase socioeconomic support. Meanwhile, it is also essential to pay attention to the differences in economic support between different regions and increase the socioeconomic support for elderly patients with chronic diseases in undeveloped regions so as to improve their health status. China's rapid economic development has brought both improvements in living standards and medical technology since the 21st century. Life expectancy has risen significantly, but so has the proportion of the elderly in the population. Compared with other countries, China's aging is characterized by high degree and rapid progress . MeanwhiChronic diseases have the characteristics of high morbidity, low cure rate, and high mortality. Many chronic diseases require long-term care and are lifelong diseases, which directly lead to the continuous medical expenditure of patients , 11. ChrThe World Health Organization (WHO) estimates that more than two thirds of all deaths worldwide are caused by chronic diseases, and these diseases are usually related to the elderly. It reveals that economic conditions are closely linked to chronic diseases. Because of the refractory characteristics of chronic diseases, the medical treatment of elderly patients with chronic diseases needs long-term economic support. Christy Pu states that economic conditions have a significant impact on the health of the elderly . HoweverMost existing studies have focused on the impact of economic support on the health of the elderly or patients with chronic diseases, only a few studies combine the elderly and patients with chronic diseases. Elderly patients with chronic diseases are different from others in that most of them have no income from work and need to rely on pension or long-term family economic support to treat chronic diseases. With respect to economic support, most of the studies only consider a single type of economic support as factor which affects health effect. The economic support stipulated in this paper combines earned income, pension, and family economic support, could better represent the economic conditions in elderly patients with chronic diseases.Three dimensions of health including self-rated health, mental health, and activity of daily life (ADL) are used to measure health status. Self-rated health is one of the most common indicators used by various databases and scholars to measure the status of individual health, which could effectively represent the status of individual health . StudiesConsidering the large regional economic disparity, this paper divides China into eastern, central, and western regions based on the geographic location. We study the economic support of elderly patients with chronic diseases in three regions respectively, to measure whether there are regional differences in the influence of economic support on different health dimensions of elderly patients with chronic diseases.On this basis, this paper uses data of China Health and Retirement Longitudinal Study (CHARLS) conducted by Peking University in 2018, taking elderly patients with chronic diseases aged 60 and above as the research object, examining the impact of economic support on the health status of elderly patients with chronic diseases in China.Based on the China Health and Retirement Longitudinal Study (CHARLS) database, this paper studied the impact of economic support on the health status of elderly patients with chronic diseases in China. The China Health and Retirement Longitudinal Study (CHARLS) national baseline was launched in 2011 and the data is tracked every 2–3 years. CHARLS has more than 17,000 respondents who are from various regions in China, covering 150 county-level units and 450 village-level units. When sampling, CHARLS uses PPS  to select county level units first and then selects village or community level units. In each village or community, CHARLS randomly selects 25–36 residences from the map, and determines the number of samples of family households in each residence. Besides, there is a section of filter at the beginning of the CHARLS questionnaire which can eliminate invalid questionnaires. Therefore, the data can well-represented the overall situation of China and the quality of data is guaranteed.CHARLS includes basic information, family, health status and function, cognition and depression, health care and insurance, work and retirement, pensions, income expenditure and assets, real estate, and housing, with a wide range of information. It is a reliable database for studying health levels and influencing factors in middle-aged and elderly people.Patients aged 60 and above with chronic diseases were selected as the research objects in this paper. After eliminating the samples lacking key variables, 3,416 samples were finally utilized. The database used in this paper is made available to the academic community with the approval of the Ethics Committee of Peking University, so ethical approval is not required.The economic support of the elderly patients with chronic diseases studied in this paper consists of two parts, namely family economic support within 1 year and socioeconomic support within 1 year. Among them, family economic support includes those provided by children, parents and siblings. Socioeconomic support includes pensions and earned income of reemployment. Pensions refer to income of government organization and institution, enterprise worker primary endowment insurance, endowment insurance of urban and rural dweller, commercial endowment insurance, and other endowment insurance. Earned income refers to the salary received from work, including bonuses and various subsidies.Self-rated health is based on the respondent's self-rating of current status of health, reflecting the respondents' assessment of their own health. Self-rated health in the CHARLS questionnaire is achieved by asking patients “How would you describe your health condition?” to measure. The question is divided into five levels, which are “very good,” “good,” “common,” “poor,” and “very poor.” According to the results of the questionnaire, the OLS regression and ordered logit regression have been carried out, respectively. Although, same conclusions are obtained by the OLS regression and ordered logit regression, logit regression can judge the health status more directly. Meanwhile, ordered logit regression can eliminate the influence of threshold of dichotomous dependent variable on the significance of the estimated coefficient. All the statistical procedures in this article are implemented by STATA15.A large number of studies have shown that depression is the most common mental health problem of the elder, which is representative of the individual's mental health status. Therefore, in this paper, the levels of mental health are measured through the depression status of the respondents . CHARLS Good functional status is the basis for maintaining the independence of the elderly. The elderly often suffer from a variety of chronic diseases, which cause health damage. The more types of chronic diseases, the greater risk of disability, which can lead to decreased ability of daily living (ADL) . ADL is The control variables are divided into four categories: demographic characteristics, unhealthy lifestyles (drinking and smoking), physical activities, and medical insurance. Demographic characteristics include gender, age, marital status, education level, type of residence. Where in Marital status is reclassified according to the six options in the questionnaire. The six options are “married and living with a spouse,” “married but temporarily not living with the spouse for work and other reasons,” “separated, no longer living together as a spouse,” “divorced,” “widowed,” and “never married,” the first three options are reclassified into “married” and the last are reclassified into “single.” Previous studies (Erpeng Liu) have pointed out that smoking and drinking will have an impact on health as unhealthy lifestyles . MeanwhiSince ADL has only two dimensions, namely healthy and unhealthy, this paper chooses Logit model to study the impact of economic indicators on ADL, and sets the model as follows:Hi represents the status of ADL. Si is the key independent variable, representing the economic support the respondents received. Xi represents control variables, including demographic indicators , health behavior , the type of medical insurance, and medical insurance reimbursement expense.Here, In this paper, the measurement of self-rated health and mental health is ordered multiple classification. We choose ordered Logit model to carry out regression analysis.Hi represents the status of health . Xi represents control variables, including economic support, demographic indicators , the type of medical insurance, and medical insurance reimbursement expense. i represents the observed value, α represents the value of the parameter variable to be estimated. ε is the random disturbance term, following the Logistic distribution. β is the boundary point of the interval.Here, Besides, we also find that the number of elderly patients with chronic diseases who have earned income of reemployment is few, the amount of earned income of reemployment per capita is less than the pension per capita. According to previous research, many elderly people in China share the responsibility of taking care of their grandchildren, which left limited time for them to work , 36. MeaWe visualize the distribution of economic support for elderly patients with chronic diseases. The economic support distribution of elderly patients with chronic disease with different health status under three health dimensions is compared, and a density curve  is drawnSince mental health and activity of daily life are different from self-rated health indicators, the self-rated health value 0 means unhealthy. Mental health and activity of daily life value 0 means healthy. Therefore, the regression results of mental health status and activity of daily life are presented in Due to the uneven development among different regions in China, this paper divides the eastern, central, and western regions of China and makes regression analysis on their health status, respectively to study the difference of the impact of economic support on health among different regions. The regression results are shown in The results show that the influence of socioeconomic support on the health of elderly patients with chronic diseases is significantly different in regions with different levels of economic development, and the influence of family economic support on the health of elderly patients with chronic diseases is still not significant. In all regions, socioeconomic support had a significant impact on self-rated health. On the contrary, the activity of daily life, socioeconomic support only has an impact in developed regions, but not in undeveloped and less developed regions. In mental health, socioeconomic support has no effect on mental health in undeveloped areas but has a significant positive effect on central and western china. Thus, it might be suggested that the impact of economic support on health is affected by the economic development degree of the region. Economic supports in different regions have different impact on all aspects of health.Based on CHARLS database, this paper studies the impact of economic support on the health of elderly patients with chronic diseases. Both stepwise regression and regional regression show that socioeconomic support have a significant impact on the health status of elderly patients with chronic diseases, which is basically the same as the previous research results of scholars –40.Socioeconomic support can effectively improve the health status of elderly patients with chronic diseases, especially in terms of self-rated health and mental health. Since the daily life ability is greatly affected by individual unhealthy lifestyles and physical activities, the influence of socioeconomic support on daily life ability decreases after the inclusion of health behavior.The condition of individual economy is an important factor affecting health, especially for the elderly. Andrews argues that higher levels of retirement income or wealth leads to increased general well-being, which improves the health of the elderly . AccordiP-value in their research is too large to be convinced as strongly significant (Compared with socioeconomic support, the intervention effect of family economic support on health is not significant. Family economic support has no significant impact on health, whether it was self-rated health, mental health, or ability to live a daily life. This is because family economic support is significantly lower than that of socioeconomic support. Although, the research of Xue Long and some other scholars believed that the economic support has an impact on health status, the nificant . Childrenificant . For thenificant . In Chinnificant . TherefoAs the economic support is limited by the degree of local economic development, this paper divides China into three parts according to the level of economic development and geographical factors, corresponding to undeveloped regions, less developed regions and developed regions in turn. The economic condition of the eastern region is significantly higher than that of the central and western regions . The levP-value is close to 0.1. The influence of economic support on self-rated health is far less than that in western China. When primary health needs are met, elderly patients with chronic diseases will have higher level of health needs, and psychological needs begin to appear gradually (Socioeconomic support cannot play a role in the self-rated health of the elderly patients with chronic diseases in the central regions, but significantly improve the health status of the elderly patients with chronic diseases in the western regions. Evans, MC study finds that economic difficulties have an impact on the health of low-income elderly persons and suggested that solving economic difficulties may help to promote the health of the elderly . The intradually . Meanwhiradually  find in Compared with previous studies, this study has some innovation. Firstly, this paper discusses the influence of economic support on health status from two dimensions: social and family. Previous studies mostly used single economic indicators, such as, pensions and family economic support, to study their impact on health, without taking into account the multidimensionality of economic support for the elderly , 23. SecOur study also had some limitations. First of all, we used cross-sectional data. The research results can only reflect the impact of economic support on the health status of elderly patients with chronic diseases but cannot explain the causal relationship between the two. Secondly, we did not distinguish specific chronic diseases and studied the difference in the impact of economic support among different chronic diseases. Third, due to the limitation of CHARLS database, there are a large number of rural samples, which may lead to a lower level of economic support.By analyzing the results of the study, we conclude that economic support has a significant positive impact on the health of elderly patients with chronic diseases. The government should pay special attention to the socioeconomic support for elderly patients with chronic diseases and formulate some policy that can improve the economic support for elderly patients with chronic diseases, such as, appropriately increasing the pension amount, expanding the scope of assistance for serious diseases and the scope of medical insurance reimbursement. In this paper socioeconomic support is composed of pension and earned income of reemployment, while the number of respondents who has earned income of reemployment is few. Therefore, increasing socio-economic support is mainly through increasing pension amount. These are key methods to improve the health status of elderly patients with chronic diseases. At the same time, we also find that there are huge regional differences in the impact of economic support on health. It is the long-term goal of the Chinese government to continuously reduce the economic differences among regions to improve the health imbalance of the elderly patients with chronic diseases among regions.Tragically, large numbers of elderly patients with chronic diseases at the bottom are unable to get enough economic support to keep healthy. Many countries are still trying to take measures to deal with the health problems of elderly patients with chronic diseases , 54. Thehttps://charls.pku.edu.cn.Publicly available datasets were analyzed in this study. This data can be found here: Study conception and design were performed by ST. Data analysis was performed by TY and DQ. The first draft of the manuscript was written by YX. ZL checked the data and edited the language. All authors commented on previous versions of the manuscript, contributed to the material preparation and data collection, read, and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Methods: Six major groups of stakeholders were identified: local authorities, small-medium industries (SMIs) , small-medium enterprises (SMEs), academia/professional associations, government, and the general public residing in the communities surrounding the VEC. During 2019–2021, a suite of stakeholder engagement initiatives was deployed, including semi-structured interviews (n = 32), a community survey for the general public (n = 309), technical meetings, and workshops (n = 4). Results from the semi-structured interviews, technical meetings and workshops were analyzed through thematic analysis and results from the community survey were analyzed using descriptive statistics. Results: Almost all stakeholders expressed the need for the implementation of a systematic health monitoring system for the VEC broader area and its surrounding residential communities, including frequent measurements of air pollutant emissions. Moreover, stricter policies by the government about licensing and monitoring of hydrocarbon activities and proper communication to the public and the mass media emerged as important needs. The exposome concept was not practiced by the SMEs, but SMIs showed willingness to use it in the future as part of their research and development activities. Conclusions: The sustainable development of hydrocarbon exploitation and processing prospects for Cyprus involves the VEC. Continuous and active collaboration and mutual feedback among all stakeholders involved with the VEC is essential, as this may allow future environmental and occupational health initiatives to be formalized.The Vasilikos Energy Center (VEC) is a large hydrocarbon industrial hub actively operating in Cyprus. There is strong public interest by the communities surrounding VEC to engage with all stakeholders towards the sustainable development of hydrocarbon in the region. The methodological framework of the exposome concept would allow for the holistic identification of all relevant environmental exposures by engaging the most relevant stakeholders in industrially contaminated sites. The main objectives of this study were to: (i) evaluate the stakeholders’ perceptions of the environmental and public health risks and recommended actions associated with the VEC hydrocarbon activities, and (ii) assess the stakeholders’ understanding and interest towards exposome-based technologies for use in oil and gas applications.  The process of understanding public perceptions about environmental health hazards, exposures, and health impacts often feeds policy making and decision support systems of public health ,2. ResidGovernment agencies and industries are often responsible for communicating environmental risk information to the public regarding, for example, regulatory decisions, industrial practices, or adverse events . AnotherThere is a need for a comprehensive methodological framework that would allow for the holistic capture of all relevant environmental exposures in and around ICS by engaging the most relevant stakeholders. The ‘human exposome’ concept was first proposed by Wild (2005) to encompass the totality of human environmental  exposures from conception onwards, complementing the genome. Implementing the human exposome methodological framework and describing variations in the exposome might allow for a thorough assessment of the entirety of environmental changes associated with ICS activities . The obsThe Vasilikos Energy Center (VEC) area is a coastal heavy industry zone in Cyprus, close to the seaside area of Limassol . SignifiThe growth of VEC in Cyprus’ seaside area and its impact on surrounding communities’ health can be better understood by employing a comprehensive framework, such as the human exposome. As a result, the exposome of the population around the VEC is defined by habitual patterns, as well as the context in which they occur, the accompanying environmental exposures, and personal and contextual factors, such as occupational factors or individual behaviors and lifestyle habits ,13,17. IAccording to the Cyprus Department of Environment, the VEC development in the area is expected to impact the flora and fauna biodiversity and the natural and marine landscape, as well as human health and cultural/archaeological heritage. Adverse impacts are also anticipated on water and soil resources, including waste accumulation; however, these can be managed through the implementation of mitigation measures . As a reThe study setting was the active industrial hub for hydrocarbons located in the Vasilikos area of Cyprus . CurrentA.Government (GOV) (n = 9): governmental departments and units responsible for hydrocarbons’ authorizations, strategic planning, and energy provision.B.Small-medium industries (SMIs)(n = 6): companies which are actively involved in Cyprus with activities of exploration, production, management and distribution of hydrocarbons, both onshore and offshore; large multi-national oil and gas companies are also included in this group.C.Small-medium enterprises (SMEs) (n = 4): companies related with the hydrocarbon industry of Cyprus, including environmental consultants, laboratories, and engineers.D.Academia/professional associations (APA) (n = 4): academics and researchers who are involved in hydrocarbon research.E.Local residential community authorities (LA) (n = 9): Local authorities of the surrounding areas of Vasilikos and, specifically, leaders of the nine communities in the area: Asgata, Pentakomo, Tochni, Kalavasos, Choirokitia, Mari, Maroni, Zygi, and Psematismenos.F.Public/Communities : residents of the nine communities around the Vasilikos (VEC) area.Stakeholders were identified by searching in relevant contact databases  and by contacting governmental departments and relevant companies in the territories of the Republic of Cyprus. A list of 45 stakeholders was created, with due consideration being given to the General Data Protection Regulation 2018 and the project data management plan. As a result, we grouped all identified stakeholders into six distinct groups (the number of organizations that agreed to participate in this exercise is included in the parentheses):A series of engagement initiatives were employed, ranging from face-to-face and virtual meetings and interviews to workshops and community surveys. The exposome concept was always presented first in these meetings and interviews, by offering its definition and practical applications, as well as case studies that were relevant to their professional field.Stakeholder workshops were held bi-annually and were open for all interested stakeholders. Their purpose was to allow stakeholders to provide their views on the specific workshop’s topics of discussion. Moreover, two meetings with the nine communities’ leaders in the Vasilikos area took place to present the aim of the study, to discuss the population survey implementation, and to explain the purpose of the stakeholder interviews, as well as to understand their views and concerns. A final workshop was also arranged in September 2021 to communicate the results of the stakeholder engagement process and to finalize the next steps based on the recommendations of the engagement process.n = 23), and in October 2020, with representatives of the LA of Vasilikos area (n = 9). The interviews ranged from 15–45 min in length. The data collected from the interviews were recorded and transcribed verbatim.Semi-structured telephone interviews using a core set of questions were chosen as the most appropriate approach for the 32 stakeholders who participated in the study , except The perceptions of the general public residing in the communities around the VEC area were evaluated with the use of a postal survey based on validated questionnaires ,22,23. TEligible participants were adults (>18 years old) living in the residential communities surrounding the VEC industrial hub, i.e., Asgata, Pentakomo, Tochni, Kalavasos, Choirokitia, Mari, Maroni, Zygi, and Psematismenos, for at least 1 year (permanent residents). The questionnaires were sent via mail to the adult population of Vasilikos area , directly from the main office of the respective community councils, in early August 2020. The local authorities notified the residents about the study through the communities’ postal system before the questionnaires were distributed in order to encourage them to participate. The completed questionnaires were returned and received in sealed postal envelopes and were handled based on the General Data Protection Regulation (GDPR) of the European Union.A qualitative research protocol was implemented as it explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers in health care ,25. QualDescriptive statistics were used to analyze the questionnaire responses by 309 residents. The last open-ended question of the questionnaire was analyzed through thematic analysis. For the rest of the close-ended questions, means and standard deviation for the continuous variables, and frequencies and percentages by category for the categorical variables, were calculated and reported. All analyses were conducted in R 4.0.2 with RStudio 1.1.463 ,30. ResuWritten informed consent was obtained from stakeholders before participating in the semi-structured interviews, workshops, and meetings. The participants were informed that the interviews would be recorded and that the collected data would be anonymous and used only for academic purposes. Moreover, the protection of the participants’ privacy in the community survey was based on the approval by the National Bioethics Committee of Cyprus (No: 2020.01.147) and in conjunction with the written opinion of the Data Protection Officer within the Cyprus University of Technology (CUT).The results emerging from the interview and community survey data were organized according to the thematic and the statistical analysis, respectively. Combining the data, eight (8) themes emerged regarding the stakeholders′ responses; assessment of health and safety issues, safety and health risks in the hydrocarbons industry, perceived environmental risks, shared responsibility on health issues, risk communication, usage of the human exposome concept by the stakeholders, and their suggestions for improvement about the industrial area of Vasilikos.The LA, SMIs, SMEs, and GOV mentioned that they regularly implement health and safety assessments that relate to their company or organization’s hydrocarbon activities. However, all the above-mentioned stakeholders considered that a systematic health monitoring system studying environment and health indicators in and around the VEC industrial facilities was an important need for managing pertinent health and safety issues. They also suggested that more environmental and health studies  must be provided in hydrocarbon facilities, especially in the VEC. Representatives from SMIs and APA mentioned: “With regards to the communities around the areas where we work, an initial assessment should be made of the likelihood and magnitude of the risk to have some impact from our area of activity”.“I believe that there is know-how and ability from the various academic departments I know. What may not exist in Cyprus, [...], are some experts in the use and management of hydrocarbons [...] such expertise probably does not exist within the academic community. There may be academic knowledge but no practical experience in the installation and operation of such facilities […] what is needed is in-depth training and experience”.With respect to the safety risks that employees and public may encounter due to hydrocarbon activities, various views and points were presented. The LA, APA, and the public reported that their main safety concern is the accumulation of industries at VEC, which increases the risk of an accident  with potentially devastating consequences for the area and its population. The SMIs, SMEs, and government clearly stated the use of appropriate safety and health directives in their everyday activities, while a few academics reported the need to have better implementation of the EU safety regulations in the processing and storing of oil/gas.“We are concerned because some permits are given, in each of the environmental studies carried out, which show that they (hydrocarbon industries) are below the permissible limits but we believe that the accumulation of many factories in the area, will result to exceedance of the permissible limits”.A representative from government mentioned that:“There is a plan for dealing with employees’ accidents and is national. There is no national plan for health risk management”.Only the LA, SMIs, and the public reported their perceived health risks associated with hydrocarbon activities. Specifically, LA and the public reported increased disease incidence in the community, such as respiratory, heart, and thyroid diseases, cancer, asthma, and depression. Similarly, the SMIs suggested that long-term exposure to several co-located hydrocarbon industries operating in a small area (VEC) possibly affects the health of employees.“During the last years, I am having heart problems, respiratory problems, thyroid, prostate, thymus and everything began with my return to Cyprus. It is important for me to know what is happening in this area”(Resident 17).Similarly, one stakeholder representing local authorities added that:“Cancer occurs in too many people in our community. After all, this is the problem we are complaining about because all the factories came to our area. There are many cases of cancer in other villages (of Vasilikos area) as well”.The SMIs mentioned no emerging risks on employees’ health and that the physical and mental health of the employees is covered by the companies’ health monitoring protocols. Moreover, these stakeholders supported that there are technical and financial difficulties in conducting risk assessments and in ensuring the health of employees and public affected in the VEC. Nevertheless, SMIs, SMEs, APA, and GOV explained that epidemiological studies and health impact studies for populations around such facilities and specifically in the Vasilikos area are needed, with the last two stakeholders agreeing that cooperation between governmental departments, companies, and communities should be applied. The implementation of environmental and health protection systems was described by the industrial representatives:“The company has a health and safety management system. Especially in the field of health we have a separate management system that has specific provisions […] The company has an internal obligation when we do the environmental impact assessment; we analyze the possible effects on health”.“The basic QESH  capital in all companies has to do with the risk and effects on the environment, health and nuisance. There is a great cost for the risk assessment […]”.The LA and the public presented a list of environmental risks associated with the presence of gases, garbage, chemicals, odors, dust, smoke, noise, and radiation, all associated with VEC activities. In contrast, government supported that their departments participate in various committees on health and safety issues, ensuring that these elements are secured with regards to the hydrocarbon activities in Vasilikos area. The SMIs, SMEs, and APA did not report any environmental risks caused by hydrocarbon industries, although the SMEs noticed the absence of measurements on gaseous pollutant emissions in these facilities and the necessity of their implementation to address environmental risks.“The biggest environmental concerns are the pollutants that will be caused by the energy center and where they will end up. After much consultation, the community here has accepted the energy center, like liquid fuels and LPG and some factories that will support them”.A governmental representative added that:“The development and monitoring of hydrocarbon activities take place under the Hydrocarbon Regulations, the Protocol on the Protection of the Mediterranean Sea against Pollution from the exploration and exploitation of its seabed and subsoil, and the Safety and Health Regulations offshore operations”.The survey took place in close collaboration with the local authority offices, which were responsible for mailing the questionnaires to the households of their communities. A total of about 2700 questionnaires were mailed to the communities around the VEC. We received 309 completed questionnaires, with the response rate being around 11%. No missing data was observed in the collected questionnaire responses. About half of the respondents (residents) (51%) rated their community good or very good as a place of residence and 29% rated it as somewhat good. However, most of the respondents believe they live in a community where air and water pollution pose a problem , water is not safe sometimes (87%), people have been exposed to toxic waste (81%), and have the same health issues, such as cancer, asthma, or cardiovascular diseases (83%) . Of thosWith their place of residence in mind, most of the respondents reported that they were very worried about air quality (81%), chemical substances (76%), waste (64%), and quality of drinking water (61%) . About hDuring the 12 months prior to completing the survey, about 60% of the respondents reported that they have been exposed to a large degree to air pollution and bad smells, and about 70% of the respondents have been exposed to a smaller or larger degree to water pollution whilst inside or outside their home. Most of the participants also perceived environmental factors as playing a large part in the incidence of cancer, respiratory problems and allergies, tumors/malignancies in children, and childhood asthma . More than half of the participants perceived these factors playing a large part in the incidence of vector-borne diseases (61%) and less than half in the incidence of depression and infectious diseases  . InteresStakeholders do not seem to share the same views with regards to the responsibility about health issues. LA, SMEs, APA, and the public agreed that the government needs to implement stricter policies and health monitoring actions, while LA and the public reported that turning the Vasilikos area into an industrial hub was a wrong decision by the government. Furthermore, SMEs and APA added that there is incomplete knowledge and expertise from the governmental authorities on hydrocarbon issues. Alternatively, the government’s responses presented unawareness of the management of health issues, mentioning either that their department is not responsible, that other governmental departments are responsible, or that they lack of knowledge of these issues.“Unfortunately, all these  are due to the public service inability. They are not educated to a technical level. None of them can assess risk nor to analyze it. They don’t have the basic knowledge in order to be educated in specialized methodologies and mechanisms”.One governmental representative said that: “We do not know if there are any health risks associated with hydrocarbon activities that are not currently being addressed. Health issues related to occupational safety and health fall under the responsibility of the Department of Labor Inspection”.When asked if the public should be informed about new or current hydrocarbon activities, all stakeholders agreed that they should. SMIs mentioned that they communicate to the public before licensing of a new industry in order to alleviate misinformation and concerns; they also reported their active participation in a VEC technical committee together with the community representatives (LA), and governmental departments to oversee safety issues in the broader VEC area. However, the SMEs, APA, and the GOV added that more risk communication to the public is necessary, because natural gas is a new topic in Cyprus and public consultations and seminars could be adopted to reduce misinformation. On the element of misinformation reduction, SMEs, APA and GOV reported that mass media are part of this awareness process and the lack of mass media knowledge of hydrocarbon issues leads to wrong messages being sent to the public. As one governmental stakeholder reported:“People need to be informed about specific aspects of environmental issues, including hydrocarbons, if there is a reason to protect them from something. But since ordinary citizens do not have the expertise, I believe that they cannot participate when making specific decisions on health issues because unfortunately they are carried away by their semi-learning and we do not have the result we want”.LA, as mediators of knowledge to the public, conceded that their residents are well informed by the community authorities on the environmental and public health issues that exist in the area. In general, the communities around Vasilikos area use a combination of traditional and technological methods of communication such as printed informational material, boxes of suggestions and complaints, SMS, email, websites, and social media—especially Facebook. A large majority of the respondents asked for more information regarding the environmental state of their community and the environmental hazards that may be related to their health in their everyday life  . About h“If it is something immediate, we use the SMS. But there is Facebook, the website of the community; we use the mail for announcements. Also, if someone wants a meeting with me, there is personal phone and they can immediately visit me at the office or at home. There is direct personal contact with the residents, either in the cafes or in the office”.The exposome framework and its tools was not applied in the everyday or research and development (R&D) activities of SMIs, SMEs, and APA. However, the three stakeholder groups appeared willing to apply the concept and methodology of the exposome in the hydrocarbon industry with emphasis on occupational health. “The exposome could be used for evaluation. If your institute offers educational programs, we would like to attend. We want it to be part of our job because it complements us. We need such scientifically validated tools to help us communicate reliable information to the public”.Currently, SMEs and APA implement specific exposure measurements and measurements of air pollutants and volatile organic compounds in their outdoor and indoor activities, respectively. Moreover, as APA reported, there is a need for an overall health impact study on VEC and industrial facilities and, as mentioned above, the application of the exposome could be useful for this issue. The public, LA and governmental representatives were not asked about the exposome framework, which is still mostly research oriented and less applied in practice.The LA suggested that compensatory measures could help improve of the VEC area, such as tree planting, reforestation, financial support, and the construction of a community hospital. The public added that beach cleaning and the use of reusable energy could take place in the area, with one resident mentioning:“I am a young resident of the Psematismenos community. I wish to breathe clean oxygen for me and my children. We are suffering enough already from the heavy industries of the area. There is no place for more industrial development in the area, only for ecological development such as tree planting, beach cleaning, and reusable sources of energy”(Resident 49).On the other hand, one stakeholder who represented local authorities added that:“[…] It is a financial issue and we fought a lot. Fortunately, the compensatory laws have been approved, of which 1.5 million will be given annually to the communities of Vasilikos, which means that each community will be able to offer a better quality of life […]”.Interviews, workshops, meetings, and questionnaires with the stakeholders of VEC paved the way for facilitating interactions and collaborations between the various stakeholders involved with the VEC industrial area for oil/gas strategic development of Cyprus. This investment for the future generations should abide by EU regulations on safety and health, ensuring the sustainable development of oil/gas for the next generations.A series of interviews, workshops, meetings, and questionnaires with the stakeholders of VEC area took place during 2019–2021 using a number of initiatives. The VEC hub development should abide by EU regulations on safety, health, and environmental aspects, ensuring the sustainable development of hydrocarbons in the region for the next generations. As such, a set of key messages, needs, and gaps emerged from the systematic engagement with all relevant stakeholders in the VEC, ranging from the government, the private sector, the research community, academia, local authorities, and the surrounding communities’ general populations. We synthesized the results of both the thematic analysis and the population survey and have presented the common points and differences that emerged through this stakeholder analysis.According to the results of the current assessment, communities reported important safety and health risks associated with the establishment of the heavy industrial facilities in VEC. The SMEs reported the lack of systematic measurements on gaseous pollutant emissions in hydrocarbon activities in the surrounding communities of VEC. In addition, the rest of the involved stakeholders shared the desire and the need for an environmental and public health monitoring system in the VEC and surroundings via a joint effort by the government, private sector, and communities . MoreoveDespite the above community concerns, the environmental issues surrounding the communities of Vasilikos cannot be fully addressed without the cooperation of both the established industries and the government. Previous studies have shown the mistrust of government agencies and industries ,4,31 andThe societal decisions should be taken to balance acceptable levels of risk with expenditures for pollution prevention and control, water supply development and protection, and remediation ,33. The n = 309) and possible sampling bias, especially in the community survey, and the different methodologies used for different stakeholder groups. The strengths of this study were the relatively good representation of all stakeholder groups with esteemed technical officers. The breadth of the stakeholder groups engaged allowed for the inclusion of all concerns and recommendations for the sustainable development of the VEC area. The fact that the general public was a key stakeholder in all these activities helped significantly to gain trust and enhance communication among stakeholders, providing a win-win situation for involved parties. However, the results presented here should be interpreted with caution because of limitations in the study design , including the small sample size  highlighted a set of key messages, as well as gaps and needs in the form of recommendations for future steps. Almost all stakeholders expressed the immediate need for the design and execution of population health monitoring and impact studies for the VEC and its surrounding residential communities, including systematic measurements of gaseous pollutant emissions. Moreover, stricter policies by the government about licensing and monitoring of hydrocarbon activities and proper information dissemination to the public and the mass media emerged as important needs. Finally, usage of exposome concept was not practiced by the industry/SMEs, but SMIs in particular showed willingness to use it in the future, upon the proper testing/evaluation of its utility.This 2-year-long stakeholder engagement process in the VEC and its surrounding area is considered vital to the health risk assessment process  and to t