Retirement is one of the most serious challenges facing Brazil currently, considering the rapid pace of population aging, growing social inequalities, and the difficulty that Brazilians have in planning for their financial future. The number of studies on psychosocial factors in retirement is limited. The aim of this cross-sectional study is to determine Brazilian health workers’ perceptions about financial planning for retirement, based on studies by  Currently, population aging represents one of the most serious challenges. The growth of this older population has resulted in an exponential number of retirees . In BrazFrom a psychological point of view, retirement can be a time of satisfaction or stress, depending on retirement-related behaviors developed over the course of the years preceding retirement . Recent Previous studies have reported that achieving well-being and satisfaction in retirement depends on several factors, such as financial safety, good health, satisfactory interpersonal relationships, engaging in leisure and work activities . Among tIn Brazil, individuals often start working early in life. The National Household Sample Survey  revealed that more than 70% of active workers started working before the age of 17 , suggestThe Retirement Preparation Programs (RPP) was established in Brazil to support workers in their retirement decisions, in parallel to incentives for voluntary early retirement programs . Three dIn many aspects, including financial, emotional, social and family relationships, such programs have the potential to impact the quality of life for a number of future retirees . In geneThe lack of adequate retirement planning is a serious concern, both economically and politically, as well as individually. Lack of adequate financial planning for retirement may negatively affect retirees who may end up lacking sufficient income in this final stage of life . HelpingThe Other studies attempted to refine Hershey and Mowen’s model by improving understanding of the aspects that influence financial planning for retirement . In addiAs stated by Although these studies constitute important advances for understanding relations among these variables and how this model functions in different cultures, a number of gaps exist to define a comprehensive model of planning for retirement. Only one study was found that addressed the Brazilian context. In that study, The results found to date support the conclusion that financial planning for retirement is extremely important and should be encouraged among workers as early as possible. The importance of this factor is corroborated by studies from the field of psychology . AlthougConsidering the theoretical references analyzed, a cross sectional study model  was usedParental influence on the lives of their children has been studied in several spheres. This influence is also found in financial planning for retirement, considering that acquisition of financial skills often begins with education on income management offered by parents . ParentaIn a study of Brazilian retirees, Hypothesis 1: Parental influence has a direct and positive relation with retirement savings.Goals stimulate planning and help to anticipate the future, support the prior construction of experience perceptions, and allow individuals to set expectations about needs they will have when facing specific times . In the Previous studies verified that retirement goal clarity acts as antecedent of two main constructors: level of activity planning and financial knowledge . These tHypothesis 2: Retirement goal clarity has a positive and direct relationship with retirement savings;Hypothesis 3: Retirement goal clarity mediates the relationship between parental influence and retirement savings.The relationship between planning behaviors and personal savings practices has been confirmed for decades . As expeThese activities involve a number of behaviors that stimulate knowledge about investments, and consequently, savings practices. Among these behaviors, those that we can emphasize are: searching for information, participating in lectures about the subject, and attending a retirement planning program . ConsideHypothesis 4: Planning activity level moderates the relationship between retirement goal clarity and retirement savings.Hypothesis 5: Planning activity level has a direct and positive relation on the level of retirement savings.A total of 319 workers from the technical, treatment and administrative areas of a private hospital in the city of Niterói, Rio de Janeiro, Brazil, participated in this quantitative study. In this convenience sample, health workers were the selected population based on several criteria: (i) health workers have special rights for retirement ; (ii) thThe sample consisted of women with a mean age of 36, less than half of whom were married or in a stable relationship. The level of formal education of the sample was higher than Brazil as a whole, with most of participants having earned high school or higher degrees. The main area of work was nursing. Workload was high, between 37 and 45 h weekly, but their earning did not correspond to the level of education and workload, as the average earnings were up to four times the minimum wage. Their family incomes were, on average, ten times the minimum wage, and this income was shared with one or two dependents .The questionnaire was designed using scales already applied in previous studies which tested the The instrument measured individual retirement saving practices . It inclThe instrument measured the effect of parental influence on money management and on creating a saving habit among their children . The insThe instrument included an assessment of the act of thinking, discussing and setting future goals, specifically those related to quality of life in retirement . It inclThe instrument measured both the frequency of searching for information and the level of effective planning activities that had occurred within the last 12 months . It inclQuestionnaires were made available in print to control shipment and facilitate the calculation of the response rate. The following strategies were used to gather results from 319 participants. First, the principal researcher contacted a large private hospital in the municipality of Niterói to introduce the project to the Human Resources coordinator; then, permission was requested to conduct the research within the institution. After receiving approval, the researcher remained in the hospital for several days to interview the employees in their workplace. Participants were interviewed using a printed and self-applied questionnaire distributed during their lunch time, as employees usually have lunch in the hospital). This approach was effective and guaranteed a fair degree of participants from the private sector, with a response rate of 87%.The database was analyzed to categorize variables and verify missing and outlier cases. Because it was the first application of the instrument in the Brazilian context, it was decided to verify the structure of the instruments and identify the best model. A confirmatory factor analysis (CFA) was therefore conducted.To verify the existence of multicollinearity between latent variable, a Pearson correlation was used, and correlations were classified as low (between 0.10 and 0.29), moderate (0.30 and 0.49) and high (higher than 0.50), as suggested by Analysis was performed using MPlus software version 6. The maximum likelihood estimator (ML) was used to maximize the probability that data were taken from the population. The adjusted chi-square, CFI, TLI, GFI, RMSEA and SRMR indexes were evaluated according to This study was approved by the Ethics Committee of the Universidade Salgado de Oliveira on February 22, 2018, under number CAAE 82650018.3.0000.5289. Prior to completing questionnaires, the participants signed the consent term, confirming their willingness to participate in the study. In this consent form, participants were also informed that their responses would be treated as confidential and that they were free to leave the study at any time.The sample included 319 workers  between 20 and 60 years of age, with a mean age of 36. The distribution of professionals by working area included a majority from nursing area (47.6%), followed by administration (18.2%). Remaining areas had low percentages, as described in The level of formal education ranged from incomplete elementary school to graduate studies. Workload varied from 25 to 45 h per week. Personal income was, on average, two to four times the Brazilian minimum wage. The majority of participants (66.5%) did not have a private pension or savings for retirement. The majority of participants were married or had stable relationships (54.5%), while the remainder (45.5%) were single, divorced or widowed.To confirm or exclude the factorial structure of the instrument created by Hershey and colleagues , we perfr2) between latent variables . These results indicated the lack of multicollinearity, with the exception of multicollinearity found between Planning Activity Level and Retirement Saving, and Planning Activity Level and Goal Clarity .First, a model that did not include the mediator or moderator variables was tested to verify the effect of parental influence on retirement savings (Hypothesis 1), followed by a model with the goal clarity level as a mediator (Hypothesis 2 and 3). To test hypothesis 4, one moderated-mediation model was tested. In this model, goal clarity mediated the relationship between parental influence and retirement savings, and planning activity was a moderator of the relationship between parental influence and goal clarity. Results showed that moderation was not significant . This model presents the mediation effect and a significant effect of this variable on the dependent variable (β = 0.19). All of these models can be observed in These data allow us to conclude the existence of a partial mediation of the relationship between parental influence and retirement savings, since the significant effect among the variables was reduced when the variable goal clarity was included in the model. In addition, planning activity represents a strong effect on retirement saving. This model presented good adjustment indices, despite the high residual value, . Hypotheses 1, 2, 3, and 5 were thus confirmed. The final model is described in This study investigated health workers in order to understand their perception about financial planning for retirement, as well as how these are related to psychological, social and economic factors involved this process. A study model  sought tIt was observed  that meaHowever, there is no doubt that more knowledge is needed with regard to Brazilians’ financial planning for retirement. The more this topic is studied, the clearer the picture becomes regarding the Brazilian population’s familiarity with financial planning. These results support existing demands for development of more strategic actions on this topic . FurtherIt is generally known that financial planning for retirement is a complex process, in which several factors play an important role in predicting and constructing effective savings behaviors for this stage of life. As a whole, the scale chosen to evaluate the dependent variable (retirement saving behaviors) as well as the three antecedents  revealed good psychometric indices, which is consistent with results found in previous studies that adopted the same scales .Our first hypothesis was confirmed, since parental influence had a significant direct effect on the level of savings for retirement, before other variables were included in the model. The habit of saving, originated in the family, influences the construction of attitudes and behaviors over the course of a person’s lifetime. For this reason, it seems that parents have a crucial role in this process . The conOur second hypothesis was also confirmed, in that goal clarity represented a positive influence on retirement savings. Retirement goal clarity is an important psychological predictor of retirement planning that is developed during adulthood and motivates the individual to plan for the future . This reIn addition to the positive influences found by both parental influence  and goalOn the other hand, the fourth hypothesis, related to the moderating effect of the level of planning activity between goal clarity and retirement savings, was not confirmed. In contrast to the findings reported in a previous study , in whicConsidering that the planning activity level represented an influence on the level of retirement savings, the fifth hypothesis was confirmed. The degree to which an individual engages in retirement planning activities has a direct and positive relationship on the individual’s adoption of a retirement saving behavior. As reported in previous studies, the adoption of planning behaviors is associated with higher levels of personal saving practice . In psycThe results of this study describe important contributions related to Brazilian behaviors regarding financial planning for retirement. Findings have reported the importance of financial planning, which should start as early as possible. Financial necessity is one of the factors that prevent people from retiring, in addition to the financial aspects be considered one of the main losses in retirement. Therefore, financial planning has a role in making retirement possible, reducing its perception of loss .The role of government as the sole source of financial support during a citizen’s retirement has been increasingly questioned worldwide. Consequently, this responsibility to guarantee comfort in this stage of life is now transferred to the individual, which reinforces the importance of our study by broadening the understanding of this complex phenomenon to establish financial planning for retirement .In addition to the results already found in the previous Brazilian study on financial planning for retirement , our finOur study has some limitations. First, the sample was limited to workers in a single private health care facility in the municipality of Niterói, Rio de Janeiro, Brazil. Therefore, the results cannot be extrapolated to other population outside Brazil. The fact that the majority of the sample was composed of workers aged 20 to 40 years is another limitation, since older workers tend to be more involved with planning for retirement especially in Brazil, where there is no culture of long-term planning . DespiteThe existence of other antecedents responsible for influencing the complex process of financial planning for retirement needs to be emphasized. In future studies, the new relationships of variables can be tested. In addition, other populations should be investigated, considering that our study included only health workers. Our hypotheses highlight the need to better understand the role of planning activities in the model studied. Longitudinal studies are also recommended to measure the effectiveness of actions designed to develop skills related to financial planning for retirement.The lack of depth of psychological understanding of the reasons related to developing a financial plan for retirement opens up a range of potential studies in this subject. Because of the complexity of issues involved in retirement planning, simply promoting a lecture or a short workshop is not sufficient for people to understand how to manage their investments, especially when they are approaching retirement.Retirement Preparation Programs constitute an attempt to help workers to develop life projects, and these programs are supported by the recommendation of the Brazilian Statute of the Elderly . In addiWe expect that the results of this study can help improve our understanding of factors that influence Brazilians workers from the private health sector with regard to their financial planning for retirement. Strategies and interventions must be created to improve and even reverse the current lack of planning for retirement in Brazil, which seems to be a common behavior requiring immediate action . This inThis study was carried out in accordance with the recommendations of Health National Council - CNS, no. 466 and the Ethical Committee of University Salgado de Oliveira with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the University Salgado de Oliveira Committee under the number 82650018.3.0000.5289.TS designed the study and collected the data. LF designed the study. All authors analyzed the data and wrote the 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.


To assess the regulation of the Chinese healthcare system in assisting a nationwide implementation of general practitioner (GP) services.Along with the perennial problems of unaffordable and inequitable healthcare, a rapidly ageing population and the increasing burden of non-communicable diseases pose challenges to the Chinese healthcare system. Recognising these challenges and to satisfy people’s demands for more and better healthcare, China has initiated a plan, named ‘Healthy China 2030’, based on the findings from a two-year joint study by the World Health Organization (WHO) and the World Bank Group (WBG) in collaboration with Chinese agencies. The Chinese healthcare plan, officially approved in 2016, is an attempt to use the people-centred, integrated care (PCIC) model recommended by the WHO and WBG to shape the Chinese healthcare system. In accordance with PCIC, China began the implementation of gatekeeping primary care by introducing GP services to local communities.A comparative analysis was employed to point out the importance of introducing GP services. A systematic assessment was carried out to evaluate the regulatory sector of the Chinese healthcare system, including a critical review of related legal norms and a theoretical exploration of external impediments .Results demonstrate that the current regulatory sector of the Chinese healthcare system needs to be improved in order to assist the nationwide implementation of GP services and to strengthen its gatekeeping role. Major deficiencies include the problematic relationship between legal norms and health policies, the lack of effective and consistent new legislation, the low rate of social acceptance, and lack of support from agencies. To address those challenges, this paper recommends that preliminary efforts be devoted, in part, to two changes in the legal structure: enacting a specific law, and creating an independent regulatory oversight body. The fragmented legal norms may also be incompatible with the concept of GP services, since they were issued to deal with the problems generated by the hospital-based delivery system. Put differently, the current version of Chinese healthcare was designed with less attention to support integrated care, and there was hardly any attempt to consolidate the fragmented legal norms. So the fragmentation of legal norms needs to be taken seriously before any substantial steps are taken to implement GP services nationwide.et al., et al., The current legislative method also has a deficiency. Regulations are more likely to be issued in the domain where bad behaviour causes the worst consequences  solidly underpins traditional Chinese culture, which assigns a low priority to resorting to court to resolve disputes , but also in terms of providing training and continued education (Article 35). With regard to the proposed GP services, who should take up those responsibilities? In accordance with the National Health and Family Planning Commission of the P. R. China , the GP et al., Furthermore, the GP system adopts a ‘1+1+1’ contract model, which means that patients are encouraged to sign the contract with one GP group plus one secondary hospital plus one tertiary hospital. This contractual character of the doctor–patient relationship under the GP system deserves special attention. It implies that people living in China need to be empowered and activated in order to choose the best contract. Once again, regulators have to be cautious when adopting new concepts. If GP services are governed by contractual considerations, then regulations have to deal with the unequal positions of GPs and their patients. In this respect, regulations should be formulated with special attention devoted to creating a supportive legal environment, such as securing patients’ right to information, providing an effective complaint process, and other empowering measures [eg, ‘building health literacy, improving self-management skills, cultivating shared decision-making and creating a supportive environment’ (The World Bank Group Moreover, does the GP have the right to choose patients when the contractual relationship implies an exclusive relationship? According to Article 24 of the Law on Practising Doctors, doctors have an affirmative responsibility to take care of patients under emergency situations. Certainly, any emergency case should be excluded from contractual conditions due to humanitarian values. How about other cases? If the GP is entitled to select patients, is there any difference between commercial insurance companies and the GP? Will the rights of doctors or insurance companies limit the accessibility of healthcare for patients who suffer from severe chronic diseases? Since the law will affect everyone, Chinese lawmakers need to consider this issue carefully.et al., et al., Last but not least, considering the fact that there exists a wide disparity between urban and rural areas in primary care in China (Shi, et al., In general, Chinese healthcare reform has been managed in a multi-leadership style. The government agencies in charge are the National Health and Family Planning Commission, the Ministry of Finance, the National Development and Reform Commission, and the Ministry of Human Resources and Social Security. Each government agency represents its own political constituency, which results in weak interagency communication and collaboration. Reform plans developed in this multi-leadership style are highly likely to fall short in accountability provisions for each sector, and to contain contradictory arrangements. Although a typical example of multi-sector cooperation exists in China, the Patriotic Health Campaign (Meng There are two essential elements of the proposed independent regulatory oversight body. One refers to the involvement of professionals with multi-disciplinary backgrounds. Since healthcare reforms depend on consistent systematic efforts, the proposed body should recruit physicians who are able to provide clinical insight due to their front-line role in the healthcare system, economists who can provide input on sustainability and effectiveness, legal professionals who can draft laws and regulations to prevent misbehaviour and shield people from the adverse effects of reform, ethicists who can provide guidance on humanitarian performance, and professionals from social media who can cultivate cultural attitudes by educating people to be responsible and rational beneficiaries of the reform.Procedural justice is another concern. Formulating an independent regulatory oversight body should not be regarded as an attempt to replace any effective government agency. On the contrary, it should function independently as a bridge to mitigate the conflicts resulting from the multi-leadership style. In addition, the oversight body should not only serve as a surveillance tool, but should also provide an open process for mediating medical disputes.As the cornerstone of the PCIC framework, the evolving GP system has been introduced to establish and strengthen the gatekeeping primary care in China. Compared with the previous system of community-based medical services, GP services are believed to perform better in serving the gatekeeper role. The new GP system is promising, not only in terms of restoring trust between doctors and patients, but also with regard to the enhanced referral mechanism, which will contribute to improvement in communication and collaboration among different levels of medical institutions. However, these promising aspects could also produce unexpected adverse effects if the healthcare system, or even the entire society, is unprepared. In this regard, we have considered the current Chinese healthcare system, with special attention paid to the regulatory sector. Results show that major deficiencies in the regulatory sector include the problematic relationship between legal norms and health policies, the lack of effective and consistent new legislation, the low rate of social acceptance of GP services, and the lack of support for GPs from government agencies. Therefore, neither the internal structure nor the external environment of the regulatory sector is prepared. Recognising that a well-developed regulatory sector is of vital importance for the effective nationwide implementation of the GP system, future efforts should be directed, at least in part, towards enacting a specific law and establishing an independent regulatory oversight body. Only after these requirements are met can GP services be implemented effectively on a nationwide scale.


Given that average salt intake among Iranians is approximately 10–15 g per day particularly from sodium hidden in bread, cheese, and fast food; lowering this mineral has been followed up seriously in this country for almost 10 years (since 2009). The main objective of the present study was to provide an opportunity to recognize unwanted and unfavorable outcomes of implementing decisions and policies together with associated problems of salt reduction in bread in order to achieve national and global health promotion goals. Thus, this qualitative and retrospective policy analysis was completed to evaluate the policy of salt reduction in bread in Iran. To collect the data, the researchers traveled to six cities in different regions, wherein relevant documents were utilized added to interviews with key actors. Related websites were correspondingly searched to find reports on this policy. Moreover, the researchers referred to some organizations in-person to search documents in this area. Five group discussions were also held to obtain public opinions in this regard. Data analysis was further carried out using framework analysis. The findings revealed that allocation of the highest rates of subsidy to wheat, flour, and bread had led to elimination of competitiveness in wheat, flour, and bread supply chain in Iran. Despite the presence of proper structures as coordinators of other organizations working on public health, there was no intersectoral collaboration in terms of maintaining health of bread products and lowering salt content in this staple food. With regard to changes in priorities of the Iranian Ministry of Health and Medical Education, attempts made to improve bread quality had also failed. In addition, first-line staff (i.e. bakers) had viewed formulation and implementation of the given policy as a top-down one. Given the ambiguities in establishment of new standards, there were similarly contradictions in execution of the policy at various levels. With reference to education provided at a national level, it was concluded that some people had become more sensitive to salt reduction in bread to some extent. As a general rule, qualitative studies are appropriate for illustrating and analyzing issues that have not been thoroughly investigated until now. In addition, these types of studies provide comprehensive and complete data on the subject matter In the present study, three data collection methods were utilized including interview, observation, and focus group discussion.2.1.The study population consisted of a total of 37 informants and key individuals including two groups of administrative assistants and experts in policy-making for salt reduction in bread such as university professors with a history of research in this field, managers, as well as policy-makers and specialists with an administrative experience regarding salt and bread policies (Box 1), selected via snowball sampling as a purposeful method of sampling. The data were then collected through semi-structured interviews with the participants in a face-to-face manner. This research tool encompassed open-ended questions prepared by the interviewer (thematic interview guide) and also created naturally throughout the interview. It is noteworthy that the 15-item thematic interview guide on salt reduction in bread  was deveClick here for additional data file.A consent form was further obtained from the interviewees, in-person or through a phone call. Afterwards; the research characteristics sheet was submitted to the participants, in-person or through emails, and they were returned after completion. Each interview lasted about 45 minutes and the data were collected during six months. In order to record the interviewees' voices, they were ensured of confidentiality of the data and their personal information. No consent to record their voices was also resolved by taking notes by the interviewer. The audio files were subsequently transcribed and a copy was then sent to the interviewees to confirm the accuracy of the data in case of any doubt in their content. The interviews also continued until data saturation.It should be noted that the researchers traveled to six different parts of Iran, and used relevant documents along with interviews with key actors. These cities were selected mainly based on the quality and quantity of wheat produced. There were also attempts to cover the entire country geographically.This research was approved by the Research Ethics Committee of Tehran University of Medical Sciences, Iran.Box 1.At the national level:Iranian Ministry of Health and Medical Education: 1 former head of the office and 1 head of the current Office of Social Nutrition Improvement, 1 major policy-maker, and 3 supervisorsMinistry of Agriculture Jihad: 1 individual in monitoring unitsTehran Bakers Union: 1 individualIran's Flour Industries Union: 1 individualIranian National Standards Organization: 1 individualAt the provincial level:Environmental health inspectors: 5 individualsGovernment Trading Corporation of Iran: 5 individualsMinistry of Agriculture Jihad: 2 individualsUniversity professors: 5 individualsBakers : 10 individuals2.2.The researcher attended bakeries  as well as traditional flour mills and assessed their work method, especially use of salt in bread. If needed, some processes were photographed and videotaped after receiving permissions. Other resources exploited in this study were documents and reports. To this end; the websites of the WHO, as well as the domestic ones were searched to find reports related to the policy of salt reduction in bread in Iran. Furthermore, the researchers referred to some organizations in-person to search for relevant documents. Other documents utilized included articles, newspapers, magazines, authorized news agency websites, as well as annual and six-month reports from various centers. The documents were also used as additional resources for validating other collected data.2.3.A total of five focus group discussions were held while people were waiting in the queue of bakeries, to obtain public opinions in this respect and to gather information about the effects of the policy of salt reduction in bread on people.3.In the vein of most qualitative studies, data analysis was performed simultaneously with data collection. This concomitance allows for returning to questions and correcting, modifying, or eliminating them for future interviews. It should be noted that the data were analyzed using framework analysis, formed based on existing ideas (i.e. a predetermined framework) which does not seek to develop a new theory. In the present study, the framework employed was policy analysis triangle adapted from Walt and Gilson (1994), encompassing four categories of context, actors, process, and content in the analysis of policies (20).Credibility was also measured to ensure the accuracy of the results. In order to boost credibility, participants with sufficient experience in this area were selected and then integration was applied in all stages of the study including diversity in data collection methods  . Moreover, there were attempts to allot sufficient time to data analysis. If required, the transcribed interviews were returned to the interviewees for further revisions. To improve transferability, all research stages were recorded to allow for the follow-up of each stage and to have a clear process. In addition to citations, research design and stages were explicated. Given the fact that confirmability is interpreted as unbiased data, controversial and negative cases were evaluated to understand the reason for inconsistency between results. Furthermore, long-term presence of the researcher and allocation of sufficient time, accuracy in all research stages, and clarity of the research methodology could help concretize the data. In addition, dependency was obtained using complementary views of supervisors and counselors in terms of coding and analyzing the transcribed interviews.4.The results were reported in four categories of the policy analysis triangle framework i.e. context, policy content, policy-making process, and actors.4.1.Implementation of a new policy depends on the setting in which it is formed. In this part of the study, the environmental aspects having direct or indirect effects on the policy of salt reduction in bread were delineated. In terms of wheat, it could be concluded that all the relevant stages had been monopolized by the Iranian government with the exception of production. While the state had devoted its main subsidy to wheat, flour, and bread with the aim of protecting vulnerable populations, this act had led to loss of competitiveness in wheat, flour, and bread supply chain in this country. Given the effect of the competitiveness on increasing product quality and the direct relationship between use of salt in bread and quality of wheat and flour; the sovereignty of the government over wheat, flour, and bread was considered as one of the challenges to successful execution of the this policy. For example, one of the interviewees had stated that:“Salt strengthens gluten bonding and gives it structure. So, relative success will be achieved in implementing this policy if wheat quality is overlooked and I think that it is aimed to solve the problems just in the last stage of the production process ”(A university professor)Over recent years, the main government incentive has been allocated to provision, supply, and distribution of wheat and bread. As a result, bread is available to Iranians at a supported cost to protect vulnerable populations. Due to continuous increase in the cost of flour and the constant rate of selling flour to bakeries, bread subsidies have further generated adverse effects such as increased government spending, difference between bread costs in urban and rural areas, as well as bread waste off the scale. Despite much emphasis of high-level documents on supports for bread production industry and promotion of culture of using industrial bread in this country, traditional flat breads, unfortunately, constitute 93% of the bread consumed by the public, and the overall popularity of loaf bread is negligible. In this respect, a former policy-maker had said that:“In the course of industrial bread production, majority of processes are automatically carried out and less flour is thus wasted. In addition, fermentation is definitely performed and salt use can be properly controlled. Even salt-free bread can be produced. Moreover, bread is baked with indirect heat and there is no residual of fossil fuels on the bread”Generally; in addition to the completely mechanized production process of industrial bread, fermentation is more complete and the final product is endowed with high food safety and health. Owing to their stable production processes and equipment, adhering to bread production standards is thus more practical in these units and they can be effectively monitored. Moreover, monitoring these units and assessing their compliance with the standards can be carried out with high operational capabilities.In spite of the structure of the Supreme Council of Health and Food Security as the coordinator of other organizations working on public health, all state-run agencies involved in wheat, flour, and bread pursue their own goals and there is less intersectoral collaboration regarding the issues of bread health and salt reduction in this staple food.Accordingly, three important factors affecting quality and health of the final product  include right ingredients; knowledge, education, and specialty of workforce , and use of appropriate tools and technologies in bread preparation. The most popular of the traditional Iranian bread prepared in Iran have been already mentioned in Lavash flat bread bakeries, because the dough is uniformly spread under the pressure and there is less probability of being torn. Therefore; use of salt, which is mainly to prevent the tearing of bread decreases in the production phase.Bakery equipment is another issue to be considered; since need for salt used in bread is reduced in some cases, according to observations, such as use of dough sheeter machines in 4.2.Following the former order of the Iranian Ministry of Health and Medical Education in 2013, a specialized working group was established to promote bread quality with the main objective of providing effective and practical solutions to eliminate use of baking soda and reducing salt content in bread production process. The intervention recommended included improving formulation of traditional (i.e. flat) bread to provide a model of healthy bread, reviewing list of materials authorized and used in baking industry, revising national standards and guidelines, reducing problems through industrialization of traditional bread production , building proper culture  for healthy bread consumption, determining quality indices of wheat for domestic purchases and imports of wheat in order to take account of effective components in production of high-quality flour and bread products such as gluten, employing food industry graduates to implement precise technical and sanitary supervision on flat and loaf bread bakeries, as well as closing traditional bakeries to build industrial complexes of traditional (flat) breads to improve quality of this product. Unfortunately, attempts made in bread production and results of meetings by the specialized working group on promotion of bread quality have failed due to changes in the government and the priorities of the Iranian Ministry of Health and Medical Education.4.3.One of the most common and useful methods for evaluating and analyzing the policy-making process is the use of heuristic stages 4.3.1.Given the much importance of bread along with complexity of wheat, flour, and bread issues; bread quality improvement was put into operation in early 2014. Eventually; after numerous meetings, review of bread and flour standards and monitoring of their proper implementation were announced and approved in 2015. Along with the implementation of the Health Promotion in Iran's five-year Development Plans in the field of prevention and health, environmental health inspectors became equipped with portable salinity meters to measure and record salt content of dough in bakeries.4.3.2.Unfortunately, first-line staff (i.e. bakers) has considered the policy of standard reduction of salt in bread as a top-down one, and even impossible in some areas. In the top-down approach, policy-makers are key actors and the role of other stakeholders is overlooked. In this approach, the government is usually recognized as the main ruler, and other actors, including individuals and organizations, are merely subordinates. With regard to a limited perspective in policy-making, there is little chance that all prerequisites for successful policy implementation are taken into account. For example, one of the interviewees had reiterated that:“The current policy is just an order. Salt in bread should be approximately 1%, but what is the strategy? How can we fulfill it? The imperative policy is not the answer. I think in-depth interviews must be conducted with bakers in order to perceive the problem”In the top-down approach, first-line actors are also dissatisfied with the policy formulated and show little commitment for its implementation, which means failure in policy execution. In addition, some stakeholders had controversial ideas concerning reduction of salt in bread, which seemed to be unknown to main policy-makers in the policy-making process. In this respect, two employees had stated that:“A big problem is that we ignore salt functions. The salt function is being substituted by some additives whose recognition is not possible due to lack of a proper method. Our major concern is use of unauthorized salt substitutes”“Memory loss and goiter has increased in this province since the implementation of salt reduction program”.4.3.3.According to Standard No. 2628 of the Institute of Standards and Industrial Research of Iran, salt content in the dry matter of bread should be measured and reported. Meanwhile, environmental health officers need to measure amount of salt in dough using salinity meters and then consider cases above 1% as violation of standard regulations. At the same time, in order to adhere to the standard of 1 g salt per 100 g of bread, bakers should consider a bag of flour as a weight criterion and add 400 g of salt to it (40 kg). It is clear that the standard of salt reduction in bread is not clear and such a contradiction in implementation of the given standard should be resolved as soon as possible.Furthermore, water quality is of great importance and very hard or soft water is not suitable for baking. In general, water hardness affects dough and the resulting bread, since minerals in water can exert impacts on rising process and solubility, intensity of fermentation, aromatic substances, and bread taste. Very soft water also causes numerous problems due to production of runny dough Some people have also questioned the ability to apply the new standard and have further mentioned that the current flour quality does not allow compliance with this standard in Iran. Others have also considered the implementation of this policy to be based on bakers' skills and have expressed that if bakers receive the necessary training from reputable organizations, such as Iran Technical and Vocational Organizations, the given standard can be properly adhered to and bread quality will be significantly improved. Some issues such as lack of attractiveness of bakery job due to its demanding conditions and low wages, seasonal nature of bakery workers in most parts of Iran, and lack of specialized bakery training centers have all led to serious problems in bakery training, especially in reducing salt in traditional bread.4.3.4.The policy of salt reduction in bread officially started at the beginning of 2016 and it has not been so far evaluated in research studies, to the best of authors' knowledge. However, a study conducted in southeastern Iran in 2015 showed that salt reduction in bread could be an acceptable and effective intervention in lowering uric sodium and systolic blood pressure in the community 4.4.4.4.1.Some bakers believed that similar pricing by the government regarding both low-quality and high-quality subsidized bread producers had put an end to competitions among bakers to offer a high-quality product. For example, an expert had said that:“The biggest problem is the subsidy. In fact, we have done away with competitiveness in this industry. This also applies to flour factories. When the government purchases any type of flour, I think there is no point in increasing its quality”Others had also assumed that encouragements and incentive policies would be more effective instead of punitive ones together with penalties for bakeries. In this respect, a baker had added that:“For example, they could put a sign on top of the bakery highlighting that the baker has managed to reduce salt content in bread. This would both encourage bakers and lead to an increase in the number of customers”(A baker)4.4.2.One of the policies adopted by the government is to use the Primary Health Care (PHC) system to educate people about needs for consuming low-salt products. In this way, bread producers  will try to offer low-salt bread when the public demands this type of product. The important note is gradual reduction of salt in such products. As seen in other countries such as the United Kingdom, salt reduction must be slow but sure in order to get people to eat low-salt products and to prevent decline in sales “The public has shown and will show positive attitudes to any factor contributing to their health. Reducing salt intake is no exception, and people are willing to reduce salt content in bread and other products. However, this decrease in salt consumption should be managed in a way that other problems (e.g. iodine deficiency) and other complications are avoided”Some people have also become so sensitive to lowering salt content in bread, so they would purchase from another bakery in case of detecting a high salt content in bread of a certain bakery. Due to the risks of diseases associated with high salt intake, some people are not just satisfied with reduction of salt content in bread and demand a decrease of this mineral substance in other salty food, including pickles and different types of sauce. On the other hand, some people are indifferent to the amount of salt in bread and only focus on its quality, taste, and appearance, as well as shelf life.5.Despite the important role of bread as the main source of salt in the diet of Iranian people, no research has been conducted thus far on reduction of salt content in bread in this country to the best of authors' knowledge. In the present study, the policy of salt reduction in bread was thus evaluated from different viewpoints. While the policy seemed initially simple, its complicated dimensions were recognized after the study and some serious challenges were also found, especially in terms of implementation of the given policy in Iran.Sangak, because of using whole-wheat flour and thorough fermentation in the process of its production by sourdough starter), so that healthy nutrition in the community can be indirectly promoted and a competitive environment can be created for other types of flour and bread.In this regard, the main problem in the area of bread production and not just reduction of salt in this product was lack of competitions either in terms of use of the main raw material, namely flour, or in the final product, i.e. bread types. On the other hand, given the strategic importance of wheat, flour, and bread and the significance of wheat in Iranian households' food basket; governmental supports for producers and consumers, especially vulnerable populations, are inevitable Ambiguity in implementing this policy is also due to lack of understanding of the environment, definition of vague goals, as well as no familiarity with existing facilities of organizations Another point is that central policy-makers should not expect unconditioned obedience of policy-executers It is notable that most of the countries that have successfully reduced salt in bread, including the United Kingdom 6.Reduction of salt in bread has faced serious barriers especially in its implementation in Iran. Even as this study mainly discussed use of salt in bread in Iran and given the implementation of the mentioned policy and lack of similar investigations on the implementation method of this policy, the present study can be utilized as a model for several countries with similar or different contexts.


The use of smartphone apps to monitor and deliver health care guidance and interventions has received considerable attention recently, particularly with regard to behavioral disorders, stress relief, negative emotional state, and poor mood in general. Unfortunately, there is little research investigating the long-term and repeated effects of apps meant to impact mood and emotional state.We aimed to investigate the effects of both immediate point-of-intervention and long-term use  of a guided meditation and mindfulness smartphone app on users’ emotional states. Data were collected from users of a mobile phone app developed by the company Stop, Breathe & Think (SBT) for achieving emotional wellness. To explore the long-term effects, we assessed changes in the users’ basal emotional state before they completed an activity . We also assessed the immediate effects of the app on users’ emotional states from preactivity to postactivity.The SBT app collects information on the emotional state of the user before and after engagement in one or several mediation and mindfulness activities. These activities are recommended and provided by the app based on user input. We considered data on over 120,000 users of the app who collectively engaged in over 5.5 million sessions with the app during an approximate 2-year period. We focused our analysis on users who had at least 10 engagements with the app over an average of 6 months. We explored the changes in the emotional well-being of individuals with different emotional states at the time of their initial engagement with the app using mixed-effects models. In the process, we compared 2 different methods of classifying emotional states: (1) an expert-defined a priori mood classification and (2) an empirically driven cluster-based classification.We found that among long-term users of the app, there was an association between the length of use and a positive change in basal emotional state . We also found that individuals who were anxious or depressed tended to have a favorable long-term emotional transition  after using the app for an extended period .Our analyses provide evidence for an association between both immediate and long-term use of an app providing guided meditations and improvements in the emotional state. Behavioral conditions, neuropsychiatric diseases, and poor general mental health are seen as major contributors to morbidity, mortality, and lost productivity on a global scale. However, these factors are often overlooked in discussions about the current state of health care, which tend to focus on physical well-being . Many stThe use of mobile phone apps in combating or mediating behavioral conditions, stress, negative emotional states, and elevating mood is also consistent with directions that public health and regulatory officials are considering. In fact, evidence is mounting from clinical trials showing that smartphone apps can be effective in a variety of settings. Agencies such as the US Food and Drug Administration (FDA) have created, and in instances passed, legislation allowing the filing and approval of mobile health apps as approved health technologies on the same level as in vitro diagnostics and drugs. Pear Therapeutics was one of the first companies to have a smartphone app for addiction approved for use by the FDA in 2016 -19. Unfocheck-in, thereby allowing an assessment of an individual user’s emotional state and mood pre- versus postactivity in real time. As repeated uses of the app by SBT users are archived, longitudinal information on its users with regard to their long-term engagement with the app is retained. This allows further analysis of the influence of repeated engagements with the app on an individual user’s basal mood over time in real-world settings. We pursued such an analysis using data from SBT users who had at least 10 engagements with the app. The SBT app allows users to choose from more than 100 unique emotions to reflect their emotional state at the time they use the app. These emotions cover a range of human emotions including anger, remorse, anxiety, calmness, and enthusiasm. Users are guided through meditations that they can choose from based on an algorithm developed by SBT. We focused our analyses on the baseline  emotional state of a user, before he or she engaged in a guided meditation or mindfulness activity and were primarily interested in the long-term and repeated use effects of the SBT app on this baseline emotional state. Essentially, we wanted to ask the question if the continued use of the app lifted the spirits of the user over time. We were particularly interested in users who tended to pick emotions associated with depression and anxiety when engaging with the app before meditating.Stop, Breathe & Think (SBT) has developed a smartphone app that provides guided meditations and mindfulness activities to promote self-awareness coaching to interested users. As noted, mindfulness and meditation have been shown to improve affect and mood and promote healthy thought patterns ,24. The The SBT app is a multiplatform  app designed to guide users through meditations and mindfulness activities to alleviate stress, anxiety, and depression and improve the sense of well-being. Upon opening the app, a user can participate in an optional 10-second reflection period. After this optional reflection period, users describe their current mood, emotional state, and physical health by choosing from a number of emotions; the SBT app then provides suggestions for specific meditation and mindfulness activities. The user can choose from among the suggested activities after being asked to endorse up to 5 different characterizations of their mood and emotional state. A user can choose not to provide any input regarding their mood, emotional state, and physical health and simply engage in an activity.It should be understood that all information collected with the SBT app is volunteered by users as stated and defined in the SBT user licensing agreement and privacy policy. In addition, for purposes of our data analyses, all the data we obtained from SBT were anonymized and put into a Health Insurance Portability and Accountability Act (HIPAA)-compliant format such that users could not be reidentified. Functionality and delivery of the SBT app and service varies from device and platform implementation . Therefore, to avoid batch effects, we focused on users who were exclusively on an iOS platform and started using the app after SBT provided its last major version of the app (05/01/2016). Users had to have completed at least 10 sessions or engagements with the app, with a minimum of 6 of those sessions including pre- and postactivity emotion selections. The SBT app content is in English and to avoid translation errors and alternative interpretations of the language used in the SBT app, we restricted our analyses to individuals from native English-speaking countries: the United States, United Kingdom, Canada, and Australia. An additional filter was used, restricting users’ ages to between 12 and 100 years.check-in involves selecting an initial emoticon and then choosing from a list of emotions within subgroups of terms that closest characterize the user’s current emotional state. These 115 emotions were chosen for the app based on internal SBT research and user requests. All emotions were classified as positive, neutral, or negative and given corresponding scores of 1, 0, and −1, respectively. All emotions and their corresponding scores are provided in The SBT app allows the user to endorse between 1 and 5 emotional states out of a possible 115, before and after engagement in a guided meditation or mindfulness activity (or series of activities if they choose to engage in more than 1 activity during a session). This emotional Partitioning Around Medoids (PAM), for these analyses [In addition to treating the preactivity emotion scores and changes in emotion scores pre- and postactivity as dependent variables and time, sex, and age covariates as independent variables, we also explored the patterns among the emotion endorsements to see if there was evidence for obvious clusters of emotions that could reflect the same general emotional state. We leveraged principal coordinates analysis (PCoA) and the nonsupervised clustering technique, analyses . We pursThe distance between the emotions was calculated using the Bray-Curtis distance measure . To detedistances (using the Euclidean distance measure) between pre- and postactivity states. The distances between an individual’s emotional status and the medoid of the closest associated emotion cluster were calculated as well. Emotions were labeled with clinical categories, associating each of them with either anxiety, depression, anger, or happiness  models and Generalized Linear Models (GLMs) as implemented in the lme4 package in R . These a10 transformation to the session index variable. This transformation markedly improved the normality of the session index as a variable (data not shown). LME models were fit, and the features associated with the preactivity emotional state as the dependent variable were selected using a forward stepwise selection procedure based on the Akaike Information Criteria. Similar models were fit with the pre- to postactivity emotional state ratio as the dependent variable. GLMs were fit to the data when changes in emotion categories  were taken as the dependent variable.We included several covariates in our analyses and tested them for their effects on the emotional state: session index , gender, age, country of origin, subscription status, and whether the user remained anonymous . As there is large variability in the number of completed sessions and the distribution of the number of uses of the app per individual has an extreme right skew, we applied a logAfter all the duration, quality, platform, and country filters were applied, 13,393 users remained . The average age of the users was 32.3 (SD 13.5) years, with 31.7 (SD 13.3) years for females, 34.6 (SD 13.4) years for males, and 33.3 (SD 15.0) years for undeclared participants. Collectively, the users completed 569,961 sessions with the app, with 302,514 of these sessions having emotional check-in data, with an average of 42.6 sessions and 22.6 emotional check-ins per user. The use of the silhouette scores based on the PCoA and PAM analyses suggested that there were likely 8 clusters of emotions . As noteP values) were calculated using a Wald-Z statistic approximation. Models fit using a subset of users who reported anxious or depressed emotions in their first session with the app are labeled as primary models. The session index is consistently associated with improvements in mood, suggesting, again, that repeated use of the app positively impacts mood.Using the average preactivity emotional scores, as well as the cluster-based distance measures, as dependent variables, we fit linear-mixed models with session, as well as the important covariates, as independent variables, while accommodating serial correlation emotions. The results using the average preactivity emotional state scores suggest that a statistically significant relationship exists between the number of uses of the app  and the preactivity emotional state, with an elevation in mood  occurring with repeated use of the app. Adjusting for scale, users experience a 2% improvement in mood after their first session, a 4% increase after their 10th session, and a 6% increase after their 100th session. The clinical relevance of this improvement in mood needs to be investigated further. We found that males have an average 2.5% higher (improved) preactivity mood than females and that older users have a more positive mood than younger users. Additional analyses suggested that repeated use of the app resulted in specific improvements in levels of anxiety and depression. After the first 10 sessions with the app—which on average corresponded to a 63.4-day period—users were 82% more likely to report no anxious emotions and 28% more likely to report no depressive emotions. This effect was even more pronounced when we only examined users whose first emotion endorsement reflected anxiety (440%) or depression (1050%). We also fit models that considered the ratio of preactivity to postactivity emotional scores as the dependent variable. Our analyses show that repeated engagements with the SBT app are associated with an improvement in users’ emotional states over time. In the absence of a randomized control trial, it is difficult to say with certainty that there is a direct causal relationship between the use of the SBT app and emotional state; however, given the large diverse sample size, we believe that the impact of unmeasured covariates on our results  is likely to be small, although potential biases in the users of the app may exist. The effect we observed is more pronounced for users who often endorse anxiety or depression when capturing their emotional state at their initial uses. We also found that age and sex covariates are associated with the basal mood or emotional state. Ultimately, our analyses suggest the possibility that guided meditations and mindfulness activities have the potential to be effective ways of reducing anxiety, depression, and stress and ultimately elevating mood, although the ultimate clinical significance of the improvements in the emotional state that we observed needs to be explored. Our analyses did reveal other interesting phenomena. For example, although a minority in our study, males tended to have higher baseline emotional scores and responded better to the SBT app than females. The age of a user was also found to be a significant correlate of the basal emotional state, with older users generally endorsing more positive emotions.Our analyses are not without limitations, the first and foremost being that there is no control group and comparator app. This makes it difficult to definitively state that guided meditation and mindfulness activities are causally related or responsible for the increase in baseline mood or emotional state over time. However, given the sample size and magnitude of the effect, the significant change in emotional state after immediate and prolonged use of the app suggests that it has potential as an intervention. Another limitation is that all the information we analyzed was self-reported without any oversight by a third party. There could be users who did not follow instructions and entered erroneous emotions to expedite engagement with the meditations. Many of the individuals we did include in our analyses did not record emotions for each and every one of their sessions, resulting in many incomplete observations. Finally, a potential limitation with our analyses is that there could have been a heavy selection bias among the individuals using the app in the sense that they were motivated enough to download it and use it. Thus, this may be an indication that they could be predisposed to responding positively to the app.Our use of the emotion clusters and similarity scoring of emotions based on our cluster analyses of those emotions allowed us to explore how often individual users transitioned from one broad set of analogous and almost synonymous emotions to another. On the basis of these analyses, we found evidence that, in general, individual users’ emotional states move from negative to positive over repeated uses of the app. We find that anxiety-prone and more depressed individuals benefit from the app more than others. These findings, as with the analyses, need to be verified in more controlled settings, such as randomized control trials, but again suggest that there is promise for the app and related apps in clinical and public health settings.There are a number of questions that deserve attention beyond those that we addressed with our data. For example, the number of uses of the app may not reflect the total length of time the app was used . Assessing the impact of the number of uses versus length of time on outcomes could provide a more detailed insight into the benefits of the app. In addition, it would be good to see if a companion study designed especially for adolescent populations also has a positive effect on their emotions . In addiAs more and more attention is given to the delivery of health care and health maintenance strategies through devices such as smartphones, robots, and telemedicine communications, greater sensitivity to the nuanced effects of these devices should motivate studies of them that are pursued in a comprehensive manner. Such sensitivity and more elaborate studies could also lead to more efficient and sophisticated deployment of these devices and help combat the need for expensive and logistically challenging visits to health care providers.


Despite the worldwide growth in mobile health  tools and the possible benefits for both patients and health care providers, the overall adoption levels of mHealth tools by health professionals remain relatively low.This study aimed (1) to investigate attitudes of health care providers and mHealth experts toward mHealth tools in the health context in general, and this study aimed (2) to test the acceptability and feasibility of a specific mHealth tool for patients with an eating disorder (ED), called TCApp, among patients and ED specialists.To this purpose, we conducted an explorative qualitative study with 4 in-depth group discussions with several groups of stakeholders: our first focus group was conducted with 11 experts on mHealth from the Catalan Association of Health Entities; the second focus group included 10 health care professionals from the Spanish College of Doctors of Barcelona; the third focus group involved 9 patients with an ED who had used the TCApp over a 12-week period, and the fourth and last focus group involved 8 ED specialists who had monitored such ED patients on the Web.The focus groups showed that health care providers and mHealth experts reported barriers for mHealth adoption more often than facilitators, indicating that mHealth techniques are difficult to obtain and use. Most barriers were attributed to external factors relating to the human or organizational environment  rather than being attributed to internal factors relating to individual obstacles. The results of the mHealth intervention study indicate that the TCApp was considered as easy to use and useful, although patients and the ED specialists monitoring them on the Web reported different adoption problems, such as the inability to personalize the app, a lack of motivational and interactive components, or difficulties in adhering to the study protocol.In general, this paper indicates that both health professionals and patients foresee difficulties that need to be addressed before comprehensive adoption and usage of mHealth techniques can be effectively implemented. Such findings are in line with previous studies, suggesting that although they acknowledge their possible benefits and cost-effectiveness, health care providers are quite resistant and conservative about integrating mHealth technologies in their daily practice. Over the last decade, the number of people who have obtained a mobile phone or some other portable electronic communication devices worldwide has increased exponentially . As a comHealth has many different applications, such as the facilitation of data collection, the encouragement of health care consumers to adopt healthy lifestyles, the self-management of chronic conditions, such as pain, psychological distress, fatigue, and sleep ,6, and tMany factors influencing the acceptance, adoption, and usage of mHealth by health care professionals have been reported in the systematic review by Gagnon and colleagues . SpecifiMeanwhile, important barriers relating to mHealth characteristics were also mentioned in the same review , such asOwing to the advantages of the use of mHealth technologies, it is important to determine what types of drivers and barriers are considered relevant by health professionals to adopt mHealth technologies efficiently. In this study, we will focus on the drivers and barriers for adoption of mHealth techniques in general health care delivery processes, and, more specifically, in an intervention using an mHealth tool specifically designed for patients with eating disorders (EDs) and the health care providers treating them.static interventions. Correspondingly, blended treatment, referring to face-to-face treatments, which include a digital intervention or component, has been gaining in popularity over the last few years [According to Holmes and colleagues , mHealthew years -19, and ew years ,21.Health professionals treating patients with EDs might be an important group that could benefit from mHealth interventions, either as an adjunct to standard treatment or as a method to providing existing evidence-based treatments on the Web . AccordiFurthermore, factors that facilitate or hinder the effective adoption of these tools by patients and clinicians need to be identified through qualitative research. In a systematic review of the literature by Anastasiadou and colleagues  that focWe conducted 4 separate in-depth focus groups for this study. The first was carried out with health care providers, and the second was carried out with mHealth experts. Both focus groups had the same structure, and both aimed at assessing important drivers and barriers, which these professionals perceived relating to mHealth adoption in different health care services. The third and fourth focus groups were based on data from a larger randomized controlled trial (RCT) assessing the effectiveness of an mHealth intervention , and they sought to assess the user (patient and provider) experience of a specific mHealth tool, called TCApp, in supporting self-management for patients with an ED. Focus group discussions were performed in accordance with the generic inductive approach .The TCApp is an mHealth tool specifically designed to bidirectionally connect patients with EDs and their therapists in the periods between medical consultations. The app has been designed and developed by the Spanish start-up company HealthApp. It offers 4 different language options , and it is available through both Google Play and Apple Store markets, and it currently has more than 1000 patients as active users. Through the TCApp, patients can record their thoughts, actions, emotions, and whatever other information their therapists consider relevant for the therapy. The app can be customized for each patient according to therapy requirements. The main objective of the app is to replace paper self-records with Web-based records, as the former sometimes present a source of discomfort for patients . In addiA total of 11 experts on mHealth from the Catalan Association of Health Entities  and 10 health care professionals from the Spanish College of Doctors of Barcelona  with a special interest in mHealth were invited to participate in focus groups organized by our research group at the Open University of Catalonia . The generic inductive approach, on which the design of the study was based, required a purposive sampling. To better identify barriers and facilitators for mHealth adoption from the point of view of 2 different stakeholders’ groups, we considered it important to carry out the first focus group with experts on mHealth from ACES and the second with health care professionals from COMB. The approval of the Ethical Committee of the University leading the study (UOC) to conduct the focus groups was obtained on February 21, 2017. Inclusion criteria for both focus groups were professionals from several private medical centers in Barcelona (Spain) who were actively engaging in mHealth technique usage, including both health care providers as well as mHealth experts, such as technical staff , ICT management staff, marketing and communication managers, and human resources management staff.The study’s population comprised a larger RCT for the mHealth intervention study, involving 8 public and private ED units in Spain. A total of 108 patients were recruited from this larger study, the protocol of which has been published elsewhere . It is wInclusion criteria for the ED specialists’ group included having monitored their patients on the Web and having performed the following actions at least once a week: follow the patient’s daily self-records and generate personalized reports or graphs and communicate with him or her via the chat function. From a total of 21 patients who were invited to the focus group, 11 decided to participate, whereas 2 had to be excluded, as they did not meet all inclusion criteria. Next to that, all invited ED specialists from the 8 ED units took part in their respective group discussion. However, it is worth mentioning that only patients from 3 out of the 8 ED units involved in the larger study participated in the focus group study. The final focus group sample thus comprised 9 patients with an ED and 8 specialists who were monitoring such patients on the Web through the TCApp. Qualitative data were collected through four in-depth focus groups, as previously indicated. The first comprised health care providers from the COMB, the second focus group was conducted with mHealth experts from the ACES, a third focus group with patients who had used the mHealth tool, TCApp, and a fourth with ED specialists who had monitored such patients on the Web.The interviews carried out in the first 2 focus groups included open-ended questions designed to address the following topics relating to drivers and barriers of mHealth adoption:Factors related to mHealth characteristicsIndividual and professional factorsHuman environment factorsOrganizational environment factors: internal and external, and we were also inspired by the adoption factors identified in the systematic review by Gagnon and colleagues [Open-ended questions for the focus group were designed following previous work of our team . This brlleagues .For the third and the fourth focus group, the interviews with patients and ED specialists were completed 3 months after the study start date. When designing the questions, we were inspired by a multidimensional evaluation framework, called Model for ASessment of mHealth (MASH), previously described and implemented by a European project in which our team also participated, termed DoChange. The MASH model was constructed on the basis of the evaluation framework of the Model for ASsessment of Telemedicine methodology . We follDomain 3 . Effectiveness.To what extent did patients’ ED symptoms and quality of life improve when treated with TCApp as a complement to face-to-face treatment?Domain 4 . User experiences.Which were professionals’/patients’ needs in implementing the TCApp services in daily practice? Were users satisfied with the app/usability of the services offered by the TCApp? Which were the most important facilitators in implementing the TCApp in routine practice? Which were the most important barriers in implementing the TCApp in routine practice?Domain 5 . Economic aspects.Are you willing to pay for use of the TCApp from now on in your routine practice?Domain 6 . Organizational aspects.Participants had to think of a future ideal scenario in which decisions at their institution were made by them and describe the specific proposals they would make to their organization about a new service that implements, in an ideal way, the TCApp together with other new technologies.Domain 7 . Sociocultural aspects.Have any issues arisen regarding cultural accessibility (considering the different languages spoken by the users) and socioeconomic accessibility ?First, for the focus groups with health care providers and mHealth experts, a formal invitation was sent to both institutions  by the principal investigator of the study, FL. Both focus groups, of 1 hour each, were conducted by FL at the headquarters of ACES and at the UOC, and they were audio recorded with permission. A second researcher, CF, was present during these events and transcribed the group discussions verbatim.The study procedure of the mHealth intervention was described in detail elsewhere ; therefoPatient information, including age, sex, diagnosis, illness duration, body mass index (BMI), degree of education, and employment status, was retrieved from the medical history of each patient, which was provided to the research team by the ED specialists responsible for each participating center.System Usability Scale (SUS) [le (SUS)  is a 10-le (SUS) .Client Satisfaction Questionnaire (CSQ-8) [ (CSQ-8)  is an 8- (CSQ-8) .Sociodemographic characteristics, including age, sex, employment status, and specialty, were collected through an introductory self-report questionnaire.Thematic content analysis was used to analyze the qualitative data from the 4 focus group discussions. . First, The analyses of all descriptive data regarding participants’ sociodemographic and clinical characteristics, SUS, and CSQ-8 were carried out using SPSS 20.0 (SPSS Inc) . CredibiIn total, 4 domains and 16 key themes were identified and were then classified as barriers to or drivers for mHealth adoption. Most of these themes, 11 (69%), were classified by professionals as barriers, and only 5 (31%) were perceived as facilitators for mHealth adoption. The complete list of domains and themes, together with professionals’ most representative examples recounted during the focus groups, is shown in Organizational Environment domain. First, the lack of time and workload were frequently mentioned by professionals as barriers . Second, the lack of a strategic plan by leaders in health institutions to implement mHealth was also reported . Third, the lack of budget and direct interest at a legislative or political level supporting mHealth implementation was another common barrier . Finally, the lack of training of professionals  and the lack of support by the information technology team in health institutions  were other main themes identified as barriers that belonged to the Organizational Environment domain, but they were less frequently mentioned by participants. Age and risk-benefit balance were identified as barriers in the Individual domain, and these generated diverse and sometimes contradictory opinions by professionals. For example, some of these professionals believed that a digital divide was a common problem found in health care institutions:Regarding barriers, the most recurrent themes pertained to the Young health professionals have more digital minds...Instead, for many professionals who are older in age, the handling of the Internet and other ICTs may seem complex and they prefer to do things in the traditional manner -paper-and-pencil methodsHowever, others thought the opposite:In my institution, older professionals do not have more negative attitudes towards ICTs than younger ones, neither do they perceive differently their utility and usefulness“The value of face-to-face contact with our patients is inherent to all of us...sometimes we are afraid of losing this when introducing a new technology”), although others did not agree. The individual resistance to implement mHealth services as a health professional was also seen as a barrier to the adoption of mHealth. In fact, many participants declared that they were resistant to change because of their fear of the unknown. The insufficient interaction among patient, health professional, and information technology team was another barrier to mHealth adoption for the domain of External factors relating to the human environment. For example, a health care provider reported the following:In relation to the risk-benefit balance, some professionals believed that the fear of losing face-to-face contact with patients was a reality difficult to overcome  health care system that is very restrictive with sharing patients’ information on the Web using mHealth tools. Regarding drivers for mHealth adoption, the importance of professionals’ training first and the subsequent implementation of an mHealth-related strategic plan by leaders were the most recurrent themes pertaining to the Organizational Environment domain. For example, most professionals highlighted the importance of a continuous training offered to them by their institution so that they could become more knowledgeable and empowered before using an mHealth tool in their regular visits. Next, the importance of having leaders who believe in mHealth innovations was very frequently mentioned as a driver for adoption .Finally, security and privacy concerns, as well as design and technical issues, all of which related to “If I personally had to implement a mHealth tool as complementary to my face-to-face visits and charge each visit 2 euros more, I would think about it”) was an individual driver that generated contradictory opinions, as it could be counterproductive at times . Finally, the importance of submitting an app to quality control to get proper homologation before implementation in clinical practice was another theme relating to mHealth characteristics, which was frequently mentioned as a driver.Moreover, the option to offer economic incentives to professionals , whereas the mean score for the SUS scale was 81.56 . This indicated moderate usability of and high satisfaction of patients with the tool. usability of the TCApp, all participants (9/9) perceived that the app was easy to use and very practical. Participants were comfortable with the app, and none of them neither reported discomfort with the technology nor were they faced with technical problems. At the start of the intervention, some assistance was required by all participants to ensure that the app was working properly. Regarding usefulness, most participants (8/9) indicated that the app was very useful for the time between regular visits to health care professionals, and they asserted that they would recommend the tool to a friend faced with a similar problem. Most participants (8/9) agreed that keeping food records, which they used to track manually in their standard CBT, generally posed a source of discomfort, as they could be lost or forgotten at home, and most participants agreed that a change to Web-based food records was more comfortable and easy to fill in on a daily basis. A total of 2 participants voiced negative comments concerning the usefulness of the TCApp, which were related to the fact that quantification of ED symptoms through presence or absence option was not always useful for them. Instead, more free text options could have given patients the opportunity to describe the context around symptoms and their function more comprehensively. Several problems regarding the design of the app were reported by patients (9/9), including problems with word limit, a 24-hour time limit , or concerns regarding the design of the Web-based chat with the therapist, which used a rather awkward and unhelpful format . Regarding the appropriateness of the TCApp’s content, opinions among participants varied as well. Positive comments expressed by 6 patients included the ability of the app to make patients gain a better understanding of their problematic behaviors. In addition, the app was described as a good companion that helped patients to better manage their negative feelings. A patient specifically stated the following:As regards patients’ perceptions about It is a good company during your treatment process, especially when you feel lonely or with the urge to carry out a problematic behavior. The option to share your thoughts, emotions or actions, and be sure that your therapist is going to read them, relieves stress and guiltprivacy and anonymity concerns: Although patients were expecting to be monitored on the Web by the same therapist who was following them in their regular face-to-face visits, this was not always possible in the participating hospitals because of the work burden with which therapists were faced. As a consequence, messages were often read and answered by another therapist, who had no knowledge of the patient’s clinical history. This was reason for some concern with certain patients regarding the privacy of their personal information and their expectation and desire to feel more secure when using the app. The second issue concerned the limited and not-personalized patient-therapist interaction. All 3 patients indicated that therapists at times did not answer their Web-based messages immediately and that when they did, answers were rather impersonal. As a result, these patients perceived a lack of guidance in their treatment when using the chat option. Finally, another negative comment expressed by 1 patient was related to organizational factors; specifically, it was related to the strict instructions given by the research team to follow the study design.On the other hand, negative comments (3 out of 9 patients) included the inability of the app to satisfy treatment needs of day-hospital patients and outpatients . A therapist also proposed to validate a protocol of correct use of the app according to a patient’s profile, specifying the frequency of use of the app and possible functionalities relevant for a specific group of patients. Second, the only problem with the design of the platform concerned the difficulty expressed by therapists to follow several patients at the same time, given that a new screen was opened for each patient. Third, most of the therapists (6/8) stated that they could not always comply with the study protocol (monitor each patient on the Web at least once a week) because of their workload or having to attend to emergencies and other priorities. A total of 3 out of 8 therapists stated that the app was not interactive enough and that the use of each functionality  depended on patients’ self-determination and willingness to use the tool. A therapist commented on this saying the following:The most frequently reported disadvantages of the app concerned (1) the lack of personalization of the app, (2) some problems with the design of the platform, and (3) the lack of time to regularly monitor patients because of workload. First, regarding the The use of the app depended exclusively on each patient. For the most resistant and difficult patients, we had to follow-up a lot and remind them during sessions that they had to use the app regularly.inappropriateness of the motivational components employed by the TCApp  for patients with EDs, especially those with a restrictive profile, was mentioned by 2 therapists. One of them asserted the following:Contradictory opinions existed regarding whether the app would be more easily implemented in private institutions or public institutions. The fear of replacing face-to-face sessions by the chat option, which is of course less costly, was expressed by a therapist working in the private sector. Another therapist from a public hospital said that the implementation of the app should be easier in private practice, as there are more economic recourses available for the integration of a complementary service that includes the TCApp. The I would modify all their content...Many patients with AN profile are stressed when receiving prizes; they want to be first in the list, corresponding to their high levels of perfectionism and competitiveness. It can be counterproductive for these patients.Finally, other disadvantages related to mHealth characteristics and the organizational and human environment shown in Personalize the app according to patients’ needs and specific characteristics.Offer retrospective record keeping of the problematic behavior, in conjunction with real-time records. For example, a therapist commented on this saying the following:Some of my patients would have preferred it if they had had the opportunity to register a problematic behavior  the day after its occurrence. Many of the patients from the control group that normally used paper records filled the record the day after the event or when they were feeling calmer or more distanced from the problematic behavior.Adapt the TCApp to nutritionists’ needs. A therapist said the following:I think the use of the app could be more appropriate for nutritionists and not for psychologists...an additional functionality assessing the caloric content of the meal records may be an option.Add psychoeducational material and relaxation or mindfulness techniques in the form of modules that would be activated according to patients’ profile and evolution. Improve the gamified environment to make the app more interactive and motivating, for example, by including vodcasts with motivational messages by recovered patients or messages by therapists, personalized reminders, objectives, or coping strategies close to each problematic behavior.Emerging literature on the field has shown that app-based treatment suggests promising results for enhancing the quality of mental health provision and treatment outcomes, whereas, at the same time, it can improve engagement with respect to different mental disorders, including depression, anxiety, stress, substance use, and symptoms of EDs ,44. DespThe results showed that in the focus groups with health care providers and mHealth experts, most of the recurrent themes were classified as barriers, less so as facilitators, for mHealth adoption. This indicates that most professionals considered mHealth techniques as difficult to obtain and use. In addition, most barriers were attributed to external factors relating to the human or organizational environment rather than internal factors relating to individual, personal obstacles. More specifically, most health professionals reported a lack of time because of workload, a lack of strategic plan by leaders, lack of budget, and direct interest at a legislative or political level to support the implementation of mHealth. Other external barriers, which were less frequently reported, concerned the lack of specific ICT training for health professionals and the lack of communication and support among patients, health professionals, and information technology teams. In addition, individual factors, including the age-related digital divide and the fear of losing face-to-face contact with patients, generated contradictory opinions among professionals. These findings are in line with previous studies ,13, suggThe results of the mHealth intervention study indicate that the TCApp was considered easy to use and useful, although patients and ED specialists monitoring patients on the Web reported different problems in adoption. Patients valued as highly positive the Web-based food records and the role these played in helping them gain a better understanding of their symptoms. In contrast, the problems reported most frequently concerned the lack of personalization of the app according to their needs , as well as the overwhelming quantification of symptoms through the app  instead of a more qualitative evaluation of them on the basis of cognitive-behavioral chain analyses through Web-based free-text options. Similarly, a previous qualitative study with focus groups by Juarascio and colleagues  for patiIn turn, ED specialists in this study highly appreciated the Web-based environment that was offered through the TCApp, especially the Web-based chat option, the usefulness of the tool outside and inside the therapeutic context, its immediacy, and the possibility to prepare for visits in advance when they felt this to be necessary. This partly runs counter to results found in the short message service text messaging intervention by Mazzeo and colleagues , targetiBoth patients and health professionals of the mHealth intervention study experienced problems in complying with the study protocol at times. One of the reasons for this was the fact that patients, mostly those who were already receiving a demanding treatment at their hospital , felt overloaded with the Web-based tasks that they had to perform on a daily basis. Another problem was that ED specialists, mostly those working in public hospitals, because of their workload or having to attend to emergencies and other priorities, tended to not give immediate responses to their patients’ Web-based messages. In fact, such responses were sometimes provided by other professionals who were available at that particular point in time, raising privacy and confidentiality issues with their patients. This somewhat contradicts the results found in the systematic review by Dowling and Rickwood  regardinOne of the main strengths of this study is that we investigated how both health professionals and patients experience mHealth techniques, as well as what they consider important factors that need improving to use such techniques more frequently. Second, we focused this study on a heterogeneous sample of health care providers and mHealth experts who deal with health-related problems on a daily basis and who could benefit from mHealth techniques extensively. Selecting a group of professionals with such diverse backgrounds, we were able to obtain more generic views of mHealth adoption issues. In addition, by focusing on a specific mental health problem, ED, we were able to examine attitudes and ramifications of both patients and ED specialists regarding the implementation of a specific mHealth tool in their daily practice. As a result, we were able to gather a broad view of mHealth adoption issues among public and private health institutions in Spain for this type of condition.The first limitation of this study is that there seemed to be a notable homogeneity among our sample of patients in terms of clinical representation, age, and gender. In fact, only female outpatients with AN decided to participate in the focus group, all of whom were adolescents and presented good adherence to face-to-face treatment . The impact of the exclusively AN sample on our findings may be that this group of patients, characterized by rigidity, compulsivity, and focus on detail , may finIn terms of future recommendations, all organizational, technological, and individual levels mentioned appear important for a correct mHealth implementation in clinical practice. For the individual aspect, hospitals may need to provide incentives and continuous training to encourage professionals to integrate mHealth techniques when carrying out their regular tasks. If professionals feel more empowered, skilled, and supported by their institution in adopting new technologies, they should be more willing to make use of the opportunity to try new innovations.At an organizational level, there is a need for a strategic plan that establishes a common framework for evaluating mobile mental health apps, which allows clinicians and patients  to identify and choose among high quality and safe mobile phone apps in accordance with their needs. Although a great number of mental health apps are readily available, and there seems to be a major potential for such apps in psychiatric assessment and interventions ,32,52,53As regards mHealth characteristics, ED specialists recommended that the TCapp should be better personalized according to a patient’s clinical profile and that its gamified environment should be improved by integrating more useful motivational and interactive components. It was suggested that doing so would lead to improvements in engagement for the most difficult patients. A relapse prevention module should also be integrated into the TCApp for almost recovered patients who generally receive less regular visits to the hospital and who could benefit from some functionalities of the app . Other ideas for future improvement included the possibility to adapt the TCApp to nutritionists’ needs, add psychoeducational material, add relaxation or mindfulness techniques, and add a group chat functionality with a therapist who coordinates the group conversation. Last but not least, taking into account that family therapy for children and young people is the gold-standard treatment for AN , a versiIn sum, this study shows that health professionals and patients foresee some issues that need to be resolved to increase adoption and usage of mHealth techniques in the near future. Owing to the possible benefits and cost-saving opportunities of mHealth techniques in health care , possibi