Although human resources for health (HRH) represent a critical element for health systems, many countries still face acute HRH challenges. These challenges are compounded in conflict-affected settings where health needs are exacerbated and the health workforce is often decimated. A body of research has explored the issues of recruitment of health workers, but the literature is still scarce, in particular with reference to conflict-affected states. This study adds to that literature by exploring, from a central-level perspective, how the HRH recruitment policies changed in Timor-Leste (1999–2018), the drivers of change and their contribution to rebuilding an appropriate health workforce after conflict.This research adopts a retrospective, qualitative case study design based on 76 documents and 20 key informant interviews, covering a period of almost 20 years. Policy analysis, with elements of political economy analysis was conducted to explore the influence of actors and structural elements.Our findings describe the main phases of HRH policy-making during the post-conflict period and explore how the main drivers of this trajectory shaped policy-making processes and outcomes. While initially the influence of international actors was prominent, the number and relevance of national actors, and resulting influence, later increased as aid dependency diminished. However, this created a fragmented institutional landscape with diverging agendas and lack of inter-sectoral coordination, to the detriment of the long-term strategic development of the health workforce and the health sector.The study provides critical insights to improve understanding of HRH policy development and effective practices in a post-conflict setting but also looking at the longer term evolution. An issue that emerges across the HRH policy-making phases is the difficulty of reconciling the technocratic with the social, cultural and political concerns. Additionally, while this study illuminates processes and dynamics at central level, further research is needed from the decentralised perspective on aspects, such as deployment, motivation and career paths, which are under-regulated at central level.The online version of this article (10.1186/s12960-018-0325-5) contains supplementary material, which is available to authorized users. Human resources for health (HRH) represent a critical element for the functioning of health systems. Poor availability and management of human resources have been recognised as key health system barriers, and despite the efforts, many low-income countries continue to face acute HRH challenges , 2. ThesThis research adds to that literature by focusing in particular on the role that recruitment policies and practices play in rebuilding an appropriate health workforce after conflict and following the trajectory and patterns over the subsequent years. Our case study was conducted in Timor-Leste starting from the immediate post-conflict period up to 2018 . Additionally, key informants were asked to suggest relevant documentation, and the contextual knowledge of the team in country also allowed retrieving further documents. In total, 76 documents were reviewed  were recorded, transcribed and translated into English (where needed). Verbatim transcripts were manually analysed, using a series of pre-defined descriptive themes Faith-based and non-governmental organisations (NGOs) were the first to be able to provide basic health services , 34, andThe administrators took the line that it wasn’t just matter of putting people back into the positions they were in and paying them, but it was creating the whole civil service. […] They were very much trying to get a sense of unity [through the civil service]. While much of the technical and financial support for the health sector (including HRH) was provided by external partners , the TimOur leaders wanted to build a public administration that was not a replica of the previous system. So, when we defined the regulations to form our public service, we did not look at the Indonesian model which was disproportionate. We started from zero. This overhaul was to be achieved in three ways. Firstly, it was imperative to rationalise the number of health workers  employed in the public sector which was inflated for political and patronage reasons under the Indonesian occupation. Secondly, there was a desire to reduce or eliminate corruption, collusion and nepotism  that was a key feature of the previous system and introduce a meritocratic approach. Finally, it was important to create a health workforce loyal to the new country, excluding those who had supported the pro-Indonesia militia during the independence struggle (KIIs). The aim was to ensure equitable access to quality service for the entire population of the newly formed state.The first criteria was that the person had to be trained as a nurse or healthcare professional. The second, we had to look for people that were from that district to facilitate them going there […]. Then the third criteria that we considered was that it had to be people that in 1999 didn’t run away to Indonesia. These people are a priority. (MoH KI)These objectives laid the foundation of the first civil service recruitment which started in mid-2001 (UNTAET Regulation 2000/03). The final estimate of the health staff needed was of 1 242 as agreed between UNTAET, MoH and the Civil Service and Public Employment Office (CISPE). Informants reported that this number, about 47% of the 2 632 in place during the occupation, was mainly dictated by the budget available, which was limited and dependant on international partners . Fifty jThe Bishop came down to calm the situation at the hospital and to listen to the demands of the demonstrators. They were saying that those who had fought for independence had not passed the recruitment. So, I went with [xxx] and we modified the recruitment. Those who had stayed would have work first, and those who went to Indonesia, they have to work last. (MoH KI)However, a number of issues hampered the recruitment process. The shortage of doctors remained a challenge and terms and conditions provided by NGOs were much more favourable so that many stayed in that sector. Additionally, strikes and protests broke out due to accusations of favouritism and mismanagement. One informant recalled:In 2001, 724 workers were recruited Table . The remRecruitment was reported to be slow and haphazard leading to poor morale and loss of trust in the administration by those involved in the process . Their aThe idea of requesting Cuban support to address staff shortages had been discussed since 2001 . In FebrInstead of recruiting, the MoH is appointing through training. The use of subsidised training effectively shifted the focus from post-graduation recruitment procedures to pre-service education scholarship awards, as those trained in Cuba were expected to return to serve in Timor-Leste and were automatically absorbed in the public health sector.The selection of students to access Cuban medical training was undertaken initially by the MoH, based on academic results in secondary school, a written exam, an interview and a physical examination (KIIs). Gender balance was also sought in the selection, and quotas were introduced based on the geographical origin of the candidates,By mid-2018, the Cuban-supported programme had graduated 934 Timorese medical doctors (KII). Based on the MoH database, this rapid scale-up of the medical workforce has increased the density of doctors per population from 0.03 to 0.71 per 1 000 in 2000 and 2017 respectively, among the highest in South-East Asia From 2011, the responsibility for selecting students into higher education for all health professions was moved to the Ministry of Education (MoEd) (KII). Key informants highlighted the alarming absence of functioning mechanisms for inter-sectoral coordination, which not only left room for discretion and abuse in decision-making, but also had important consequences for the development of the health workforce. Indeed, the fact that decisions about access to training were moved outside the MoH and some groups were exempted from the standard selection procedures had (and continues to have) critical consequences in terms of quality as well as of numbers and profiles of the future health workforce and may determine a mismatch between intake and needs which the MoH has been left to deal with.Universidade Nacional Timor Lorosa’e—UNTL), but also the Ministry of Finance, the Public Service Commission (PSC), the Human Capital Development Fund (HCDF) and, more recently with the attempt to decentralise the deployment process, the Directors of Municipalities.The tensions between different national institutions also reveal that, from the aftermath of the independence, the decision-making arena has become more crowded. As a consequence, a number of emerging competing agendas and interests made coordination and alignment more difficult. New actors involved in HRH recruitment and deployment practices included not only the MoH, the MoEd and National University of Timor-Leste As the number of actors involved in HRH decision-making increased, so did the official legislation applicable to the civil service in general and to health workers specifically Table . Importapolitika bolu malu). In relation to recruitment for the MoH, we undergo procedures that are not necessarily based upon the principles of meritocracy. […] We observe the issue of corruption, collusion and nepotism, the family approach. Why this is happening? Because, apart from being a post-conflict country, there are also demands for livelihoods. At the same time, we have significant gaps in regulations and procedures that define the recruitment process and therefore it was still dominated by a situation called ‘calling each other’ In this context, the absorption into the public sector of the growing number of health workers became a pressing problem. Although estimates vary (from 200 to 600), a high proportion of the pool of qualified doctors and other professionals is currently unemployed, due to lack of funds from the Ministry of Finance to recruit them into the civil service. Worryingly, pressure will be mounting over the next few years as the sustained production of health workers will continue and even increased, based on politically pressured student intake. Indeed, beyond the privileges accorded to veterans’ families described above, the introduction in 2016 of a ‘special regime’ to access higher education, following a simpler selection process without technical tests, for families of military and police officers, diplomats, members of Parliament, journalists, elite athletes and students from international secondary schools  contriburegimen de internato) with a standard stipend regardless of professional level of $200  and $150 (in urban locations) for a period of 6 months to be extended if the need persists and the performance of the intern is satisfactory. However, as KIs said, the success of this programme in reducing the tensions is yet to be seen, and there is a widespread perception that the government has been and continues to waste money on the training of medical doctors rather than using data and evidence on the real needs.As an interim measure to address the absorption issue, a dispatch from the Minister of Health (07/2018/I/MS) was issued in January 2018 to recruit 320 recently graduated health workers as interns The contrast of the current situation with the immediate post-conflict phase could not be starker. As one respondent put it:Our analysis has some limitations. First, the long period of time covered, spanning over almost 20 years, created challenges during data collection, both in terms of locating and accessing documents that may have been lost, as well as contacting key informants, in particular international actors who have left Timor-Leste. Data were also difficult to retrieve due to the weak information systems. Additionally, many interviewees struggled with recall bias. However, the fact that respondents were open about it and distinguished between clear and only vague memories helped us make sense of their accounts. In a sense, even the mental selection between remembered/forgotten could be interpreted as an indicator of the key, most debated and contested areas of decision-making. In line with this, in order to elicit views on issues clearly remembered and to reduce recall bias, the topic guide we developed focused on the most relevant changes or challenges which respondents were asked to reflect on. We also carefully applied triangulation between different key informants as well as with documents and data to ensure the accuracy of the information and the relevance of the analysis.Throughout the analysis, we have been explicitly reflective on our positionality with respect to the study subject . Some auThe study findings provide critical insights to enhance our understanding of HRH policy development from a policy and political economy perspective, in a post-conflict setting, but also following the developments over the longer period. The analysis allows the identification of the main phases of the policy trajectory during which different drivers played a significant role in shaping policy outcomes. In terms of actors, there was a shift over time as the relevance of external players faded in favour of that of internal actors and institutions. As in other settings during the immediate post-conflict phase , 49–51, Agency and structure elements and their interplay influenced the policy processes and outcomes. Initially, the focus was on health workforce recruitment as is often the case , which wIt appears that the recruitment system created in the aftermath of independence did consider both technical and political aspects and, perhaps because of this, was generally effective and survived over time. The relative success of this first round of HRH reforms could also be linked to specific individuals, their skills and leadership, both among external and national actors. Local elites were quick to organise themselves with enthusiasm and focus , also beLater, while the technical foundations of the recruitment system remained in place and were actually strengthened by institutions such as the PSC, the shift to ‘appointment through training’, due to the Cuban-supported training and to the virtually automatic absorption of newly graduated staff, meant a shift of power from the MoH to new actors  with diverging interests not related to the long-term needs of the health sector, and increased the possibility of rule-bypassing, discretion and patronage.The tension between competing agendas may have been initially reduced or resolved thanks to the fiscal expansion and to the presence of the CMB and their ‘substitution’ role , 57. HowOur research aimed to provide a long retrospective account of the development of the systems to recruit health workers in post-conflict Timor-Leste. In this study, we explored the policies in place at central level, the main phases and key drivers of their evolution. Our findings point to patterns and elements both of the agency and structure in shaping the policy-making processes and outcomes.While the influence of international actors was a prominent feature of the initial phase after the conflict, in Timor-Leste, there was an important change as national actors increased in numbers and relevance later on. This shift led to a fragmented institutional landscape with diverging agendas and lack of inter-sectoral coordination, to the detriment of the long-term strategic development of the health workforce and the health sector. Furthermore, a key issue that cuts across all phases is the difficulty in reconciling the technocratic elements of the reforms with the social, cultural and political aspects. Finally, the research component discussed here looks exclusively at processes and dynamics at central level, and finds that they have focused on regulating HRH recruitment and production, which are the most visible aspects for those operating centrally. Further research on issues such as deployment and transfer, motivation, promotions and career paths  as well as on how implementation practices differ, modify or bypass central regulations, from the perspective of decentralised actors will be important to shed further light on the topic and complement the central-level perspective.Additional file 1:Summary of key bibliometric characteristics of documents reviewed (PDF 279 kb)Additional file 2:Standard topic guide for key informant interviews (PDF 393 kb)Additional file 3:Data extraction template and coding framework for the documentary analysis (PDF 274 kb)


Recognizing the biopsychosocial dimensions of chronic medical conditions in children and preparing them to adapt to medical processes is one of the most significant issues in the field of health psychology. The aim of this study was to measure heart rate variability and cognitive abilities based on attachment style in children with chronic medical conditions. To this end, 45 children aged 12–15 years who had received a diagnosis of a chronic medical disease and were matched with the inclusion/exclusion criteria, were entered the study using available sampling method. These children were assigned to three groups of secure, avoidance and anxiety attachment style based on the Collins and Reid Attachment Scale. These groups had been demographically homogeneous. Then heart rate variability and cognitive abilities were measured. One-way ANOVA results showed a significant difference between the three groups in the heart rate variability and cognitive abilities. Post hoc test showed that children with secure attachment style had higher efficiency in heart rate variability and cognitive abilities. These results indicate that attachment style is one of the factors influencing the health status of children with chronic medical illness. These findings highlight the importance of paying attention to psychological factors, especially attachment and its role in the health status of children with chronic medical conditions. The role of psychological factors in this adjustment is of interest to health psychologists and attachment style is one of these psychological factors7. It has been specifically addressed in this research.With the development of theoretical foundations in health psychology, the focus of many studies is on the areas of child health, including the recognition of the psychosocial dimensions of chronic medical conditions. Having chronic disease and its long-term treatment process, along with physical problems, exposes the patient child and his family to high social and psychosocial damages8 considers attachment to be a stable emotional bond that one person forms with another. He emphasizes the necessary of the intimate, warm and continuous relationship between the mother (or her permanent substitute) and the child for the child’s mental health. Recent studies which have focused on attachment in the context of physical illness show the relationship between attachment and medical illness9 and the effect of medical illness on attachment characteristics of individuals10. David, Black, Coster and Paige11 study showed that psychological risk factors such as attachment can predict the growth of chronic disease and its severity in adolescents more than in older ones. And in the studies using psychological interventions in health and medical situations, the significant effects of attachment factor have been confirmed12.John Bowlby13. Studies have shown that anxious people have lower HRV and lower HRV is associated with low psychophysiological coordination, poorer prognosis and increased risk of fatal heart deaths6. Psychological interventions can improve the psychophysiological functions of patients and increase their physical and mental health14. In connection with the attachment theory, there is also evidence that the secure attachment between the child and the caregiver improves the psychophysiological coordination of the child and reduces painful cardiovascular activity15.The stressors of the chronic diseases, challenge individuals and affect psychophysiological responses such as secure responses and cardiovascular functions too. In this regard, heart rate variability (HRV) is an important indicator of anxiety, emotional regulation and health16 showed that chronic stress through the activity of the Hypothalamic-Pituitary-Adrenaline (HPA) axis reduces the decision-making process and damages the hippocampal and amygdale areas, leading to decreased activity in the forehead and consequent weakness in cognitive functions. Accordingly, as the main goal of this study, it can be assumed that attachment quality, along with determining the quality of response to stressful conditions and the individual neuronal activities, also affect their cognitive abilities17. The cognitive ability of humans has evolved due to the need to solve the ecological problems and to guide complex social environments19. Stress is one of the important factors leading to cognitive impairment. People who experience high levels of stress often cannot focus on a specific task, and with more cortisol levels, more cognitive impairment occurs20. On the other hand, the early experiences during the life contribute to the improvement of the process and the quality of the cognitive abilities. Studies have shown that there is a correlation between childhood injuries such as physical disease, non-primary caregiving and neglect with smaller hippocampal volume and lower cognitive ability during adolescence21 and these children are more vulnerable to psychological damage because of the weakness in the ability to solve the problem22.On the other hand, the Radleya, Morilakb, Viauc and Campeaud’s study22. Considering this important issue, the present study, with emphasis on the importance of extending psychological assessments in the field of pediatric health psychology, intends to study the effect of secure, avoidant and anxious attachment styles on cognitive abilities and heart rate variability (HRV) in children with a chronic medical illness. Therefore the main purpose of this study was to identify the differences of HRV and cognitive abilities according to attachment styles in children with chronic medical conditions.Considering the high vulnerability of children with chronic medical illness during their evolution, attention to attachment style in addition to medical treatment is important in relation to their physical, cognitive and psychological well-beingDescriptive Characteristics of the subscales of HRV are presented in Table In order to evaluate the research hypotheses, the subscales parameters of HRV, including resting heartbeat and respiration rate were evaluated in three groups of children with secure, avoidant and anxious attachment styles. One-way analysis of variance (ANOVA) was used to analyze the data. To this end, the scores of these subscales as dependent variables and group variables (in three levels) as independent variables were entered into the one-way ANOVA.The ANOVA statistical assumptions for all dependent and independent variables have been implemented. The Kolmogorov-Smirnov test was used to check the distribution of the normality and the Leven test was used to test the consistency of variances.2,42 = 44.48, P = 0.000) and respiration rate . Accordingly, at least two groups should have a different mean in the heartbeat and respiration rate. To investigate this, Tukey’s post hoc test was used.The results of the ANOVA in Table As shown in Table Further, descriptive statistics derived from the subscales of cognitive abilities of children in the three groups of secure, avoidant and anxious are given in Table To examine the hypotheses related to cognitive abilities, scales of cognitive abilities including sensory-motor skill , visual information processing , working memory  and effort-error learning  were evaluated using one-way ANOVA. In this regard, after ensuring that the ANOVA assumptions were followed, the scores of cognitive abilities subscales were entered as dependent variable and the scores of attachment styles were entered as independent variable.2,42 = 0.967, P = 0.388). However, in the case of the accuracy subscale, the difference between secure, avoidant and anxious attachment groups was significant at the level of 0.05 . About the visual information processing scale, the difference between secure, avoidant and anxious attachment groups in the subscales of objective sensitivity , response inhibition  and continuous attention  were significant. Active memory , short-term memory  and strategy selection , which are the subscales of the working memory scale, were significantly different in the secure, avoidant and anxious attachment groups. In the subscales related to effort-error learning, the difference between the secure, avoidant and anxious attachment groups in quick learning  and learning-memory  were significant at 0.05.As the one-way ANOVA results Table  show, inThe results of the post hoc test Table  show thaAbout the visual information processing scale, there was a significant difference between the secure group and the avoidant and anxious groups in objective sensitivity subscale, and also between the avoidant and the anxious group; The means differences indicate that in this subscale, the secure group had the best function, the avoidant group had a better function than the anxious group and the anxious group had lower efficiency than the other two groups. There is also a significant difference between the secure group and the other two groups in the response inhibition subscale, but there is no significant difference between the avoidant and the anxious groups. Based on the difference in the means, in this subscale, the secure group responded better than the other two groups and the avoidant group was better than the anxious group and the anxious group had the lowest response inhibition. In the continuous attention subscale, there was a significant difference between the secure and anxious groups and also between the anxious and avoidant groups but there was no significant difference between the secure and avoidant groups. Regarding the difference between the mean values, the secure group was more concentrate than the other two groups and the anxious group had the lowest attention.In working memory scale, the Tukey test showed that the secure group had the highest performance, the avoidant group had better efficiency compared to the anxious group and the anxious group had the lowest performance in the active memory subscale. In short-term memory subscale the secure group had the best performance, the anxious group had a higher performance than the avoidant group and the weakest function was for the avoidant group. And in the strategy selection subscale there is a significant difference between the secure group and the anxious group as well as the avoidant group with the anxious group. The secure group has the highest performance in this subscale and the anxious group has the lowest performance.Finally about the effort-error learning scale, in both quick learning and learning-memory subscales, the secure group has a significant difference with the other two groups and the other two groups do not have significant differences. The secure group performed better in these two subscales than the other two groups. The avoidant group had a better mean in comparison with anxious group.In the present study, assessment of the attachment styles, heart rate variability and cognitive abilities in a sample of children with chronic medical condition showed that there is a significant relationship between attachment styles and cardiac and cognitive functions. It can be observed that the children with secure attachment have more normal heartbeat than the avoidant and anxious children; about the respiration rate there were no significant difference between secure and avoidant groups, but the anxious group had a lower efficiency in comparison with the secure and avoidant groups. In cognitive abilities, the results showed that the children with secure attachment have better function in visual information processing, working memory and effort-error learning; but in accuracy subscale of the sensory-motor skill, avoidant group has a better function than the secure and anxious groups.5. In another study comparing children with secure and unsecure attachment style, secure children showed higher self-esteem in stressful situations, insist on solving the problem, have initiative and perseverance, use more efficient strategies and thus have better physical and mental health23. Research done by Morley and Moran24 has also confirmed insecurity attachment as a vulnerability factor. In this research, insecure attachment styles are associated with several variables such as anger and hostility, anxiety, depression and behavioral disorders. These indicate the undeniable importance of insecure attachment as a major contributor to biopsychosocial vulnerability in children and adolescents.Along with current study’s finding, dealing with stressors such as illness, individuals with a secure attachment style fill more security, show better cognitive abilities and are more successful in educational, occupational and interpersonal functions25  stressors such as disease, activate the attachment style and its associated cognitive-behavioral pattern as well as the neurophysiological responses which can determine the psychophysical health. Therefore, changing the attachment quality will be accompanied by changes in the pattern of individual’s neurophysiological responses and subsequent physical health, as well as changes in cognitive-behavioral patterns and subsequent psychological health. The present study assumes that secure attachment style followed by higher efficiency in HRV and cognitive abilities, because of the better cognitive-behavioral patterns and neuropsychological responses. Anxious children had lower concentration and accuracy but quicker promptness and higher heartbeat than avoidant children, which could be because of their high stress.Some theoretical studies have identified ways to describe this vulnerability. In this context, based on the opinion of Anderson and Hinset al.20 showed that children with positive mental representations of parents had better function in memory tests. In other words, insecure attachment style has a negative effect on memory performance. These people do not really want to remember the painful events and therefore are more likely to approve false suggestions. It can remind the results of the present study in which secure children had higher performance in memory subscales compared to insecure children. Canterberry and Gillath27 assumed that these children are less able to hold the information in their memory for a long time. Maltais, Duchesne, Ratelle and Feng’s study28 also found a positive meaningful relationship between learning abilities and success in education with secure attachment. Secure children also had better self-esteem and emotion regulation strategies, and fewer symptoms of anxiety. The present study emphasized the same results in children with chronic medical condition. On the other hand, avoidant children have intensive self-dependency and tend to deny and suppress their negative emotions to deal with high stress; and anxious children have lower concentration, memory and learning performance than children with secure attachment style due to their high stress and negative emotions.On the other side, studies have shown that children’s memory is affected by inconvenient experiences and the attachment style has a mediating role in this relationship. Chae and 29 emphasizes the importance of paying attention to attachment factor in medical treatment plans.Generally, the present study’s view is that the attachment style affects the patterns of HRV and cognitive abilities in children with medical disease, and these patterns, on the other side, can affect quality of the health conditions. Along with this view, mothers of secure children, in this study, indicated that their children are in harmony with the medical staff and their treatment process goes well, while the mothers of insecure children were always afraid that their child did not have enough co-operation to their treatment, they would have been very upset and even in many cases their illness recurs, resulting in hospitalization. So the present study supports the value and effectiveness of the attachment style in the physical and cognitive functions of children diagnosed with chronic medical conditions. This, along with other studiesDespite the efforts to control the probable factors, the design was not able to form homogeneous groups with a specific disease, which could have uncontrollable effects on the results of the design. Although attempts were made to reconcile all three groups according to the inclusion/exclusion criteria and matched them according to the demographic information and types of the disease, it is suggested that future studies form more homogeneous groups and assess the role of different factors such as age, sex and type of disease as moderating variables. This study also was a case-control study and the results showed the relationships between attachment, HRV and cognitive factors just among children with medical conditions, rather than comparing with health children. It is suggested for the future studies to compare groups of health and ill children. Consequently, Structural Equation Model would be a potential good method to examine the associations among these multiple factors, which this study could not arrange because of the small sample size limitations. Few participants were among the constraints of this study. It should be noted that, due to limited access to patients, the present study was conducted on a limited sample group, but it is suggested that subsequent studies conduct with more number of participants to increase the validity of the findings. But the present study is just the beginning which can promise the basis for implementation of broader studies that should be done to strongly investigate and discuss the effects of attachment styles on more neuro-psycho-physiological health indexes in children with chronic medical illness.The present research was a correlational study with a causal-comparison design. The population was the 12–15 years old children who had received diagnosis of a chronic medical disease. Inclusion criteria were passing at least one month of the medical treatment period, the child’s admission to guidance school education, the parents’ at least primary school education, the basic social and economic income per month. Exclusion criteria were having no history of stroke, addiction, personality and psychotic disorders in parents and children, lack of mental disability in the child, and non-divorce or death of parents. These inclusion and exclusion criteria were checked during an initial interview and also double-checked according to the medical records of the children. Eligible children who were available have been detected and then -after announcement of readiness and agreement- the informed consent form for the participation in the project was signed by the mothers. The form included the researcher’s moral commitment, the engagement commitment of the participant, the participant’s authority to terminate cooperation at each stage of the implementation of the research. Afterwards, the demographic information form and Collins & Reid attachment questionnaire have been completed for the participants. Then, regarding the children’s demographic information and their attachment scores, they were assigned to three demographically matched groups of secure, avoidant and anxious attachment style. The selection procedure has been finished when all three secure, avoidant and anxious groups included 15 children. All three groups were matched in the mean age of children (14.24 with a standard deviation of 0.981), mothers (36.04 with a standard deviation of 4.55) and fathers (40.40 with a standard deviation of 4.46), the average of family income (507.71 $ per month with a standard deviation of 0.85) and disease kind . In the next step, all children in secure, avoidant and anxious groups were evaluated by the Procomp2 tool for measuring HRV and the Cambridge Neuropsychological Test Automated Battery (CANTAB) software for measuring cognitive abilities.It should be mentioned that this study has been received institutional review board approval from psychology department of University of Tehran and all methods were performed in accordance with the relevant guidelines and regulations.30 mentioned, we have defined the subject’s attachment styles based on his/her achieved score in these subscales. Accordingly, secure attachment style identify with a high score on the proximity and dependency and low on the anxiety dimensions; Anxious attachment style identify with a high score on the anxiety, proximity and dependency dimensions; And avoidant attachment style identify with a low score on the proximity, dependency and anxiety dimensions. Scoring method was based on a 5-point Likert scale and a “high” score has been define as being above the midpoint on this scale, and a “low” score as below the midpoint. On this view, individuals who score at the midpoint should be excluded from the sample. The test-retest reliability of this questionnaire was reported more than 80%32. The results of Pakdaman research33 also showed that the validity of the Persian version of this questionnaire was 76%. In the current study the coefficient of Cronbach’s Alpha was 0.75.Collins and Reid prepared their questionnaire Based on the Hazan and Shaver’s Adult Attachment Questionnaire which has described three main attachment styles. This self-descriptive 18-item questionnaire measures relationship skills and dominant form of secure, anxious or avoidant attachment style based on three subscales of dependency, proximity and anxiety (each composed of six items). Anxiety subscale measures the extent to which a person is worried about being abandoned or unloved. The proximity subscale measures the extent to which a person is comfortable with closeness and intimacy. The dependency subscale measures the extent to which a person feels he/she can depend on others to be available when needed. As ColinsECG was used to measure HRV. To assess the heartbeat and respiration rate, this tool detects electric shocks and records waves across the skin. An ECG heartbeat includes a P wave, a T wave, a U wave and a QRS set. Each of these waves and the distances between them are related to different parts of the cardiac function and can be used to evaluate the health of the heart. The wave R represents the contraction of the ventricles (heartbeat). R-R is the heartbeat interval, or the normal to normal (NN) distance, and represents the distance between heartbeats. The device used to measure HRV in this study was ProComp 2, which shows heartbeat and respiration rate which was measured in resting mode. To do this, the front of the instrument’s wire was connected to the participant’s left hand and the end of the wire was inserted into the device’s B channel. The next wire was added to the H channel of the device to measure the heartbeat of the chest.34. The primary objective of this software was to evaluate the cognitive decline function in elderly people with dementia; but in the following years, it has been used for evaluation of the neuropsychological functions in clinical populations and different age groups with different demographic characteristics35. The results of the studies showed a test-retest correlation of 56% to 86% for the subscales36. The coefficient of Cronbach’s Alpha for the current study’s sample was 0.87.The neuropsychological tests which have been presented in this tool were originally prepared in 1980 by Sahakian, Robbins and Freez at Cambridge University. This tool has 7 scales which measure cognitive abilities such as memory and learning, executive function and active memory, visual memory, attention and reaction time, semantic and verbal memory, decision-making and response control, and social cognition. These scales included 24 subscales. The results of the aforementioned abilities and subscales refer automatically to determined ranges of norms matched according to age and gender, and standard scores automatically provide by the CANTAB


Clinical Pharmacy Services (CPS) are a reality in many health systems around the world. However, there are few studies that discuss the facilitators and the strategies to implement CPS in healthcare systems. In this way, the objective of this study was to identify the facilitators and strategies involved in the CPS implementation process in some public health units in a metropolis in the Northeast Brazil.A qualitative study was carried out with health-system pharmacists and managers who experienced the implementation of CPS. Therefore, focus groups were conducted with pharmacists, and the interviews with the managers. The discussions were carried out through semi-structured scripts and were recorded in audio and videos, after the signature of the consent form. The recordings were transcribed and analyzed independently through content analysis, followed by consensus meetings between researchers.Two focus groups were conducted, with an average of seven pharmacists per group, and five interviews with local health managers. Participants reported 39 facilitators who were related to the categories: local healthcare network, healthcare team, pharmacists and implementation process of the CPS. And 21 strategies attributed to the following categories: local healthcare network, pharmacists and implementation process of the CPS.This study identified facilitators and strategies of the implementation of CPS. Most of the positive experiences were related to the clinical skills and proactive attitudes of pharmacists. These findings may support pharmacists and health managers to implement CPS in health systems.The online version of this article (10.1186/s12913-018-3403-4) contains supplementary material, which is available to authorized users. Over the past years, the increase of drug-related morbidity and mortality has caused losses in different health systems in countries such as Canada , the UniThe literature shows that CPS have expanded , 12 and In this scenario, it is highlighted the implementation science, since it is responsible for investigating and understanding the multiple factors that influence the implementation processes . The litAlthough identifying and understanding implementation factors may represent a key process in the implementation of CPS, there is a lack of studies focusing on facilitators and strategies for the CPS implementation process in healthcare systems , 29, 30.The Brazilian health system is a universal system that guarantees health services and drugs to all Brazilian citizens at the primary, secondary and tertiary care , 32. In The Brazilian ministry of health develop the CPS implementation process in four steps, from July 2015 to March 2016. In the first step, a collaborative partnership was formed between the Brazilian ministry of health and local health managers to ensure provision of structural conditions  for the implementation of CPS. The second stage corresponded to the hiring of a team of specialists (supporters) with experience in the implementation of CPS in the Brazilian health system. The third stage related to the implementation of CPS through clinical training of 42 health-system pharmacists based on the Pharmacotherapy Workup . FinallyA qualitative study was performed through two focus groups and five semi-structured interviews with pharmacists and local health managers involved in the CPS implementation process in order to explore their perceptions. The focus groups and interviews were conducted in April and August 2016, respectively.This study used the recommendations proposed by Consolidated Criteria for Reporting Qualitative Research (COREQ) . AdditioThis study was conducted with 13 health-system pharmacists and five local health managers that were involved in the CPS implementation. The pharmacists who consented to participate were those who agreed to implement CPS in their respective workplaces. In order to get a comprehensive understanding of the facilitators that influenced the CPS implementation process, the health-system pharmacists were divided into two groups: (i) seven accredited pharmacists, who fulfilled all steps of the process and implemented CPS in their workplaces; and (ii) five non-accredited pharmacists, who did not complete all steps of the process and did not fulfill implement CPS in their workplaces. The local health managers were those who held important positions in the local healthcare network  during the implementation of CPS.The topic guide was formulated from a brainstorming meeting with the authors and has open questions that had the objective to investigating barriers, facilitators and strategies to implement CPS  and two external researchers (AMP and SRF) based on the content analysis proposed by Bardin .The data collected were coded, categorized, and organized during consensus meetings between the researchers. In these meetings, each researcher commented on the decision of the other researcher until they reached a consensus on the interpretation of the data. In order to increase methodological accuracy, at the end of this stage, two senior researchers (DPLJ and DMMP) reviewed all the data collected.This method was carried out in multiple steps and with several different researchers and evaluators (independently or in consensus meetings) to achieve the reliability and validity of the data. Finally, we emphasize that the triangulation was performed throughout the step-by-step execution of the methods. Thus, we used different data collection techniques (focus groups and interviews), several evaluators  to interpret the transcripts, and two methods for data analysis . These methods used of triangulation in qualitative research, based on concept proposed by Carter et al. .Facilitators are the factors or the determinants of practice that influence the implementation effort . In thisTwo focus groups were conducted, one with seven accredited pharmacists and the other one with five non-accredited pharmacists. The interviews with key informants were carried out with five local health managers. The local health managers were two pharmacists, two physicians, and one occupational therapist.The focus group and interviews discussions generated 140-min and 100-min recordings, respectively. Participants reported 39 facilitators and 21 strategies related to CPS implementation. To aid understanding, the facilitators were related to four categories: local healthcare networks, healthcare teams, pharmacists, and implementation process of CPS. The strategies were attributed to three categories: local healthcare networks, pharmacists, and the implementation process of CPS. Tables In the focus group and interviews, it was reported that facilitators related to the local healthcare network and characteristics of the local management model. All participants of this study pointed out the commitment of the local management as a facilitator, which showed that accessibility and responsiveness in providing material resources were necessary in the implementation of CPS.“The room was acclimatized, the computer was placed for me to attend [the patients]; after a request to the local management, it was quiet to perform patient care. I can attend to them without difficulty” (Accredited Pharmacist D).Regarding the structure of the local healthcare network, the organization of services, health facilities, and local pharmaceutical services was reported to be a facilitator. Some units presented infrastructure as a facilitator, with adequate and comfortable physical space for pharmaceutical care (private acclimatized room), computer equipment, and clinical devices .“We always had a room available, and we received material from the local health management” (Accredited Pharmacist G).Some reported facilitators were related to certain health units where pharmacists worked, characterized by high demand and easy access to patients. These attributes facilitated the sensitization and capitation of patients to CPS. In addition, it was mentioned that the service profile of some units  favored the clinical performance of pharmacists since these institutions offer integral care and interdisciplinary assistance, focusing on patients, families, and the community.“I think the great facilitator is the high demand of patients and the very close contact we have with them. Both during care, when we do the drug dispensing, or even when talking to them” (Non-accredited Pharmacist E).The pharmacists reported the support of pharmacy staff in the execution of logistic activities. These activities were delegated to the pharmacy staff. In this way, the pharmacists managed to organize their work process in order to dedicate more time to the CPS.“Today, I can share with them [pharmacy staff] some routines that were not previously divided as they were focused on me. I gave them more autonomy” (Accredited Pharmacist D).Focus group and interviews pointed collaboration and good communication among healthcare team members as an indispensable factor for the implementation of CPS. According to the participants of this study, the relationship of pharmacists with the healthcare team facilitated the referral of patients to CPS, improved the communication with other professionals, and increased the recognition of pharmacists within the healthcare team.” (Accredited Pharmacist H).“They [healthcare team] were satisfied; they gave feedback and referred patients. This was a positive point to show the pharmacist's work to the healthcare team, especially when the physician reacted very well and they interacted a lotAccredited pharmacists reported facilitators related to their attitudes, as willpower, commitment, and proactivity to learn and perform clinical activities. The motivation generated by the positive results of CPS boosted the progress of these services. Managers also reinforced the availability and intellectual/personal commitment of pharmacists to obtain knowledge that would help the implementation of CPS.” (Accredited Pharmacy D).“A great facilitator, in the first place, was my willpower [...] to want to do, to want to learn, despite the difficulties; I think the proactivity of each one was fundamental for this“I want to be with the patient [...] not only as a pharmacist, but […] like a human who wants to make a difference in the patient’ life, since the time they are diagnosed until the moment they know that it is possible to live with the disease and have a good quality of life” (Accredited Pharmacist G).The clinical profile was cited as a facilitator. We defined this profile as a set of intrinsic characteristics of a professional who is motivated and had an affinity for clinical activities, and previous knowledge, skills and attitudes. Some pharmacists reported having a previously created clinical profile to act directly with the patient, which was stimulated by the CPS implementation process. In addition, lifelong knowledge has helped pharmacists in clinical practice and patient management.The pharmacists’ work process, integrating collaborative practices with other members of the healthcare team, in a different setting was pointed out as an important facilitator. In addition, access to medical records, previous pharmacist-patient interactions.“I have full access to the patients' medical records, and physicians are accessible. With RT [reference technicians] we can talk about patients, like any healthcare team” (Non-accredited Pharmacist C).Participants reported that assistance provided by supporters during the implementation of CPS was an essential facilitator, both in theoretical and practical training, as mentoring activities during pharmaceutical care. The local health manager also recognized the expertise and contributions of supporters in CPS implementation. In addition, the systematization of the pharmacists’ work process through documentation in medical records helped assimilate and incorporate clinical activities into the work routine of the pharmacists.“The biggest facilitator for me was the existence of supporters, without them the provision of CPS did not work, [...] to have a mentor able to tell you: ‘See, this will work, this will not work. Go that way, because this is the best way you can go’” (Accredited Pharmacist C).The fact that the implementation process was initiated by the Brazilian ministry of health was mentioned as a facilitator. This brought confidence in the participants because of the previous positive experiences and they still felt challenged to implement CPS in their workplace.“I think being challenged to do something different was one of the things that boosted [pharmacists] the most” .Non-accredited pharmacists, on the other hand, did not report facilitators related to CPS implementation process.Some strategies were ensuring minimal physical infrastructure for services and more active participation of local health managers on the implementation process. In addition, accredited pharmacists emphasized the strategy to ensure the presence of pharmacy interns in the CPS implementation process.“I do not think [local health management] giving us a glucometer in December is a support. Support is to be together, to attend.” (Non-accredited Pharmacist C).Pharmacists proposed strategies they themselves should develop to facilitate the implementation process. Accredited pharmacists reported proactivity and humanized posture during clinical activities and recruited patients through an active search. The non-accredited pharmacists suggested delegating some activities to the pharmacy staff and delegating the recruitment of patients to the healthcare team.“The best strategy is your work with patients [...] the way you work, how much you make a difference in their treatment [...]. It is the pharmacist in front of the patients, really looking at them, to listen. I realized that it is crucial that you listen to your patients” (Accredited Pharmacist G).“I bought all basic materials  [...] because I think it is important for the achievement and success of the service” (Accredited Pharmacist E).Several strategies were cited that aimed at strengthening relations between pharmacists, the healthcare team, and the patients. Thus, it was proposed that the pharmacy staff should be able to collaborate in logistic activities by sensitizing the healthcare team and patients, in addition to disseminating implemented CPS through lectures, waiting area approach, home visits, and shared care.Non-accredited pharmacists pointed out the importance of strategies that would help reconcile the time between the logistic and clinical activities and how to delegate logistic activities so that new activities required for CPS implementation process were incorporated.“I used shared care with nurses and physicians as a strategy, because in this way they could understand the process, the service, and what could be the result [...] they saw my way of intervening in care and then I created a bond for the next consultation.” (Accredited Pharmacist B).Some accredited pharmacists suggested some strategies that could be adopted in future implementation processes in local healthcare networks. According to them, it would be interesting to adapt the CPS according to social demands where the service will be offered and select the pharmacists according to their “clinical profiles”. According to the proposal, this could ensure better medication adherence and reduce the dropout rate during the process.“There was a lack of selection on the professionals’ profile [...] there were many professionals who actually started doing this because they were involved, but they had no “clinical profile”, no capacity, or no help, either they had no infrastructure or, due to any other difficulty, they gave up the project and this was discouraging for other professionals too” (Accredited Pharmacist C).The focus groups and interviews brought reflections to the implementation of CPS in certain public health units of a city in northeast Brazil. The accredited pharmacists showed themselves as protagonists in the situation, proposing facilitators inherent to the own attitudes. On the other hand, non-accredited pharmacists held a secondary role in which they attributed the protagonism to other people, such as the health team.Tsoi et al.  exploredLocal healthcare managers focused on factors related to the organizational structure of the municipal healthcare network. However, by the influence of their political positions, they may have overestimated some facilitators, such as emphasizing the adequate number of pharmacists available in the local healthcare networks. Political discourse can often be influenced according to the manager’s interest and/or the power of that position can be conveniently applied to emphasize some specific item or detail –44. TherSimilar to this study, several studies have shown that factors related to the commitment of healthcare managers, such as the availability of time and material resources, may contribute to an increase in the satisfaction of pharmacists, as well as encourage their autonomy and initiative to perform clinical activities –47. TapiRegarding the physical structure, according to the model proposed by Donabendian , the impThe clinical profile of care of certain health units at Brazil’s Mental Health Services (CAPS) was a facilitator. CAPS promote public comprehensive care for people with severe and persistent mental disorders in Brazil in a humane and integral way, holding a holistic view of the patient . Silva aThe presence of trained teams with defined and organized practices improves the work process of pharmacists, facilitating the implementation and ensuring quality in the services provided , 56. TheAll participants of this study reported the collaboration with the health team as a facilitator. The literature has discussed the growing role of pharmacists as members of the healthcare team in primary care, contributing and acting directly on patient care , 60, 61.The facilitators inherent to the pharmacists in the present study were related to knowledge, skills, and attitudes. These elements form the basis of clinical pharmacists’ competencies and directly reflect on patient care . The cliA point highlighted in the present study was the motivation generated by the positive results. The positive results  generated by CPS can sensitize managers, the healthcare team, and the pharmacists by motivating them in the implementation process . MotivatAnother topic addressed in this study was the knowledge of pharmacists related to previous experiences with CPS. Alcântara et al.  investigIn relation to the work process, some pharmacists were included in healthcare teams composed of professionals from different areas of knowledge, who acted in an integrated way, sharing experiences with patients, families, and the community . In the Access to patients’ clinical information was considered a facilitator. The literature shows that one of the major limitations for pharmacists to provide care to patients in primary care is the lack of access to patients’ clinical information, such as medical records –74. ThusPharmacists were assisted by specialists who trained them and offered mentoring activities in order to obtain the best performance in providing CPS. In studies on pharmacists receiving training, advantages in the provision of services, improved professional practice, and feeling more confident in patient care, were recognized –77. MentIn this study, the systematization of the new work process through medical records was reported as a facilitator. A roadmap for advancing implementation of services in primary care described by Blanchard et al.  demonstrIn addition, according to the implementation process, the fact that the project started with the support of the Ministry of Health was considered an indispensable facilitator. Penm et al.  investigIn this study, voluntary participation of the pharmacists in the process of implementation of CPS was placed as positive. In a review, Luetsch et al.  exploredPharmacists attributed guarantee of minimum physical structure and effective participation of local health managers as local healthcare network strategies. Similarly, Minard et al.  exploredAnother strategy reported to support pharmacists’ working process was the collaboration of interns. The main objectives of interns in pharmacies are defined between the training institution and the university. Overall, assignments are designed to cover key areas of pharmaceutical competence on-site training, providing support to pharmacists working process , 89. ThuOne of the strategies mentioned by accredited pharmacists was the proactivity in the implementation of CPS, the engagement in the process in an attentive and humane manner, recognizing the patients’ needs and seeking to assist them. With these attitudes, pharmacists can impact the quality of service provided, recruit patients more easily, and stimulate the building of a relationship of trust between the patient and the pharmacist –92. On tThe training of pharmacy staff was mentioned as a strategy to support the provision of CPS. Similarly, Mackeigan et al.  performeRaising awareness among the health team through the disclosure of CPS has been reported as an essential strategy. To sensitize the healthcare team, the disclosure of the impact of pharmaceutical services through media, posters, and lectures was used as a strategy. Such marketing strategies have been successful in other similar studies , 96. AccThe non-accredited pharmacists mentioned that a valid strategy for the implementation of CPS would be a reconciliation between logistics and clinical activities. Some professionals may see the insertion of new activities in their routine as increasing workload . SimilarA suggestion of strategy to ensure that CPS were implemented in this study was the adequacy of the type of service according to the social demands of the setting where it will be provided. Latif et al.  exploredFactors related to the professionals’ profile were reported as a strategy to be performed. Elvey, Hassell e Hall  examine This study used triangulation of methods and sources in order to increase the reliability of the results. These may have helped to get a comprehensive understanding of the facilitators and strategies related to the implementation process. Moreover, this may allow the minimization of political influences in the results of the study, since the implementation process was observed from the standpoint of accredited, non-accredited pharmacists, and local health managers, who operated in different settings in the municipal healthcare network.One of the limitations of this study was the refusal of some non-accredited pharmacists to participate in the focus groups. If more pharmacists had participated, new implementation factors could have arisen. Another limitation was that we exclusively investigated the perception of strategies of pharmacists on the implementation of CPS in healthcare systems, rather than evaluating the perception of other actors involved in the process, such as local health managers. In addition, this study did not investigate whether the strategies listed can actually bring real benefits to the implementation process.This study identified facilitators and strategies involved in CPS implementation process revealed by pharmacists and the local health manager. Facilitators to implement CPS included physical structure, human resources, training of professionals, management commitment, well-defined work processes, and interprofessional collaboration. Similarly, strategies were associated with protagonist approaches and active attitudes of pharmacists, such as reconciling logistics and clinical activities, sensitizing the healthcare team, disclosing CPS, and sensitizing and get patients by active search. In addition, this study can guide pharmacists, managers, and policy makers in the implementation of CPS in healthcare systems provided for patients, families, and communities.Additional file 1:Focus group and interviews questions. (DOCX 12 kb)


The Biologically Oriented Preparation Technique (BOPT), developed by Ignacio Loi and published in 2008, is a consolidated concept in the modeling and preservation of pericoronal soft tissues. The present study describes the analogical and digital methods allowing adequate design and preparation of the emergence profile of BOPT crowns in the working model, with a view to comparing the workflow and advantages of each method. At present, not all the digital procedures have been fully optimized to completely replace the traditional analogical methods. Nevertheless, it is only a matter of time until dental digitalization technology totally replaces the analogical clinical methods. The digital workflow for this procedure is quickly implemented and optimized, and represents the most realistic option, with possibilities for further development in the immediate future. The Biologically Oriented Preparation Technique (BOPT) was developed by Ignacio Loi and published in 2008, and has become a consolidated concept in the modeling and preservation of pericoronal soft tissues ,2,3,4. AMore recently, this philosophy has been transferred to implantology in the preparation of crowns (with certain specific features) over truncoconical implant-supported abutments without a finishing line and convergent towards the occlusal plane. This novel approach demonstrated a significant increase in the thickening of the peri-implant soft tissue volume after 10 months of prosthetic loading in a recent pilot clinical study .One of the key principles of the BOPT technique is that gingival tissue is able to adapt to prosthetic shape in both prostheses over teeth and over implants. Accordingly, adequate design of cervical emergence of the crown plays a crucial role in the application of this technique  along with the use of shoulder-less convergent abutments that are less voluminous than conventional abutments in the “subcritical profile” zone . These cThe present study describes analogical and digital methods allowing adequate design and preparation of the emergence profile of BOPT crowns in the working model, as an essential part of the development of implant-supported crowns of this type.A description is provided below of the preparation of cervical emergence for BOPT prostheses over implants in the working model, based on two workflow options: analogical and digital. Both protocols involve the use of a plaster  or resin prototype working model  on which the pre-existing peri-implant gingival morphology has been “remodeled—modified” to obtain a gingival emergence design optimized for the prosthesis, which is then manufactured in a “guided” manner from that “starting point.” In other words, the mucosal emergence design artificially created in the working model around the analogical-abutment unit will simulate the desired final cervical morphology, which is then transferred by the laboratory technician to the crown  that will be prepared adapted to that specific cervical design ,12,13.After obtaining the silicone impression (with an open or closed cuvette), and before casting, we insert a silicone O-ring (measuring about 1 mm in thickness) around the head of each analog , with thInitially, a pencil is used on the model to trace the limits of the cervical contour of the desired emergence profile for each crown. A manual reduction of the plaster is performed  using diamond drills and laboratory scalpels, until the adequate “ovoid” emergence profile characteristic of BOPT crowns is obtained, with correct buccolingual over-contouring  and adequate inter-proximal festooning (to maintain sufficient papilla thickness), without extending in depth within the sulcus more than 1–1.5 mm .In this way, the dentist or laboratory technician, by following the specific “clinical recipe” of each case, can design and produce a correct crown emergence profile through selective reduction of the plaster model, based on objective criteria according to the gingival thickness and radiographic bone profile.The BOPT crowns produced over these personalized emergences in the model  will traThe above-described procedure involving the plaster model is perfectly transferable to the digital setting thanks to intraoral scanning and the design and preparation of prototype models that incorporate from the start the coronary emergence profile specifically individualized for the BOPT prosthesis of each implant.®, Carestream Dental, Atlanta, GA, USA), can use the corresponding tool to trace the limits of the cervical contour of the desired emergence profile for each crown on the digital model  , Carestream Dental, Atlanta, GA, USA) of the clinical scanner (CS 3600chnique) .In this way the clinician prepares an adequate “digital recipe” specifically adapted to each case, and which will include the digital model files with the tracing of the cervical contour and written indication of the crown emergence starting point, from the head of the implant or from the abutment, specifying the required distance (in mm) in depth buccal, lingual, and inter-proximal .With this specific information, the laboratory can design upon the digital model (before printing) the morphology of the “reduction” around the implant required to achieve a personalized emergence profile , which iFrom this point, the procedure for preparing and adjusting the BOPT crowns on the resin model  and in tAt present, not all the digital procedures have been fully optimized to completely replace the traditional analogical methods. Nevertheless, it is only a matter of time until dental digitalization technology totally replaces the analogical clinical methods ,15.The correct development of the digital method in preparing emergence profiles as contemplated in the present study is necessary and inevitable, and its advantages and inconveniences must be compared versus the traditional analogical method.Analogical preparation of the plaster model through manual reduction and modeling can be done in the laboratory and also in the clinic by dentists who wish to have closer control of this crucial phase of the prosthesis, obtaining the cast and using the rotary/manual instruments available in the dental clinic. Nevertheless, most dentists will find it more convenient to use the digital computer design option prior to obtaining the resin prototype. In this regard, the digital method affords the dentist greater control of these important initial parameters in preparing the BOPT prosthesis in a more simple and effective manner.The resin prototype has analogs that can be extracted, thereby facilitating the preparation of the prosthesis and the checking of fit or undesired contact zones of the crown upon the working model. However, it must be remembered that in some cases, the fact that these analogs are removable may result in undesired imprecisions compared with the traditional plaster models. Thus, the procedure, the printer quality, the software, and the analogs used in the prototype are crucial factors that must be taken into account .It is also important to remember that the three-dimensional effects when designing the crown contours on the digital model on the computer screen are not as real as when the physical plaster model is used, even to the trained eye . As a reLastly, it must be remembered that the main inconveniences of the digital method for the dentist very probably are the important efforts needed in terms of economic investment and training associated with the introduction of this technology in the dental clinic. This is particularly so considering that at the present time at least, the increase in quality of the final outcome is not always proportional to the efforts made ,19,20. NThe advantages of digital flow invite not only dentists but also the work team  to engage more active in treatment development through enhancement of communication in the organization and with patients, enriching the knowledge gap on the team. Noteworthy to mention, in both approaches, the final restoration was installed in four visits but an increased chair time consumption is observed with the analogical approach. The average chair time increase was of 8% disaggregated in 1% and 7% for in-office and lab procedures, respectively. Thus, the digital workflow confers slightly better time-effectiveness lower treatment cost. The BOPT approach enhances both the supracrestal tissue attachment  and periThe traditional analogical workflow for the preparation of BOPT prostheses has been extensively developed and affords satisfactory and predictable outcomes. However, the digital approach is undergoing rapid development and optimization, and constitutes the most realistic option, with possibilities for improvement in the immediate future through better communication and data transfer between the dental clinic and the laboratory.


Recently, interest in compulsory licensing of pharmaceuticals has been growing regardless of a country’s income- level. We aim to investigate the use of compulsory licensing as a legitimate part of the patent system and tool for the government to utilize by demonstrating that countries with a mature patent system were more likely to utilize compulsory licensing of pharmaceuticals.We used a multivariate logistic model to regress attempts to issue compulsory licensing on the characteristics of the intellectual property system, controlling for macro context variables and other explanatory variables at a country level.N = 24) and a non-CL-attempted group (N = 115). An attempt to issue compulsory licensing was associated with population (+) and a dummy variable for other regions, including Europe and North America (−). After controlling for macro context variables, mature intellectual property system was positively associated with attempting compulsory licensing.A total 139 countries, selected from members of the World Trade Organization, were divided into a CL-attempted group (Our study provided evidence of an association between attempting compulsory licensing and matured patent systems. This finding contradicts our current understanding of compulsory licensing, such as compulsory licensing as a measure to usurp traditional patent systems and sometimes diametrically opposed to the patent system. The findings also suggest a new role of compulsory licensing in current patent systems: compulsory licensing could be a potential alternative or complement to achieve access to medicines in health systems through manufacturing and exporting patented pharmaceuticals. Compulsory licensing, primarily attempted in low- and middle-income countries (LMICs) for HIV/AIDS treatments , 2, occuRecently, interest in the compulsory licensing of pharmaceuticals has been growing regardless of a country’s income level. The UN High-Level Panel on Access to Medicines recommended the implementation of legislation and use of compulsory licensing, which is one of the notable flexibilities of TRIPS, for legitimate public health needs . FurtherAlthough compulsory licensing is recognized as a legal measure against patent abuse and public health problems, there has been continuous debate regarding compulsory licensing between high-income countries and LMICs. The basic argument in favour of compulsory licensing stems from the availability of affordable and essential medicines for improved public health . Public On the other hand, others argued that the rights behind patents are historically and statutorily granted with the issuance of a patent and should be protected through a limited time period , 14. ForThese normative arguments provide clues to partially understand the validity of compulsory licensing and reason for its existence in the patent system. In line with these debates, evidence, specifically from empirical literature, is still needed to understand the association between compulsory licensing and the intellectual property system, particularly the patent system. However, few literature sources are available, even non-empirical literature that provide associations between compulsory licensing and the patent system at the country level. For instance, a recent study summarized notable factors significantly influencing the issuance of compulsory licensing based on previous literature: local manufacturing capacity or importing possibilities to supply medicines and pressure from patent holders’ threat of market withdrawal . AdditioHowever, we should note that the compulsory licensing of patents was originally discussed and legislated in high-income countries, including the United States, Germany, and England with the development of the patent system , 18. ForGiven this, we aimed to empirically investigate the associations between attempts to issue compulsory licensing of pharmaceuticals and the intellectual property system and to demonstrate the positive role and function of the matured intellectual property system in attempting compulsory licensing. Not surprisingly, a close relationship exists between the patent system and compulsory licensing of patents. Issuing compulsory licensing of patents requires a granted patent, and the grant of the patent requires a functioning patent system. In this study, we investigated the use of compulsory licensing as a legitimate part of the patent system and tool for the government to utilize by demonstrating that countries with a mature patent system were more likely to utilize compulsory licensing of pharmaceuticals.Given the availability of the data, we selected 139 member countries of the WTO, including observers. We examined the presence of attempted compulsory licensing of pharmaceuticals between 1995 and 2014. Attempted compulsory licensing data were obtained from a previous study [Based on already known literature and theories , 20–24, First, compulsory licensing has been mostly attempted in Africa, Asia, and Latin America , 2. ThusSecond, the number of patients is an important context by which limited access to medicines is perceived as a public health problem, and might be connected to attempting compulsory licensing . In lineThird, the political system might matter in attempting compulsory licensing. For instance, the political system might induce the increased supply of public goods and public policy . AdditioFinally, the Pharmaceutical Intellectual Property Protection (PIPP) index was used to identify associations between attempted compulsory licensing and the characteristics of intellectual property systems. The PIPP index summarizes the presence, term, and strength of various types of patents that can be claimed for pharmaceutical innovations . Specifichi-squared test or Fisher’s exact test was applied for the categorical variates and t test was conducted for the continuous variates to examine whether the variables of interest differed by the groups. Next, two multivariate logistic regressions were conducted to elucidate factors that affected the attempting compulsory licensing. Variables of interest such as region, population, income, and polity were added in the model to adjust for the macro context. Population and income were used after log transformation to normalize the distribution. The PIPP index was then added to answer our research questions. Furthermore, we conducted additional analysis assigning weights to the variable of income level to reflect the real world situation. Data management and analysis were performed using R statistical software (version 3.4.1). Significance was considered for p-values less than 0.05.Descriptive analyses were used to present the difference between two groups, including the CL-attempted group and non-CL-attempted group. Specifically, Model:Among 139 countries, 24 attempted compulsory licensing, while 115 did not. In the CL-attempted group, the number of attempted compulsory licensing ranged from 1 to 16. The mean, median, and mode of attempted compulsory licensing were 3.9, 3 and 1, respectively.Table Table In model 1 with two different data sources, we found consistent results. Specifically, the regions, including Africa and Latin America (reference others), populations, and the PIPP index were significant factors in attempting compulsory licensing. However, the variables of income and polity were not significant factors. Specifically, there was a higher likelihood of attempting compulsory licensing in African and Latin American countries compared than in other regions such as Europe and North America. The population was positively associated with attempting compulsory licensing. Interestingly, we found that the PIPP index was positively associated with attempting compulsory licensing. In other words, countries with mature patent systems had a higher likelihood of attempting compulsory licensing in our model. In model 2, in which weights were applied to the variable of income in the model, we found the similar results. The significant variables in model 1, such as the region, population and the PIPP index, were also significant variables in model 2. Additionally, a higher likelihood exists for attempting compulsory licensing in Asian countries than that in other regions such as Europe and North America.Compulsory licensing could be issued by a government in situations where the patent holder is either not using the patent or is not using it adequately, including pharmaceuticals in demand that are not fully available. When governments attempt to issue compulsory licensing or non-governmental entities request a government to issue compulsory licensing, the outcome is often a decrease in prices, similar to the case of the introduction of generics in the market , 31. AltWe designed this study to demonstrate the positive role of the matured intellectual property system in attempting compulsory licensing. The issuance of the compulsory licensing of a patent requires a granted patent, which is the outcome of a functioning patent system. Therefore, a link exists between the compulsory licensing of patents and the patent system. In this study, we presented that the use of compulsory licensing is an essential part of the patent system and a legitimate tool for the government to utilize by demonstrating that compulsory licensing of pharmaceuticals is utilized in particular countries with a mature patent system.To our knowledge, this study is the first to empirically analyse the relationship between compulsory licensing and patent systems. We used a multivariate logistic model to regress the attempt to issue compulsory licensing on the characteristics of the intellectual property system , controlling for macro context variables  at a country level. Interestingly, mature patent systems were positively associated with attempting compulsory licensing. How then might mature patent systems affect the issuance of compulsory licensing?The history of compulsory licensing might help to explain these interesting results because they provide a reason for the existence of compulsory licensing in a patent system. We will trace the origins of the compulsory licensing of patents in high-income countries and discuss interesting cases from Canada in the late 1980s.The following legislative cases in the 18-nineteenth century demonstrate that high-income countries actively reviewed and introduced compulsory licensing to complement the intellectual property system and develop their own industrial policy.The compulsory licensing of patents was followed by the compulsory licensing of copyrights . In EnglThe United States, specifically the state of South Carolina, established the Act for the Encouragement of Arts and Science, providing privileges and restrictions imposed to authors (copyrights) as well as to inventors (patents) in 1784. The Act first devised compulsory licensing as a new remedy against the abuse of the patents when only invalidation of the patents existed. It should also be noted that the United States had been more aggressive in dealing with patent abuse during the development of new industry. Similarly, England and Germany discussed compulsory licensing as measures to minimize the adverse effects of the patent system and complement the shortcomings of the patent system in 1851 and 1853, respectively [These trends favouring compulsory licensing in various fields persisted in the 1900s , 33. TheHowever, the positive stance regarding compulsory licensing of high-income countries notably changed in the twentieth century, specifically during the negotiations for TRIPS . LMICs aMeanwhile, WHO adopted the Doha Declaration at the fourth Ministerial Conference, and affirmed that compulsory licensing is the right of the member countries of the WTO. The Doha declaration confirmed that compulsory licensing is intended as an efficient and straightforward instrument for LMICs to improve access to needed medicines . The DohOur findings suggested a new role of compulsory licensing in current patent systems. Compulsory licensing is alternatively or complementally used in countries where mature patent systems were established. For instance, China released “Measures for Compulsory Licensing of Patent Implementation” that integrated and updated intellectual property laws to allow compulsory licensing in 2012 . Under tFurthermore, compulsory licensing in the patent system could be harmonized with the health system to secure access to essential medicines. In 2016, for the first time, the German Federal Patent Court notably ordered a provisional compulsory license under Section 24 of the Patent Act. The Court allowed a license seeker to continue to market an HIV drug that was made and sold since 2008 in Germany. Prior to that, the patent holder had requested a preliminary injunction against a license seeker in 2015 based on an active patent granted in 2011, partially covering the drug. The license seeker offered a voluntary license on the patent to the patent holder, but failed. The license seeker then responded by requesting a compulsory license under the Patent Act . SpecifiFinally, compulsory licensing could be utilized to export pharmaceuticals to other countries according to paragraph 6 of the Doha declaration. However, cases on the compulsory licensing of pharmaceuticals for export are rare . MeanwhiThis study possesses several limitations. First, this study used the presence of the attempted compulsory licensing of pharmaceuticals between 1995 and 2014. The number of countries that attempted compulsory licensing during the study period was 24, comprising approximately 20% of the total of 139 countries analysed. Therefore, some may argue that compulsory licensing is not suitable for quantitative research. However, it should be noted that empirical research might provide more practical implications on issuing compulsory licensing in the real world. This research will contribute to expanding the current understanding of compulsory licensing. Second, because of scant available data and fewer cases on compulsory licensing, a cross-sectional analysis was applied to investigate the associations between attempting compulsory licensing and intellectual property systems. However, panel analysis might be a more accurate method to understand these associations. Third, this study used the database constructed by Son and Lee (2018) to detect the presence of the attempted compulsory licensing of pharmaceuticals occurring between 1995 and 2014 [Our study provided evidence of an association between attempting compulsory licensing and matured patent systems. Specifically, we demonstrated that the use of compulsory licensing is an essential part of the patent system and a legitimate tool for the government to utilize. This finding contradicts our current understanding of compulsory licensing, such as compulsory licensing as a measure to usurp traditional patent systems and sometimes diametrically opposed to the patent system. Furthermore, the findings suggest a new role of compulsory licensing in current patent systems: compulsory licensing could be a potential alternative or complement to achieve access to medicines in health systems through manufacturing and exporting patented pharmaceuticals.