Irregular migrants (IMM) are excluded from the National health insurance in most developed countries and may use the emergency department (ED) as a source for medical care.This study aims to compare the use of ED by IM with that of Israeli citizens (IC) in a large urban hospital in Tel Aviv, including socio-demographic characteristics, hospitalization proportion and medical conditions on admission.This cross-sectional study included all IM and IC patients older than 18 years who attended the ED between 2007 and 2011, and compared their socio-demographic characteristics, the administrative details of the visit and clinical variables upon admission. Hospitalization proportion was calculated by dividing the number of patients who were admitted to the hospital ward by the number of all patients who attended the ED.IM who attended the ED were younger compared to IC , mostly males  and mainly originated from developing countries. IM were more commonly self-referred, more likely to attend the ED during evening hours and weekends, complained of occupational injuries and frequented the surgical rather the medical ward of the ED compared with IC. IM stayed at the ED for longer periods than IC, yet the proportion of their hospitalization was lower than that of IC .IM stayed in the ED for longer periods and were less likely to be admitted to the hospital wards, suggesting presentation of non-severe medical conditions or possible barriers in ensuring care continuity in the community following discharge. Minimizing the barriers of IM to primary care in the community can reduce unnecessary referrals to the ED. Additionally, hospitals managements should respond to the high-volume of IM by shifting staff to busy hours and improving the communication with IM. The World Health Organization estimated that there are ~ 214 million international migrants globally . These bThe medical staff in the ER is supposed to assess the medical condition and treat IM, and also to respond to various social determinants of health influencing the medical conditions of the migrants. For example, the staff should understand the occupational exposures of the IM to certain diseases or risk for on-job injuries, and to respond to social and economic aspects related to their ability to follow the medical recommendation after discharge due to poor housing conditions and insecure employment. Additionally, hospital managements may be concerned with the limited ability of the migrants to pay for the services, especially in cases of hospitalization, as admissions are costly and are often not reimbursed by7 the IM . The proIsrael absorbs all Jewish migrants under the law of return . Those mIt is estimated that more than 60,000 migrants who originated from the horn of Africa  have entered Israel, who are mostly residing in the poorest neighborhoods of Tel Aviv . The TelThis study aimed, for the first time in Israel, to assess the use of ED services by IM and compare the presenting medical conditions, care provided at the ED and hospitalization proportion between IM and Israeli citizens (IC). In line with previous publications from other developed countries which have exclusive national health insurance for citizens –17, our This cross-sectional study included all IM and IC patients older than 18 years of age who attended the adult section of the ED at the TASMC between January 1st 2007 and December 31st 2011, during the major mmigration flux of IM into Israel. The data were available from the computerized registration files. Patients who were referred to the gynecological or the pediatric wards of the ED were excluded from this study. IM were defined as non-Israeli citizens without medical insurance, whereas IC were defined as citizens or residents who were insured by the national health insurance law, regardless their country of origin. Data collected for this study included socio-demographic characteristics , administrative details  and clinical variables . Hospitalization proportion was calculated by dividing the number of patients who were admitted to the hospital ward by the number of all patients who attended the ED from each group. Time spent in the ED was measured from the time of registration to the time of release .Risk factors that affected ED visits were identified by logistic regression using generalized estimating equation multivariable model, which included all the independent characteristics that were statistically in the univariate analysis. Due to the gender differences between IM and IC, a shared model was performed by matching IM and IC according to gender, age (±4 years differences) and for the year of the visit. The group matching included 28,871 pairs. The association between the visitor type (IM/IC) and the likelihood of being hospitalized from the ED was tested using conditional logistic regression.SPSS (v 20.0) was used for the statistical analyses.Between 2007 and 2011, 549,713 attendances were recorded at the adult ED of the TASMC, of which 528,218 (96.1%) were IC and 21,495 (3.9%) were IM. Of all the patients who visited the ED, 169,878 (30.9%) were admitted to one of the hospital’s wards: 165,697 (97.5%) were IC and 4181 (2.5%) were IM., p < 0.001, Fig. The number of visits of IM to ED increased during the study period, yet their average hospitalization proportion was significantly lower than that of IC  Table . Most IMp < 0.001), whereas the gender ratio of hospitalization of IC was similar for both genders . The proportion of hospitalization of the IM generally increased with age, whereas the rate among IC was stable throughout the different age groups (Fig. Male IM were more likely to be hospitalized than females (61.9% versus 38.1% of the hospitalized IM, respectively, ups Fig. .Fig. 2aFactors which increased the likelihood of hospitalization among IM included being male, older age, living outside of the city of Tel Aviv, being treated at the internal ward of the ED, attending the ED between 2009 and 2011, arriving during the evening shift and on working days and being referred by a health provider- generally similar to IC Table . LogistiThe mean duration of hospitalization for IM aged 18–49 years was longer by one day and 14 h than that of that of IC in similar ages.IM comprised ~ 4% of all individuals who visited the ED of the TASMC and 2.5% of its hospitalized patients. IM stayed in the ED for a longer time than IC before being discharged, yet their hospitalization proportion was lower.The ED functions as a medical site for urgent and severe medical conditions, such as life-threatening events and other major injuries. However, because IM have limited access to ambulatory treatment alternatives, they may refer themselves to the ED also for non-severe medical conditions. This high volume of IM self-referral is likely to reflect a limited access to primary care, possible inadequate orientation of the alternative ambulatory treatment sites, dissatisfaction with previous providers in the community and the anticipation for rapid diagnosis and treatment. Additionally, language barriers, financial constraints, health literacy and lack of understanding of the healthcare system may inhibit IM to use community services . The ED As expected, IM in our study were younger than IC, mostly in their working years and the majority were males. Evening hours and weekends were the preferred times for IM to attend the ED. This may be related to their work duties during the week, while trying not to miss paid days, thus using off-office hours to seek for medical services at the ED. Contrarily, IC enjoy labor rights and are eligible to take a paid sick leave and visit their medical providers during working hours. The relatively lower proportion of hospitalization of the IM compared with that of IC may suggest that their presenting medical conditions in the ER were milder and did not require intense care. This may be aligned with their younger age compared to IC. It is also possible that IM were hospitalized due to financial difficulties, as they are supposed to pay for the hospital care. Migrants may also refrain from hospitalization as they are missing working days which affect their income. Better access of IM to ambulatory care with more flexible hours may have reduced the volume of cases who attend the ER. The estimated male:female IM ratio in Israel is 5:1 , which mIM complained of more occupational injuries than IC, and consequently were treated in the surgical ward of the ED. IM are generally more likely to work in jobs that expose the workers to risks , which aThe total length of the visit of IM in the ED was longer than that of IC. This may be of particular significance, as ED are generally overcrowded . It is pThe volume of IM who use the ED, especially for routine non-severe medical conditions presents a unique challenges to the hospitals’ administrations, as found in other developed countries –17, 26. This is the first study performed in Israel to assess the use of ED by IM, yet it is subject to several limitations. First, the data were originally collected for administrative purposes up to 2011, and therefore specific health determinants, such as profession, education, income, living condition and complete medical records were not included. Second, IM do not have identification numbers and their names are sometime difficult to spell by the local staff. It was therefore difficult to define recurrent visits with first referral to the ED. Third, IM are usually generally younger than the general population in the hosting country and therefore are exposed to different risk and have other medical conditions. Lastly, female IM can also be hospitalized after visiting the gynecology ED, which was not captured in this study. It is therefore likely that actual female hospitalization rate was higher.The results of this study may be used by hospitals management to improve the medical services in the ED in order to meet the migrants’ health needs, as was developed in Geneva, where a “migrant friendly” institutional culture was embedded in the hospital operational scheme . For exaThe hospitalization rates of IM in Israel were lower than that of citizens, and they may use the ED for non-severe medical conditions that could have been cared for in the community. In order to address the medical needs of the IM who are excluded from the national medical insurance, the access of the migrants to ambulatory community care should be improved.


Osteoarthritis (OA) is a health condition sensitive to patient’s preferences and values regarding the benefits and risks of the different treatment options. In this sense, patient decision aids (PtDA) can play an important role in helping patients to incorporate their values, needs, and preferences into the decision-making process, thus improving person-centered care. Previous research has focused almost exclusively on knee OA, and therefore, the aim of this study is to develop and evaluate the effectiveness of a PtDA for patients with hip OA.The general design consists of two phases: (1) design a web-based PtDA for patients with hip OA, following the recommended procedures: systematic review of safety/effectiveness of treatments, and an iterative process of development with the help of an Advisory Committee composed of health professionals and patients, and (2) to evaluate the impact of the PtDA on hip OA patients’ decision-making process related with their treatment. For that aim, a multicenter randomized controlled trial will be carried out with 124 patients with hip OA in Tenerife (Spain) comparing intervention or usual care.PtDAs have been recommended as a useful and effective resource for improving PCC in many health conditions. The intervention is intended to empower patients by fostering their active participation during the decision-making process about their treatment and by ensuring they make informed decisions congruent with their values and preferences. This study will contribute to the scientific knowledge about effectiveness of PtDAs in hip OA, in order to improve the quality of health care offered to these patients.NCT04241978. Registered on 24 January 2020.ClinicalTrials.gov  Osteoarthritis (OA) is one of the most prevalent chronic diseases , which aConservative therapeutic options for hip OA include exercise, weight loss, and walking aids, as well as drugs and corticosteroids injections in more advanced stages. When these options fail to improve symptoms, a surgical intervention called arthroplasty or joint replacement is recommended, with some variations depending on the damaged joint. This technique has been shown to be safe and effective , althougPatient decision aids (PtDAs) are one of the most used interventions to promote SDM and help patients to decide between different treatments options . They prThis clinical trial protocol follows the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 statement   development of a web-based PtDA for hip OA patients and (2) assessment of its effectiveness in a randomized controlled trial (RCT).We performed two systematic reviews to identify evidence on hip OA treatments’ effectiveness (search strategy: “hip osteoarthritis AND treatment” in the title), on one side, and decision support interventions for hip and knee OA patients, on the other. We consulted the databases Medline, Embase, and WOS on January 2019. For OA treatments, we only included clinical practice guidelines and systematic reviews with meta-analysis, prioritizing those more recent with enough quality. For the second review, we included all type of empirical studies which applied a PtDA for hip and knee OA patients, with the only aim of identifying the PtDAs and try to access to its content.scientific team  with expertise in assessing the quality of the evidence presented to the Advisory Committee, and in its interpretation, and a technical team (web developers and designers). An Advisory Committee will also be created with 6–8 external primary and specialized care professionals  with experience in hip OA management, and/or patient decision-making, and 3–4 individuals living with hip OA and their families and/or caregivers.The Project Management Group will be composed of a Evidence synthesis and prototype of the PtDA: the scientific team will analyze and discuss the evidence on the efficacy and safety of the different treatment options, based on the results of the systematic review, and a first draft of the PtDA contents and structure will be developed following the International Patients Decision Aid Standards (IPDAS) . Along wReview and evaluation of contents: the PtDA will be sent to all members of the Advisory Committee. Content and presentation issues will be reviewed and refined, in an iterative process that will result in a second version of the PtDA. The review will be through virtual or face-to-face meetings, according to the availability of the members of Advisory Committee. There is not a predefined number of review cycles, and it will depend on the time schedule of the project and the consensus reached in the successive reviews.Field testing: this new version of the PtDA will be tested in individual interviews with 10 hip OA patients (with and without previous arthroplasty), who will evaluate its acceptability in terms of content , structure, format, and navigability. Qualitative and quantitative information will be collected. After modifying those aspects highlighted by patients in order to improve the PtDA, it will be ready to evaluate its effectiveness.The procedure for the development of the PtDA will consist of the following steps:A parallel, multicenter, superiority RCT will be carried out in hospitals and primary and specialty care centers of Tenerife (Spain). Patients will be randomly allocated to intervention (web-based PtDA) or control group .Adult patients with a diagnosis of hip OA, eligible for either surgical or non-surgical management, and with fluency to read, write, and speak Spanish will be included in the trial. Exclusion criteria will be as follows: previous hip arthroplasty, patients with terminal illnesses, be participating in other trials, or mental or sensory alterations that impede or hinder the response to the measurement instruments or do not have the capacity to make decisions.Computer-based randomization with Stata® 15.0 will be performed centrally by an independent researcher . Randomization will be stratified by patient inclusion in waiting list for arthroplasty (yes/no). Sealed envelopes with each patient’ allocation will be prepared, which will be opened only after the patient sign the informed consent for participation in the study. The nature of the intervention makes impossible to blind patients and researchers to group allocation.Eligible patients will be identified through the review of participating centers’ clinical charts. A member of the research team will contact them by telephone to explain the study and invite them to participate. Those who agree will complete the baseline assessment in the same phone call, and an appointment will be scheduled with a researcher at their referral primary healthcare center or hospital. There, patients will be asked to read the project information sheet, which will explain in detail what their participation will consist of, and to sign the informed consent. Then, patients allocated to the intervention group will review the PtDA accompanied by a researcher, who will give support in navigation if necessary. Then, they will complete the questionnaires assessing the outcome measures, in the same web interface. Patients in the control group will follow the same procedure, but instead of the PtDA, they will review general information about OA of the hip, knee, ankle, and foot, information included in a brochure delivered in primary care centers of the Canary Islands Health Service, which will be also presented in a web format.Knowledge of the disease and treatments: assessed with a 7-item questionnaire previously used in studies of PtDA in OA, specifically adapted for hip OA . This inValues about characteristics of treatments: patients will be asked to rate in a 0–10 scale the importance they attribute to different characteristics of treatment: mode of administration, improvement in pain and function, risk of mild and serious adverse effects, time until symptoms’ improvement, duration of benefits, and in the case of arthroplasty, period of rehabilitation and risk of needing surgery revision.Treatment preference .Intention to undergo the preferred treatment: assessed with one item ranging 0 (not sure) to 5 (completely sure).Concordance between values and intention to undergo arthroplasty vs. conservative treatments: binary variable (yes/no) derived from the association between values and intention to undergo arthroplasty see the “” sectionDecision quality about arthroplasty: binary variable (yes/no) defined as a combination of adequate knowledge (≥ 60% of correct responses) and concordance.Satisfaction with the decision-making process: assessed with the 12-item questionnaire developed by Barry et al. . In a prSafety: patients will be asked whether participation in the study has produced any psychological undesired outcome such as anxiety, mood changes, uncertainty, or any kind of concern.The primary outcome of this study will be decisional conflict regarding the treatment for OA, assessed with the Decisional Conflict Scale (DCS) , immediaAt baseline, in the telephone call to recruit patients, assessment will include the primary outcome (DCS), as well as the following control variables: sociodemographic  and clinical data ; the Patient Activation Measure (PAM) ; and gend = 0.5) [Assuming type I and II errors of 0.05 and 0.20 respectively, a total of 126 patients (63 per group) are needed in order to detect a medium effect size , mixed linear regression model with intervention as independent variable will be used, adjusting for DCS baseline scores and sociodemographic or clinical variables which show significant between-group differences at baseline. Center will be included as a random intercept to control for the potential intraclass correlation. The same analysis will be carried out for the remaining continuous outcomes. Treatment preference will be analyzed by means of χ2 test. Concordance between values and intention to undergo arthroplasty will be calculated by means of a method similar to the one proposed by Sepucha et al. [Data will be analyzed on an intention-to-treat basis, although given the nature of the intervention, we do not expect relevant protocol deviations. The baseline equivalence of the randomized groups will be assessed by means of Student’s a et al. : first, The project team at the Evaluation Unit at the Canary Islands Health Service  will serve as the data coordinating center responsible for data collection forms, coordination of data transfer, and data analysis. This is a minimal risk study and we do not expect harms derived from participation. Therefore, an independent safety data monitoring committee is not needed. Nonetheless, researches who will apply the intervention and collect outcomes data will asked for any undesired outcome and register any behavioral or verbal sign which could indicate discomfort, annoyance, or worry.Study data will be stored on secure drives on a server’s institution  and managed according to the General Registry for the Protection of Personal Data (RGPD UE 679/2016) and Spanish Organic Law 3/2018, of December 5, on the Protection of Personal Data and Guarantee of Digital Rights. All documents that contain names or personal identifying information will be stored separately from other study data and identified by code number. Access to files will be limited to research staff involved in the study. The statistician performing the data analyses will receive depersonalized data where the participants’ identifying information will be replaced by an unrelated sequence of numbers.The results of this study will be published in a peer-review journal and presented in international conferences.Patient-centered care is currently advocated as the gold standard of health care, and SDM is one of its essential aspects. In order to encourage SDM, many interventions aimed at patients, health professionals, or both have been developed, to be applied or used before and/or during the clinical encounter , 28. AmoIn relation to the systematic review for the development of the PtDA, it is expected to find limitations related to the coverage and completeness of the information obtained, since the bibliographic search does not guarantee the obtaining of the universe of articles. We will expand the search with consultation of other sources such as specialized websites and institutions working in this area of research.The main limitations of the effectiveness study are the impossibility of blinding participants to treatment allocation, and the absence of follow up, which precludes the assessment of patients’ subsequent interaction with their health care providers and their actual treatment choices. We will try to mitigate the lack of blinding giving control participants a brochure with general information about OA. In the absence of data about patients’ actual decisions, we will measure the intensity of their intention to undergo their prefer treatment. On the other side, we will only collect baseline data for the primary outcome and knowledge, in order to avoid overloading patients with too many questionnaires; nonetheless, an adequate randomization and allocation process should overcome the influence of this limitation.The strength of the study relies on its methodological rigor, beginning with the development of the PtDA based on recommended guidelines , 32, invThe trial has been registered at ClinicalTrials.gov under the identifier number NCT04241978 on 24 January 2020. The recruitment started in February 2020 and is expected to end by October 2020. This is the Version 3 .Additional file 1. SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents.


This study contributes to our understanding of organizational identity through dichotomous motivations of altruism and egoism in non-profit organizations (NPO). By applying an empirical analysis of NPO members, organizational identity is found to be well explained by altruistic motivation and egoistic motivation. More importantly, this study finds that collectivism positively moderates the relationship between altruistic motivation and organizational identity, and negatively moderates the relationship between egoistic motivation and organizational identity. It is noticeable that altruistic motivations have a stronger impact on organizational identity when collectivism is high, while egoistic motivations have a stronger impact on organizational identity when collectivism is low. Finally, this study generates helpful management implications based on research findings. It is suggested that the managers of NPOs could enhance members’ organizational identity by taking motivations and collectivism into consideration, that is to say, in order to build up organizational identity of NPO members, both righteousness and shared interests matter simultaneously. Non-profit organizations (NPO) have grown tremendously in China over the past two decades . CorrespFor the growth of an organization, organizational identity serves as the main way for organizations to enhance cohesion and plays a key role in organizations’ success . LikewisMotivation is found to be vital for organizational identity . The occTherefore, this study explores the shaping mechanism of altruistic motivation and egoistic motivation on the organizational identity of NPO members respectively. Along with the fast development of economy, China’s occupational values has been changed profoundly which can be reflected by the new generation of Chinese who have more individualism value and less collectivism value than the previous generation . FurtherOrganizational identity has long been recognized as a critical construct of organizational behavior, affecting both the satisfaction of the individual and the effectiveness of the organization . OrganizThe rational incentive hypothesis indicates that self-interest is at the root of human behavior. Human behavior is motivated primarily by self-interest . HoweverHypothesis 1a: Altruistic motivation has a positive impact on organizational identity.Hypothesis 1b: Egoistic motivation has a positive impact on organizational identity.Collectivism value, as one of the cultural values that have received widespread attention and heated discussion, reflects the degree of concern of individuals on other individuals and organization . CompareConcretely speaking, we will discuss the contingency influence of members’ collectivism value on the relationship between altruistic motivation and organizational identity, and the relationship between egoistic motivation and organizational identity, respectively. It is noticeable that the collectivist tends to distinguish others into in-group and out-group, and is willing to share the personal knowledge and information with those in group that he/she is familiar with . TherefoHypothesis 2a: The positive relationship between altruistic motivation and organizational identity will be stronger as collectivism is higher.Hypothesis 2b: The positive relationship between egoistic motivation and organizational identity will be stronger as collectivism is lower.The whole survey that lasted for about 2 months was conducted in NPOs in China. Before the formal date of collection, we carried out a pilot testing with a sample of 20 NPOs to examine whether the overall survey was clear, thorough, and robust. After the pilot test, the investigators modified the wording of some items according to the feedback from the participants. The formal survey was conducted in Zhejiang and Sichuan Provinces. Members of NPOs participated in the study on a voluntary basis, and a convenience sampling was adopted. Overall, 68 NPOs were involved. There are totally 130 questionnaires given out and 114 received. All the participants are volunteers of NPOs. We conducted the hierarchical regressions on SPSS 20.0 to test the hypotheses proposed in this study.As we asked the same individual about both dependent and independent variables at the same time, the common method bias (CMB) should be concerned . In ordeThis study aims to propose a model of how altruistic motivation and egoistic motivation affect organizational identity of NPO members under different levels of collectivism. The main variables are measured as follows.The dependent variable. Organizational identity was measured by the 6-item scale developed by The independent variables. Altruism motivation was measured by the 8-item scale developed by The moderated variable. Collectivism was measured by the 5-item scale developed by Control variables. Apart from demographic variables such as gender, age, education, tenure  was alsop < 0.001; β = 0.397, p < 0.001). The results in Model 3 showed that collectivism positively moderated the relationship between altruistic motivation and organizational identity , and negatively moderated the relationship between egoistic motivation and organizational identity . Therefore, Hypothesis 2a and Hypothesis 2b were fully supported.As a tentative exploration of the effect of altruistic motivation, egoistic motivation and collectivism on organizational identity, we conducted ordinary least square regressions, involving three models in total. The results of regression models are presented in In order to more clearly characterize the moderation mechanism, slope tests were conducted to evaluate whether the relationship between altruistic motivation and organizational identity, and the relationship between egoistic motivation and organizational identity were intensified or weakened by different levels of collectivism. This study has some limitations that may require further discussion and exploration. First, since cross-section data were used, it was unable to efficiently judge the causality between variables. Thus, in a subsequent study, the methods of longitudinal and cross-level research can be further applied to make the outcome more perfect and enhance the quality. Second, the sample size of our study is relatively small which may in turn effect the reliability of the results. Future study may involve more NPOs across several provinces in China so that more comprehensive data can be collected.The past two decades have witnessed an unprecedented boom in the NPOs in China . AccordiThe research findings of this study show that both altruistic and egoistic motivations exert significantly positive influence on the organizational identity of NPO members. This indicates that altruism and egoism are not dichotomous, and they jointly matter in the shaping organizational identity in the context of NPOs. In other word, to join in NPOs involves righteousness and shared interests simultaneously. Furthermore, the collectivism value could exert roles of reverse moderating on the relationships between motivations and organizational identity. For the members with high collectivism, altruistic motivation is the key source of organizational identity. However, for the members with low collectivism, egoistic motivation become a key source of organizational identity. On the era of the declining collectivism value , it is sFurthermore, the study is useful to NPO managers aiming to develop targeted approaches to attracting and retaining volunteers. In view of the above conclusions, the following optional methods can be adopted to promote the human resource management for NPO members. First, emphasizing the mission and values of NPOs through HR practices such as recruitment, selection, orientation and training is an important tool for ensuring motivation and retention of members . This stTo conclude, in order to build up organizational identity of NPO members, it is noticeable that righteousness and shared interests simultaneously matters. Thus, the view of shifting from a focus on altruism to a balance of altruism and egoism has stronger explanatory power for the shaping of NPO members’ organizational identity. Based on our research result, it is suggested that NPOs should balance values-based HRM system and performance-based HRM system.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.All authors contributed equally to formulating the conceptual framework, analyzing the data, and writing the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Cognitions and perceptions, such as motivation and return to work (RTW) expectations, can influence work participation of employees with chronic health problems. This makes these cognitions and perceptions important factors for occupational health professionals to intervene upon in order to increase work participation. There is, however, no overview of interventions that influence these factors and are aimed at increasing work participation. Therefore, the purpose of this scoping review is to explore available interventions that are focused on cognitions and perceptions of employees with chronic health problems and aimed at increasing work participation.A scoping review was carried out following the framework of Arksey and O’Malley. Ovid MEDLINE and PsycINFO were searched for original papers published between January 2013 and June 2020. We included studies that describe interventions that focus on at least one of ten cognitions and perceptions and on work participation. The risk of bias of the studies included was assessed using quality assessment tools from the Joanna Briggs Institute.In total, 29 studies were identified that studied interventions aimed at changing at least one of ten cognitions and perceptions in order to change work participation. The interventions that were included mainly focused on changing recovery and RTW expectations, self-efficacy, feelings of control, perceived health, fear-avoidance beliefs, perceived work-relatedness of the health problem, coping strategies and catastrophizing. No interventions were found that focused on changing motivation or on optimism/pessimism. Four interventions were judged as effective in changing coping, self-efficacy, fear-avoidance beliefs, or perceived work-relatedness and work participation according to results of randomized controlled trials.This review provides an overview of interventions that focus on changing cognitions and perceptions and work participation. Evidence was found for four effective interventions focused on changing these factors and increasing work participation. Occupational health professionals may use the overview of interventions to help employees with chronic health problems to increase their work participation. Occupational health professionals (OHPs) play an important role in increasing work participation in employees with chronic health problems. By OHPs, we refer to all professionals who make decisions about work participation or about receiving benefits for employees with health problems. In their practice it is important for them to focus on factors that may influence the work participation of these employees.According to the International Classification of Functioning, Disability and Health (ICF model) different domains of factors can influence a person’s work ability: disease-related factors, external factors and personal factors . PersonaTo promote work participation in employees with chronic health problems, relevant cognitions and perceptions should be identified. Next, the hindering cognitions and perceptions should be limited and the positive cognitions and perceptions fostered .To help employees who have cognitions and perceptions that can negatively influence work participation or to foster positive cognitions and perceptions, it is important for OHPs to get an overview of available interventions that may help to influence these factors. OHPs can recommend these interventions in order to increase work participation. However, as far as we know, no such a review about these interventions exists. Therefore, the purpose of this scoping review is to explore available interventions that are focused on at least one of the cognitions and perceptions and aimed at increasing work participation of employees with chronic health problems. The main question for this study is: Which interventions are available that are focused on cognitions and perceptions and aimed at increasing work participation of employees with chronic health problems?To answer our research question, we conducted a scoping review. We chose for a scoping review, because in contrast to a systematic review we do not have a focused research question on finding evidence for an association between variables. Instead, we have a broad and explorative research question about available interventions. In addition, we aim to summarize and disseminate our research findings to physicians and to consult physicians and patient representatives to get feedback on our findings, which is an essential component of scoping reviews .We used the Joanna Briggs Institute Reviewers’ Manual for methodology for Scoping Reviews  and the The main question of this scoping review, as identified in the introduction is: Which interventions are available that are focused on cognitions and perceptions and aimed at increasing work participation of employees with chronic health problems?The search strategy was developed with the help of a research librarian (JD). In order to find relevant words in titles and abstracts that can be used in the full search strategy, we first performed a limited search in Ovid MEDLINE to identify relevant articles. The complete search strategy consists of terms related to three elements of the PICO. In this review the population (P) are employees of working age (18–67 years) with chronic health problems. We defined chronic health problems according to the definition of the World Health Organization: Diseases with long duration and generally slow progression . The intOnly studies recently published, between January 1st 2013 and June 15th 2020, in peer-reviewed journals were included. Cohort studies, (randomized) controlled trials, and studies with pre-test post-test designs were included. Reference lists from relevant reviews and meta-analyses we found were screened for additional relevant studies. Articles were only considered eligible for inclusion if they were available in English or Dutch.Case studies and qualitative studies were excluded from this review. We also excluded articles in which participants are younger than 18 or older than 67 years, are students, are military personnel or veterans, are volunteers (no paid job) or are employees with substance abuse problems.For identifying and selecting relevant studies, we used the web application Rayyan . The titFor data charting we used a charting table drawn up by the research team. In this table, the following characteristics of the studies included in the review were described: first author, year of publication, country, study design, characteristics of study population  and intervention types . In addition, we described the cognitions and perceptions in that study, how they are measured and the follow-up period. Finally, we described the effect of the intervention on the cognition or perception of interest and on work participation. The data were charted by two researchers (MdW and BH). All data charting was discussed between the two researchers until consensus was reached. After this, the other researchers  each checked one third of the data-extraction, so that all data were ultimately checked.We assessed the quality of the studies with the assessment instruments of the Joanna Briggs Institute, which has different criteria for different study types, and we presented the scores in tables . The detThe last stage in the framework of Arksey and O’Malley  is the cThe search process is presented in Fig. Table Fifteen of the sixteen RCTs had a moderate risk of bias and one had a low risk of bias. Five of the cohort studies had a moderate risk of bias, one had a high risk of bias and three had a low risk of bias. Of the non-randomized experimental studies and single group pre-test post-test studies, there were three with a moderate risk of bias and one with a low risk of bias. Scores on each criterion of the quality assessment tools are presented in Additional file Nine studies, of which five were RCTs, studied the effect of an intervention on self-efficacy and work participation , 28–31. Seven studies, of which three RCTs, studied the effect of an intervention on perceived health and work participation , 32, 33.One study of Aasdahl et al.  studied No studies were found on interventions that were focused on motivation and aimed at increasing work participation.No studies were found on interventions that were focused on optimism or pessimism and aimed at increasing work participation.Two RCTs with interventions focused on feelings of control and work participation were found , 18. TheMost of the studies we found which focused on cognitions and perceptions and work participation were aimed at the factor catastrophizing. In total, ten studies were found that focused on this factor and work participation , 35–39. Six RCTs were found about interventions focused on fear-avoidance beliefs and work participation –26. OnlyOne RCT of Muschalla et al.  was founSeven studies described interventions on coping strategies and work participation, of which five RCTs and two cohort studies , 33, 40.Two OPs, two IPs and a patient representative were consulted to give feedback on the findings of this scoping review. The OPs and IPs recognized interventions or components of the interventions and had experience with recommending them to employees. The patient representative recognized components of interventions in the interventions she had followed.We asked the OPs and IPs specifically about their experience with interventions on changing motivation and optimism/pessimism, because on these factors no interventions had been identified in this scoping review. They were not aware of interventions on these factors either. However, they indicated that they would try to influence some cognitions and perceptions of employees, for example motivation and self-efficacy, by themselves during their consultations.For choosing an intervention that they would recommend to employees in daily practice, they would, however, not only look at the effectiveness of the intervention. They also considered it very important to look at the type of client (e.g. level of education) and the disease or disorder he or she has, for choosing the right intervention. Some physicians mentioned the importance of deciding together with the employee which intervention is the best fit for the employee. The patient representative emphasized that her preference for one intervention above another is partially based on how much expertise the providers have with the interventions. Because in the Netherlands the employer has to pay for the intervention, the costs of the intervention, the amount of money the employer wants to invest in the employee and the reimbursement policies of insurance companies are all important for determining whether interventions are recommended or not. Some OPs and IPs mentioned that most of the time it is not one person-related factor, but multiple negative cognitions and perceptions that are present in employees, which could make it important to combine interventions or components of interventions.In this scoping review, we identified 29 studies, of which 23 with a moderate risk of bias, that studied interventions aimed at changing at least one of ten cognitions and perceptions in order to change work participation. The interventions included in the study mainly focused on changing recovery and RTW expectations, self-efficacy, feelings of control, perceived health, fear-avoidance beliefs, perceived work-relatedness of the health problem, coping strategies and catastrophizing. We found no interventions on changing motivation or on optimism/pessimism.From the results of this review, we can conclude that four interventions were effective in changing cognitions and perceptions and work participation, and can be recommended to employees by OHPs: The “Stimulating health participation and relapse prevention at work” intervention described by Arends et al. , the “CoThe four interventions that were effective in changing cognitions and perceptions and in increasing work participation had only one main provider, and this was an occupational physician , psycholSome of the interventions found in this scoping review which were specifically aimed at one person-related factor also had effects on other person-related factors. For example, the intervention of Muschalla et al.  on develFor certain cognitions and perceptions, no interventions were found at all. This was the case for the factors motivation and optimism/pessimism. The OPs and IPs we approached did not know interventions specifically aimed at these cognitions and perceptions either. However, they did mention that they sometimes try to influence the cognitions and perceptions (such as motivation) of the employees during their consultations without implementing a specific intervention. This is in line with the results of two studies of Müssener et al. , 49 in wThis review provides an overview of interventions aimed at changing cognitions and perceptions and work participation. OPs, IPs and other OHPs can use this overview to get an indication of which intervention they should recommend in order to increase work participation in employees with chronic health problems. We followed all the steps of the framework of Arksey and O’Malley  for condA limitation of this review might be that some interventions are tested on specific groups, for example on employees with depression , 35. It This review provides an overview of interventions that focus on changing cognitions and perceptions and work participation. OHPs may use the overview of interventions to help employees with chronic health problems to increase work participation.Many of the identified interventions were not proven effective. Therefore, more studies, and especially more RCTs with a low risk of bias, are needed to study how hindering cognitions and perceptions can be limited and positive cognitions and perceptions fostered. In addition feasibility studies are needed to assess the practicality of the different interventions. Because many of the interventions included in the review are multidisciplinary interventions that focus on many different aspects and are also tested on different groups of employees, it is also important to study which component of the interventions actually helps for which group of employees. According to the consulted stakeholders the expertise of the intervention provider, the type of client (e.g. level of education) and the disease or disorder he or she has are very important to consider when recommending interventions. Results of research assessing which intervention components work for whom, may contribute to the development of more effective and efficient interventions to increase work participation. Finally, research is needed to determine whether these newly developed interventions actually could improve work participation and whether they are cost-effective, because costs are a very important aspect for OHPs in determining whether they should recommend an intervention according to the consulted stakeholders.In conclusion, 29 studies were found which described interventions that focused on cognitions and perceptions and were aimed at increasing work participation. Four of these interventions , 26, 27 Additional file 1:Table 1. Ovid MEDLINE search strategy. Table 2. Ovid PsycINFO search strategy.Additional file 2:Table 1. Details of included studies.Additional file 3:Table 1. Risk of bias of randomized controlled trials. Table 2. Risk of bias of cohort studies. Table 3. Risk of bias of non-randomized experimental studies and studies with a single group pre-test post-test design.


This paper examines the impact of the internet usage and knowledge intensive activities on households’ healthcare expenditures Similarly, the paper aims to recognize and understand, from a value-creation perspective, the correlation between: internet access of households (IA), individuals frequently using the internet (IU), individuals searching on internet for health-related information (HI), payments made by households for healthcare (PHH), expressed as euro per inhabitant and employment in knowledge-intensive activities (KIA). The approach utilized in the present study consists of two steps. First, a theoretical framework was conducted to determine the existing relationship between major variables. Next, the Vector Autoregressive (VAR) approach was applied in a case study at European level to prove the three hypothesis we consider. By analyzing the connection between the major variables, a positive and long- lasting impulse response function was revealed, followed by an ascending trend. This suggests that a self-multiplying effect is being generated; and it reasonable to assume that the more individuals use the Internet, the more electronic acquisitions occur. We can thus reasonably conclude that the improvement of the internet usage and knowledge intensive activities on households’ healthcare expenditures process is strongly dependent on people’s capability. Improving IU and KIA is the new reading key in the decision-making process in health system approach. Internet usage (IU) plays a crucial role in Supply Chain Management (SCM), and the robust published literature confirms its centrality in transforming today’s health management system. However, there is a significant debate on impact of internet usage and knowledge intensive (KIA) activities in SCM. IU offers vast prospects for developing a collaborative system model that can create synergies, both inside and outside the healthcare scenarios. The opportunities offered by IU are indeed really promising, especially for improving management decisions, implementing robust risk management and operational efficiency, enhancing KIA innovation capabilities, and creating a better overall customer experience.This approach is developing patchily, with social, technological, and human health consequences that need to be considered in order to provide real long-term advantages for households’ healthcare, both in terms of health efficiency and also from a cost reduction perspective. There are several obstacles to using IU appropriately, including security, privacy, ethics, and governance health expenditure issues.The paper aims to measure the impact of IU and KI activities on households’ healthcare expenditures, to show how these critical aspects can represent a useful tool in the decision-making process of SCM and to emphasize the existing correlation between them. Due to the complexity of the subject matter, we followed a tiered approach, dividing the research work into two steps. First, we identified through a theoretical framework a previously hidden relationship among Internet Usage, Health Information and Knowledge-Intensive Activities. This first step allowed us to identify the variables needed to recognize the impact more concretely, and to design a case study (step two) that could contextualize the revealed relationship. Accordingly, a Vector Autoregressive (VAR) model was applied to conduct empirical research on European context.Based on the above-mentioned approach, the article is organized as follows: the introduction presents the challenges and general goals of the present research, while Nowadays we are facing the demographic change. In Europe it is estimated that over one third of the population in 2025 will be more than 60 years old, in addition the older population aged between 65 and 79 has increased significantly since 2000  and thisIn European countries the state of health of elderly people points out the prevalence of physical problems. The most commonly reported chronic conditions include arthritis diabetes and heart disease, while the main causes of death concern cardio-circulatory diseases and malignant neoplasms .According to the World Health Organization, we can distinguish diseases in two main categories: infectious and non-communicable. Those infectious are generally caused by pathogenic microorganisms and spread directly or indirectly between people, while non-communicable ones (NCDs) also known as chronic diseases and tend to accompany an individual throughout his life.Most NCDs are associated with older population groups but the reality shows that over 15 million deaths among the population aged between 30 and 69 years are attributed to non-communicable diseases: this makes us understand how the entire population is at risk of contracting at least one non-communicable pathology. Even if NCDs show a global reduction they still kill over 41 million people worldwide and they are the cause of death of 15 million people between the ages of 30 and 69 years. World Health Organization suggests the best way to control non-communicable diseases is to focus on reducing the risk factors associated with them, boosting interventions focused on prevention and control .In Europe, public health spending is growing fast among governments. In 2015  it averaAccording to OECD most healthcare costs are attributed to the largest non-communicable diseases , and theOne of the main tools currently used to disseminate best practices regarding the lifestyles and habits of the population as well as information necessary to maintain good health status is undoubtedly the Internet .The internet was defined as a global connection tool for individual networks run by governments, industry, universities and private actors. Originally conceived to connect few actors, mostly institutional, since 1994 it has expanded to serve billions of users for a multitude of purposes anywhere in the world, this connection tool has turned into a formidable platform that has upset the way we do business and the more generically we communicate, guaranteeing a globalized dimension to the whole world. Currently it has become a universal source of information for the entire world population, if in case you are at home, at work, at school or in your spare time.Another element that characterizes the internet has been its evolution which has not found any precedent in the past. This element is characterized by two applications, the social web and mobile technology. They have generated a significant break with the traditional use of the internet. One of the most significant examples of social web is Facebook, launched in 2004 grew into the global network reaching 4422 million of active users. On the other hand, mobile technology has enabled greater internet coverage, allowing anyone to be connected anywhere .From the democratization of the Internet, ITU, OECD and Eurostat, together with other important world organizations, they have discussed and developed a list of indicators to measure the level of diffusion and the impact of information and communication technologies (ICT). Since 2005, over 50 indicators covering different areas have been developed, such as: ICT infrastructure and access; access and use of ICT by households and individuals; use of ICT by businesses; the ICT sector; trade in ICT goods; ICT in education; and e-government .(1)Infrastructure  and hard(2)Socio-economic dimension ,23;(3)Users’ ability to use internet related devices ,24,25,26From the last REPORT of ITU  it emergA relevant activity online, among adult and older people, it is to google health information: “…any information which is related to the practice of medicine and health-care…” and “…information which can aid in the prevention, detection, and treatment of disease…’’ . Internecaeteris paribus conditions keeping a high rate of health safety for the human capital means having a high rate of occupational flexicurity [According to the third key element of the Digital Divide, the numbers of employees in Knowledge-intensive service and activities , could be considered as a proxy. KISA (or KIA) are knowledge-intensive services that include—according to OCSE definition : High-texicurity  and thusxicurity ,38.(1)Internet access of households is influencing in a positive manner the internet usage and the Knowledge intensive activities.(2)Internet usage is influencing in a positive manner both the search for healthcare information on the internet and also the knowledge intensive activities.(3)Internet search for healthcare is affecting the spending of households on healthcare.In conclusion, we can assert that exist three research field to deeper. They can be synthetized in this way:In the next section we applied an empirical methodology in order to explain this theoretical framework.Our study is based on the fact that more and more individual are using the internet as a source of information for treatment for health issues. In order to assess the implications for this widespread phenomenon, we have chosen the following variables: internet access of households (IA), individuals frequently using the internet (IU), individuals searching on internet for health related information (HI), payments made by households for healthcare (PHH), expressed as euro per inhabitants and employment in knowledge-intensive activities (KI).Internet access of households (IA): the statistics is presenting the use within househoulds of Information and Communication Technologies at European level. Data for this collection are supplied directly from the surveys with no separate treatment, presenting the access to and use of ICTs by individuals and/or in households and the use of the Internet and other electronic networks for different purposes by individuals and/or in households;Individuals frequently using the internet (IU): the statistics is presenting the access to and use of ICTs by individuals in order to measure the access to selected IC technologies, the use of computers, location, frequency of use, activities , the use of the Internet , internet commerce , e-skills;Individuals searching on the internet for health-related information (HI): the statistics is presenting the percentage of individuals seeking Health-related information, such as: injury, disease, nutrition, improving health, etc. The data is collected taking into consideration the last three months before the survey.Payments made by households for healthcare (PHH): the statistics is presenting household payment’ means a direct payment for healthcare goods and services from the household primary income or savings, where the payment is made by the user at the time of the purchase of goods or the use of the services. The statistics is expressed as euro per inhabitants.Employment in knowledge-intensive activities (KI): the statistics is presenting employment in Knowledge Intensive Activities (KIA) identified based on a level of educated persons in sectors of economic activity. The data is covering EU Member States, EFTA and candidate countries are extracted and compiled from EU-Labour Force Survey for the population, using annual average data.Using Eurostat data, our variables that were taken into consideration were:The VAR model used is an unrestricted panel VAR, since the variables are integrals of different orders. The Model proposed by us is original and observes the recommendations of Harvey , in 1990The VAR methodology is widely used in literature due to the large applicability, regardless of the field and topic. VAR models do not require in depth knowledge about the influences between dependent and independent variables but rather a list of variables which can be hypothesized to affect each other intertemporally.Thus, because of the interdependencies between our variables, the impact between them being mutual, we have decided to use a VAR Panel model, one the most versatile research methodology available in our research inventory. Therefore, we taken 27 cross-sections to the European member states, excluding only Malta, due to the lack of data. The period taken into consideration spans across 10 years, from 2007, until 2016.According to Canova and Cicarelli (2013)  panel VAThe data used were collected from Eurostat, using the latest data available, starting from the date of 2007, until 2016, making sure they were seasonally adjusted and complete for a using the panel methodology. In addition, the data were differentiated by first degree, and a logarithm was used in order to respond to the tests needed for the VAR methodology.On the basis of the results of literature review we have formulated 3 major hypotheses, as follows:Hypothesis 1 (H1).Internet access of households is influencing in a positive manner the internet usage and the Knowledge intensive activities. Thus, in our opinion, the higher the internet access, the higher the internet usage of households and the knowledge intensive activities.Hypothesis 2 (H2).Internet usage is influencing in a positive manner both the search for healthcare information on the internet and also the knowledge intensive activities. Thus, in our opinion, greater internet usage develops know how and insight in health-related issues.Hypothesis 3 (H3).Internet search for healthcare is having a negative influence on the spending of households on healthcare. So, we are stating that by searching information on health on the internet, the members of the households can make informed and thus better decisions and subsequently, increase the efficiency of the spending.The main reason we have chosen the VAR approach is that VAR is a natural tool for forecasting , focusinAfter we have estimated the VAR, we have tested whether our model is satisfying all the necessary VAR tests. Thus, the VAR satisfies the stability condition as shown in Therefore, we have ensured the essential condition for VAR stability. From this point on, we can continue our first study. According to The VAR satisfies the autocorrelation condition, as shown in Also, one can see in Following the verification of VAR stability conditions and the tests ensuring data accuracy, we performed the impulse functions to observe the impact of the of the variables selected and to confirm our hypothesis.Following the validation of the model thru the tests presented in As we can observe from the Our second hypothesis is also confirmed by the impulse response function. Thus, as we can observe in Out third hypothesis is also confirmed, as we ca see in In addition, in The present research demonstrates to the scientific community that Internet Usage is strongly related to knowledge intensive activities on households’ healthcare expenditures, and the longitudinal case study on European State confirms the hypothesized interrelationship. The theoretical framework modelling highlighted several identifiable benefits for households and companies for increasing the effectiveness of financial allocation on health. In addition, the recent evolution of the Covid-19 epidemic is clearly increasing the importance of Internet Health activities. Thus, the internet access will influence internet usage in a positive manner and thus, increase the efficiency of the supply chain management of the households regarding the healthcare expenditures. It makes perfect sense that this relationship works in a mutual way, both variables are influencing each other. The relationship between internet usage and internet search for seeking health related information shows a very strong correlation, an upward trend and persisted effects. Moreover, the more access to information the individuals are having, the lower the possibility of accessing healthcare services in the traditional way of “seeing the doctor”. Thus, in our opinion, the negative relation between access to information and paying less for medical services, is in line with the rational behavior of individuals to make their expenditures more effective, the healthcare services not being an exception.Therefore, lastly, we can observe that the knowledge intensive activities are responding in a positive manner to the increase of the household payments. Therefore, we believe that there is a demand expressed in higher household payment will stimulate knowledge intensive activities.Our study is trying to “connect the dots” between expenses and empowerment, according to WHO definition  and we hIn an ever-changing economic environment due to the recent evolutions of Covid-19, or the so-called black swan phenomena, we may have to increase the importance of internet health activities and to properly regulate and finance them. This study can be useful for corporate management health system, in fact, along with the direct economic benefits for supply chain management in health system, especially for the households, “Internet Usage” may accelerate the longer-term investment in decision support system , offering developing countries unprecedented opportunities to enhance their predictive systems, to improve their economic policies and execution, and to improve the health care assistance. A better allocation of resources  is necessary in decision-making processes regarding the investments.The novelty of the present study is the comparative approach made it possible to build a theoretical framework for the real evaluation of the impact of internet usage and knowledge intensive activities on households’ healthcare expenditures. Second, the research emphasizes the need to reform and reshape the studies on Supply Chain Management, convincing that it is necessary to understand that the obstacles between the Digital Divide and internet usage, i.e., must be addressed with conscious decision-making processes, strategically and resolutely, to transform points of weakness into opportunities.A number of opportunities for future research arise from the present study. The research should stimulate researchers’ reflections on the relationship among internet usage, Supply chain management, health related activities and Digital Divide. Nevertheless, the work presented here can be considered a brief systematic study, so it is advisable to implement future research on the topic. In particular, it would be helpful to study the structure of internet health activities, their perspectives in the new COVID-19 era, in order to identify the main financial and real flows and of course the results of the internet health activities implemented by households. Such analysis may lead to the detection of the area and the implications of the internet health activities. In addition, is important to observe the manner in which the goods and services related to internet health activities are produced and marketed, and the competitive advantage for their promotion. In addition, it could be useful to replicate the methodological approach applied here in other European economic spaces, to analyse features of intra-community trade and compare them with the extra-community ones.This paper is a first step to fill the gap in research on the relationship among principals’ variables. It is focused on a European panel; for this reason, it is a limited analysis which should be supplemented by future in-depth research. One of the biggest limits of our research is the time series data available on households’ preferences and activities. Information on how these preferences are shaped, modified, or altered are unavailable to academia but are accessible to big companies. Therefore, it would be necessary to conduct a systematic survey of households’ orientation in terms of internet health activities in order to validate the interrelationship, evaluated through the empirical VAR approach implemented in this paper’s case study.Based on our results, we considered that we have proven that there is a strong relationship between household’s characteristics  and their access to the internet. This results in the fact that when people use these internet tools to learn more about its own health issues it is correlated to making health care empowerment via the internet. As consequences, households understand their role, given the knowledge and skills acquired by their health-care provider.A number of opportunities for future research arise from the present study. The research should stimulate researchers’ reflections on the relationship among internet usage and digital competencies for health decision making processes and also for observing the results. Nevertheless, the work presented here can be considered a brief systematic study, so it is advisable to implement future research on the topic. In particular, it would be helpful to study the structure of the main goods that are being marketed and traded using the Internet, in order to identify the main financial and real flows indicators. In addition, it could be useful to replicate the methodological approach applied here in other European economic spaces, to analyze features of intra-community health scenarios and compare them with the extra-community ones. In the future we should consider an analysis on the sustainability of healthcare behavior of households to analyze community and cultural differences about patient participation.


The incidence of brain metastases (BM) in breast cancer patients is increasing. This is probably a result of improved survival rates with long-lasting remissions even in metastatic breast cancer patients. BM are a sign of advanced disease with currently limited treatment strategies and usually short survival times. Although BM are a rare event after initial diagnosis of early breast cancer with a 5 year incidence of 1.7% ,3, and 7To improve treatment and possibly prevention of BM, better insights into mechanisms of brain tropism are required, and, therefore, research in this area is of high clinical relevance. The biology of BM is poorly understood. The ability to pass the blood–brain barrier and to survive and adapt within the new microenvironment may also determine the ability of tumor cells to metastasize to the brain in addition to a genetic predisposition of the tumor cell.Treatment strategies for patients with BM are not well defined, as, until recently, these patients were excluded from many clinical trials. Therefore, evidence is based mostly on small cohort studies. As systemic treatments have limitations to be delivered through the blood–brain barrier, treatment of BM consists of neurosurgery and/or radiotherapy. Recently, various clinical trials have investigated the systemic treatment of BM in breast cancer patients with immunotherapeutic options and small molecules. With an increasing attention to the high clinical need for better evidence, some trials specifically allowed the inclusion of patients with active BM ,7, and wFinally, screening for BM, even in high-risk cohorts, has not been introduced into clinical routine. In addition, strategies to prevent patients from developing BM are unknown.In the context described above, it is the aim of this Special Issue to bundle current knowledge and new findings. This extends from basic research on the biology of BM in breast cancer to an overview about efforts to characterize features of breast cancer patients with BM in clinical cohorts and to updates about current and future treatment strategies. Therefore, this Special Issue should be of interest to basic researchers as well to clinicians involved in this emerging field.


The deteriorating political and economic situation in Venezuela has ramifications far beyond the Latin American country’s borders as almost five million Venezuelans fled and migrated into countries in the region due to the crisis at home. The scarcity of health services, the lack of information sharing, and the absence of reliable data in Venezuela create challenges for confronting developing health emergencies and disease outbreaks. The need for accurate data is especially dire given the current COVID-19 pandemic and evolving movement of refugees. While countries and international organizations came together to form a coordinated response to Venezuela’s political and humanitarian crisis, this geopolitical progress is threatened by the rapid spread of COVID-19, and the instinct for countries to focus inwards on domestic response priorities, rather than engage in regional cooperation. It is critical that the international community set aside geopolitical differences and cooperate to seek an accurate picture of the conditions on the ground to improve the welfare of Venezuelan migrants and to provide a more robust response to the current pandemic. On January 23, 2019, Venezuela’s opposition leader Juan Guaidó announced that the presidency of the country was “vacant” and declared himself acting president. The then 36- year old, was a member of the country’s national assembly and had been elected to lead the legislature just 18 days prior. By law, as the leader of the national assembly, Guaidó had the right to fill the presidential vacancy. To date, almost 60 governments around the world have recognized him as the legitimate president of Venezuela, including the United States and most European and Latin American countries. However, Nicolás Maduro has remained in political and military control of the country and is recognized as president by countries such as Russia, China, Iran, Syria, Cuba, and Turkey. Despite the evolving situation and long historical roots, the political and humanitarian crisis can be traced back to 6 years before Guaidó’s declaration and has resulted in extended health, economic, and geopolitical ramifications.In April 2013, Nicolás Maduro was elected president with a 1.6% margin after his mentor and predecessor, Hugo Chávez, died in office. Tanking oil prices in 2014 hit the Venezuelan economy hard after years of mismanagement, corruption, and international sanctions. Living standards fell as Venezuelans struggled with inflation, budget deficits, food and medicine shortages, and deteriorating living conditions. Political and personal freedoms likewise suffered, as protests became illegal and press were unable to report freely. Routine human rights abuses such as torture, beatings, and arbitrary detentions were common  tate authorities’ ineffective measures or inaction to address the acute deterioration of health care facilities and equipment, the unavailability of medicines, in particular for patients with chronic diseases, and the outbreak of diseases that had been eradicated, led to violations of the right to an adequate standard of health of a large number of people throughout the country .” In resThe health crisis compounded the severity of the situation. The Maduro regime refused to release information required to analyze the consequences of the health crisis, including weekly epidemiology bulletins . The VenMost of the people who have fled Venezuela have remained within Latin America. As of December 2019, 1.63 million Venezuelan migrants reside in Colombia, 864,000 in Peru, 385,00 in Ecuador, 371,000 in Chile, 224,000 in Brazil, 145,000 in Argentina, and at least 10,000 in other countries  pandemic is putting additional strain on health systems worldwide and certainly in Venezuela and its neighbors. Latin America comprises less than 10% of the global population yet accounts for nearly one-third of reported COVID-19 deaths. The fallout could push an additional 16 million residents of the region into extreme poverty, according to a report from the United Nations . AccordiVenezuelans in Brazil suffer together with the entire population due to the disastrous response to the pandemic, marked by denialism and political conflict . On AuguPublic health experts warn that COVID-19 transmission rates and mortality will be higher in Venezuela compared to other countries in the Americas. Even with the government-imposed quarantine, food and water shortages force people to leave their homes. The government continues to threaten physicians and health care workers with retaliation if they speak out publicly about COVID-19 cases . There aIn response to international and domestic movement restrictions put into place to respond to the COVID-19 pandemic as well as the lack of job opportunities in host countries, stigmatization, xenophobia, and violence, refugees have begun to return to Venezuela. Recent reports indicate that many refugees, including a recent influx of 60,000, are causing bottlenecks at border-control points leading to illegal crossings from Colombia. Venezuelans are met by security forces and mandatory quarantines lacking proper infection prevention control, PPE, and social distancing, creating a perfect environment for virus introduction and community transmission. Maduro has placed blame on his own people, noting these refugees returning home are responsible for recent surges in cases . A senioThe geopolitical tensions surrounding Venezuelan political affairs only exacerbate the migrant crisis. While Latin American neighboring countries have taken on the responsibility of accepting Venezuelan migrants and refugees, the international community’s political strategies have deepened the core of the problem. The pandemic found regionalism at a time of decline. In the past, the Southern Common Market (MERCOSUR) was able to adopt rules on residency that made it possible to regularize the situation of tens of thousands of migrants in the region . The UniInternational economic sanctions placed on the Maduro regime to increase economic pressure and a decline in oil production are far outweighed by years of dismantling the private industrial sector and government corruption. Russia and China, which support the Maduro government, vetoed a resolution at the UN Security Council that called for free elections in February 2019. While the Lima Group, a 14-country bloc in the Americas, has repeatedly called for a peaceful transition of power, the Maduro government has been able to hold onto political and military control.Efforts of cooperation to foster a coordinated response to the Venezuelan humanitarian process culminated in the “Quito Process” in September 2018, which formulated a road map and multilateral initiative of many Latin American countries that aims to help integrate Venezuelan migrants into host countries through coordinating domestic policies. The Quito Process has so far resulted in two declarations and one action plan in which governments in the region have sought to meet the most critical needs of Venezuelan migrant populations in the different countries. In addition, the UNHCR and International Organization for Migration (IOM) launched the Regional Refugee and Migrant Response Plan in December 2018, which is a first of its kind operational and coordination strategy and an appeal for $738 million in funding to support over two million Venezuelans in the region and half a million people in host communities.With Venezuela’s political system remaining in deadlock, her people continue to suffer. The international divide hampers decision-making at multilateral organizations such as the International Monetary Fund and the World Bank, where divided recognition of the Venezuelan government blocks the country from receiving desperately needed loans. The international tensions politicize aid to the Venezuelan people who are in dire need of humanitarian aid due to food shortages and lack of adequate healthcare access. The lack of cooperation tempers data collection and information gathering on the ground. Disparate data only paint an incomplete picture and could miss crucial needs of Venezuelans both inside and outside of Venezuela. As the crisis continues, Venezuelans continue to migrate to neighboring Latin American countries, carrying with them the ramifications of their broken health system. Migration is a social determinant of health primarily because the conditions of the migratory path determine the health of migrants and, as discussed, the exportation of infectious diseases from Venezuelans across international borders has had serious repercussions on the health systems of the neighboring countries. The severity of the COVID-19 pandemic globally further illustrates the need for data collection and information sharing.In his seven years in power, Mr. Maduro has overseen the collapse of Venezuela’s health care system, the destruction of the national economy, and a marked increase in the country’s international isolation. Venezuela now ranks second, only to Syria, for countries with forcibly displaced populations. The difficulty in handling the situation does not mean that countries should close their borders to migrant populations. Rather, it is imperative that cross-border political cooperation organizes for a joint investigation and response to migrant health needs. Coordinated access to migrants could provide information to deepen international response. These mechanisms and health structures can be a combination of official and unofficial; to provide participation of public institutions for the stability of these structures for long-term solutions and to activate community-based institutions to better understand the perceived needs of the people. Furthermore, health services must adapt to become more inclusive of migrant’s health needs, as well-established structures that can overcome the financial barriers to health care access. As the COVID-19 pandemic continues to spread, the existing paradigms on how to deal with crises in and around Venezuela continue to change. With cooperation and joint efforts between countries, along with support rather than conflict from the international community, migrant health and border health challenges resulting from the Venezuelan migrant crisis can be better controlled.


Agricultural higher education is one of the important context in which students may be face with educational burnout during their studies due to their conditions, such as the nature of the field of study, lack of graduates' employment, and reduction in motivation. This research aimed to investigate the factors underpinning the student's academic burnout of Iranian agricultural higher education system. The research was a kind of descriptive-correlational that has done through a survey. The statistical population composed of all students at all educational levels in agricultural faculties of the Iranian state-run universities . Accordingly, 386 people were selected using the Krejcie and Morgan's tables and stratified random sampling method with proportional to size. A researcher-made questionnaire with 104 questions arranged in six parts used for data collection. The validity and reliability of the questionnaire were confirmed by calculating the Cronbach's alpha, average variance extracted (AVE) and composite reliability (CR). According to the results, the variables of high workload and achievement motivation were the most influential factors on academic burnout, respectively. This study's results can be a useful step for policymakers and planners in the agricultural higher education system to prevent student's academic burnout and remove obstacles to dynamic academic achievement. Education; Psychology; Academic burnout; Achievement motivation; Proper workload; Agricultural students; Higher education; Iran. Students play a key role in any educational system  to meet the goals of the system . To be mAcademic burnout signals the decline of an individual's aptitude to adjust himself/herself to the stressful factors of education . In geneResearch in different countries  on academic burnout has demonstrated that students in these countries are also suffering from this problem so that academic burnout clearly affects their grades as well as their relationship with the university . AcademiAcademic burnout has plagued Iranian students as well . The degAgricultural higher education is one of the important context in which students may be face with educational burnout during their studies due to their conditions, such as the nature of the field of study, lack of graduates' employment, and reduction in motivation . For ins2In recent years, many studies have conducted about job burnout. Most studies on burnout have conducted on specific situations such as healthcare workers  and saleIn recent years, academic burnout in students for different reasons including understand different students' behavior such as academic achievement during education, affecting students' relationships with their college and university, and affecting students' enthusiasm for continuing education has turned into a significant research subject at universities . AcademiThere are different factors affecting extend of students' academic burnout. For instance, Marzooghi, Heidari, & Heidari  concludeA study on predicting academic burnout based on academic quality of life and hope for employment among university students showed a significant negative correlation between academic quality of life (QAL) and hope for employment in students with academic burnout . AnotherQuality of teaching and learning environment is considered as one of the factors that students face. This component includes teacher–student relationship, the quality of teaching, deep approach to learning, evaluation, pedagogical counseling, psychological contract, social relations between students, and usability of studies , 29. In 2.1-There are significant and negative relationship between high workload and academic burnout.-There are significant and negative relationship between achievement motivation and academic burnout.-There are significant and positive relationship between quality of teaching and learning environment and achievement motivation.-There are significant and positive relationship between hope for employment and achievement motivation.-There are significant and negative relationship between high workload and achievement motivation.-There are significant and negative relationship between hope for employment and academic burnout.-There are significant and negative relationship between academic quality of life and academic burnout.-There are significant and positive relationship between academic quality of life and achievement motivation.As mentioned earlier and adapting from Meriläinen 's model,33.1This is a qualitative research in terms of paradigm and is a non-experimental research with an applied purpose. This is a correlational research that was done through a survey. It is a correlational research because measures and assesses the statistical relationship between different variables. In this regard and since structural equation modeling has been used to analyze the data a variance–covariance matrix was employed.3.2The statistical population of the study composed of the students of different educational levels in agricultural colleges of the state-run universities of Iran . Accordingly, 386 students selected using Krejcie and Morgan 's table 3.3The survey instrument is a questionnaire included 104 questions arranged in six sections related to measuring main variables. They were related to the assessment of academic burnout (14 questions) , workloa3.3.10.50 [0.75 to 0.84 and all were highly satisfactory. Due to the weaknesses of Cronbach's alpha method, including considering the same values for all statements of a component [0.70 [α, AVE and PC were presented in A panel of agricultural faculty members established the face validity of the questionnaire. Average Variance Extracted (AVE), which used for discriminant validity, was also calculated. The components with AVE more than 0.50  have accomponent , the Comnt [0.70  have acc3.48.50 software was used to estimate the model for research hypotheses. The Lisrel models comprise both measurement and structural models. In the measurement models the links between the latent variables and their indicators is investigated, whereas the structural models investigate the links between the latent variables. Relevant indicators  have been used to determine the goodness of fit of the model.Data were analyzed using Structural Equation Modeling (SEM) technique and Maximum Likelihood Method. The Lisrel 44.12 are displayed in 2).In this section, we investigate the relationship between latent variables and their indicators. To determine the reliability and validity of the model, the level and significance level of the relationships between each latent variable with the relevant indicators was considered. In fact, the research model was reflective, in which the direction of causal relationship between the variable and the relevant indicators was from the variable to the indicators; and in terms of the correlation between the indicators of each variable, the indicators had a lot of correlation. In the reflective model of this study, it was expected that with the change in an indicator, the effects of the change will be reflected in all other indicators. The results of this analysis for the standardized value of the parameter, t value, standard error, and RBased on 4.2In this section, the relationships between latent variables examined. The goal was to discover whether the theoretical relations between variables verified by the data. Accordingly, the research hypotheses were tested. To test the hypotheses, the path coefficient of variables on each other and t-value were calculated. The results were presented in 2 for the endogenous latent (dependent) variables of the model that indicated the effect of exogenous variables on the endogenous variables are also presented in The path coefficients presented in 2” [2 was 0.59 for achievement motivation variable that is explained by high workload, quality of teaching and learning environment, hope for employment and academic quality of life. It was 0.62 for academic burnout variable that is explained by high workload, hope for employment, academic quality of life and achievement motivation. Thus, the appropriateness of fitting the structural model was confirmed. On the other hand, this means that 0.62 of the variations in variability of academic burnout are related to the four variables of high workload, hope for employment, academic quality of life, and achievement motivation.In fact, three values of 0.19, 0.33 and 0.67 were the criteria for weak, moderate and strong “R2” . Given tAccording to path coefficient in 4.3Finally, the goodness of fit statistics of the model were evaluated to find out how much the model is in agreement with data. For this purpose, goodness of fit indexes was calculated as in 5In this research, an attempt was made to provide a comprehensive view of the components and their effect on students' academic burnout based on existing resources. To accomplish this research, eight hypotheses concerning the influence of the components on the increasing of students' academic burnout were formed and five of them were confirmed. Comparing different components, the results revealed that high workload had the most impact on increasing student's academic burnout. Students from different fields of agriculture stated that contrary to the working nature of their fields, a lot of theoretical assignments are given in these fields and this is a factor affecting their academic fatigue and their lack of interest in the field of agriculture. Given the high unemployment rate in agriculture, students are not interested in doing their homework because they find the field unfavorable and they show no interest to study in this field. The same results were found in earlier studies, e.g. Jacobs and Dodd . But othRegarding the moderate variable, achievement motivation, the results of model fitting showed that high workload had a negative effect on the achievement motivation, so that the more the workload, the less motivated the student would be. Therefore, students should do different duties because they need enough facilities and resources. When the academic tasks are a lot and the students do not have enough resources, they are going to experience higher levels of stress, and their ability and motivation for doing these tasks will be declined. Therefore, teachers must reduce the amount of theoretical assignments that are irrelevant to their job prospects in order to motivate their students. They should give more practical assignments and entrepreneurial skills. In this regard, the curriculum content should be designed in such a way that attracts students' attention and be applicable in their daily lives. In addition, the assignments given to students should increase their skills related to the field and their future job. Therefore, the educational planners should revise the course syllabus and make the lessons more practical. The course syllabuses should also be run properly so that students learn their field skills. This finding is not agreement with the results of previous research , 28, 29.Hope for employment had no direct effect on increasing academic burnout, which is not in line with previous research , 27. On Also, the results of model fitting show that quality of teaching and learning environment had a direct effect on achievement motivation. This result is in good agreement with other studies , 29, 38.Motivation can be effectively created by the relationship between teacher and student and teachers' paying attention to educational justice, introducing teachers to new teaching methods and improving the teachers' quality of teaching by holding in-service classes for them, providing appropriate feedback by the teachers to the students after evaluating and performing assignments. Also, applicability of the courses offered in the field of agriculture is another motivating factor due to the nature of the field. As undergraduate students in the last two years and MSc. and Ph.D. students need more communication to perform activities such as paper presentations, and doing thesis and dissertations, therefore, the availability of professors and adequate educational guidance and counseling will lead to the elimination of student stress.6The results of the research indicated a negative and significant relationship between high workload and achievement motivation and the student's academic burnout directly. Other variables such as hope for employment and academic quality of life also influence academic burnout through achievement motivation. Of course, it cannot be said that quality of academic life cannot affect academic burnout certainly. It is necessary to re-examine this issue in future studies. At the end, it is mentioned that studying the relationship between academic burnout and other related variables  is suggested to reach a wider attention. Then, educators should increase the selfefficacy level among their students to predict or control academic burnout. It can be gained by presenting some tasks which can enforce personal achievements. In addition, verbal reinforcement is the other method to reinforce selfefficacy. However, due to significant role of external factors in academic burnout , educational administartors are suggested to prepare enough equipment and resources such as equipped and updated libraries and computer sites. In general, the results of this study can be effective step to prevent academic burnout, as well as removing obstacles to dynamic academic achievement. For example, developing a regulation for reducing students' workload and directing their homework to practical activities related to the job market and society and closely monitoring its implementation is a simple solution for improving academic motivation and reduce student's academic burnout. Another suitable field for further research is the study of the effect of students' academic burnout on the performance of universities. It is noteworthy that managers in universities and educational institutions are not willing to change the educational system to increase the vitality and motivation of students; For this reason, research on the causes of unwillingness to change, especially the four pillars of education  in universities can also be a good ground for further research.M. T. Moghadam: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.E. Abbasi: Conceived and designed the experiments; Analyzed and interpreted the data; Contributed reagents, materials tools or data; Wrote the paper.Z. Khoshnodifar: Analyzed and interpreted the data; Wrote the paper.10.13039/501100008257Tarbiat Modares University.This work was supported by The authors declare no conflict of interest.No additional information is available for this paper.