Fetal Alcohol Spectrum Disorder (FASD) is the leading cause of non-genetic intellectual disability and social maladjustment in children. International guidelines recommend abstinence from alcohol during pregnancy. Réunion is the most affected of all French regions with an estimated Fetal Alcohol Spectrum (FAS) prevalence of 1.2‰ births. General practitioners (GPs) are at the forefront of identifying patients with FASD. Objective: To understand how GPs identify FASD.Qualitative study using a grounded theory approach, through semi-structured face-to-face interviews with GPs. Interviews were conducted with the aim of reaching theoretical saturation. These were transcribed verbatim and then analyzed by four researchers to ensure triangulation of the data.GPs reported barriers to the identification of FASD: challenges in overcoming social taboos and paradoxical injunctions, the influence of limited knowledge and experience, non-specific and highly variable symptoms, ambiguous classification and method of diagnosis involving the mobilization of a multidisciplinary team and lengthy consultations. Conversely, they felt competent to identify neurodevelopmental disorders of any cause, but were concerned about the long waiting time to access specialized care. From the perspective of GPs, it is crucial to prioritize promotion and training aimed at improving the identification and coordination of care pathways for children diagnosed with neurodevelopmental disorders, such as FASD.The online version contains supplementary material available at 10.1186/s13690-023-01221-0. Fetal alcohol syndrome (FAS) is called "full" when it includes growth retardation, craniofacial dysmorphia, and neurodevelopmental disorders. It is called "partial FAS" when it is a more moderate form without these three developmental abnormalities , 2.Alcohol-Related Neurodevelopmental Disorder (ARND): manifested by psycho-affective disorders, adjustment disorders related to memory problems, attention, behavior with hyperactivity, socialization with difficulties in social interactions , 4.Alcohol-Related Birth Defects (ARBD): are malformations, mainly cardiac and musculoskeletal, as a result of alcohol consumption during the first trimester of pregnancy , 4.Fetal Alcohol Spectrum Disorder (FASD) is a group of disorders that occur in a child whose mother drank alcohol during pregnancy. Several types of damage are reported:Excessive alcohol consumption almost always results in FAS. Because it is impossible to define thresholds at which it would consistently occur , 6, the FAS is a major public health problem. It is considered the leading cause of preventable non-genetic intellectual disability at birth and social maladjustment of the child: disruption of schooling, unemployment, mental health problems, or trouble with the law , 10.A meta-analysis published in 2017 by Popova et al. estimated the prevalence of FAS at 0.146 per 100 persons worldwide . In FranAccording to the Leeuwenhorst Group, "the generalist is a medical doctor who provides personal, primary and continuing care to individuals, families and populations, regardless of age, sex or pathology. It is the synthesis of his or her functions that is unique" . The genSeveral studies, mainly quantitative using questionnaires, have consistently shown that general practitioners (GPs) are reluctant to address the issue of alcohol consumption during pregnancy –16. The Réunion, located in the Indian Ocean, is a French overseas territory with a diverse and multicultural population. The region faces significant challenges related to socioeconomic precariousness and illiteracy rates. The local culture is deeply intertwined with secular knowledge, mainly centered around the cultivation of sugar cane and the consumption of rum. Notably, alcohol taxation is low and alcohol advertising is prevalent in the area .Previous research has mainly focused on the detection capabilities of different health care disciplines, such as pediatricians, midwives, and others, with regard to patients with FASD. However, limited attention has been paid to the challenges faced by GPs in identifying individuals with FASD, despite their privileged position in monitoring families, which provides a unique opportunity for early identification of neurodevelopmental disorders.The responsibilities incumbent upon family physicians situate them at the vanguard of primary prevention endeavors. Their pivotal roles encompass the discernment of indicative manifestations conducive to averting or eradicating the etiological underpinnings of health maladies, both for individual patients and broader demographic cohorts. In this context, their purview extends to the identification of behavioral patterns among women of reproductive age concerning alcohol consumption, while concurrently encompassing the early identification of prodromal cues indicative of neurodevelopmental disorders. The latter holds significance as timely recognition thereof holds the potential for accurate diagnosis and the institution of pertinent therapeutic interventions.In 2015, the French government designated La Réunion as a pilot region for the implementation of a program to prevent and treat fetal alcohol spectrum disorders. Between 2016 and 2018, an action plan for the prevention of FAS was implemented. Six axes have been defined, including one on professional training and another on the implementation of a care pathway for affected women and children [During the first evaluation of this action plan in 2019, the Regional Health Agency of La Réunion highlighted the lack of uptake by GPs in La Réunion of the training courses offered on FASD, as well as the lack of effectiveness of measures to identify alcohol consumption in pregnant women [General practitioners reported difficulties in discussing alcohol during consultations, especially with women. Alcohol remains a taboo subject in French society .The aim of the present study was to better understand the difficulties experienced by GPs in identifying pregnant women who drink alcohol and in identifying individuals with FASD in the pediatric or adult period. The results of the study could allow the design and implementation of interventions to overcome these difficulties and improve the identification of FASD.The study was conducted in La Réunion, a French region where the prevalence of FASD is considered to be the highest in the country.Two studies were conducted jointly by two researchers on the same sample of GPs. The first, conducted by François Baelen (FB), aimed to understand the barriers and motivations of general practitioners in La Réunion in the prevention of FASD, while the second, conducted by Louise Delfarguiel (LD), focused on the detection of alcohol consumption in pregnant women and the identification of individuals with FASD. This study followed a cross-sectional qualitative design, guided by the principle of grounded theory. This research approach was chosen to comprehensively explore the perceptions of GPs regarding the identification of FASD. By adopting this methodology, the study aimed to uncover barriers and motivations in an unbiased manner, allowing for a thorough examination of the topic without influencing the responses provided by the participants.Purposive sampling was theoretically constructed and adapted as the study progressed to recruit a diverse population of physicians with respect to age, gender, years in practice, type and mode of practice, and location . Each physician was contacted individually by telephone or e-mail. The study was introduced by the researchers  by mentioning the research topic without revealing the research question. Participation was completely voluntary. Informed consent was obtained. Participants were assured of anonymity. Only volunteers were selected to participate in the study. The criteria for non-inclusion were refusal to participate and GPs with a particular type of practice or practicing exclusively unscheduled care.Two frameworks of open-ended questions were developed by the two researchers. They were then modified according to the emergence of concepts and the construction of theory  of the GPs were not recorded in order to limit the risk of identification. Interviews were numbered and transcribed anonymously. All audiovisual and voice recordings were destroyed at the end of the transcription process.The analysis followed the principle of anchored theorization. The interviews were transcribed verbatim and coded using Nvivo® version 11.3 software, first in an open-ended manner and then gradually organized into axial coding. As the analysis progressed, a categorization of these codings revealed concepts that were related. Theoretical saturation of the data was sought through additional interviews. The analysis of the interviews was carried out by four researchers involved in the data collection , and then the results were also analyzed by two other researchers (SL and MS) to ensure the triangulation of the data.An anonymization step was performed during the data processing in order to avoid any personal data collection. In accordance with current regulations, a request for compliance with the reference method (MR004) was submitted to the Commission nationale de l'informatique et des libertés (CNIL), registered under number 2219132v0.Initially, 31 GPs were contacted to participate in this study. In the end, 20 interviews were recruited. Of the remaining 11 GPs, some did not respond due to lack of time and interest in the subject, others responded positively but further data collection was no longer necessary because the theoretical saturation of data had been reached  for 9 women and 11 men. The mean age of the GPs at the time of the interviews was 44.7 years , with a mean number of years in practice of 18.8 years .Interviews were conducted until theoretical data saturation occurred at the 15th interview. The last 5 interviews were conducted to verify the absence of new data useful for theory construction. The data or results analyzed were not shared with the participants.General practitioners (GPs) face numerous and diverse barriers to identifying pregnant women who consume alcohol and individuals with FASD in the pediatric and adult stages. These obstacles stem from both intrinsic factors related to the GP profession and extrinsic factors related to the societal context, particularly in Réunion. Intrinsic barriers are related to the challenges inherent in the role of the general practitioner, while extrinsic barriers are related to the prevailing taboo surrounding alcohol, especially for pregnant women, and to the social characteristics specific to Reunion.I think that women don't talk about it too much...it's true that uh...we feel that it's more taboo for women than for men." (GP 15). A denial by some GPs who, although aware of their prejudices, said they were less likely to broach the subject and underestimated alcohol consumption in this population: "It is said that alcoholism is more hidden, more secretive among women, that they talk less about it, and it is true that, as a result, it is a problem that I broach even less often with women" (GP 19).The idea that alcohol is taboo in society, especially among women, led to the patients' denial of its use: "There are more advertisements for rum than for FAS..." (GP 1). Nevertheless, the prevention campaigns were considered effective by the doctors and led to a good awareness of the population of the dangers of alcohol in general: "We have the impression that there is still better knowledge on the part of the general public." (GP 11).GPs also expressed a sense of powerlessness in the face of paradoxical social injunctions regarding alcohol advertising in Réunion: "I think that today the majority of women know that they shouldn't drink alcohol during pregnancy...well, there are a lot of messages that are being spread lately...on the radio, also on billboards..." (GP 7).Overall, GPs felt that, thanks to mass prevention campaigns, patients were well aware of the importance of not drinking alcohol during pregnancy: "Often at the pregnancy discovery consultation with the prescription of beta-HCG and then afterwards we give the little booklet and there we explain the risks during pregnancy with regard to food, tobacco, alcohol" (GP 20).Alcohol and tobacco were often discussed at the first consultation at the beginning of the pregnancy and then less or not at all during the follow-up: "I tell her that from now on it's zero... we have to set the bar on alcohol" (GP 6).The GPs advocated abstinence from alcohol during pregnancy: "Well, FAS, I don't see it... or I miss it completely..." (GP 7). The low prevalence of FAS meant that GPs had little experience of the condition. They reported that, despite its high local incidence, they did not think about identifying it. "Afterwards, it is not something that I tend to detect in babies, even though I do a lot of pediatrics and prevention in children" (GP 19).Awareness varies according to the personal experience of each doctor. Many GPs considered FAS to be a syndrome rarely seen in general practice: "Well, how can I put it? FAS is still a bit strange for me. Well, it's clear that I feel like I don't know enough about it overall..." (GP 7). This lack of knowledge was accentuated by the great variability of the non-specific symptoms that make up the condition: "After that, it's probably more complex...there are different forms and it's not 1 or 0. It's polymorphic." (GP 3).This lack of experience led to a general lack of knowledge about the signs that can identify FASD: "I don't feel that I am particularly trained now" (GP 14).Overall, GPs reported a lack of training in this area: "Pregnant women, it's true, we don't see them that much. We see them from time to time ... yes, when they are sick ... well, often it is rather the gynecologists who follow them" (GP 16).Overall, they lamented a gradual decline in antenatal care as it became the domain of midwives and gynecologists. GPs are consulted by patients for acute pathological episodes: "So I didn't make a diagnosis, in the sense that the children I know who have it, have always been diagnosed beforehand" (GP 19) and "They are examined by the pediatrician in the city or in the hospital before they come to the GP" (GP 1).The GPs haven’t reported an impression of being in the first line for diagnosing patients with FASD. They remained uncertain about the pathway of care that lead to the diagnosis. Diagnosing FAS was often made by other health professionals: "I'm really embarrassed because ... There was REUNISAF before... and now I don't know..." (GP 6) and "Oh no, I don't know... maybe the children's hospital... no, I don't know, I would have to look, I don't know" (GP 9).Many had doubts about the care pathway following the diagnosis was made: "As a general practitioner, honestly, we're going to do our job of alerting as soon as we realize there's a psychomotor delay or whatever, but ... like anything, I don't mean FAS more than anything else" (GP 13) or "I'm qualified to assess the child's development, so I refer them to the specialist who will do their job of diagnosing a developmental disorder, and in the spectrum of developmental disorder there may be FAS." (GP 19)The specificity of FASD symptoms within other neurodevelopmental disorders remained unclear for most GPs. According to the participants, physicians' goals should focus more on identifying acquisitional delays in general in order to refer the child early for a specific diagnosis and treatment: "It's true that when you have a consultation where you go from one to the other to ask yourself questions, you need to have time." (GP 11) or "it's not often easy and we don't see the children for very long..." (MG 16).GP related a perception of pressure of time in their day-to-day clinical time. Curative-centered practice remained the norm according to the GPs. Their meetings follow one on another at a pace leaving too little room for preventive and screening interventions. Identifying this disorder was all the more complex because of the limited time available for a medical meeting: "GPs reported that obstacles to the identification of FASD were the taboo and the paradoxical injunctions of society, the limited knowledge and experience, the non-specific and highly variable symptoms, the ambiguous classification and method of diagnosis involving the mobilization of a multidisciplinary team, and the length of consultations. The results of the study showed that GPs did not prioritize the identification of FASD in adults and expressed skepticism about the effectiveness of treatment, believing the disorder to be irreversible. In contrast, GPs were confident in identifying neurodevelopmental disorders resulting from a variety of causes, but were concerned about the long waiting times for access to specialist care.Practicing in Réunion means taking local specificities into account. In Reunion, it is traditional to consume alcohol for social reasons (family celebrations or others), but also for therapeutic reasons . A study carried out among Reunionese women with children suffering from FASD revealed a feeling of shame and guilt leading to a denial of their alcohol consumption. In fact, the patients reported that it took them a long time to admit that their drinking was excessive and to speak of "alcoholism" . This deGPs highlighted another important aspect of La Réunion, namely the ubiquitous presence of alcohol advertising, which actively promotes its consumption. The GPs noted that this advertising environment plays a role in encouraging alcohol consumption among the population. The strong impact of these advertising campaigns on the population leads the general practitioners to feel that prevention is worthless . This isAn Australian study found that health professionals did not systematically prevent alcohol use during pregnancy because they believed that pregnant women knew about the harmful effects of alcohol on the fetus and had stopped drinking as a result . This isParticipating GPs emphasized the importance of addressing alcohol use during the initial pregnancy consultation. This particular moment was identified as a critical opportunity to provide lifestyle advice and guidance, prompting GPs to actively inquire about alcohol use at this early stage of care. Many brief alcohol interventions for pregnant women are effective in increasing abstinence during pregnancy and preventing FASD, but even a single question about alcohol use during pregnancy can be powerful . They weConsistent with previous research, studies to date have reached a consensus on the central role of GPs in the prevention and detection of FASD. These studies have recognized and supported the significant contribution of GPs in both preventing cases of FASD through appropriate counseling and education, and in identifying individuals at risk or already affected by the disorder , 30. HowHealthcare professionals have difficulties in identifying FASD because of the wide variety of symptoms, the lack of standardized diagnostic tools, and the limited time available for consultation , 35, 36.A study comparing 5 diagnostic methods –39 conclSeveral attempts at classification have been proposed to assess the severity of the effects of alcohol on the fetus and to make a diagnosis: Dehaene proposed FAS type I, II, III, IV according to the severity of dysmorphic damage and the knowledge of prenatal alcohol exposure . The 199The lack of knowledge of local specialized referral health care providers for patients diagnosed with FASD has been reported in the present study as well as in previous studies , 15. TheIt is even more difficult to improve the prognosis if the diagnosis is made late, for example in adulthood. In addition, GPs in this study rarely mentioned adults with FASD and more often spoke about identification in the pediatric population, suggesting that the prevalence of undiagnosed FASD is underestimated , 43. FASGPs agreed that their role was more important in identifying and referring children with FASD in general than in FASD itself. In fact, they objected that FASD is difficult to diagnose in practice for various reasons already discussed: time constraints, knowledge, or the need for a multidisciplinary team. Rare GPs feel confident in recognizing and referring children with FASD . In addiThe amount of time spent on prevention in the consultations of French general practitioners remains low compared with the time spent on curative care. The results of the study Pelletier-Fleury N and Al suggest that 50% of GPs report little or no primary prevention activity in almost 75% of their daily consultations .The average consultation time for a French GP is 17 minutes . This isThe strength of this study is the focus on GPs’ interpretation of their clinical role in identifying patients with FASD. We interviewed patients from a wide range of the French region with the highest prevalence of FAS, with a higher probability for GPs to meet patients with FASD.Among the limitations of the study, three of the interviews were conducted at the physicians' place of work between consultations or at the end of the day, which may have had an influence on the length and quality of the interviews. Finally, the interviewed population could sometimes have answered a little less spontaneous and more thoughtful. A more relaxed attitude was regularly observed at the end of the recording with some-times more spontaneous discussions. Furthermore, it is noteworthy that more than one-third of the contacted GPs expressed disinterest in participating in the study. This potential sampling bias raises the concern that the GPs who did participate may have had a greater interest or motivation in identifying alcohol consumption in pregnant women or FASD. As a result, the findings should be interpreted considering this potential bias, which may limit the generalizability of the study's results to the broader GP population.Providing training to general practitioners (GPs) in early identification and intervention for alcohol consumption in both the general population and specifically among pregnant women .Focusing on the identification and coordination of care pathways for children affected by neurodevelopmental disorders (NDDs) such as Fetal Alcohol Spectrum Disorders (FASD).Actively identifying and referring adults suspected of having FASD for further evaluation and support.Implementing educational initiatives targeting young women in middle and high school to raise awareness about the risks associated with alcohol consumption during pregnancy.The study has highlighted several potential perspectives for practice based on its findings, which include:Furthermore, future studies are recommended to consider patients' perspectives on the role of GPs in identifying FASD or other NDDs. It is also suggested to conduct consensus-building approaches to develop a standardized assessment tool for diagnosing FASD in Réunion, ensuring consistency and reliability in the diagnostic process. These recommendations aim to improve the identification, intervention, and support provided by GPs for individuals affected by FASD and other NDDs.Reunion is the French region with the highest documented prevalence of FASD. However, the GPs reported difficulties in identifying patients, due to a lack of knowledge and experience, but also due to the difficulty of diagnosis with a great variability and lack of specificity of FASD symptoms, and the absence of a consensus on the classification or diagnosis of FASD. They reported a lack of knowledge about caregiving strategies and local providers. It is highly important to limit alcohol advertising, reinforce prevention messages about alcohol use among pregnant women and to have a well-identified care pathway to which GPs could refer their patients with NDD in order to benefit from an early functional assessment and care.Additional file 1: Appendix.


HACCP  and modern quality management systems have a significant impact on public health in the food industry. These systems ensure that food products are safe for consumption by identifying and managing potential hazards at every stage of the production process. To stimulate ongoing studies in both developing and underexplored areas of inquiry, this research synthesizes and organizes the contributions made in this field. It examines more than 40 years of studies from Scopus data base on HACCP and modern quality management systems in the food industry using the VOSviewer software version 1.6.18  and bibliometrix R-package. This represents, to the authors’ knowledge, the first bibliometric analysis undergone in this direction. The graphical framework demonstrates the highest developments in research and the literature review investigates barriers and opportunities of implementing HACCP in food industry organizations. Findings indicate that until the beginning of the 1990s, there was not a large number of scientific production in the field of HACCP and modern quality management systems in the food industry. The USA were the most prolific affiliation terms of scientific production until 2012, when studies from Italy, the United Kingdom, China and Greece intensified. Currently, the most prolific country in terms of publications is Italy. In terms of global cooperation, the United Kingdom, The United States and The Netherlands represent most active nations on this topic Motor themes that reflect the main interest of the researchers include food diseases, quality control, hazards or food supply. The study also provides future research directions regarding food quality and safety management. These should be focused on improving the safety, quality, and sustainability of food products, while also adapting to changing consumer demands, emerging risks, and regulatory requirements. Regardless of their position in the food chain, product safety represents a very important concern for all traders. Also, consumers aware of the link between food, diet and health are increasingly interested in safe food . The comThrough Regulation no. 852/2004 the general hygiene established requirements that must be respected throughout the food chain . The regIn Cyprus, with the assistance of consultancy firms, the government helped food companies implement the Food Hygiene Directive 93/43/EEC following EU accession in 2004 . In SerbBy applying HACCP requirements for SMEs that provide services in this field, in South Korea, Lee and Hong  determinThe implementation of the food quality standards is not an easy task for companies, especially if they come under the small business category where the number of employees is small. The application of HACCP analysis, especially the establishment of critical control points and identification of hazards, requires thorough skills and knowledge on the part of quality managers . In thisThe HACCP aims to monitoring the entire production flow in order to achieve a safe product according to the applicable standards . The benRosak-Szyrocka and Abbase , throughFollowing the technical approach to the implementation of the management system at the level of a company in Kazakhstan, Akhmetova, Fuschi and Vasiliunaite  noted thThe “farm to fork” principle requires all companies in the food industry to rethink the way they implement their food quality management system in order to comply with sustainability criteria in the food chain .Lack of knowledge of the HACCP benefits, lack of managers' motivation to implement this system, lack of company staff training are barriers to the adoption of HACCP in the food industry. In addition, there are the high costs associated with the correct implementation of HACCP. The managers of food businesses need to be aware that the application of HACCP rules leads to increased performance of production processes, reduced losses and therefore lower costs. The improvements of customer relationships, as well as an increase in the customer portfolio and the firm's prestige are the benefits of running the company's business according to HACCP rules . AnalyziRQ1What are the studied barriers of implementing HACCP as modern quality management system in food industry organizations and through what research methodologies?RQ2What are the explored opportunities of implementing HACCP as modern quality management system in food industry organizations and through what research methodologies?RQ3What is the frequency of scientific production on HACCP and modern quality management systems in the food industry?RQ4Which are the most important journals, countries, research organizations in terms of scientific knowledge on HACCP and modern quality management systems in the food industry?RQ5What are the main research clusters referring to HACCP and modern quality management systems in the food industry?RQ6What are the main future research directions regarding the analyzed topic?The main research questions of the current study are the following:The novelty and most important contribution of this research resides in the fact that it represents the first bibliometric investigation of HACCP and modern quality management systems in the food industry. Furthermore, another major feature of this study is that it offers a thorough evaluation of barriers and opportunities of implementing HACCP as modern quality management system in food industry organizations.In order to investigate novel approaches in the field of on HACCP and modern quality management systems in food industry, researchers may find this study useful because it offers a general grasp of the completely investigated domain. Additionally, this research can help organizations in the food industry, public and private universities, as well as research centers, gain a deeper understanding of the future paths for the development of HACCP and other modern quality management systems in the food domain.2The development and implementation of management systems that would guarantee the safety of food products for the consumer and also provide the required and stable quality of products is becoming increasingly important in the food industry of all countries as a result of the growing perception that food products pose a significant health risk. The challenge of adjusting to the realities of a market economy is one of the most pressing issues facing businesses today. When it comes to today's business climate, a company's ability to stay afloat and maintain a strong position in the goods market is directly proportional to its degree of competitiveness. Consequently, competitiveness is linked to price stability, product quality, worker productivity, and resource conservation. Doing so is feasible, provided the business in question employs a tried-and-true quality management system .2.1Food can be affected by a number of pathogenic factors that will alter its physical, chemical and sensory quality. Whether they originate from the overuse of pesticides, the environment, the water, the production process, the transport or handling processes, these pathogens are detrimental to health. The food safety can be ensured through food quality control.At the EU level, the Directive 93/43/EEC obliges economic operators, using the HACCP method, to identify essential food safety activities, to establish, to maintain and to review the necessary safety procedures. All this is part of the quality management system (QMS) and its formulation is the responsibility of each food company . This syThe food safety must be approached in a systemic way, by applying the seven basic principles of HACCP: (1) conduct a hazard analysis, (2) identify critical points, (3) establish control limits, (4) develop monitoring procedures, (5) establish corrective actions, (6) establish audit procedures, and (7) keep records . The HACFood safety requires the establishment of a long-term management strategy, through which connections are established between all existing quality management systems in the organization. The development of a QMS requires staff training, rethinking the way activities are carried out , awareness of the impact that each action has on the quality of the food product. Thus, QMS encompasses elements relating to the organizational structure , the way processes are carried out (with a presentation of specific activities and the duties of each person involved), process auditing, etc. QMS should be seen at organizational level, as a concept designed to enable the continuous development of the company, to exude confidence in relations with business partners and consumers, to demonstrate the company's ability to provide quality products. QMS is a proof of compliance with quality standards.2.2Food safety management systems improve several production processes, including HACCP implementation, health and safety procedures, supplier management and traceability ,26. ImplFood safety management systems can enable food production organizations to increase their profitability and competitiveness. Implementation of food safety management systems is also associated with increased employee productivity , customeThe International Organization for Standardization (ISO) was founded in 1947. More than 19,000 international standards geared toward businesses and technological groups have been published by it thus far. The standards published by ISO serve as the foundation for the quality and food safety management systems. These standards are created using a complicated process that combines the extensive information and experience amassed by scholars from throughout the globe. By putting the relevant international standards into practice, the food business becomes more productive and the barriers to the global market are eliminated. Additionally, conformity with international standards provides buyers with additional assurance that the products are secure, effective, and environment-friendly. Utilizing ISO provides many advantages to organizations, including lowering manufacturing costs, improving efficiency operations and optimizing production lines, boosting customer satisfaction and quality, expanding, preventing the emergence of trade barriers, facilitating access to international markets, boosting market share, boosting productivity and an organization's competitive advantage, developing ecological advantages, and preserving the environment.The British standard BS 5750, which was introduced in 1979 and stands for the quality assurance standard based on the NATO series of standards, particularly AQAPS, is the foundation for the ISO family of standards. The family of ISO 9000 standards, which includes the most well-known ISO standards, takes a diverse approach to various aspects of quality management. Organizations which seek to guarantee that their services and products always fulfill client needs and that the quality assurance system is updated on a regular basis can use these standards as a set of recommendations and tools.The level of knowledge of quality assurance systems can be evaluated from at least two perspectives: identifying the number of organizations, companies, institutions and factories that have implemented such management systems and identifying in their framework of the staff's level of knowledge of the requirements imposed by them. Companies without certification might nevertheless use and apply quality assurance standards. Yet in recent years, clients have become more demanding and one of the first requirements they impose when choosing suppliers is the presence of a certificate attesting to the fulfillment of the requirements set forth by the quality assurance standards. The effectiveness of a food quality and/or safety assurance system depends on the individuals within the businesses that have adopted and/or certified it.The existence of a very large number of distinct food safety standards, which food suppliers must adhere to and certify in order to be able to bring their products to the market, is exerting pressure on the global food business. The rising costs of certification in conjunction with the strict private standard requirements suggest an increase in costs without improving food safety. As a solution to these issues, ISO has created a solid standard that will be acknowledged and backed by global consensus, creating good practice norms globally.With the title “Food safety management systems - the requirements for any organization in the food chain,” ISO 22000 was released in September 2005. The Food and Agricultural Organization (FAO) and the World Health Organization (WHO), which established the Codex Alimentarius Commission, also made contributions to the creation of this standard. Even today, the HACCP  codex is recognized as a crucial management tool for managing food safety, especially when used in conjunction with an auditable management system. In reality, ISO 22000 will make it simpler for businesses all over the world to implement it in a way that is unique to each product or nation.Over the last 10 years, scientists have made several significant discoveries related to quality management in the food industry. There have been significant advancements in food safety technology, including the development of rapid testing methods and the use of blockchain to track the origin and movement of food products. These technologies have helped to reduce the risk of foodborne illness and improve the traceability of food products. Dr. Aliyar Fouladkhah and his team developed a rapid testing method to detect salmonella in food products, which can provide results in as little as 24 h . Other rScientists have recognized the importance of effective supply chain management in ensuring food safety and quality. This includes identifying potential risks in the supply chain and implementing measures to mitigate those risks. Dr. John Spink and his team have been studying food fraud and the risks it poses to the food supply chain . Their rResearchers have explored the use of artificial intelligence (AI) in the food industry to improve quality control and reduce waste . For exaThe implementation of quality management systems, such as HACCP, has become increasingly important in the food industry. These systems help to ensure that food products are safe and of high quality. It is stated that the implementation of Hazard Analysis and Critical Control Points (HACCP) in small-scale food processing facilities can help to improve the safety and quality of food products . Also, tThere has been a growing focus on sustainability in the food industry, including the use of sustainable farming practices and the reduction of food waste. These efforts can improve the quality of food products and help to protect the environment. Dr. Adrian Muller and his team have been researching the environmental impacts of food production and consumption, and have highlighted the need for more sustainable farming practices . Dr. Sha2.3In past years, food safety issues have occurred often, threatening the health and safety of people's livelihoods and lives. The notion of “from farm to table” has been promoted, but the most pressing issue for the government, the related businesses, and the authorities is still how to implement an effective food safety management system. HACCP is a new form of economic regulation or intervention. It's a private process management tool. Now it's mandatory for whole sectors, requiring specific risk assessment to relate HACCP regulations to public health results. Food safety requirements under obligatory HACCP are implicitly defined by risk assessment . HACCP iThe HACCP concept was first developed in the 1960s by the U.S. National Aeronautics and Space Administration (NASA), working with Pillsbury, one of the world's largest producers and cake manufacturers of cereals and other food products, to ensure crumb- and pathogen-free food that had extensive shelf-life properties for space travel—the first pathogen monitoring and measurement requirement imposed on the food industry . DespiteHACCP's efficiency in avoiding food-borne illnesses and reducing food safety hazards depends on proper implementation and utilization . Food coOverall, these and other discoveries have helped to improve quality management in the food industry, making food safer, more traceable, and more sustainable over the last decade. Their research has helped to improve the safety, quality, and sustainability of food products, and will continue to shape the future of the food industry.2.4The fact that companies implement food safety systems increases the confidence of their customers  in the food they sell. The consumers are interested in safe, verified products that do not harm their health. Every year, each country budgets significant amounts of money for the purchase of food to supply establishments where food is needed, such as the hospitals for their patients, the educational institutions , the military units, the institutions responsible for the social care of people, etc.The main problem of public institutions in the process of purchasing food is the insufficient level of knowledge to select the most viable supplier . An impoEU level, the Directive No 24/2014 (Art. 62) entitles the contracting authorities to require economic operators, through contract award notices, to submit the certificates issued by the independent bodies attesting compliance with food quality assurance standards [At the tandards . The conThe tender compliance with all the conditions of the procurement documentation is a prerequisite for consideration . If a teSuch a report, in which the auditors have recorded that the company complies with the quality management rules, constitutes an equivalent document within the meaning of Article 62 of the Directive 24/2016 . The facOn the other hand, the requirement to present a particular certification, such as ISO 22000 , constitThe quality standards implementation based on the HACCP principles, in addition to achieving food safety and customer confidence in the company concerned, allows access for the companies to public tenders and contributes in the same way to the increase of the customer portfolio.2.5HACCP is an important tool for businesses operating internationally, helping them to what can go wrong in food production. Regarding the implementation of HACCP, businesses face both barriers and opportunities when they want to implement such a system.The literature was researched to identify the main barriers, and a selection of articles presenting the challenges faced by various developing and developed countries was performed. The analysis of the main barriers began by searching for relevant articles with the help of Scopus and Google Scholar databases from 2000 to 2021. Only articles in English were selected from the databases used. Therefore, 13 articles considered relevant for the field of study have been analyzed. To identify the most suitable articles, the search included the following keywords: barriers and opportunities, HACCP, difficulties in HACCP implementation, benefits in HACCP implementation, and HACCP implementation. The results for the key barriers for implementing HACCP are shown in Despite the benefits brought by HACCP for the management system of a company active in the food sector, analysing the research listed above, we note that the biggest barrier encountered by economic agents is represented by budgetary constraints, as investments are needed for restructuring the organization and implementation of the new system. Integrating HACCP into the fabric of a business requires ongoing funding for employee training, salary increases, employee training, and hiring of skilled labour.Another barrier, mentioned very often in the literature refers to the knowledge and perception of employees, regarding the implementation of HACCP. There is a lack of motivation on the part of the management, but also of the employees. None of the study participants went through a training program regarding HACCP implementation. It was noted that the organizations participating in the study consider their products safe, and they do not require the implementation of such a plan. Thus, considering that their products are safe, they do not want to accumulate new knowledge to approach HACCP.All the documentation required for implementation and the lack of support from the authorities are other barriers. They are of the opinion that the existence of specialized training programs and support through funds from the authorities is necessary. Also, the implementation requires numerous studies and documents that are carried out by a third party, which according to the companies, complicates the process and makes it more difficult.After analysing the studies carried out within the companies that have implemented HACCP, or intend to do so in the future, a series of opportunities have been extracted, which can allow the business to develop.Among the most listed opportunities were those related to food safety and organizational improvements. The implementation of the HACCP system allows the company to take a more careful approach to food safety, identifying potential hazards at any stage of production. In the framework of HACCP, the dangers  that may exist in food from the moment of handling and manufacture to the distribution and consumption of the product by the buyer, are evaluated. This improvement comes with a number of benefits such as: retaining customers, attracting new customers, limiting complaints, increasing consumer confidence, and maintaining market access.This new system comes with organizational changes from top management to employees. HACCP provides the perfect framework within the company where employees work happily for the success of the business.Even though the high implementation costs are always mentioned, the financial opportunities that appear with the implementation of the HACCP system were also highlighted. Its implementation allows the company to increase product prices, lower production costs, eliminate errors and reduce complaints, thus eliminating part of the expenses. Customer trust increases for companies that have implemented such a system, choosing their products because they are safe, thus revenues are increasing.The implementation of HACCP is an essential component for reducing risks and increasing the quality of products offered to consumers. We believe that there should be more research highlighting the importance and benefits of implementing such a system. Also, at the government level, it is essential to have training and information campaigns for companies in the food industry. It is necessary to involve governments by highlighting the problems encountered by companies that have not Implemented such a system. Thus, consumers will turn to secure companies, and companies will focus on implementing such a system to attract customers.The main barrier to the implementation of HACCP is the financial constraint, especially for small and medium-sized companies that cannot afford such a financial effort, the existence of a source of financing and consultancy is necessary.3Scientific production evaluation provides the foundation for many significant decisions, including organizational development, university funding priorities, legislation development, cooperation opportunities, and many others . The impThere are many reasons to conduct bibliometric and systematic reviews, but they are most frequently performed to provide a summary of prior research on a particular subject which may be used to investigate, assess, and synthesize current research, investigate at specific research issues, and suggest future research directions. The methods employed to perform reviews have evolved to accomplish a variety of objectives as scientific literature has expanded and multiplied in the electronic era. In the current digital world, scientific production is being created at a faster pace, that generates difficulties for academics, regulators, researchers, and professionals to stay current with developments in their fields .The interest in bibliometric analysis as a significant scientific endeavor has grown significantly in recent years. Various study domains, such as: agronomy , businesIn order to establish correlations using social network analysis to obtain a broad view of the research area and using keyword network assessment to find the most crucial topics and the relationships between them , bibliomThrough the use of bibliometric analysis, the current study aims to assess how HACCP influences modern quality management systems in the food industry. In consideration of this, the article's aims are to present a critical overview of prior research, identify trends and patterns in HACCP and modern quality management systems in the food industry research, and highlight the most important related topics and study gaps using a comprehensive bibliometric analysis. By rigorously identifying and evaluating the scientific production, major contributions to the field, and major future research directions, the results show the structure, evolution, and important trends and implications of the HACCP and modern quality management systems in the food industry research field. Moreover, through an in-depth systematic review, this research provides a thorough evaluation of barriers and opportunities of implementing HACCP as modern quality management system in food industry organizations.Since it encourages rigorous planning, consistency in execution, and transparency that enables study replication, a protocol is crucial for bibliometric analysis, as it enables researchers to anticipate difficulties, obviate arbitrary choices, uphold study integrity and responsibility . There aThe research protocol combining bibliometric analysis and systematic review  containsStep 2of the research protocol entails carrying out the review procedure using the subsequent methods:-For the systematic review: synthetizing the barriers and the opportunities of implementing HACCP in organizations.-For the bibliometric review implied applying the following techniques ,82:1.Descriptive statistics - examines the growth of annual scientific output, the spread of publications by document type, subjects of study, highly prolific academics, highly productive journals, and the dissemination of scientific production by countries and funding agencies.2.Performance analysis - which studies whether scientific production has evolved in connection to the citations acquired for the studied works.3.Science mapping, performed using VOSviewer program  and bibliometrix R-package, it encompasses three subtopics: conceptual structure: co-word analysis  mapping technique VOSviewer was utilized . It alsoi, R stands for the number of researchers who are included in the analysis and For many units of analysis, including researchers, research institutes, and countries, co-authorship networks can be built. Equation i and j appear together. i and j appear together in the abstracts.The association strength is a method that VOS uses to normalize co-occurrence frequencies. The association strength  follows  (Eq. (2)i and j is calculated using the association strength as follows [i and j and i and j.The relationship  follows  (Eq. (3)i and j, as accurately reflects their relationship http://www.bibliometrix.org).The VOS mapping approach creates a map based on the similarity matrix after computing the similarities. Let n represent how many objects need to be mapped. The VOS mapping algorithm creates a two-dimensional map in which the items are positioned so that the distance between any two items, ed apart . A conceThe analyses of the final results of bibliometric and systematic review, presentation of research findings, namely a thorough content analysis and evaluation of scientific production, are included in Step 3 of the research methodology. Furthermore, trends, possible areas of study and study limitations are identified and presented.4The main results obtained after the centralization of the data through Bibliometrix from the R program are presented in Lotka's law is the first scientific or informetric rule. A bibliometric example is Lotka's rule of scientific productivity, where the number of authors was plotted against the number of contributions made by the writers on a logarithmic scale. It details the regularity of author contributions in every specific topic . For theThe relationships between the main 10 authors’ countries (left side), abstract words (middle) and keywords plus (right side) are depicted in Based on the processing of the data from the Scopus database, 361 articles were published between 1978 and 2022. Although the first two articles were published in 1978, until 1982 no other indexed document was published in Scopus on this topic. The academic community had not yet paid much attention to the investigated topic in this period. However, several ground-breaking articles created the framework for the study of HACCP and modern quality management systems. Also, until the beginning of the 1990s, there was not a large number of scientific production in the field of HACCP and modern quality management systems in the food industry. For this reason, The number of publications represents a leading determinant of a field's development base and a guideline to forecasting developments. Based on an examination of the distribution of yearly scientific production, We identified that the majority of the most-cited publications in the topic of HACCP and modern quality management systems in food industry were published in the last five years, namely during 2018–2022, indicating that the research findings during this time period were more important and relevant to other scholars. We did this by examining the local and worldwide citation rates of the articles in this field. Regarding the document types published in the field of HACCP and modern quality management systems in the food industry, it is found that most of them are articles, respectively 58% of the total scientific production. These are followed by conference papers (n = 14%) and reviews and book chapters, each with a proportion of 12% of the total. The conclusion that derives from The fourth research question aims to investigate the present status of international collaboration on HACCP and modern quality management systems in the food industry. In order to achieve this objective, a series of analyzes were performed based on information processed from Scopus, Biblioshiny, as well as a series of elements taken from Google Scholar, in the case of authors and journals that have public profiles on this platform.A first analysis concerned the top 10 prolific authors with scientific production on HACCP and modern quality management systems in food industry . The valThe most significant author in terms of articles produced is Luning PA from Wageningen University (The Netherlands). During the 18-year period, Luning wrote six publications on this topic, getting more than 10,800 citations for the overall scientific production. The H index from the Google Scholar is 54 and i-10 index is 126. Pieternel Luning and her group researched various themes such as culturally framed food safety management systems , shortcoIt is important to highlight that the majority of the authors in The next step of the research analyzes the countries’ production over time illustrated in Regarding the most prolific corresponding authors' country, the United Kingdom (UK) stands out as the country from which 90 articles with corresponding authors were published. UK is also the country with the most single country publications (SCP). SCP are publications with all of the authors originating from the same country, and thus indicating intra-national cooperation . The difThe most frequently cited publications are one of the most significant markers to measure the hot issues in a professional field. Comparing articles generated with and without international collaboration, it highlights that scientific production created through international collaboration (MCP) received more citations per article than documents published by authors from a single country. This suggests that raising the number of citations requires worldwide cooperation. It is noteworthy to mention that the countries with the lowest levels of international cooperation, like Australia and Spain, had fewest citations per publication. The country with the most citations is Belgium (n = 733), also having an average number of articles citations. This is followed by UK, USA, Netherlands and Greece, each registering over 300 citations.To deeper analyze the international collaboration on HACCP and modern quality management systems in the food industry, a country cooperation network graph was created using VOSviewer software. This examines the most successful international relationships and illustrates a map of the co-authorship countries. The circles' size reflects the number of documents that researchers from most prolific countries have written, and the colors symbolize the working groups . There wEach academic publication has a distinct goal, range, concentration, and area of interest. Popular journals are a significant source of cutting-edge research content in addition to representing the preference and recognition of the majority of researchers in this discipline. Identifying articles from well-known publications can also help researchers identify their research findings with accuracy . The jouNP – number of publications; Q – quartile; N/A – no available information; Cite Score - evaluates the journal impact by calculating for the current year the total number of citations a journal has received during the last four years divided by the total amount of papers published in that journal during the four years. CiteScore Tracker – is a current evaluation of a journal's performance over the course of the year updated every month. SJR - the SCImago Journal Rank takes into consideration the number of citations a journal receives and the reputation of the journals from which those citations originate, estimating the prominence of scientific publications. SNIP - the number of citations received to publications issued in the previous three years divided by the total number of works published in the previous three years.To analyze the distribution characteristics of the major research affiliations a and fouRegarding funding sponsors, the main institution is the European Commission with four documents, followed by the National Natural Science Foundation of China with three affiliated documents, National Institutes of Health (USA) and National Science Council (USA), both with two documents each. It should be noted that most publications do not have their affiliation included in the published documents, not being sponsored by foundations, so this information is not found in all articles. There are 328 papers that do not have the funding sponsor included.Bibliographic coupling usually develops while publications cite the same work. This can show the relative merits of a certain publication to a corpus of related works and the approach can be utilized with publications, journals, scholars, institutions, and nations. By examining the bibliographic coupling of authors, it is feasible to determine which publications and writers are connected by many citations. For this stage of our research, we developed a co-citation analysis using the VOSviewer software with the aim of investigating the most-cited scholars. The most popular method of evaluating the impact of authors, journals, and publications is through the examination of article citations since it identifies the relevant authors in the field of study ,78. Fig.Research question five aims to clarify how do the keywords referring to HACCP and modern quality management systems in the food industry cluster together. Keyword analysis illustrates relevant research areas and identifies interlinks in various topics of research. Keyword analysis can rapidly and reliably capture the issue of HACCP and modern quality management systems in the food industry since keywords serve as a high-level summary of the articles’ subject. The keyword analysis was evaluated using VOSviwer and it is illustrated in The sixth research question aims to provide information regarding the main future research directions regarding the analyzed topic. In this sense, the thematic evolution option from Bibliometrix software was used. Theme mapping is a technique that combines the benefits of conventional indexing and artificial intelligence with the intention of exploring and justifying research themes. The issues brought on by a big volume of disorganized information can be resolved through the theme map. The workload and significance of the topic are represented by the horizontal and vertical axes, which show centrality and density, respectively. The position of a theme's quadrant on the subject map can be used to determine where it is in its present development .The thematic map is divided into four quadrants: niche themes, emerging or declining topics, basic themes, and motor themes, depending on the importance and degree of growth of the topic . Niche tTo analyze the main future research directions regarding the analyzed topic, Word Dynamics from the Bibliometrics program was used using the database downloaded from Scopus. This organizes the words most often found in the articles in the database according to the year of use. According to data processing, the most relevant words in the trend are food safety, having the most appearances in scientific production in recent years, followed by quality control and risk assessment . From th5The results of this study, including the research framework, may be useful to academics and to a broad range of organizations in the food industry looking to implement a change that produces insightful analysis.By using more databases and visualization techniques, the resulting outcomes may be expanded. The usage of additional beneficial visualization tools like Bibexcel, Gephi, or Pajek is an option. Therefore, useful data may be provided to offer specific answers to study topics. In the near future, a more thorough analysis might be conducted by involving other databases such as Web of Science in order to gather more data insights on the search themes. The breadth of the study and the subject's expandability can both be expanded with the addition of fresh information and sources. This research can be updated using the same methodology as the corpus of papers and studies grows, adding fresh overlays and ultimately strengthening the subject.•Assessing the impact of food labeling and consumer education on food safety: There is a need to more accurately assess the impact of food labeling and consumer education efforts on consumer food safety practices and knowledge. Research could explore consumer education campaigns to better inform consumers about food safety practices.•Implementation of digital technologies: The use of digital technologies, such as the Internet of Things (IoT), can provide real-time monitoring and analysis of food production processes, and can help to identify and mitigate potential quality issues. Moreover, research is needed to explore innovative technologies, such as robotic systems, that can help to improve food safety management systems and reduce the risk of foodborne illness.•Exploration of emerging risks: As the food industry continues to evolve, emerging risks, such as those related to novel food products or changing consumer preferences, will need to be identified and addressed.•Investigating new technologies and processes to improve food safety: There is a need to assess the effectiveness of new technologies and processes in improving food safety, such as computerized monitoring systems and robotics, in industrial food production and processing.•Assessing the efficacy of risk communication and risk assessment strategies in practice: There is a need to better understand how risk communication and risk assessment strategies can be used in practice to ensure food safety. Research is also needed to assess the effectiveness of the different communication strategies and their impact on consumer food safety.•Researching improved methods to store and transport food safety: Research is needed to identify the most effective methods for storing and transporting food safely, and evaluating the impact of improved storage and transport practices on food safety.•Exploring different methods to manage food safety across international food systems: Research is needed to identify the best strategies to effectively manage and monitor food safety measures across different countries, cultures, and food systems.•Assessing the effectiveness of food safety regulations: Research is needed to assess the effectiveness of food safety regulations, and to identify ways to improve compliance with these regulations.•Investigating the impact of food labeling and consumer education on food safety: Research is needed to explore the impact of food labeling and consumer education efforts on consumer food safety practices and knowledge.The main future research directions regarding food quality and safety management are the following:Overall, future research in the field of quality management and HACCP will be focused on improving the safety, quality, and sustainability of food products, while also adapting to changing consumer demands, emerging risks, and regulatory requirements.6In order to shed light on the state of research and trends in the field and give researchers and industry representatives a foundation for further work on HACCP and modern quality management systems in the food industry and identifying the barriers and opportunities of implementing HACCP in organizations, the goal of this study was to analyze the scientific production on the HACCP and modern quality management systems in the food industry in the time frame 1978–2022 using a bibliometric approach as well as a systematic review.The objective of this article was to carry out a global review of HACCP trends as well as to highlight the relevant topics covered in the research papers on HACCP and on the modern quality management systems within the food industry. Main findings illustrate that scientific production in the field of HACCP and modern quality management systems in the food industry intensified after the 1990s, with the USA being most prolific affiliation terms of scientific production until 2012. Recent studies from Italy, the United Kingdom, China and Greece intensified and currently, the most prolific country in terms of publications is Italy. The most active nations in terms of global cooperation are the UK, The USA and The Netherlands. Main motor themes that reflect the main interest of the researchers refer to food diseases, quality control, hazards or food supply. Emerging or declining topics include several less important topics such as fish, mycotoxins or personal hygiene. Future research should be focused on improving the safety, quality, and sustainability of food products, while organizations adapt to evolving consumer requirement, emerging risks, and regulatory requirements.The bibliometric analysis is of interest to researchers as well as to companies involved in the food industry. The scientists can find in this work discussion topics treated by other professionals, recommendations for addressing other topics of interest in this field, but also proposals for a multidisciplinary approach to science in order to determine new theories and methodologies that are relevant to the food safety.This research received no external funding.Elena Radu, Adriana Dima, Ecaterina Milica Dobrota, Ana-Maria Badea, Dag Øivind Madsen, Cosmin Dobrin, Silvius Stanciu - Conceived and designed the analysis; Analyzed and interpreted the data; Contributed analysis tools or data; Wrote the paper.Data will be made available on request.No additional information is available for this paper.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Oculocutaneous albinism is a congenital disorder that causes hypopigmentation of the skin, hair, and eyes due to a lack of melanin. People with albinism are at increased risk of developing skin complications, such as solar keratosis and skin cancers, leading to higher morbidity. As education is crucial in managing albinism, leveraging information technology, such as WhatsApp, can provide an effective intervention for digital health education.This study aims to assess the impact of WhatsApp as a tool for providing health education among people with albinism.U test was used to compare the pre- and postknowledge scores. Spearman correlation was used to correlate data.The design of the study was interventional. The intervention consisted of weekly health education sessions conducted in a WhatsApp group for the duration of 4 weeks. The topics discussed were knowledge of albinism, sun protection practices, the use of sunscreen, and myths about albinism. They were all covered in 4 WhatsApp sessions held in 4 separate days. A web-based questionnaire was filled out before and after the intervention by the participants. Mann-Whitney P=.01), knowledge of sunscreen (P=.01), and knowledge of sun protection (P<.01) was observed following the intervention. Before the intervention, a positive correlation was observed between age  and education level  with participants’ overall knowledge. However, after the intervention, there was no significant correlation between knowledge and age or education level. A percentage increase of 5.23% was observed in the overall knowledge scores following the intervention.The mean age of the study participants was 28.28 (SD 11.57) years. The number of participants was 140 in the preintervention period and 66 in the postintervention period. A statistically significant increase in overall knowledge (WhatsApp is an effective tool for educating people with albinism and can act as an alternative to the conventional methods of health education. It shows promising outcomes irrespective of the health literacy level of people with albinism. This educational intervention can positively impact behavior change and translate to consistent sun protection practices. The limitations of this study include the possibility of social desirability bias and data security. Oculocutaneous albinism is an inherited disorder of hypopigmentation in which there is little or no production of melanin. People with albinism usually have light-colored skin, white hair, and red eyes. Melanin plays a major role in photoprotection and its lack in people with albinism increases the risk of photodermatoses. These may range from benign conditions like freckles or solar lentigos to more severe skin issues, such as nonmelanoma skin cancers—basal cell cancers and squamous cell cancers. Notably, the prevalence of nonmelanoma skin cancers is 20.9% in Nigeria , 11.8% iPreventing these photodermatoses includes promoting sun protection practices and educating people with albinism, which is crucial for this purpose. Studies conducted in Africa have documented that health education programs can improve compliance with sun protection practices among individuals with albinism ,5.In recent times, IT has revolutionized the dissemination of information, and the use of social media is a prime example. Social media refers to internet-based platforms or application software that enables individuals to communicate, gather, and exchange information, ideas, and images in real time with other users . These pAmong the apps employed in digital health education interventions, WhatsApp holds a unique position. It is a messenger app that enables users to make voice calls and send instant messages, photos, videos, and voice messages over the internet . In contAlthough several studies have used WhatsApp as a health education intervention, there is limited literature available on its application in dermatology in West Africa, specifically for people with albinism -17. The Ethical clearance was obtained from the ethical review board of Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria (NAUTH/CS/66/VOL.16/VER.3/86/2023/039). All study participants gave informed consent. Data anonymity and confidentiality were guaranteed.The study was designed as an educational interventional study. A WhatsApp group was created for the purpose of this study, and it was named People With Albinism Health Education Group. Participants were recruited from various WhatsApp groups for people with albinism in Nigeria, and this was done by sending a group invite link via the group admins to these groups. Participant Disclosure Form  was postThe WhatsApp messenger app was used as the intervention tool. The participants used their smartphones or tablets. The intervention included weekly sessions of health education delivered through text, images, videos, and voice messages, lasting for a month . The topics covered in the sessions were the following: (1) understanding albinism, (2) skin problems associated with albinism, (3) sun avoidance and sun protection practices in albinism, as well as (4) myths about albinism and debunking them. In each session, a group admin educated the group for 1 hour . After eA web-based questionnaire was created using Google Forms, and the link for the form was posted in the People With Albinism Health Education Group. The participants filled out the forms before and after the intervention. The questionnaire consisted of sections consisting of questions on social demographics and 4 domains .The reliability of the questionnaire was analyzed using the Cronbach alpha test and achieved a score of .72. This indicates that the questionnaire demonstrates a reasonable level of internal consistency. The questionnaire was reported in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).Data from the web-based questionnaires was downloaded as a CSV file, and data cleaning was done using Microsoft Office Excel (version 2021). Duplicated and incomplete data were removed. Further analysis of data was done using SPSS . All continuous variables were tested for normality using the Shapiro-Wilk test and found to be nonnormally distributed; thus, median and IQR values were used as measures of central tendency. Age was further classified into 4 groups based on their quartile distribution. All noncontinuous variables were summarized using frequencies and percentages.To create a measure of respondents’ knowledge, their responses were graded as follows: strongly disagree=0, disagree=1, neutral=2, agree=3, and strongly agree=4. Responses to questions that included negative or false statements were reverse-scored. The sum of scores for each person was obtained in each domain, namely knowledge of albinism, knowledge of sun protection, knowledge of sunscreens, and knowledge of myths. The percentage score for each person was determined by dividing their sum score by the maximum achievable score in the domain and multiplying by 100. The percentage knowledge scores thus generated were treated as continuous variables.U test was used to compare the percentage knowledge scores before and after the intervention. Furthermore, Spearman correlation was used to correlate percentage knowledge scores before the start of WhatsApp sessions with age and the highest level of education. We also used Spearman correlation to assess the relationship between percentage knowledge scores after sessions and variables such as the number of sessions attended, age, and the highest level of education. Alpha level was set at P<.05.To compare initial and final responses to individual questions, the Fisher exact test was performed on the frequency of each question. Mann-Whitney A total of 246 people were recruited in the group. The number of respondents to the web-based survey was 140 before the intervention and 66 after the intervention. Conversely, after the intervention, the correlation of knowledge score with age or level of education was weak and not statistically significant. Moreover, the overall knowledge scores and various knowledge domains correlated significantly with the number of sessions attended. The main finding of this study was a notable improvement in the overall knowledge of participants following the intervention. This study assessed the effectiveness of WhatsApp as a channel for providing health education to people with albinism. It is one of the most popular social media apps in Nigeria and can be used to share information, thereby strengthening the link between health care and IT.The median age of the participants was 28 years. This is consistent with the age group that uses WhatsApp the most in Nigeria . A notabSignificant improvement was seen in the overall knowledge score after the intervention, specifically in the domains of sun protection and sunscreen use. This may be a result of using a combination of texts, images, videos, and audio messages during the intervention. The possibility of using multimedia through WhatsApp distinguishes this app from other digital health interventions that rely solely on text messaging. Mayer  stated tComparing the outcomes of this study is difficult due to the paucity of research that used WhatsApp as an intervention tool for health education among individuals with albinism. Pereira et al  conducteAge and educational level of people with albinism correlated positively with the overall knowledge level in the preintervention stage. After the intervention, there was no correlation observed, as the intervention benefitted people with albinism of all age groups and different educational statuses. This implies that the majority of the participants were brought to the same knowledge level irrespective of their age or educational status. This study also demonstrated that the number of sessions attended affected the knowledge levels, highlighting the importance of early involvement of the participants in such interventions to achieve maximum impact. Overall. These findings showed that WhatsApp is a valuable tool in digital health interventions that can be explored in the field of dermatology.The increased knowledge among participants following our intervention may lead to behavior-based sun protection practices. This adjustment in behavior can be reinforced by periodic conversations and reminders regarding albinism and photoprotection in the WhatsApp group. Recent reviews of social media interventions for health behavior change have shown that social media can have a substantial effect on health behavior .With regard to myths of albinism, we noted that there was no statistical significance in knowledge levels before and after the intervention. A possible explanation for this is that most of the participants had a good understanding of the myths about albinism before the intervention. This can be attributed to the educational status of the participants. The highest educational level of most of the participants was tertiary education, indicating that they were sufficiently informed to distinguish between myths and facts about albinism. This is supported by the finding that knowledge of myths was significantly correlated with the educational status of respondents.Further work will be required to explore the long-term impact of WhatsApp-based health education on sun protection practices among people with albinism and to investigate the scalability and cost-effectiveness of such interventions in larger populations.As an interventional study, there is a possibility of social desirability bias . This caData security is another limitation of WhatsApp. Although WhatsApp offers end-to-end encryption of messages that ensure the security of information, there is still the chance of data security breaches.Additionally, the smaller number of postintervention participants compared to the number of participants before the intervention probably affected the overall power of the study.Further studies could be conducted on the long-term effectiveness of WhatsApp in attitudes and behavior changes related to photoprotection in people with albinism. Additionally, research with a control group of people with albinism undergoing traditional methods of communication could allow for a comparison between WhatsApp and traditional means of health education. Further research on expanding the use of mobile apps in dermatology would improve health care services, especially in Nigeria.WhatsApp has been useful in the health education of people with albinism, providing them with knowledge on albinism, sun protection practices, and myths about albinism. Interactive messaging and the use of multimedia were important in the success of this intervention program. Therefore, WhatsApp has proven to be a promising tool in teledermatology in Nigeria. There is a paucity of studies evaluating the effectiveness of using WhatsApp in the health education of people with albinism. However, we consider this study to be the first of its kind in demonstrating it as a suitable approach.