The recent health crisis has particularly affected small- and medium-sized enterprises (SMEs). Some have had to temporarily close their doors. Others chose to innovate by developing new products to take advantage of the situation and survive. However, innovation is a risky strategy, so there are many failures. Innovation collaboration is one way of limiting these failures and increasing the chances of project success. Nevertheless, little is known about SMEs’ innovation collaboration practices in the context of a crisis, and even before the pandemic, and further research is needed. This study aims to understand the innovation process and the collaboration practices adopted by SMEs for their product innovation projects to cope with the pandemic, by comparing their pre-pandemic practices with those implemented at the start of the pandemic. Based on four successful product innovation projects in two different SMEs, our results show that, at the start of the pandemic, collaborations included a larger number of partners, involved in more stages of the innovation process, in order to accelerate the new product development and commercialization, rapidly provide the necessary resources and response to customer needs. Small- and medium-sized enterprises (SMEs) are particularly vulnerable to crises  such as In contrast, SMEs have certain characteristics – flexibility, rootedness in their local community, proximity to customers, agility – that give them unique capabilities to respond quickly and effectively to a crisis, seize opportunities and emerge stronger . These cAccording to In the context of a crisis, SMEs may opt for innovation to ensure their survival and an adequate post-crisis recovery . ResearcNevertheless, innovation is a double-edged sword: it increases the possibility of outstanding performance, but also of failure, for both SMEs and large firms . Rhaiem Thus, SMEs must explore different avenues to innovate while minimizing risks. Innovation collaboration is one such avenue. To innovate successfully and develop new sources of income, SMEs sometimes collaborate with external partners and adopt a more open innovation (OI) strategy . In the The COVID-19 pandemic provides a unique context to study the response of SMEs in crises. Our study focuses on the innovation process and collaborative practices within four successful innovation projects, both pre- and post-pandemic, by answering the following research question: how has collaboration within the product innovation process in SMEs been modified by the pandemic? Based on two Canadian (province of Quebec) manufacturing SMEs that each successfully commercialized a new product innovation before the pandemic and another one at its beginning, our objective is to gain a better understanding of the innovation process and the collaborative practices adopted by these SMEs. Studying four completed product innovation projects allows for the comparison of the entire innovation process, from idea generation to commercialization, the type and number of collaborative innovation partners, and the intensity of this collaboration throughout the entire process.The article is organized as follows. First, we describe the theoretical concepts and tools used to understand the phenomenon under study, followed by the methodology used to carry out our study. We then present and discuss the results in relation to the mobilized literature. Finally, we conclude by addressing the theoretical and managerial contributions, as well as the limits, of our study.Our study bridges the gap between the literature on innovation, collaboration and the innovation process. The concepts mobilized are presented in five main parts: (1) product innovation; (2) product innovation process; (3) resource-based view (RBV) theory; (4) innovation collaboration and OI; and (5) collaboration partners. These concepts and theories are used to build an analysis grid that helps organize and interpret the results of our research. This grid, which facilitates the analysis process, is presented at the end of this section.The Oslo Manual is widely recognized and respected as a comprehensive international guideline for measuring and understanding innovation activities. It provides a standardized framework and terminology that enables meaningful comparisons and analysis across different countries and industries . By usinIn its fourth edition, the Oslo Manual defines innovation as ‘a new or improved product or process (or combination thereof) that differs significantly from the unit's previous products or processes and that has been made available to potential users (product) or brought into use by the unit (process)’ : 20. In Product innovation unfolds through a process in which a product is designed, developed, and commercialized to respond to a market opportunity, also known as the product innovation process .The best-known model of the product innovation process is the Stage-Gate System (SGS) developed by To meet the demands of today's market – shorter product lifetimes and tighter time-to-market – the innovation process must be flexible and fast in addition to adapting to customer needs that change more rapidly than in the past . To accoAccording to To innovate successfully and secure sufficient resources and skills, SMEs sometimes collaborate with partners on the development of new product ideas, even more in a crisis context . CollaboThe RBV theory , accordiThe decision to collaborate depends on the resources available internally to the SME and the complementary resources available to a partner. This decision also lies in a needs and opportunities analysis . Thus, t‘Replicating products/business process already available from/to other firms or organizations, with no or very few additional changes by [a] firm.Developed by [a] firm by adapting or modifying products/business processes available from/to other firms or organizations, including reverse engineering.Developed by drawing substantially on ideas, concepts and knowledge sourced or acquired from other firms or organizations, directly or via intermediaries.Developed as part of a collaborative agreement with other firms or organizations, with all parties contributing ideas or expertise.Mainly developed by [a] firm on its own, from the idea to implementation’.These distinctions between the contribution of internal and external sources pave the way for the concepts of cooperation, collaboration, and co-innovation, which have long been used undifferentiated in the literature  to developed mainly in-house (item e). In between, item b requires some internal innovation activities, item c requires considerable external input and item d external input as part of a collaboration with other organizations . These iterature . The terterature : 134:ColInnovation collaboration is part of the OI trend which ‘denotes the flow of innovation-relevant knowledge across the boundaries of individual organizations. This includes proprietary-based business models that use [among others] collaborations […] to produce and share knowledge’ : 133. WhOI is a logical step for many SMEs to successfully innovate, develop new revenues and increase profitability . OI chanHowever, innovation collaboration involves challenges and even barriers. These include (a) loss of control over valuable knowledge; (b) high coordination costs; (c) loss of control over strategy; (d) difficulty finding the right partner; (e) difficulty establishing trust; (f) concerns about triggering antitrust policy enforcement, about employees leaking valuable information or know-how or about potential costs of dispute settlements; and (g) lack of time or financial resources . Trust tThe integration of collaboration partners can take place at various points during the innovation process. Such collaboration reduces technical and commercial risks and improves the chances of successful product innovation .Collaboration partners can be divided into five categories: (1) business enterprises (affiliated and unaffiliated), including suppliers, specialized knowledge service providers and commercial research institutes, customers and competitors/investors/other businesses; (2) government, including research institutes and other departments and agencies; (3) higher education; (4) private non-profit, including research institutes and other private non-profits; and (5) households/individuals : 138. ThTo explore the influence of the pandemic on collaboration in product innovation projects, we have developed an analytical framework known as the analysis grid presented in the next section. This framework serves as a bridge between the existing literature on innovation, collaboration in innovation (including collaboration partners) and the innovation process.A multiple case study allows us to explore and learn from innovation collaboration in a real SME context . The innBased on a dozen SMEs, two Canadian manufacturing SMEs were selected for this longitudinal analysis. These two SMEs were able to carry out one product innovation project before the pandemic and another one at its beginning. These two SMEs were widely quoted in the media during the pandemic period. We had the opportunity to meet their managers to highlight the consequences of the crisis on their collaboration practices and their innovation processes, in a very particular period of their history.In the four projects studied, new product ideas were developed through a process that included collaboration activities. The entire process could thus be documented. The innovation projects studied have different characteristics and are set in different contexts. At Alpha, the project studied before the pandemic concerns the development of refrigerated equipment for the food industry. At Beta, the project before the pandemic concerns the development of tooling for the automotive industry. In the context of the pandemic, the two projects put forward by Alpha and Beta concern the development of personal protective equipment intended to ensure the safety of thousands of employees in the food and medical sectors. Considered as working in non-essential sectors, according to the criteria established by the governments at the time, the two SMEs temporarily ceased their activities at the beginning of the pandemic. Their product innovation initiatives, however, allowed them to resume operations and re-employ most of their employees.Data were collected through semi-structured interviews before the pandemic and at the beginning of the pandemic with two managers in each SME. Each interview lasted approximately 90 min and was conducted on the premises of the companies . At Alpha, interviews were conducted in December 2018 (pre-pandemic project) and July 2021 (project completed in March 2020). At Beta, interviews were conducted in March 2019 (pre-pandemic project) and September 2021 (project completed from March to June 2020).With the respondents’ consent, the interviews were recorded and then transcribed. The interview patterns covered several topics: (1) description of the company and project, (2) innovation process, (3) organization, management, and structure of the innovation . The data collection also included the consultation of nearly 100 pages of internal  and external (websites and press reviews) documents. Collecting data from a variety of sources and methods (interviews and secondary documents), known as triangulation, reduces the risk that a study's findings will reflect a single ‘viewpoint’ . This trAnalysis of the interview and document data followed the principles of thematic analysis : using NThis section presents, first, the results obtained regarding the innovation processes of SMEs for the two periods studied. Second, the collaboration practices established by SMEs in the realization of their product innovation projects during these two periods are presented. Based on the analysis grid, we categorized the results following the categories and elements of comparison.Before the pandemic, the innovation processes of both SMEs followed a series of stages, activities, gates, and tasks that are similar to the original SGS model. The process distinctions between the two SMEs were more in the number of tasks, which were reduced at Alpha compared to Beta. These differences can be explained by the type of product developed, which at Beta required patents, unnecessary for Alpha. Alpha's closer proximity to its customers also resulted in a reduction in commercialization tasks. In comparison, Beta operates in a larger market requiring a commercialization plan, which increased the number of marketing tasks.At the beginning of the pandemic, the innovation processes adopted by the two SMEs were characterized by their agility and speed. The stages and activities of the original SGS model are present, but some were grouped for speed. For example, some activities associated with the product development stage were performed simultaneously with those of the test and validation stage, which reduced their number. These groupings of stages and activities also reduced the number of gates from five to three and simple and few tasks were put forward in the process. In the context of the emergency associated with the pandemic, new products had to be developed and marketed quickly to protect the hard-hit food and medical employees. The higher number of tasks at Beta is explained by the fact that the SME had to adapt to a new sector of activity , which led to the implementation of various tasks such as those associated with obtaining certifications from government medical authorities.our translation)This time frame is short compared to the typical time required to develop personal protective equipment for the medical sector in a non-pandemic context.  was developed, tested and marketed at the local and provincial levels. Beta's innovation process took longer because of the approvals required before it could be marketed. It took 4 months (from March to June 2020) to develop the idea of a reusable face mask and market it locally and provincially.The changes made to the innovation process of the two SMEs at the beginning of the pandemic brought it closer to Stage-Gate Express while borrowing some of the principles of Agile Stage-Gate: iterations, feedback loops, and rapid exchanges between members of the extended team, including external collaborators. The collaboration partners also varied between the two periods studied. The adaptation to a new sector of activity  for Beta also led to changes in partners.The collaboration practices before and at the beginning of the pandemic are depicted in Several points emerged from the results presented in The location of the partners was mainly local at the beginning of the pandemic and expanded, as the borders between the provinces opened, to a more provincial and national market. The health crisis forced the closure of companies in many countries and limited the access of the SMEs to these external markets, whether for the supply or the sale of the new product developed. This became a constraint for the SMEs, which had to act mainly on the local market, more accessible. However, this proximity favoured a faster development of the new product, necessary to protect several thousand employees quickly.As for the duration, it should be noted that the two projects carried out in both SMEs, at the beginning of the pandemic, were more radical than those carried out before the pandemic. In both cases, collaboration contributed to the success of the projects. The nature of the partners’ involvement was at level d where the new product is developed ‘as part of a collaborative agreement with other organizations with all parties contributing ideas and expertise’ : 135. Thour translation)The foundation was to save Quebec (Province of Canada), to save people. We could not be open for our regular business. We could be open to develop protection strategies.  did not exist. We did not know what was coming. Nobody knew what was going on. We were in a situation where at that time, the CERB (Canada Emergency Response Benefitour translation)We were trying to generate as much value as possible to be able to call people back as quickly as possible to retain our workforce. Because it is pretty hard in our fields to get skilled labour. It became an extended team. We brought together local companies to develop the new product. Several companies  are involved in designing, developing and manufacturing the new product. At the beginning of the process, everything was decided with the client. A team effort with people from all over. A company could not have done this alone in such a short time frame.  and a consultant  in the product development and testing stages. Developing a new product in the context of a pandemic was:It also helped make the innovation process more succinct, fast, and agile. Communication between the various partners was constant and necessary in solving problems, reducing technical risks, and confirming the continuity of the process.The results, presented in In response to a crisis, some firms are likely to explore innovative solutions by seizing opportunities in new markets , which tThe product innovation processes studied indicate that both SMEs typically follow the stages and activities identified in the SGS theoretical model. These results are comparable to those obtained by The two cases analyzed also show that the nature of partner involvement, as proposed by Comparing the collaboration practices in the innovation processes of the two SMEs, we notice distinctions between the two periods studied. Among other things, we note that suppliers and subcontractors are more involved in the pandemic context. When uncertainty is higher, their involvement can help SMEs confirm the feasibility of a project, reduce technical risks  and acceThe involvement of customers is also crucial in both SMEs, where they are more present in the context of the pandemic. This proximity to customers assures SMEs that the products developed meet their needs, which has, as Crises create an opportunity to innovate and collaboration plays an important role in accelerating the innovation process . A rapidOne might think that trust between partners emerges from mutual dependence, exacerbated by a sense of urgency generated by an unprecedented situation. SME managers can then become imbued with a rescue mission, beyond the SME's current activities . Crises Based on multiple case studies of two manufacturing SMEs, our study shows that the health crisis changed product innovation processes and practices of innovation collaboration. The longitudinal approach of our study based on two periods shows how a crisis of the magnitude of COVID-19 influences the product innovation process and how collaboration with different, and sometimes new, partners favours its speed and success. A sense of urgency may prompt SMEs to quickly call on more collaborative partners and to involve them for longer in the process. With a simplified and accelerated innovation process, commercial success can still be observed in times of pandemic.Regarding the theoretical contributions, this article combines two theoretical fields that tend to evolve in isolation: the innovation process (Cooper, 1990In terms of managerial contributions, developing a new product in a hurry requires agility, related to the ability to adapt, which is important in the innovation process of SMEs. Collaboration in product innovation projects helps to bridge resources and skills and promotes the success of projects while contributing to the performance of SMEs. Innovation may allow SMEs to resume their activities when other businesses are closed, as is the case in the SMEs studied, by exploring the development of new products that differ from their usual ones. Collaborations with new partners, such as experts and government agencies, can be an essential element in the development of such new products. Our study highlights that the relational skills and networking of SME managers are important to identify partners and benefit from their contribution to product innovation projects, emphasizing the importance of social capital . TherefoAs with any research, our study has limitations. First, our study focuses on changes in the practices of SMEs that successfully commercialized a new product at the beginning of the pandemic. It therefore does not enable us to identify the main obstacles faced by SMEs that did not attempt or succeed in developing new products during the pandemic. Also, the product innovation projects were not identical before and at the beginning of the pandemic in the two SMEs, which limits the extent of possible comparisons between the innovation collaboration process in normal times and in times of crisis, as well as the generalization of our conclusions to SMEs and projects that do not share the same characteristics. We can wonder whether the similarities and differences observed are due to other factors, namely the business model, the governance conditions, and the initial relational strategies. Questions also persist as to whether the observed changes in product innovation processes and collaboration practices are temporary or permanent.These limitations may also form the basis of further research. It could, for example, be interesting to study whether the changes observed will persist when the context is equivalent to that which existed before the pandemic. Will innovation process and collaboration practices then be more in line with what they were before the crisis? Will SMEs have learned from the crisis and continue to collaborate in product innovation and accelerate their new product development projects by adopting a more streamlined process? A quantitative survey with a larger sample of SMEs to assess whether their innovation process and innovation collaboration practices have changed during the pandemic could also allow the characterization of profiles and the identification of the obstacles and levers to such innovation. Our results pave the way for further study on concepts such as organizational learning, organizational change, relational capital and crisis in product innovation by manufacturing SMEs.In addition, this study focused on two manufacturing SMEs with a need to fill resources to innovate adequately. Future research could compare the collaboration profiles of SMEs with those of large firms to shed a different light on this phenomenon and gain a more complete picture. Also, comparing manufacturing firms with service firms would further explore the importance of context in collaboration practices. Finally, this empirical study is based on a sample of SMEs located in the province of Quebec, Canada. Both SMEs are therefore influenced by their context and researchers are encouraged to replicate this study in other regions and countries. Despite the limitations highlighted, this study contributes to the understanding of the adaptations made by SMEs to their innovation process and innovation collaboration in times of crisis.This study attests to the high adaptability and resilience of the studied SMEs in the early stages of the pandemic, as they changed their processes and expanded their collaborative networks to rapidly commercialize new products. This indicates a potential for increasing the speed of innovation, which could ultimately shorten product lifetimes once again. This article hopes to join a multitude of other contributions to better understand how the pandemic has changed the innovation process and innovation collaboration.


International electives provide a learning platform where interprofessional education and collaborative practice (IPECP) skills can be cultivated. However, hardly any frameworks to guide the implementation of interprofessional education (IPE) during international electives, especially in the context of low-income settings have been published. To address this gap, this study used the modified Delphi approach to develop an IPE framework guide for international electives to be used by health professions training institutions in Sub-Saharan Africa.A rapid literature review and a study among students and faculty in four African health professional training institutions were done to inform the process. This was followed by the modified Delphi technique that used three Delphi rounds with a panel of eight experts to build consensus on the final framework for IPE during international electives. The level of consensus was set at ≥70% on each of the statements in all rounds.n = 37, 71%) reached consensus while  of the statements did not reach consensus and were discussed in round 2. Round 2 led to 42 statements to be utilized for round 3. In round 3, all statements (42) reached a consensus and an IPE framework to guide the implementation of international electives was developed. The framework consists of three sections. Section one highlights the various IPECP competencies to be gained by learners in the areas of teamwork, interprofessional communication, roles and responsibilities of interprofessional collaborative practice, values and ethics of interprofessional collaboration, and reflection and evaluation of oneself and the team. Section two gives guidance on the structuring of the IPE international electives in health professional training institutions. This includes subsections on operational/institutional needs, acculturation considerations, teaching strategies, assessment strategies, mode of delivery, and public health considerations. Section three consists of the various practical guides and approaches that health professional training institutions could use according to what works best in their setting.Out of the 52 statements in round 1 (The modified Delphi technique was an adequate approach to aid the development of an IPE framework to guide implementation during international electives in various health professional training institutions. Interprofessional education (IPE) in health is defined as when two or more professions learn with, from, and about each other to enable effective collaboration and improve health outcomes . A few iThe World Health Organization has supported IPE by developing a framework for action on IPECP that proposed new models of educating healthcare providers . This frThe Interprofessional Education Collaborative (IPEC) defined the key competencies of IPE as; values/ethics for IPECP, roles/responsibilities for IPECP, interprofessional communication practices, interprofessional teamwork, and team-based practice . All theDespite the relevance of all the above frameworks on IPE competencies that also include aspects of respect for culture and uniqueness of other professions, it is challenging to develop guidelines for implementing IPE in various learning contexts including international electives. International electives are defined as the time of learning where students have a choice of where to learn, and the discipline they should be taking across borders from their own country . These mIPE international electives though scarce, have been implemented between Vanderbilt University USA and Nicaragua Eye Hospital and were perceived to be effective to enable students gain IPECP . HoweverMuch of the research on IPE and learning has been informed by psychological and cognitive theories pushing aside the role of the learning environment and cultural context. This study was guided by the social constructivism theory, a social-cultural theory advanced by Vygotsky et al. . This thTo address this gap, the purpose of this study was to develop an IPE framework guide for international electives to be used by health professions training institutions. Though the study was conducted in Sub-Saharan Africa, the framework developed can be adapted to various settings where international electives do occur.This study was conducted in Sub-Saharan Africa utilizing faculty and experts in representative health professions training institutions. The training institutions offer electives as part of their curriculum and conduct training for various health professional disciplines at the undergraduate level. In this study, we employed the modified Delphi technique to develop the IPE implementation framework for international electives in health professions training. In the Delphi approach, the first round could involve unstructured open-ended questions/ statements to guide the discussion with a panel of experts . When a The Delphi process involved a series of stages before coming up with a final framework. These included conducting a rapid literature review, exploring opinions from students and faculty, and finally engaging the panel of experts for consensus building.via Makerere University to identify literature on key concepts related to the topic under study. These included: internationalization in health professions education, international electives, the importance of IPECP in health care, current global disease burden, IPE during international electives, perceptions of faculty and students on IPE during international electives, IPE frameworks and their development, Learning theories for IPE, IPE competencies, the importance of IPE, the value of international electives, operational needs for international elective programs, teaching and assessment methods for IPE in international electives, and delivery approaches to teaching IPECP during international electives. The specific search terms used were: interprofessional education, international electives, interprofessional collaboration, Africa, IPE frameworks, Delphi technique, internationalization in health professions education, multidisciplinary, collaborative, interprofessional, interdisciplinary, teamwork, IPE teaching, assessment, theories, health professions education, and teaching.Firstly, a rapid literature review was conducted to inform the Delphi process for our study. This was done to enable a detailed understanding of IPE and international electives in line with the study objectives and to identify learning theories to be used. The rapid review was conducted using PubMed accessed through HINARI We searched PubMed for manuscripts written in English, and from the years 2000 to 2022 as our inclusion criteria to enable us to have more articles included since there is scanty literature on this topic. The earliest year of the manuscript included was 2000 while the highest was 2021 with the majority being published in the last 10 years as shown in In this process, 84 manuscripts were identified and included see . The refIn addition to the rapid literature to inform the Delphi process, we sought opinions from students and faculty from four African health training institutions that participated in the study to understand their perceptions of IPE during international electives and their suggestions and views on an IPE framework for international electives. The students and faculty were given a brief orientation on what IPE is so that they could give meaningful responses related to IPE. The opinions and perceptions of the students and faculty were further utilized to enable the identification of some key constructs to be added to the draft framework that was used to build consensus. This study was conducted qualitatively among faculty using key informant interviews and quantitatively among students using an online survey. AtlasTI version 8 software was used for qualitative data analysis while SPSS IBM statistics 21 was used for quantitative data analysis. The various training institutions included: Makerere University Uganda, Kenyatta University Kenya, University of Ibadan Nigeria, and the University of Zimbabwe.The specific details of the findings from the students have been published in the Journal of Interprofessional Care . The finThe last stage was engaging the panel of experts to develop a draft framework. The draft framework was used to build consensus from the panel of experts and gain validation of the final framework.Through the rapid review, a Delphi guide developed by Bentley et al.  to develExperts in IPECP, health professions education, and international electives were purposively sampled. Recruitment was from Makerere University and Busitema University in Uganda, Yale University USA, Stellenbosch University South Africa, University of Free state South Africa, University of the Western Cape, South Africa, and the University of Global Health Equity Rwanda. Some of the experts were members of the African Forum for Research and Education in Health, Ghana (one) and the African Interprofessional Network (one) while some (five) did not belong to any of these professional bodies in Africa. Furthermore, multidisciplinary representation was considered, and the experts were from various disciplines, i.e., medicine (three), nursing (two), pharmacy (one), occupational therapy (one), and physiotherapy (one). This enabled us to gain a heterogenous panel, a key requirement for the Delphi approach. In total, eight experts were recruited which is an acceptable number for the Delphi method. All eight members of the panel were academic experts in IPECP, health professions education, and international electives, with more than 5 years of experience as an academic faculty, and have had exposure to guiding and conducting international electives in Africa for more than 5 years.The Delphi method lends itself to the concept of the researcher assessing the scope of the problem and the available resources to determine the panel size that would be appropriate . FurtherEngagement with the experts was done virtually due to their various geographical locations. The Delphi process involved three rounds. We began engagement with the panel of experts jointly as one group through email to generate interest and commitment. An email introduction to the 8 experts was done detailing the study aims, the process of participation, the time frame, etc. To ensure we capture full commitment to participate, a doodle poll was sent for all the experts to indicate their time of availability for Rounds 1 and 2. They were given 2 weeks to have this completed. All data collection and rounds were done online using Zoom meeting software for Rounds 1 and 2 (that were recorded), and email sharing for Round 3. Rounds 1 and 2 lasted one and a half hours while Round 3 lasted 3 weeks.For capturing the ratings of each expert on all 52 statements, the study tool was built in Microsoft Forms on an online survey platform. During the Zoom session, each of the participants was sent the online link. The researcher (FN) led the sessions and shared her screen to enable the experts to see the statements but also jointly go through them one by one as each of them submitted their responses using the online survey link as per the draft framework that was developed . This waper se or Likert scale, we used a percentage level of agreement to establish consensus. A score of ≥70% on a particular statement was deemed as relevant and important to be included in the framework while a ≤ 69% score on any statement meant that there was a lack of consensus and thus needed to be discussed and taken up for Round 2. This percentage level of agreement and disagreement was adopted from existing literature from studies that have used the Delphi process for health issues consensus building.Globally, there is a lack of uniform guidelines on what constitutes consensus in a Delphi study . DiffereDuring Round 2, participants were given the scores on all statements, i.e., those that achieved consensus and those that did not. Participants were invited to comment, discuss, and rate the 15 statements that did not reach consensus, i.e., statements with scores of ≤69%. Each of the participants was given a chance to discuss and give their views on these statements and all the suggestions were captured by the researcher. An agreement was reached to leave out the section on the importance of international electives in Africa. This is because the framework is meant to guide the implementation of IPE during international electives and the importance of IPE is already well elaborated from the various existing frameworks and literature  has been used in other studies to build consensus in various health professions education research including IPE . Many tiIn this study, we had representation from various geographical locations, disciplines, and expertise which enabled triangulation and adaptability in various training institutions including Africa . AlthougThe IPE core competencies of this framework were tailored toward gaining IPECP skills that can be applied in all areas of healthcare practice for the students in their future practice. These competencies in our framework were adapted as a combination of various IPECP competencies developed by the European Interprofessional Practice and Education Network , the IntStructuring any new approach in health professions education involves various levels of preparation. This includes the leadership, administration, teaching faculty, training facilities, teaching and assessment methods, public health safety considerations, and modes of delivery among others. Section 2 of the framework covers this in detail. It gives guidance and approaches on how to enable leadership support for IPE during international electives. For international electives, this should be done through institutional partnerships with home and host institutions. Our framework emphasizes reciprocity to enable equity which is key in building equitable partnerships for training, especially in international electives where there is often an imbalance in opportunities for students from various African training institutions . In thisThe teaching and learning approaches put across as options in this framework have been described in the literature that was used to inform this process. In particular small group learning  has been efficient in various approaches to group training . This, tUtilization of bedside teaching , clinicaClinical observerships as a form of training commonly used in international electives in developed countries  did not Assessment of acquisition of IPECP competencies during international electives should be formative and summative as exhibited in this framework to capture the various IPECP skills gained by the students as they participate in an IPE international elective. Pre and Post-elective surveys have been popularly used to establish the IPECP gained . In the Globally various modes of delivery have been used to deliver IPE. These include the physical or in-person approaches that involve face-to-face interaction of interprofessional teams of students with faculty , and theThe modified Delphi technique was an adequate approach to aid the development of an IPE framework to guide implementation during international electives in various health professional training institutions. The IPE framework developed is adaptable and can be implemented in various health professional training institutions. The framework developed enables effective structuring of IPE international electives given that it has all domains required in implementing international electives, i.e., the core competencies to be gained, the operational institutional needs, teaching and assessment methods, modes of delivery, and public health considerations, especially for the fact that international electives require mobility to another country. Unlike other frameworks, this framework also provides some practical guidance on various approaches to implementing IPE during international electives thus creating a benchmark for new approaches to learning during international electives, especially in low-income settings.IPE is one of the key health professions education research priorities for sub-Saharan Africa . Our worThe modified Delphi approach is an adequate approach to be used to develop IPE frameworks to support IPE training in various learning environments including international electives. With the framework now in place to guide the implementation of IPE in international electives, a pilot has been done in the four institutions that participated in this study’s Delphi information process. The results have been published by BMC Medical Education . HoweverGiven the qualitative nature of the Delphi approach, trustworthiness and rigor were observed. For credibility, prolonged engagement with the experts, various rounds to enable consensus, having a cut-off point for consensus, review of the final framework by the experts were done. To ensure triangulation the use of both a research study and rapid literature review to inform the process, experts from various training institutions, and disciplines was done. A detailed description of the methods used was done to enable transferability in similar contexts. To ensure the dependability of the findings various rounds with scores to establish consensus were done. Lastly, confirmability was observed by having the final framework reviewed by the study team and the panel of experts for accuracy and alignment with the study objectives.The panel of experts was in different countries and time zones thus leading to the use of online options to conduct all the other rounds. However, despite the online virtual approach, we were able to record the sessions thus enabling the replay of the sessions for point articulation. Furthermore, the online approach enabled timely rating of the statements which allowed a quick turnaround time. The number of experts involved may be seen as a limitation to some however, this was still within the acceptable number for a Delphi panel recommended  . Four inThe original contributions presented in the study are included in the article/This study followed all the required regulations and guidelines by the Helsinki Declaration. Ethical approval to conduct the study was granted by the Makerere University School of Medicine Research Ethics Committee (SOMREC) Mak-SOMREC-2021-96 and the Uganda National Council for Science and Technology (UNCST) HS2078ES. Administrative clearance was obtained from the University of Ibadan, the University of Zimbabwe, and Kenyatta University. Written Informed consent was sought from all participants of the study.FN, IM, AV, SK, and AM conceptualized and developed the study and jointly drafted the manuscript. FN implemented the study. FN, IM, and AM cleaned and analyzed the data. TR and FW contributed to the final review and development of the framework developed in this study.


Despite a high prevalence of mental disorders among asylum seekers, many barriers to mental healthcare exist. Cultural and contextual factors strongly influence the experience and expression of psychological distress, putting asylum seekers at greater risk of misdiagnosis and inappropriate treatment. The Cultural Formulation Interview (CFI) is a useful tool to map out cultural and contextual factors of mental disorders; however, to the best of our knowledge, it has not yet been investigated in asylum seekers specifically. The primary aim of this study is to evaluate the value of the CFI in the psychiatric assessment of asylum seekers. Second, we will describe the themes relevant to psychiatric distress in asylum seekers that are identified by the CFI. In addition, asylum seekers’ experience of the CFI will be evaluated.This cross-sectional, mixed-method clinical study aims to recruit a group of 60–80 asylum seekers (age 15–29) with mental health symptoms. Data will be collected using structured  and semi-structured (CFI & CFI-debriefing) questionnaires to assess cultural background, contextual factors, and illness severity. Multidisciplinary case discussions will be held after the completion of interviews, following a methodological stepped approach. Combining qualitative and quantitative research techniques, this study aims to generate reliable knowledge on working with the CFI in asylum seekers. Based on the findings, recommendations for clinicians will be developed.This study addresses the knowledge gap on using the CFI in asylum seekers. Compared to prior studies, it will provide new insights into the use of the CFI in the specific context of working with asylum seekers.Prior research on the CFI in asylum seekers is limited, partly because of their high vulnerability and low access to care. The study protocol has been tailored in close collaboration with several stakeholders and validated after piloting. Ethical approval has already been obtained. Together with the stakeholders, the results will be translated into guidelines and training materials. Recommendations to policymakers will also be provided. Over 880,000 people applied for international protection across Europe in 2022, with more than 35,000 of those applications being made in Belgium. These are the highest number since the 2015 refugee crisis . HoweverIt can be hard for care providers to distinguish between psychiatric disorders and symptoms of temporary distress , or to rA vast number of studies demonstrate that immigrants and ethnic minority patients are at higher risk of being misdiagnosed, in particular refugees and recently arrived immigrants –16. ClasThe DSM-IV Outline for Cultural Formulation (OCF) provided a framework for assessing the cultural features of an individual’s mental health problem and how it relates to its social and cultural context and history. To operationalize the OCF for clinical practice, it was revised into the DSM-5 CFI . This quThe CFI was evaluated among diverse migrant populations, revealing themes such as cultural identity, trust, stigma, and psychosocial needs to be important for improving understanding and therapeutic relationships , 24. TheTo date, the evidence of the CFI’s impact on clinical outcomes remains limited . Two stuIn this study, we aim (1) to determine the value of the CFI in the diagnostic assessment of asylum seekers with psychiatric symptoms (main research aim), (2) to identify the main themes that emerged from the CFI with asylum seekers, and (3) to evaluate asylum seekers’ experience of the CFI. We hypothesize that the CFI is an acceptable and feasible instrument to enhance sensitivity to cultural and contextual factors in mental healthcare for asylum seekers and impacts the diagnostic process. However, its use among asylum seekers has at the best of our knowledge not been studied until now and its value in diagnostic assessment is still unclear.In a cross-sectional clinical study design, we will recruit a group of 60–80 asylum seekers with mental health symptoms. Using a mixed-method approach with structured, semi-structured, and open questionnaires we will assess the cultural background, contextual factors , mental health symptoms, and illness severity. After conducting the interviews with each participant, the results will be discussed during a multidisciplinary case discussion.A descriptive approach will map out the main themes related to psychiatric distress in the illness narratives of asylum seekers that are identified by the CFI. An evaluation study will assess the experience of the CFI in asylum seekers using both quantitative  and qualitative methods, and comparing results among any relevant subgroups . Based on the reports of the multidisciplinary case discussions, we will analyze the impact of the cultural and contextual information obtained through the CFI on the diagnostic assessment. To ensure the implementation of the results, we will organize a participative trajectory with field workers to translate our findings into recommendations.This study, set in routine clinical care for asylum seekers, differs from prior research on the CFI that was majorly limited to academic settings . On one Inclusion and exclusion criteria are described in If willing to participate after a time of consideration, patients once more receive verbal and written information about this study during their first appointment with the interviewer. The written information is available in Dutch, French, English, Dari, Pashtu, and Arabic (classic). Translations have been performed by certified translators and double-checked by native speakers. During the first appointment, special attention is paid to ensure that the information on the study is easily understandable and culturally sensitive. Consequently, they are asked for their informed consent. Written informed consent implies voluntary participation, the freedom to withdraw at any time, and the absence of treatment or procedural implications for non-participation. Contact information is provided to caregivers and participants to allow them to request additional information or contact the researchers.Talking about sensitive issues may trigger difficult emotions and traumatic memories, which could increase the mental burden of the participant. Therefore, the interview can be paused, or the participation interrupted if needed. To monitor this appropriately, reasons for drop-out will be carefully documented.Following the information and consent procedure, a researcher-psychiatrist will conduct a clinical assessment. This assessment is split into 3 interviews, each with an estimated duration of 1.5 h see . CertifiFirst, the researcher-psychiatrist will administer the DSM-5 CFI, completed by the first (explanatory models) and sixth  supplementary module.The second session will start with the administration of the 11th (migrants and refugees) supplementary module. Subsequently, the participant’s experience of the CFI will be debriefed using a set of open and closed questions. A mental state examination will also be taken.The last session consists of a standard structured psychiatric assessment. The instruments are described below.The informed consent explicitly mentions that following the interview the main issues will be discussed with the referring caregivers of the participant to ensure adequate follow-up.Formulating a diagnosis in mental health is an act of double interpretation, as it relies on the clinician’s interpretation of the patient’s understanding of his difficulties . To answBuilding on the existing evidence, we developed a methodological stepped approach see . The intDuring workshops with caregivers from participating asylum centers and hospitals, the findings will be translated into practical guidelines. Both the results of the content and the experience of the CFI will be discussed. The goal is to optimize mental healthcare for asylum seekers by discussing the most pressing needs and addressing barriers to CFI implementation. Identification of needs and barriers will enable the formulation of recommendations for different policy levels.From a quantitative perspective, the main research question involves the prevalence of diagnostic revision. Previous research based on the DSM-IV OCF suggests that about 50% of the participants underwent diagnostic revision, although the prevalence of diagnostic revision after DSM-5 CFI administration seems more limited , 15, 32.From a qualitative point of view, it is important to ensure that the sample is adequately diverse. For obtaining this diversity, we aim to include a group of 20 non-Afghan asylum seekers. In 2021 20% of adult asylum seekers and 75% of non-accompanied minor refugees had the Afghan nationality . SupposiConsidering the feasibility and limits  of this study, the goal is to include a minimum of 60 and maximum of 80 participants over 18 months. A pitfall in obtaining the needed number of inclusions is the dependence on our partners. If insufficient inclusions result, recruitment sites will be expanded. The stigma that sticks to mental healthcare can also be a barrier to inclusion. For this reason, we will hold on to our decision to recruit participants through referral by trusted caregivers.The cultural formulation interview (CFI) is a standardized 16-item questionnaire designed to focus attention on the patient’s perspective and social context during psychiatric assessment in a narrative way . The quea priori to administer the first (explanatory models) and sixth  supplementary module. The 11th module (immigrants and refugees) will be used as a proper assessment of the migration trajectory  and past experiences (illness prototypes). The sixth module aims to understand an individual’s cultural identity and how it has affected their health and well-being. The 11th supplementary module intends to gain insight into pre-migration difficulties, migration-related losses, and challenges, in the ongoing relationship with the country of origin, the resettlement, the relationship with the mental problem, and the future expectations . ValidatFor the evaluation of the experiences of the CFI by asylum seekers, we will combine 2 instruments. The first instrument is the debriefing instrument for patients (DIP), which has been developed in the DSM-5 field trial  and was The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview for DSM-5 psychiatric disorders. It was designed to meet the need for a short but accurate structured psychiatric interview for clinical trials and epidemiology studies , 45. TheThe PTSD Checklist for DSM-5 (PCL-5) is a standardized assessment tool to assess the presence and severity of PTSD-symptoms. It consists of 20 items that evaluate the five PTSD-symptom clusters. The PCL-5 has been shown to effectively identify PTSD in individuals from diverse cultural backgrounds and has different validated translations , 49. TheThe Hamilton Depression Rating Scale with 17 items (HDRS-17)  will be The WHOQoL-BREF questionnaire is a shortened version of the World Health Organization Quality of Life (WHOQOL) assessment . It consThe Brief Symptom Inventory (BSI) is a standardized tool that consists of 53 items measuring symptom severity on 9 symptom dimensions . The BSIThe interviews will be recorded and transcribed, after which the original audio will be deleted. Data will be managed using REDCap, an electronic data capture tool hosted by the University of Antwerp. REDCap is a secure, web-based platform that supports data capture for research studies . The tooThe approach of the CFI emphasizes intersubjectivity and the inherent difference between the clinician and the patient  . This apA thematic analysis will be conducted to identify themes related to psychiatric distress that are added by the CFI to the illness narratives of asylum seekers , 66. BraThe qualitative data analysis relates to the data from the semi-structured, open CFI debriefing interviews. The quantitative analysis of acceptability, feasibility, and utility is described below. A thematic framework analysis will be used to map out the perceptions of the CFI administration and the influencing factors on the perception of asylum seekers . The fraTaking into account a possibly relatively small amount of data per interview question due to their structured nature, a larger number of participants (30 to 60) may be needed to achieve saturation . Data wiThe evaluation of the value of the CFI in the diagnostic assessment will be based on the reporting of the multidisciplinary case discussions. These reports consist of our stepped approach : (1) a dMayring has developed a model of qualitative content analysis that includes three distinct procedures: (a) summary, which involves reducing and paraphrasing the material; (b) explanation and clarification of the material; and (c) structuring, which involves filtering out a particular structure from the material and examining it . During a priori to suffice for obtaining thematic saturation.Considering the high degree of diversity of our sample, which guarantees the maximal stretch of the hypotheses, it is necessary to aim for a big enough sample. Insufficient saturation can lead to analytic difficulties in conventional content analysis . As for Quantitative data consist of scores on the debriefing instrument for patients (DIP), on the psychometric scales, and of the presence of diagnostic revision. To allow a better understanding of our study sample, an introductory descriptive analysis will characterize the background of the participants, such as their age, gender, education level, country of origin, and procedural status. The diagnoses and symptom severity of the study sample, as well as other relevant variables like treatment history or the use of psychopharmaceutical drugs, will be outlined.For the CFI debriefing instrument for patients, the negatively worded item ‘Took more time to share my perspective than I wanted’ will be scored in reverse. Means and standard deviations for each item and for the factors of Clinical Utility and Feasibility will be computed. Where applicable, the internal consistency of the items will be assessed using Cronbach’s alpha. Based on characteristics such as illness severity , psychotic vs. non-psychotic disorder, and minor vs. adult, subgroups will be determined and differences in the experience of the CFI between these subgroups will be evaluated.The presence of diagnostic revision is determined by the difference between the clinical and the culturally sensitive diagnosis as discussed during the “stepped” multidisciplinary case discussion. It can be expected that a case has a principal diagnosis and one or more differential diagnoses at both moments of the assessment. For this study, a change of diagnosis will be determined as a change in DSM-5 diagnostic category . Post-hoc comparisons of sociodemographic and clinical variables between patients with and without changes in diagnosis will be conducted.To ensure the quality of the study, several precautions have been taken. Credibility will be strengthened by the prolonged engagement of the main researcher in the field of research on mental health for asylum seekers , 76. AltThis protocol paper aims to guarantee transparency and enhance transferability, providing a thorough description of the context, setting, participants, and methodology . CollaboThe main researcher (LC) will lead the coding and analyzing process. To maximize the dependability of our study, the general aim is to double-code 20% of the data and to let a supervising team member (SVDA) check and validate the codes and themes . ConsistThe study team members are all clinical psychiatrists with experience in cultural psychiatry. Commitment and idealism drive the research team of this study to act as advocates for the mental health of vulnerable populations such as asylum seekers. This might impact the attitude toward the findings. The COREQ  checklist will be used to report on crucial aspects of the study’s methods, context, findings, analysis, and interpretation .To the best of our knowledge, this study will for the first time evaluate the use of the CFI in asylum seekers in particular. More specifically, we will analyze the value of the CFI in the process of a psychiatric assessment, the content added by the CFI to the illness narratives of asylum seekers, and the asylum seekers’ experience of the CFI. This project answers a knowledge gap on the use of the CFI in asylum seekers and will provide knowledge for guiding further implementation.Research on the CFI among asylum seekers is important because they experience many barriers in mental healthcare . It can This is the first study that uses the CFI combined with a thorough symptomatic psychiatric evaluation, in a population with exclusively asylum seekers. The strengths of this study are the embedding of the project in the stakeholder’s network, its multimethodological approach, and the clinical relevance of the research questions.Another strength of the study is the methodological stepped approach for the multidisciplinary case discussions, integrating routine psychometric measurement, representative of standard clinical assessment. This will allow a valid comparison between classic and culturally sensitive psychiatric practices. It also allows for the first time to thoroughly describe and analyze the role of the CFI in the diagnostic process. To ensure credibility, interviews and case presentations will follow an identical pattern and be based on the verbatim transcripts of the interview with the participant.This innovative approach also implies certain limitations. Although the applicate symptomatic questionnaires have been validated in ethnically different populations, it is possible that misunderstanding or restrictive responsiveness has an impact on the validity of the responses. Previous research also revealed that CFI questions about cultural identity and background can lead to perceptions of “alterity” and distance instead of alliance . For theCertified interpreters will be used if the participant is not fluent in Dutch, French, or English. Working with interpreters will allow the participant to express themselves in their native language. While it may result in translation difficulties, it also ensures clinical representativeness.The involvement of the researchers in participant interviews allows for the potential introduction of personal bias. This aspect is therefore also recognized by the constructivist stance of this research.Oral and written information for patients, translated into 3 national  and 3 foreign  languages, will be given, underlining that participation is voluntary and can be withdrawn at any time without negative consequences. It will be clearly expressed to the patients and included in the informed consent that elements discussed during the different interviews, will not interfere with their asylum procedure. Expectations or fear in this sense will therefore be disproved before the interview. Attention will be paid to the easy comprehensibility of the informed consent. Written informed consent will be asked of all the participants. For minors, an agreement of the legal representative will be requested.Studies on CFI often excluded asylum seekers from participating, given their restricted access to the healthcare system , 83, 84.The protocol and research procedures have been validated after an initial pilot phase.Main ethical approval for the study was obtained from the Ethical Review Board of the University of Antwerp (BUN B3002022000005) and of the Ethical Committee of the non-profit organization Brothers of Charity (0G054-2022-09). All the involved healthcare institutions and asylum centers gave their written consent for participation. The study will be executed in accordance with the good clinical (GCP) guidelines, the ethical principles outlined in the Declaration of Helsinki, and the general data protection regulation (GDPR).This research has been designed to create knowledge on the CFI’s content, experience, and added value in working with asylum seekers. The findings will be disseminated via peer-reviewed publications, conference presentations, and lay reports. Feedback moments for caregivers will be organized , during which findings will be member checked. Out of this interaction, training materials and recommendations for different policy levels will be formulated. Participation in the public debate will be undertaken to defend the interests and needs of asylum seekers.LC is the main researcher of this project and has written the initial draft of this protocol study. SA and BS are involved as supervisors of the research project. MS-O and MB are members of the research project’s scientific board. GB functions as a coordinator of the project within the NGO “Brothers of Charity.” SA reworked the first review of the manuscript. BS, MS-O, MB, and GB reviewed the manuscript’s revised version. All authors contributed to the article and approved the submitted version.This research project has received a grant (no. 2021-J5200810-219976) from the King Baudouin Foundation (Belgium), within the UCB Community Health Fund framework. The initial research project was called “Impact of COVID-19 pandemic on the well-being and health of young asylum seekers and unaccompanied refugee minors with mild and severe psychiatric conditions in Belgium.” The decision to focus on adolescents (15–29 years old) in this study was influenced by the funding criteria set forth by the funder. Publication of this article has been supported by the University Foundation of Belgium (WA-0440).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In this paper we estimate monetary and non-monetary poverty measures at two sub-regional levels in the region of Tuscany  using data from the ad-hoc Survey on Vulnerability and Poverty held by Regional Institute from Economic Planning of Tuscany (IRPET). We estimate the percentage of households living in poverty conditions and three supplementary fuzzy measures of poverty regarding deprivation in basic needs and lifestyle, children deprivation, and financial insecurity. The key feature of the survey is that it was carried out after the COVID-19 pandemic, therefore, some of the items collected focus on the subjective perception of poverty eighteen months after the beginning of the pandemic. We assess the quality of these estimates either with initial direct estimates along with their sampling variance, and with a secondary small area estimation when the formers are not sufficiently accurate. The COVID-19 pandemic outbreak has affected all segments of the population and has been particularly detrimental to members of social groups in the most vulnerable situations. The pandemic has created both a public health crisis and a severe crisis on both the global and national economies and continues to affect populations especially in economic and social areas. Some recent studies have shown that not all the EU felt the pandemic impact on their economies to the same extent: the southern European countries like Spain, Croatia, Greece, and Italy, where the tourism sector plays a relevant role, were the most fragile EU .In this paper, we study the economic poverty at regional and sub-regional level after the impact of COVID-19 pandemic in Tuscany, a region in central Italy that heavily founds its economy on exports and various forms of tourism. Tuscany is also a region that, in the face of an underlying cultural homogeneity, has a variety of natural and human environments, as well as structural and economic contrasts across different areas.Understanding poverty at local level is then essential to adequately identify this phenomenon, and to design local policies that aim at mitigating its consequences. Therefore, considering the heterogeneity of the regional territory, we think that it is particularly useful to analyse the phenomenon of economic poverty at sub-regional level. To this purpose, we use data from the Poverty and Vulnerability survey held by Regional Institute for Economic Planning of Tuscany (IRPET) in September 2021.We consider two hierarchies of sub-regional disaggregation. The first sub-regional level that we consider is a partition of Tuscany into six areas, officially defined by IRPET, obtained as an aggregation of the so-called Local Labour Market Areas. Such grouping of six different areas, refers to the levels of employment, the remuneration of productive factors  and consequently, to different levels of wellbeing. In detail, the six areas are the following: Cities, the urban territories, with an important presence of the tertiary sector to businesses as well as to persons; Made in Italy, manufacturing areas based on the traditional production vocations of textiles, leather, leather goods, furniture, etc.; Other Industry, manufacturing areas not belonging to the Made in Italy sector; Seaside Tourism, coastal territories having a seasonal tourist characterization; Agritourism area, promoting sustainable agriculture and ecological tourism; Internal Areas Northern Apennines, the farthest area from centres, lacking of essential services. The second sub-regional level is the official NUTS-3 level.When referring to domain measures of poverty and deprivation, we believe that it is important to understand poverty beyond monetary deprivations and to provide reliable evidence to monitor specific domain policy. Therefore, we use the survey data to estimate the percentage of households living in poverty conditions and three fuzzy supplementary measures of poverty based on a fuzzy approach. This approach has a longstanding usage in the literature, see  vision of the poverty concept. The conventional classification into a rigid dichotomy according to the traditional approach to poverty can then be viewed as a special case of the fuzzy conceptualization of poverty, where the membership function equals 1 for those below the poverty line and 0 for those above the poverty line.longitudinal context. The conventional approach measures mobility, simply in terms of movements across some designated poverty line, does not reflect the actual magnitude of the changes affecting individuals at all points in the distribution. Consequently, the degree of mobility of persons near the chosen line tends to be over-emphasised, while that of persons far from that line largely ignored.There are several advantages of treating poverty and deprivation as a matter of degree, applicable to all members of the population, rather than as simply a ‘yes–no’ state. First, Non-monetary deprivation depends on forced non-access to various facilities or possessions determining the basic conditions of life. An individual may have access to some but not to others. Hence, non-monetary deprivation is inherently a matter of degree, and some quantitative approach such as the present one is essential. Second, further insights into the relative income situations of individuals and groups can be obtained by incorporating into the poverty rates a measure of the actual levels of incomes received, particularly at the lower end of the income distribution. Third, the fuzzy approach provides more robust indicators of poverty  in the Betti and Verma  proposedmentclass2pt{minimIdentification of items of deprivation to be included in the analysis.Transformation of the items in the Exploratory and confirmatory factor analysis to identify measures of deprivation.Calculation of weights of individual items of deprivation within each dimension.Calculation of scores within each dimension.As regards the computation of the fuzzy supplementary (FS) measures, the general procedure to quantify and put together diverse indicators of deprivation is based on the following steps:Calculation of an overall score and parameter Construction of the fuzzy deprivation measures separately in each dimension, taking their simple average as a measure of overall non-monetary (supplementary) deprivation.We remind to Betti et al.  for moreAs in step 2, to transform a generic item into the i et al. . In the As of step 6 and the calculation of the parameter direct estimates, that is, a direct estimator is design-based. Sometimes though, these direct estimates may suffer from high variance if the number of sample units in the subdomain is not large enough. The term small area is used in the literature to refer to these subdomains. The idea behind Small Area Estimation (SAE) is to borrow strength from auxiliary variables to obtain indirect estimators that may exhibit a lower mean squared error than that of the direct estimator. Many small area models have been proposed in the literature  estimator of l in Eq. .To compute the fuzzy supplementary measure of poverty, we consider eleven binary deprivation indicators focusing on households’ current situation (September 2021).The frequency distribution of these items is shown in Fig. The dimensions of deprivation have been further investigated by an exploratory factor analysis (see Table The Kaiser–Meyer–Olkin measure of sampling adequacy (0.81) indicates that the factor analysis method is suitable for the collected data Table . Table 4Successively the latent structure identified has been validated using a confirmatory factor analysis (CFA). The interpretation of these results is shown in Table The second dimension shows high factor loadings for items regarding expenditure for children needs and education. Therefore, we interpret it as an indicator of “Children specific deprivation”  suggesting that the items reflect approximately one construct each. The only item that has an item complexity value above two is that of covering costs of transports. The reason of this may be in that this item is approximately correlated to all other items in the same extent, so that it is less clear to what dimension it belongs more.Then, we calculate weights step 4) and scores (step 5) withing each dimension and solve the non-linear equation in Formula  and scorentclass1pt{minimaAs said in the introduction of the paper. we consider the IRPET’s territory subdivision of Tuscany into the six areas Table  and NUTSThe results from direct estimation shown in the section below confirm this intuition and, consequently, the need to use SAE methods. To apply such methods, we first estimate sampling errors for each domain using the bootstrap. Next, we review possible  data sources suitable to find auxiliary variables at small area level. The auxiliary variables that we use  is the most dominant dimension of poverty in all areas considered Fig. , and it Figure Table As regards NUTS-3 level results, we notice , and the percentage of households owning the house where they live . Table In this paper, we estimated monetary and non-monetary poverty measures at two different levels of disaggregation in Tuscany. The data comes from a sample survey held by the Regional Institute for Economic Planning of Tuscany (IRPET), focusing on the economic and social features of the Tuscan households, with particular attention to the current economic situation (September 2021) and prospects.In particular, we estimated the percentage of households living below the poverty line and three (fuzzy) supplementary measures of poverty that we identified in: deprivation in basic needs and social inclusion, children specific deprivation, and financial insecurity. Our results reveal the areas and the provinces with the major amount of people living in (monetary) poverty conditions, but also, they show that the perception of financial insecurity is dominating at each level of territorial disaggregation. Also, it reveals that children vulnerability is a problem that is similarly spread in Tuscany, while poverty in basic needs seems to have hit some areas/provinces more than others. Thus, measures related to monetary issues, as HCR and FS1 are those presenting more heterogeneity across provinces and across the six areas.The importance of these findings is crucial from the point of view of local policy making, indeed specific addressed policy could reduce regional vulnerability and/or foster the capacity for resilience  addressing the gaps in social protection of Tuscan citizens and ii) making the regional welfare system more resilient to future shocks through more effective and flexible policies.For these reasons we estimated the variance of the measures discussed as an assessment of their reliability. We noticed that in some areas/provinces, the estimated coefficients of variation were not so contained to guarantee a proper level of accuracy of the direct estimates.For this reason, we used small area estimation to obtain new estimates with lower mean squared error. With this technique we were able to take almost all the estimates at a level more than acceptable. To state if an estimate is acceptable, we used the guidelines by Statistics Canada. However, some studies apply small area estimation regardless of the magnitudes of CVs (see Graf et al. Nevertheless, for some areas the small area gains were not always sufficient. These results may be in part because the number of areas considered is low so that the variance resulting from small area estimation may be overestimated. In principle, this is not a major problem if the variance is estimated in a conservative fashion. However, when the areas/province show a good level of accuracy we use the direct estimates as an official estimate. In fact, the properties of direct estimators are well-known while small area models may suffer from bias when the number of areas is small. We also noticed that in provinces with large sample size, the small area error tends to be greater. Situation like this have been already addressed in the literature and seem to be an effect of the large sample size.


Biofeedback training is a method commonly used in various fields of life, for example, in medicine, sports training or business. In recent studies, it has been shown that biofeedback, and neurofeedback, can affect the performance of professional athletes. Training based on the neurofeedback method includes exercising the brain waves. The aim of the article is to evaluate the influence of neurofeedback training on the physical fitness of professional athletes representing various sports disciplines, such as judo, volleyball and soccer. Based on 10 scientific papers from various sources, including PubMed, the latest research on neurofeedback and its impact on athletes has been reviewed. On the basis of the literature review from 2012 to 2022 on the neurofeedback method in sports training, it can be stated that this type of practice has a significant impact on physical fitness and sports performance. This review comprised 10 research studies with 491 participants in the neurofeedback groups, and 62 participants in the control group. Two reviewers independently extracted data and evaluated the quality of the studies utilising the PEDro scale. Properly planned and conducted neurofeedback training affects stimulation and improvement of many variables . Sports training is a specific form of exercise. Its effectiveness depends on properly selected methods. Excessive training loads can result in overtraining, while insufficient training loads do not lead to significant sports achievements . It shouBiofeedback is a brainwave training process. These waves are categorised on the basis of their frequency. Neurofeedback (NFB) is a method that assists subjects in consciously controlling their brain waves. In fact, EEG is recorded during the neurofeedback treatment . NeurofeIt is important to focus on the role of neurofeedback in professional sports. In the 1980s, scientists developed a method of periodisation for sports training . There aIn research on the subject, evidence has been demonstrated regarding the effectiveness of neurofeedback training as a mental support method for professional athletes. An important aspect is the proper selection of training protocols and specialised staff, which allows influencing the desired parameters . In geneIn 2010, a study was also conducted among Canadian athletes participating in the Vancouver Olympics, which showed that the use of NFB increased their stress control, which resulted in better results at the Olympics compared to the previous year .The aim of the paper is to review the scientific literature on the impact of neurofeedback methods used in sports training on professional athletes’ performance. In our work, we attempt to answer the questions as to what neurofeedback training protocols are effective for achieving appropriately targeted goals in athletes and how and to what extent they shape their mental abilities.This study conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement  and the The review of articles was carried out by searching for information on biofeedback and neurofeedback regarding the performance of professional athletes, using PubMed and other available scientific databases. The keywords neurofeedback in sports training and efficiency of EEG biofeedback were used to search for scientific articles indicating the impact of biofeedback and neurofeedback on sports performance. The presence of a control and research group is a desirable phenomenon in the researched subjects. It is important to have the most extensive research group, the results of which can be compared before and after training. In the review of the literature, many sports disciplines mentioned the impact of the above technique.The purpose of the analysis was to search electronic databases with scientific articles, including PubMed, Google Scholar, Scopus, Web of Science and current scientific databases. The following keywords were used in the search: EEG, neurofeedback, sports. Publications from 2012 onwards were taken into account. In All research papers were included in this study. Conference proceedings, commentaries, reviews, editorials, research notes, letters, duplicated publications and expert experiences were excluded.The following inclusion criteria were taken into account when selecting the appropriate items: The original publications included studies on athletes in which the training protocol is shown over time. The publications in which the athletes were professionally active during the protocol were considered for analysis. Age was not a criterion for exclusion, but automatically taking into account only active people, the range was approximately 18–35 years. Age was a criterion for inclusion, and considering only active people, it was within the range of approximately 18–45 years. The older range was rejected due to the existence of diseases affecting the results. Exclusion criteria included the presence of mental and physical disorders that significantly influenced the course of the study .The PEDro scale was utilised to examine the quality of the included studies . This scFirst, 450 studies were identified. After removing duplicates, 405 (n) remaining trials were screened for eligibility. Then, 140 studies were excluded because they were not about neurofeedback in sports, focused on unrelated subject areas (n = 120) or did not have an available full text (n = 20). Finally, according to our inclusion/exclusion criteria, 10 studies were considered acceptable for this literature review .For the purpose of a detailed analysis of scientific publications, the description of the research group, training methods, duration of the research and observed results were indicated by the authors of the paper. The majority of publications covered a control and research group. In most of the studies, the effect of a specific neurofeedback method on the level of physical fitness was considered. In all of the analysed studies, it was shown that neurofeedback influences the physical and mental fitness of NFB participants. This was confirmed by controlled tests carried out before and after special training .From the analysed literature on the subject, high research quality was found for five scientific reports, one of moderate, and four of low risk. Taking the above literature into account, it should be borne in mind that neurofeedback is a relatively new method, and its impact on various fields (such as sports) has not been well-studied by specialists. Nonetheless, neurofeedback is used in many fields as a form of treatment or training . The benRaymond demonstrated positive changes in the heart rate regulation process among professional dancers after neurofeedback training . SimilarIn tennis, there are various pressure situations that players experience. In a study by Habay et al., it was shown how mental fatigue (MF), a state that lowers physical and cognitive performance, affects table tennis players . The resIn a study conducted among professional Serie A football players , Esteves et al. demonstrated that neurofeedback training plays an important role in preventing injuries . The neuThere are many unconventional forms of neurofeedback considering physical aspects. Music belongs to one of these branches. In this way, it contributed to maintaining motivation in the rehabilitation process of the world champion in kayaking with chronic fatigue syndrome. Through repeated movements to musical rhythm, this outstanding kayaker was able to endure the tedious rehabilitation process and return to high psychomotor performance .In the research by Maszczyk et al., it is clearly indicated that this type of training significantly affects the dynamic balance of judokas . NeurofeNot all scientists agree that an athlete will be able to unconsciously control the processes occurring in the body without electrical devices that accompany them during training. Nonetheless, neurofeedback training is being incorporated to enhance performance in sports, cognitive fields and the artistic industry. In research on the subject, it has been shown that the use of neurofeedback improves performance . In a stVan den Berghe et al. presented a method for detecting changes in peak tibial acceleration during adaptation to low-impact self-running. These authors also used auditory neurofeedback in their study. Ten runners, with high tibial acceleration, were equipped with a wearable auditory neurofeedback system. All participants found a way to run with lower peak tibial acceleration. No change points were detected in the absence of neurofeedback. For each person in the neurofeedback conditions, at least 1 change point was detected, indicating that runners responded quickly to real-time auditory feedback. The system allows running with less impact load, reducing peak tibial acceleration for ground running compared to running without the device. The neurofeedback system and its strong sensory–motor coupling assisted rapid reduction of axial peak tibial acceleration during the initiation of gait retraction .Furthermore, Jeunet et al. conducted a study aimed at identifying the neurophysiological (EEG) correlates of covert visuospatial attention (CVSA) that could be used in NF training procedures dedicated to improving the performance of football goalkeepers. A significant positive correlation was revealed between the improvement of CVSA ability in athletes and an increase in their resting alpha power. This result suggests the possibility of designing innovative ecological training procedures for goalkeepers, such as using a combination of NF and cognitive tasks performed in virtual reality .In a study conducted by Mikic et al., the impact of holistic training on physiological and behavioural measures in semi-professional athletes was evaluated. During the neurofeedback session, participants were accompanied by self-relaxation and audio–visual stimulation following daily physical activity . The traFurthermore, Visser et al. aimed to investigate the activity of the frontal cortex during table tennis (TT) gameplay . In the Additionally, Studnicki et al. characterised artifact removal strategies in neurofeedback data for whole-body tasks such as table tennis . Using aLarson et al. included only one professional athlete in their study, despite conducting 15-month neurofeedback training. The results may be subjective due to the evaluation of only one individual. Indian athlete—Abhinav Bindra—won a gold medal at the Olympics in Beijing. Her training included “neurofeedback” methods, which helped her achieve a “psychokinetic state” that contributed to her great triumph. However, we cannot fully confirm the effectiveness as the studies were conducted on a single individual . The prePusenjak et al. , MirosłaFuture research should be focused on greater unification of desired research characteristics and replication of studies in a given sports discipline. In many of the studies, the influence of external factors and changes beyond neurofeedback training were not taken into account. In them, the results of neurofeedback should not only be presented, but also all changes identified. Another weakness of the methodology is the use of different training protocols in each study. Specific protocols and justifications should be created for a given sports discipline in future research. In each sample, professional athletes were enrolled, which is a positive phenomenon and should be continued in the future. The justification is that the application of the appropriate protocol in novices is significantly different from advanced groups, and the results vary significantly. Another difference in the protocols used is the time intervals and duration of training. Hosseini et al. A total of 29 conducted a single training session compared to Mikicin et al. , who useTwo researchers performed the literature search, study selection, quality assessment and data extraction. There were a small number of studies included in this review, which suggests a certain bias in the interpretation of the results. Most studies lacked a control group, making it difficult to determine whether the effects were due to neurofeedback interventions or non-specific effects. Another limitation is that different neurofeedback protocols with different waves and frequencies were used in the studies.In all of the analysed scientific studies, the effect of sports training was confirmed on the basis of the EEG biofeedback method. It has been shown that biofeedback used in professional athletes’ training improves their ability to control psychophysiological factors, including GSR and HR after exposure to stress, and thus, contributes to the improvement of well-being .The analysis of selected literature allows emphasising the effects of using neurofeedback in sports training. It has been shown that the contraction of this method in the training of professional football, judoka, volleyball players and boxers, causes an increase in behavioural performance and in speed reaction, a decrease in blood cortisol levels and an improvement in motor coordination. These positive results, achieved thanks to the skilful use of the neurofeedback method, directly influenced the increase in the level of sports abilities of the athletes who used this methodology in their training.