However, the scientific literature is currently unclear about which forms of PD are used to develop eHealth and which arguments are used to substantiate the decision to use a certain form of generative PD.Generative participatory design (PD) may help in developing electronic health  interventions. PD is characterized by the involvement of all stakeholders in creative activities. This is different from the traditional user-centered design, where users are less involved. When looking at PD from a This study aimed to explore the reporting and substantiation of generative PD methodologies in empirical eHealth studies published in scientific journals to further develop PD methodology in the field of eHealth.A systematic literature review following the Cochrane guidelines was conducted in several databases . Data were extracted on the recruitment and management of stakeholders, the use of tools, and the use of outcome measures.Of the 3131 studies initially identified, 69 were selected for qualitative synthesis. The reporting was very variable, depending to a large extent on whether the study stated that reporting on the PD process was a major aim. The different levels of reporting and substantiation of the choices of a recruitment strategy, stakeholder management, and tools and outcome measures are presented. Only a few authors explicitly used arguments directly related to PD guiding principles such as democratic, mutual learning, tacit and latent knowledge, and collective creativity. Even though PD principles were not always explicitly discussed in the method descriptions of the studies, they were implicitly present, mostly in the descriptions of the use of PD tools. The arguments used to substantiate the choices made in stakeholder management, PD tools, and the type of outcome measures adopted point to the involvement of PD principles.Studies that have used a PD research methodology to develop eHealth primarily substantiate the choice of tools made and much less the use of stakeholders and outcome measures. Stakeholder participation is considered to play an important role in developing electronic health interventions  -4. HowevPD is becoming increasingly intertwined with research and is therefore also considered to be a research methodology. Looking at PD from a research perspective, the methodological choices to be made are of particular interest. Methodological elements that play a key role in PD research are the recruitment and management of stakeholders , the useLooking at the literature on participatory methods to develop eHealth, a recent systematic literature review showed that 24 frameworks have been used . HoweverTurning to stakeholders, the varying involvement of patients as end users has been widely discussed in the literature ,13. WarnHow stakeholders, tools, and outcome measures are employed in the PD process depends on which PD methodology is followed. Furthermore, there is a lack of a strong methodological explanation that could help develop a more rigorous science of PD ,4. UsingThe PD literature encompasses various theories that form the foundations for methodologies -4,9,10. experts of their experiences given appropriate tools to express themselves [Democracy: In contrast to traditional design practices, the aim is to involve all stakeholders including nondesigners and future users who will be affected by new technologies. Users can become part of the design team as emselves . The aimMutual learning: Participants (both designers and nondesigners) learn from each other, but they also learn from themselves when reflecting on their own work.Tacit or latent knowledge: To assess the needs of people beyond the observable or easily detectable, that is, in the form of tacit needs. This deeper knowledge includes explicit and implicit day-to-day technological expertise from the present, future, and past . Sandersthe path of expression. Creativity facilitates a design process from which values emerge and become inscribed in the product or service [Collective creativity: PD is considered to be essentially a process of collective creativity . Sanders service . Everyon service .making things [Given the developing nature of the PD methodology, the theoretical and empirical literature does not always incorporate these insights and the four guiding principles. In the theoretical design literature, the relationship between PD principles and the use of stakeholders, tools, and outcome measures is only implicitly suggested ,4. For ig things . As suchg things . Dependig things ,19. It hLittle has been reported on the specific arguments used to explain the choice of specific stakeholders, tools, and outcome measures. Although stakeholders can be involved in various ways in the development of gerontology , mobile In addition, given the very limited presence of evaluations in the empirical literature, it is difficult to establish the outcome measures that are used, let alone the principles upon which they are selected. Eyles et al  failed tGiven these uncertainties, the aim of this study was to explore the substantiation behind the methodological choice to use a certain form of PD in developing eHealth. This paper was intended to be a start in looking at the state of reporting of PD research methodology and, therefore, used a systematic literature review to summarize the current status of reporting in peer-reviewed scientific journals. This research has the potential to guide researchers and practitioners to areas where greater substantiation is needed when using or reporting PD. By considering the current methodological choices, some recommendations are also provided that may also help researchers and practitioners select a method that helps them better achieve their aims.A systematic literature review with qualitative synthesis was conducted to summarize existing knowledge on PD methodology in the development of eHealth technology. In the medical field, the Cochrane review process is considered the gold standard. Given that this review is focused on eHealth, this systematic review follows the Cochrane guidelines . To ensuGiven that PD methodology is developing, the focus was on the reported use and justification of the choices made in using PD tools, stakeholder management, stakeholder recruitment, and the outcome measures selected. The first research question focuses on the use of PD: “How is the use of PD, in particular the involvement of stakeholders, the use of tools, and the use of outcome measures described in the empirical literature about eHealth development?” The second research question focuses on the justification for a type of PD: “What reasons, related to the guiding principles of PD, are offered to substantiate the preference for a given use of stakeholders, tools, and outcome measures?”Search queries were developed by an experienced medical information specialist (WB) and the searches used terms such as participatory design, co-design, cocreation, and collaborative design in the field of telehealth. In addition to these terms, we used a more descriptive approach where we combined human centeredness, patient involvement, etc, with shared decision making or doctor-patient relations in the field of telehealth. The term user involvement was also added to the search. The term participatory research was not used as the terms “co-creation,” “co-design,” and “participatory” were assumed to cover this field.The search strategies for all the databases that were used can be found in The following working definition for PD was used: PD refers to the collective creative design process of designers and nondesigners, whereby users are considered partners during the design process. PD activities can generally be described as cocreation workshops or cocreation exercises, or they can be more specifically described by referring to make , tell , and act  tools. Studies that used other terms were also included if they were described by the authors as co-design or PD-related activities ,17. StudThe selection criteria for inclusion and exclusion are shown in All types of empirical study designs were included, and no restrictions were placed on the types of participants. For instance, studies involving only patients or only care professionals in PD were included. The presence of PD activities was chosen as the inclusion criterion rather than other features of PD because this area has the most clearly defined consensus in the literature. Other aspects of PD, such as stakeholder recruitment, stakeholder management, and PD outcome measures, were not used as the inclusion or exclusion criteria as these terms can be used in somewhat arbitrary ways.Language: English languageFormat: Full text available (including full conference papers)Study design: Empirical study describing the direct or indirect observation or experience of using participatory design (PD) to develop electronic health  published in a peer-reviewed journal or conference proceedings. The aim of the paper was to report on the use of PD to develop eHealth.Product or service developed: eHealth relatedMethod of development: PD as a collective creative design process of designers and nondesigners whereby users are considered to be partners in the process and the use of PD activities is described with this mindset (including participatory prototyping)Design development phases: All innovation phases included Setting: at least one of the PD tools used must be in a group setting Language: Other than EnglishFormat: Only abstract or full text unavailableStudy design: Nonempirical studies , studies not peer reviewed Product or service developed: Other than electronic health  where users are considered as subjects in the design process (user-centered design), the use of PD is not described Setting: All PD tools used only by individualsDesign development phases: Value cocreation excluded (market phase and later marketing phases)The identification and selection of studies is summarized in To provide an overview of the general characteristics of the studies, the eHealth domain, the health domain, and the theoretical references used to refer to PD were summarized. In addition, the use of stakeholders, tools, and outcome measures was assessed as follows.First, regarding the use of stakeholders, different strategies could be used depending on the interpretation of PD principles. Therefore, data were extracted related to the number and type of stakeholders, stakeholder recruitment, and stakeholder management. Second, regarding the use of tools, different tools can be used at different times depending on the PD principles. Therefore, the type of tool and the purpose in using the tool were extracted. Finally, the study was placed in a design phase depending on the stage in which the study started: predesign, early design, or post first prototype .Third, as the use of outcome measures is influenced by the general methodological aim and the principles that are emphasized, the type of outcome measure that was used to evaluate eHealth and the PD itself was extracted.Owing to the variety of study designs, a quality assessment was not appropriate. Instead, an assessment of sufficiency of reporting was conducted, as used in a previous systematic review . This waSetting: Is it clear where the PD development of the intervention took place?Stakeholders: Is it clear who was involved in the PD, and does one know all that one needs to know about the participants?Facilitators: Is it clear who facilitated the PD process?Procedure: Is it clear what PD methods were used?Materials: Are any physical materials used in the PD process adequately described?Intensity: Is the length of the PD phase and individual sessions clear?Schedule: Is the interval and frequency of the PD sessions clear?Clarity: Is the description of the overall PD process clear?online self-management tools [person-centered Web support [Web-based plan for integrated care [The general health and eHealth technology characteristics and the theoretical references used in the studies when referring to PD are described below. The year of publication ranged from 2006 to 2019. The 69 studies cover 65 unique eHealth technology products and services. The majority of these were either Web-based tools such as nt tools , person- support , or a Weted care , or mHeaThere is a large diversity in the health domains considered. The mental health domain was most often addressed by the eHealth technology. The most frequent aims of the eHealth were disease-specific interventions  and self-management. The prevalence of self-management aims could be expected because the PD democratic principle emphasizes the involvement of users, and this may help the later uptake by these users of eHealth focused on self-management.In addition to the health and eHealth technology characteristics, the theoretical references of PD are presented here. Nearly all studies, 65, mentioned a theory of PD. Clemensen et al’s description of the PD methodology ,29 was rThe reporting on stakeholder recruitment, stakeholder management, PD tools , and outcomes measures to evaluate eHealth and the PD process is presented in Overall, 25 of the studies stated that an aim of the study was to describe the PD process or provide details of the PD process or of a design process similar to it . In many studies, an argument based on analogy is used to explain why they chose certain tools by referring to other PD literature where similar tools were used with similar design process aims (type 2).Some authors specifically argued why they used certain generative tools by explaining the type of knowledge that they seek to capture (Type 3). Phillips et al  explaineSome studies also related the knowledge advantage of using tools to the stakeholders involved in the PD project (type 4). This type of study justifies identifying knowledge domains related to stakeholders and then choosing outcome measures to capture that knowledge. One study explicitly stated the value of having a design expert in the teams to help select appropriate tools . AnotherSome of the studies evaluated the eHealth product or service output after the PD activities were concluded. The eHealth output varies depending on whether the development is in the predesign, early design, or post first prototype stage. Overall, 50 studies considered that the outputs of the PD process were in agreement with findings from similar studies or, in the case of an eHealth product, that after testing, they were effective. For instance, in an early design study, it was reported that “our design considerations show agreement with previous work related to human-factors for telerehabilitation technologies” . A studyOf these 50 studies that considered the outputs to be positive or effective, 22 studies reported outcome measures. These outcome measures concerned the development of the eHealth , the quality of the eHealth , and the outcomes for the user  tools are used to harvest ideas for the product or service development, (2) arguments in favor of the tools based on other literature, (3) arguments explaining the aim of the tools to retrieve specific type of knowledge, and (4) arguments explaining the aim of the tools in relation to the stakeholders involved.path of expression. Even though the knowledge development theory could be a building block in a methodological framework, it is remote from practical methodological guidelines on selecting between PD tools.This focus on knowledge arguments was expected as this is implied in other publications. However, it has not yet been explicitly summarized in terms of levels of argumentation. Others have stated the importance of recognizing the fundamental role of knowledge development in PD. Given the nature of PD, this implies gaining an understanding and a generative creativity that leads in itself to different ways of knowing . In termIn terms of outcome measures, only a limited number of studies reported outcome measures to evaluate eHealth development and the use of the PD process itself. One study in this review described the outcome measures in considerable depth for the evaluation of both eHealth and the method . CompareThe identified lack of outcome measures is in line with findings elsewhere. Previous systematic reviews have also highlighted the lack of transparency about the evaluations of PD ,8. HowevThe results of this study are limited for several reasons. First, the search strategy for relevant research is limited by the focus on papers published in scientific journals. Given that many reports on PD in developing eHealth are not in scientific journals, the review only provides a partial view of the state of reporting PD methodology, namely only that in the empirical scientific literature.The screening process is limited by the definitions applied for the terms used in the inclusion and exclusion criteria. As there is no universally agreed definition of PD, a working definition was chosen that focuses on one strand of PD research, namely where stakeholders are a partner in the process. Consequently, studies describing PD in a more user-centered way were excluded, and their inclusion may have led to different results.Turning to the analysis and conclusions, the following limitations were identified. First, it is challenging to draw conclusions based on the reporting of the PD methods as described in the papers selected in the systematic literature review. The actual methodological intentions and considerations made during the PD project may differ from what is reported in the studies. The limited number of studies reporting outputs and outcome measures may be related to the recognized publication bias toward reporting positive results and eHealth products and services that are already fairly developed. In addition, the evaluation of the eHealth technology may have been reported in a separate publication; for example, in the paper by Waller et al  includedThe PD methodology is still under development ,4,108. PThe fact that the methodological reasonings behind the use of PD are not widely reported could be because of several reasons. From a scientific perspective, PD has mixed origins, ranging from social science through action research to the design sciences . This maThe academic design culture is still developing alongside other different cultures such as engineering, the arts, and the social sciences . AlthougThis observation can be further explained using the observations by Spinuzzi , who clascientific attitude toward carrying out a PD project. Improving documentation on the choices of certain PD recruitment strategies, the use of certain tools, or the use of outcome measures could provide more information that could then be reported in scientific journals. Improving education about the scientific documentation of PD projects for designers and eHealth developers could help to improve future reporting. One key challenge here is to translate design terminology to scientific terminology and vice versa; for example, prototype testing in design might be translated as hypothesis testing in science.PD reporting could be improved if PD researchers were to adopt a more Research through Design [Further research can help improve the methodological framework for PD in eHealth. A particular focus on the knowledge development process, as a core aspect of PD, would greatly help in substantiating methodological choices and in measuring the outputs of a PD process, especially in eHealth given the various areas of technical knowledge involved. There is a growing interest in the methodology of design known as h Design , which cStudies that use a PD research methodology to develop eHealth primarily substantiate the choice of tools and much less the selection of stakeholders and outcome measures.


The purpose of this study is to analyze the wages of South Korea’s care workers as reported by the Korean national health insurance services database. We also try to identify the factors determining the wages of these 1,221,085 care workers. According to the results of the analysis, first, the wage level of care workers is fundamentally low compared to other jobs; second, the labor conditions of home care facilities  are poor, because these depend on wages, which in turn depend on the external environment, such as care institutes’ management; and third, it was verified that the locations of care institutes affect the wages of care workers. As the South Korean population continues to age, the supply of high-quality care workers has important clinical implications for improving the quality of care received by the elderly. Throughout this study, it is argued that the establishment of a social service corporation has become desirable in terms of strengthening public care institutes in Korea. The Moon Jae-in government is currently discussing the establishment of the social service corporation (or agency). With the growth of social services centered on the private sector in Korea, the demand for “socialization of care” has increased due to limitations in service quality. There are many reasons for including this, but the poor working environment of long-term care workers is considered to be one of the main reasons. The purpose of this study is to analyze the wages of South Korea’s care workers, identify the factors determining these wages and discuss what policy implications can be obtained.Long-term care workers in Europe are mostly middle-aged women in their forties and older and have low work quality due to low wages and job insecurity . OECD coCare workers in Korea are also mostly women in their fifties or sixties, who have graduated from high school. Their wages are less than 50 percent of average wage in all industries, and a high percentage of care work roles are irregular employees. Care workers suffer from working hours that surpass legal limits . ApproxiIn Korea’s long-term care insurance policy, the roles of insurer and administrator are taken by the public sector and the role of direct service providers is taken by the private sector. Care workers belonging to old age social care services and approved facilities under the long-term care insurance introduced in 2008 are personnel providing services based on the national certification system. Thus, care worker salaries are determined by respective long-term care institutes’ management within the minimum wage policy. In this situation, long-term care institutes, which must generate profits, may choose to reduce personnel expenses. According to a recent survey, the highest portion of care workers (36.9 percent) chose to change jobs due to low salaries . In the Long-term care insurance for the elderly provides high-quality services that allow elderly clients to maintain their quality of life. However, as mentioned above, in Korea, care work can be considered unappealing, due to low salaries and unstable employment. This study focuses on wages and begins by exploring current wage levels and the factors affecting them, using the Korean national health insurance services database (Korean NHIS DB).Studies of caring labor began in the 1980s when the increase in demand and the problem of supply came to the fore. First and foremost, the 1994 study by Bussemaker and Kersbergen identified that from the perspective of women’s studies, female complementary caring labor is a significant factor that excludes social citizenship, including women’s pensions . MoreoveExperts in the European Union (EU) assembled professionals from the UN Statistical Commission, the UN Economic Commission for Europe (UNECE), the European Commission (EC) and the International Labor Organization (ILO) to create the task force on the measurement of quality of work. These experts discussed the paradigms of the EC’s ‘quality of work’, the ILO’s ‘decent work’, and the EF’s ’quality of work and employment’, which are used to monitor Europe’s labor conditions. In addition, the taskforce attempted to establish guidelines regarding the international quality of work or recommendations on the measurement of qualitative factors, which can be utilized in both developing and developed countries . In 2008With regard to the second indicator, this study focuses on care workers’ wage. Fujisawa and Colombo (2009)  reportedPrevious studies are meaningful in that they assess real parameters (such as wages) via surveys. However, since these studies were conducted individually, the scope of analysis subjects, the separation of home help services and care facilities, and the division of care workers and workers in other fields do not follow a common standard. In addition, it is difficult to compare or connect various study results, because previous studies have different standards, for example in terms of dividing the wages per month or per hour; not including the allowance for improved labor conditions, which started to be paid in 2013; and analyzing features of the working environment such as working hours. Lastly, since previous studies were based on questionnaires, it was difficult to adequately account for national distribution, the characteristics of institutes and the individual characteristics of care workers.Normally, wages in the Korean labor market are affected by gender, age, marital status, household members, demographic characteristics, education, forms of employment and social security . AccordiIn order to analyze the factors affecting the wage of care workers, it is necessary to separately take into account the ordinary labor market and the employment status of other care workers. As of September 2015, approximately 94 percent of care workers are women and 16 percent of them are in their forties, 49 percent in their fifties and 29 percent in their sixties. Care workers are hired in a labor market where middle-aged and old women provide caring services based on public assets–expenses regarding the supply of insurance benefits within the frame of long-term care insurance, which is social insurance ,18. As aThe data used by this study to analyze the wages of care workers are from the national health insurance corporation database. The following is the process of data extraction. In the first stage, the sample group of care workers was gathered. The sample subjects are 1,221,085 care workers, from among 1,488,998 care workers certified during the period from 1 July 2008 when elderly long-term care insurance was introduced, to early 2015. In the second stage, to analyze care workers who were working in early 2015, 567,712 were sorted by narrowing down to the office workers in national health insurance. In the third stage, the analysis targets were narrowed down to home help services care workers, who were the biggest proportion  and the residential care facilities’ care workers, who were working within a standardized system . In the fourth stage, targets were limited to the care workers at home care facilities ; monthly working hours were restricted to 40–160 h; and extremes were eliminated by limiting the monthly wage of residential care facilities to between 1 and 2 million won ($909 and 1819) and the hourly wage of home help services from 5000 won ($4.55) to 10,000 won ($9.10) see . Based oThrough comparative analysis with existing reports or studies, this study identified differences in terms of wage, age and the characteristics of relevant institutes by implementing descriptive statistical analysis. Moreover, so as to identify the factors affecting the wage of care workers, multiple regression analysis was conducted by having two categories: care workers from residential care facilities and those from home care facilities. The analysis was implemented based on STATA 14.0 .According to previous studies, the main factors influencing care workers’ wages in general were age and career. ,15,16 InIn 2017, the average wage for workers in Korea can be seen to be quite low compared to the average wage of 2.9 million won per month ; monthlyIn the case of Korea, unlike the study by Lee and Lee (2006)  that argThe factors affecting the wages of care workers at residential care facilities are presented in The factors affecting the wages of care workers at home care facilities are presented in This study analyzed the wages of care workers by utilizing various database categories in the national health insurance corporation database. To summarize the results, excluding the improvement in the labor conditions fee, the monthly wage of care workers as of early 2015 at residential care facilities was 1.32 million won ($1200)) (1.42 million won ($1291) per year including the improvement of labor conditions fee) and the hourly wage was 6573 won ($5.98) (7198 won ($6.55) including the improvement of labor conditions fee) in home help services. Wages are higher for younger care workers, especially those in their forties; when they are experienced; when the institute is founded by either a corporate body or local government; when the institute has been operating for a long time; and when the institute is located in a noncapital region.When it comes to factor analysis of the wages paid to care workers at residential care facilities and home care facilities, in the case of those at home care facilities, wages were found to be high when the institute operation term was short; when the region was a military area; and when the region had a large elderly population. Home help services mainly operate in regions of high demand for care protection services and the lack of care workers results in high wages. However, in residential care facilities, since they are mostly located on the outskirts of cities, they are less influenced by regional characteristics than home help services because they are also absorbing the demand of city-dwellers.When putting together these results, first, the wages of care workers are fundamentally low because their hourly wage is merely 23.2 percent higher than the official minimum wage for those working at home care facilities and 18.6 percent higher for those working at residential care facilities when the improvement of labor conditions fee paid by insurers is not included. Therefore, it is difficult to enhance relatively poor wages with just the hourly 625 won ($0.57) of improvement represented by the labor conditions fee. Second, the scale of care workers working at residential care facilities is similar to those of the institutes established by individuals, corporate bodies and the institutes established by local governments, but the scale of the home help services is overwhelmingly smaller than that of institutes established by individuals. Thus, the status (as expressed in factors such as wages) of care workers working at home care facilities may be lower than that of care workers at residential care facilities. Both the management and supervision of institutes established by individuals and the management and supervision with regard to the overall employment of care workers need to be strengthened. Third, it was verified that the regional characteristics of care institutes have different effects on the wages of the care workers at residential care facilities and home care facilities. In other words, since home help services are affected by regional characteristics more than residential care facilities, suitable approaches for care workers at residential care facilities and home care facilities have to be considered prior to reflecting regional characteristics when developing policy measures regarding their wages.Therefore, as in the Nordic case, a structural-level policy for the care worker core labor market is needed. According to the results of analysis, it is a reasonable choice to work in a well-run care facility in order to receive high wages as a care worker. In addition, care work at home care facilities appear to be unstable because it depends on the wage level, which in turn depends on the external environment in terms of factors such as the region and the care demand. This is because they are unable to establish their status as professionals, treated according to individual competence. Therefore, it is necessary to strengthen the standardized qualifications system for care workers; to form a compensation system; and to form a ladder structure ,23 throuAs states continue to age, the supply of high-quality care workers has important clinical implications for improving the quality of care received by the elderly. Since many bedridden patients are in residential care facilities, care needs to be provided by people who are physically robust . In the case of home care facilities, it is sometimes required that care workers provide medical services in the private sector without the help of specialists. Hence, high wages are required for high-quality care workers to be recruited and retained.Strengths and LimitationsThis study is meaningful in the context of care worker wage-related studies in the sense that it analyzed a sample of care workers’ wages paid by care institutes, by using the national health insurance DB data. However, since it could not include individual-related variables—education, marriage status, dependent family members and so forth-due to the strengthening of the Personal Information Act, it could not adequately control for demographic characteristics, which have an immense influence on wages. In addition, the data used in this study are not open source. This is a limitation of this study.Who is responsible for a compensation system that reflects skilled workers’ wages and job security? Who could implement such a system? Care workers respond to gaps and government policy determines the supply of care workers to the labor market. Guaranteed employment security for care workers ultimately depends on the Korean government . In otheThroughout the empirical analysis, the objective of improving the labor conditions of care workers has been pursued and is considered a reasonable and worthy aim. In addition, it seems that the private delivery system’s environment is inferior and so the development of social service corporate and community care could be considered, referring to the Nordic model.


In the pre-intervention portion of the study, it was found out that the doctors and nurses had higher knowledge scores compared to the non-clinical hospital staff (p ≤ 0.05). A statistically significant improvement was seen after the educational intervention was deployed (p ≤ 0.05). The study concludes that the non-clinical staff, being a vital part of the healthcare framework, need to be educated and effective approaches for official inclusion of relevant information need to be incorporated into clinical practice to limit the transmission of COVID-19.With the increasing spread and mortality of the COVID-19 (Coronavirus disease 2019) pandemic, it is essential for the healthcare community to be prepared per the international standards. This study is focused on assessing the preparedness of healthcare personnel and the effectiveness of an educational intervention to improve this preparedness in those dealing with the COVID-19 infection. A prospective, multicenter audit cycle was conducted on 400 healthcare professionals  sampled through stratified random sampling. A questionnaire that was based on “Centers for Disease Control and Prevention (CDC's) checklist for healthcare personnel's preparedness for transport and arrival of patients with confirmed or possible COVID-19” was sent to the participants after which an informative document, framed on the information provided by World Health Organization (WHO), CDC, and local guidelines from the Government of Pakistan's website, was distributed through social media platforms. The questionnaire was repeated after 2 weeks to close the audit loop. Chi-Square test and paired sample  Coronavirus disease or COVID-19 is a newly discovered infectious ailment of the respiratory tract that was first reported in the province of Wuhan, China in December of 2019 and since then, has spread rapidly across the globe . The firThe Centers for Disease Control and Prevention (CDC) has laid out a checklist in reference to the preparedness of the healthcare personnel (HCP) to standardize care geared toward controlling the pandemic . LimitedKeeping in view the rapidly rising number of cases, this study is aimed at evaluating the preparedness of the healthcare professionals as per the international guidelines, finding out if a statistically significant difference is present between the preparedness of healthcare workers based on their designation, and if an improvement could be made through an educational intervention.t-test was applied to test significance between the mean percentages of the correct answers and positive responses before and after the intervention .The study is a prospective, multi-center, audit. Ethical approval was obtained from the Institutional Research Forum of Rawalpindi Medical University and allied hospitals. Data were collected from the three major government hospitals of Rawalpindi; Benazir Bhutto Hospital, Holy Family Hospital, and District Headquarters Hospital, Rawalpindi. In accordance with the Centers for Disease Control and Prevention's (CDC) definition of health care personnel (HCP), those serving in the frontline who had an increased risk of exposure, whether direct or indirect, were included in the study . This enp ≤ 0.05). The questionnaire items on safe practices that showed a significant difference between the designation groups were those that inquired about the healthcare professionals' compliance with source control measures and their experience with a disease outbreak. However, surprisingly, in these two categories, the nurses and the supporting staff outnumbered the doctors. Overall, the knowledge questions were better answered than those about adherence to preventive measures. Noteworthy was that only about 30%, in all the groups and in total, responded positively when it came to observing source control measures, and awareness and participation in COVID-19 preparedness programs. In addition, fewer than half of the participants in each group considered themselves prepared for dealing with the pandemic.The usage of sanitizer was highly prevalent among doctors, nurses, and maintenance workers, with <3% being unable to use which they stated was because of unavailability. In contrast, about 70% of the HCP were working at the duty stations where visitor management and exclusion was not being regulate 62.6% attributed this to the absence of such guidelines while the other 37.4% believed that the manpower was not there to ensure the observation. Furthermore, among approximately three-quarters of the respondents not following measures to control the spread of infection from the source, ~30% mentioned the cause to be a shortage of masks, around 4% stated that there were not enough rooms to allow isolated examinations at a safe distance, while the rest (67%) believed both were the reasons.t-test showed a higher average percentage of participants who were following the CDC checklist for preparedness after the intervention. The statistical significance of this increase is shown in Paired sample p = 0.000). In view of the importance to ensure social distancing, usage of social media messaging services was preferred over the face-to-face methods of holding workshops and lectures (The study was aimed at finding out the preparedness of the frontline healthcare professionals of Pakistan compared to the standards set by CDC. The audit cycle, which was performed in an attempt to find out if an educational intervention could bring an improvement in this preparedness, showed substantial improvement after the intervention (lectures . Moreovelectures . Thus, slectures , 14.Three major government hospitals of Rawalpindi were included in the study rather than a single institution in order to make sure that the results held external validity as well. In Pakistan, government hospitals are visited by a larger number of people as compared to private establishments, with the majority of the population being poor and uneducated, and subsequently, more likely to be in neglect of precautionary measures, rendering added importance for the healthcare professionals to be knowledgeable and prepared , 16. A pAfter the intervention, the participants considered themselves better prepared to deal with the COVID-19 situation which is particularly fruitful in the scenario because an increase in perceived self-confidence can result in better workplace performance . AdditioThere are a few limitations of the study as well. The lab personnel were excluded from the study since CDC has separate additional infection prevention and control guidelines for them that were not explored by us . The queThe foundation of the intervention was based on an informative self-learning method, which may not have been ideal but in order to comply with the protocol of social distancing to limit transmission, options were limited. Therefore, workshops, classes, and lectures with face-to-face teaching could not be organized. Furthermore, there was a chance of limited involvement of the participants with online meetings, especially since the work overload had increased in the already hectic schedules of the medical community owing to the pandemic, which is why they were not conducted. Further studies are advised to establish whether the preparedness could be further improved through combined approaches of clinical training and didactic teaching ways. Finally, the study alone is not able to confirm if an actual change in the management and practice was continued over time. Hence, the official inclusion of such guidelines is imperative.Since the COVID-19 pandemic has spread into various regions of the world, most of the countries, including the developed states of the United States of America, China, Italy, have had an enormous burden placed on their health care systems; physical, mental and financial. The disease is new and much about it is unknown and thus, health organizations all over the world are developing guidelines as they discover more on how healthcare professionals need to be prepared accordingly. The audit conducted indicated that the doctors and the nurses had a better performance in answering most of the knowledge questions but the practice of precautionary methods was still inadequate. The non-clinical staff, however, still was lacking in most aspects, and considering that a healthcare facility cannot function without them, it is the need of the hour to educate and prepare them accordingly. Moreover, after the information from reliable sources was distributed via social media platforms, a statistically significant improvement in performance was observed, which allows the authors to establish that official planning and strategies to ensure the spread of accurate information and the correct methods to make use of safety measures is crucial.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Research and Ethical Committee, Rawalpindi Medical University and Allied Hospitals, Rawalpindi. The patients/participants provided their written informed consent to participate in this study.NZ developed the original idea and structured the manuscript. ZJ compiled the data and managed the final formatting. NZ and ZJ performed the statistical analysis and interpretation. MM carried out the proofreading. All authors have agreed to the submission process.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.


An increasingly frail population in nursing homes accentuates the need for high quality care at the end of life and better access to palliative care in this context. Implementation of palliative care and its outcomes can be monitored by using quality indicators. Therefore, we developed a quality indicator set for palliative care in nursing homes and a tailored measurement procedure while using a mixed-methods design. We developed the instrument in three phases: (1) literature search, (2) interviews with experts, and (3) indicator and measurement selection by expert consensus (RAND/UCLA). Second, we pilot tested and evaluated the instrument in nine nursing homes in Flanders, Belgium. After identifying 26 indicators in the literature and expert interviews, 19 of them were selected through expert consensus. Setting-specific themes were advance care planning, autonomy, and communication with family. The quantitative and qualitative analyses showed that the indicators were measurable, had good preliminary face validity and discriminative power, and were considered to be useful in terms of quality monitoring according to the caregivers. The quality indicators can be used in a large implementation study and process evaluation in order to achieve continuous monitoring of the access to palliative care for all of the residents in nursing homes. In the past decade, in many Western countries, an increasing number of elderly persons were admitted to nursing homes. Projection studies concerning numbers of deaths and place of death suggest that, by the year 2040, the majority of deaths will occur in nursing homes ,2. MoreoWhen implementing palliative care in a nursing home context, it is important to evaluate its success and measure its outcomes for residents. One way to do so is the use of quality indicators within a continuous cycle of implementing, monitoring, and improvement . By contA previous program to develop and implement palliative care quality indicators, the Belgian Q-PAC study, used a rigorous development method combining literature review, expert consultation, and pilot testing, resulting in a core set of 31 quality indicators covering a broad range of aspects of palliative care. The set was meant to be used for all palliative care services and settings, including nursing homes ,28,29. HBecause of the increasing need for development of palliative care and its monitoring in nursing homes, we started a project to develop a set of quality indicators for the quality of palliative care in nursing homes. Previous research already highlighted the importance of person centered care through autonomy and involvement of family, but also communication and advance care planning in nursing homes ,32,33,34We used a two-step approach with a mixed-method design based on a standardized indicator testing protocol for generic quality indicators in order to develop the quality indicator set and measurement procedure ,35. FirsIn phase 1, we identified a comprehensive set of candidate quality indicators for palliative care in nursing homes. Therefore, we adapted the existing Belgium quality indicators for specialized palliative care listed in the Q-PAC  study  to the nThe preliminary set of candidate quality indicators was sent to 15 experts (see results infra). They were asked to score the quality indicators with “1” as “not appropriate” to “9” as “very appropriate” in order to measure the quality of palliative care in nursing homes. Experts were provided with the candidate indicator’s description, rationale, numerator and denominator, question  and literature source. They were also able to suggest missing domains or themes.The median scores on appropriateness were calculated per candidate indicator. The quality indicators were then categorized based on the RAND/UCLA consensus method: accepted, to be decided, or rejected. Indicators were immediately accepted if they had a median score of 7 or more and if no more than two experts scored the indicator with a 1, 2, or 3 (strict positive consensus). Indicators with a median score of 3 or lower and for which no more than two experts scored the indicator 7, 8, or 9 were immediately rejected (strict negative consensus) . All othAfter defining the quality indicators together with the experts, we developed four questionnaires to be able to calculate the performance score per quality indicator. These questionnaires were based on questions of validated scales as much as possible, or if no good question gathering the right information for a specific indicator existed in the literature, it was developed by the researchers, together with the experts. An overview of all indicators, accompanying questions and evidence can be found in the Two questionnaires were developed to measure indicators of quality of care for residents who currently lived in the facility: one for the resident  and one A questionnaire was developed for the closest family caregiver   and a seWe used a mixed-method design, including a quantitative application of the quality indicators and qualitative interviews with the nursing home staff using the instrument, in order to evaluate the face validity, feasibility, discriminative power, and usefulness of the instrument. Nursing homes were recruited on a voluntary basis through a call for participation via involved community-based organizations. From the 24 candidates, we selected a purposive sample of nine nursing homes, while considering the number of beds (between 64 and 290 beds), the organizational structure  and the geographical location (every Flemish province was represented). Nursing homes were able to measure the quality indicators via questionnaires through a cross-sectional inclusion design. This method allows for nursing homes to gather information on residents who were currently living in the nursing home as well as those who had passed away. Following inclusion criteria were used:lived for a minimum of one month in the facility;Residents who were currently living in the nursing home and:lived for a minimum of one month in the facility; and,passed away four weeks to six months earlier in the nursing home.Residents who had passed away and:All nursing homes followed the same measurement procedure based on a previously developed and tested method in order to measure the quality indicators via questionnaires . Before Nursing homes were asked to include minimum of 2/3 of all residents at random and all deceased residents who met the inclusion criteria. We developed an inclusion matrix, depending on the number of residents per nursing home. We used online questionnaires via Limesurvey because nursing home staff were responsible for the distribution of questionnaires and to ensure responders privacy. No IP addresses were saved to guarantee anonymity. Residents could fill out the questionnaire via portable computers or tablets available in the nursing homes; family members received a link to the questionnaire via email; inhouse caregivers accessed the online questionnaire via computers in the nursing homes or on their private computers.Per nursing home, a report was created, summarizing the individual and overall performance scores in a structured and standardized way. Nursing home coordinators were responsible for communicating the results to the nursing home staff (step 3 and 4 in Data collection was closed after one month. Performance scores (non-adjusted mean) per quality indicator were calculated while using the defined numerators and denominators range 0–100). In order to evaluate feasibility and discriminative power for individual quality indicator, we used descriptive and psychometric analyses in Microsoft Excel and SAS. Furthermore, the interviews were conducted with all coordinators in order to evaluate the face validity and usability of the indicators and the feasibility of the procedure. Together with the diaries of the coordinators and the field notes of the researcher, these interviews were analyzed while using a thematic framework approach, which was based on the barriers and facilitators for implementation framework of Grol and Wensing 0. In ord,40. TablThis study is approved by the Ethical Review Board of Brussels University Hospital of the Vrije Universiteit Brussel (protocol: QPACWZC01 BUN: 143201838240). All of the respondents  received an online questionnaire, including cover letter and informed consent. Only questionnaires with signed informed consent were used to calculate performance scores. No IP addresses, names, or other personal identifiers were saved in the online questionnaire system. All of the indicators and questionnaires were developed and evaluated in Dutch. All of the interviews and trainings were performed in Dutch. The English translation was done specifically for this article. Dutch versions of the indicators or questionnaires are available on request.Based on the existing QPAC quality indicator set for specialized palliative care, the additional literature search (phase 1) and interviews with relevant stakeholders (n = 10) (phase 2), we identified 26 candidate quality indicators in eight domains of quality of palliative care for elderly persons in nursing homes. Based on their individual evaluation of the 26 candidate quality indicators, seven quality indicators were immediately accepted and included. None were immediately rejected, so the remaining 19 quality indicators were debated in a one-day plenary discussion until consensus was found. Nine of 19 quality indicators were eventually accepted and three were newly developed during the meeting and added to the draft set. After the discussion, a set of in total 19 quality indicators were drafted and per email consented by all experts . In SuppNine nursing homes tested the quality indicator set and measurement procedure. In total, 294 residents, 393 professional caregivers (345 for residents who currently lived in the facility and 48 for deceased residents), and 34 family caregivers completed the whole questionnaire and hence were included for the pilot study. We asked nursing homes to list the total number of inclusions, but four of them did not perform this assignment correctly; hence, we lack information on the response rates in this study. In total 214 of the residents were female and the majority (53%) of residents was between 85- and 94-years old. None of the indicators had too many missing (>10%) answers. The quality indicators showed good discriminative power, as there were no indicators that had 95% or more answers in an extreme category . Only twThe results indicate clear work points and results are recognizable”. They also agreed the results were easy to interpret and useful in terms of improving their service, but they indicated that they struggled in establishing concrete improvement goals that are based on the quality indicator scores. The coordinators evaluated the length of all four questionnaires as feasible, but four coordinators declared that they would prefer paper questionnaires for residents and family, as this may improve response rates. As indicated by one of the coordinators: “We would prefer paper questionnaires … we [staff in de nursing home] don’t have professional email addresses and I didn’t want to send the questionnaires to their private email. Also, our residents don’t know how to use a computer or tablet and therefore some residents who normally could fill in a questionnaire alone, now couldn’t”. We interviewed all nine coordinators of the included nursing homes. With regard to face validity, all of the coordinators confirmed that the appeared to reflect their practice and seemed valid. As indicated by one on the coordinators: “Training was okay, the manual is clear and I think we could have managed without [the manual]”. Additionally, all of the coordinators indicated that the workload was feasible and worthwhile, although they declared that preparing the list of respondents was time-consuming, as they had to acquire their own approach.Moreover, all of the coordinators indicated that they would use the instrument again and evaluated the instruction manual as useful and sufficient and assumed the instrument could be executed without the researchers. One of the coordinators said: “Based on field notes, the interviews with the coordinators, and diaries of the same coordinator, we made an overview of facilitators and barriers regarding the use of the instrument  in generIn this study, we developed and evaluated a quality indicator set and a tailored measurement procedure consisting of 19 indicators to monitor the quality of palliative care in Belgian nursing homes. The composition of this indicator set is based on previously developed quality indicators for specialized palliative care, but, after adaptation to the nursing home context by experts and stakeholders, the themes differ somewhat: more emphasis is placed on autonomy and dignity of the nursing home residents. From this first pilot study, the quality indicators seem to be valid and the measurement procedure feasible for caregivers in nursing homes who are interested in improving the quality of end-of-life care within their center. From the psychometric analyses, we found that most of the quality indicators were feasible and they showed good discriminative power. The instrument appeared to reflect practice and hence confirmed face validity, according to coordinators during the qualitative interviews. The measurement procedure was evaluated by the interviewed coordinators as feasible and they indicated the measurement of the quality indicators could be performed based on the manual without extra help of the researchers. Overall, this study shows that the quality indicators are ready for further use in a large implementation study in Flemish nursing homes in order to further evaluate their feasibility, usefulness, discriminative power, and potential for quality improvement.An evaluation of the quality of care with quality indicators best includes process as well as outcomes indicators of care in one monitoring cycle ,41. The An important strength of our study is the rigorous, systematic development method while using stakeholders and the mixed-method design, including the RAND/UCLA method for indicator development, quantitative analysis of data, and qualitative interviews with the coordinators in the nursing homes to evaluate the instrument. Hence, we were able to evaluate the instrument and its measurement procedure in terms of face validity, feasibility, discriminative power, and usefulness. Additionally, because the thoroughly follow-up with the involved coordinators before, during and after the pilot, barriers and facilitators influencing the course of the measurement were identified. The small database is one of the limitations of this study. Psychometric analyses were limited and a study on further implementation is necessary to evaluate and validate the instrument including the quality indicators. The absence of response rates is another limitation of our study. Although coordinators drafted a list of included residents, we were unable to match them with the questionnaires because of GDPR policies. Additionally, although we aimed to include as many residents as possible while using three versions of the questionnaire in the resident’s evaluation, we have no insights regarding whether residents with cognitive problems, such as dementia, were sufficiently involved in the quality monitoring. Worldwide initiatives have been taken to monitor and improve the quality of palliative care in different settings ,45,46,47In light of care improvement in the field of palliative care in a nursing home context, a large-scale research project, ‘PACE steps to success’, has recently been implementing a combination of tailored improvement initiatives focusing on communication, advanced care planning, and knowledge and skills on end of life care while using a train-the-trainer implementation model. Although the intervention did not show significant effect on their primary outcome (comfort in the last week of life for residents), the process evaluation showed that the implementation rate was highly variable between countries and teams, and several challenges arose, such as attitude and motivation of staff, and skills and expertise of the trainer appointed to the individual nursing homes ,48. Our In this study, we developed and evaluated a quality indicator set and a tailored measurement procedure consisting of 19 indicators to monitor quality of palliative care in Belgian nursing homes. We combined both objective and subjective measures into four questionnaires for different perspectives in order to reach a comprehensive picture on quality of palliative care, end-of-life care and advance care planning in nursing homes. Care teams in nursing homes are able to monitor themselves based on these indicator scores. We found, while using both quantitative as qualitative analyses, the developed instrument had good face validity, feasibility, discriminative power, and it is useful in terms of quality monitoring according to caregivers, though establishing concrete improvement goals based on quality indicator scores remains difficult for them. The quality indicators are ready for further use in a large implementation study and process evaluation in Flemish nursing homes in order to further evaluate their feasibility, usefulness, discriminative power, and potential for quality improvement.


Concerns have been expressed about the view point of WHO AFRO concerning research for health in the African Region. WHO AFRO considers research a critical component in the improvement of health in the Africa region. Ensuring the effectiveness of our strategies, policies and programmes requires evidence. In the context of the ongoing COVID-19 outbreak, WHO research interests cover key areas of the response. The WHO AFRO consider research as critical in our efforts at protecting people against health emergencies and pandemics like the COVID-19 and ensuring universal access to proven interventions. In view of this, the WHO has taken steps to strengthen capacity for research in the region. The results of these efforts may take time to manifest but will surely do as we persist in our drive, with support from our partners. Our attention has been drawn to some recent commentaries on the need for research tailored to the realities of the African people in the context of COVID-19. In her contribution to the Guardian, Dr Monique Wasunna, director of DNDI´s Africa regional office, warned that if research is not conducted in Africa, potential life-saving innovations will be delayed . We agreOur top priority is to support Member States to achieve universal health coverage as part of the collective action to achieve the Sustainable Development Goals based on the Primary Health Care approach. Our organization-wide strategic plan for achieving this, is the Thirteenth General Programme of Work (GPW13) 2019-2023. The main thrust of this guiding document is to promote health, keep the world safe, serve the vulnerable, by delivering on three triple billion targets: 1) Achieving universal health coverage, with 1 billion more people benefiting from universal health coverage; 2) Addressing health emergencies, with 1 billion more people better protected from health emergencies; 3) Promoting healthier populations, with 1 billion more people enjoying better health and well-being. Research and innovation occupy a central position in the GPW13, to focus global public goods on impact and ensure that WHO is a knowledge-based organization facilitating normative guidance, sharing data and scaling up innovations.“we need our collective knowledge, insight and experiences to answer the questions we don´t have answers to, and to identify the questions we may not even realize we need to ask”. In recognition of these facts, we have taken steps to enhance the conduct of research in the region. A recent national health research systems assessment in the region revealed gaps in many countries in terms of research norms, infrastructure, and funding. These are gaps that need to be filled urgently as we strive to conduct research in the region [The ongoing COVID-19 pandemic has further unraveled the urgent need for therapeutics, vaccines, diagnostics and other public health interventions. This leaves the medical and public health community with only non-pharmaceutical interventions (NPIs) to rely on for reducing the burden of COVID-19. Improving our response to the COVID-19 Pandemic in the WHO Africa region requires innovation, new information and research and development (R and D) is urgently needed. The SARs-CoV-2 virus is a new pathogen that spreads quickly, and is causing enormous health, economic and societal impacts around the world. Response to this pandemic requires a multi-sectoral approach, guided by critical knowledge on the diverse dimensions of the disease. Dr Tedros A. Ghebreyesus, WHO´s Director General has urged that, e region ,4.We considered this step critical for three main reasons: (1) governments and health care leaders should know if there are unique aspects about how these interventions may work in their populations and health care systems; (2) there is a moral imperative for Africa to be part of the global initiative to find solutions to any pandemic; and (3) the recognition that it will be more difficult to advocate for access to effective products if countries/regions have not played their part in trying to determine which products are effective. Response to the COVID-19 pandemic requires action beyond the health sector and simply adopting strategies only based on well-known pathogens, risks failing to exploit all possible measures to slow transmission of the virus. This calls for research to answer various questions and develop innovative approaches in response to the pandemic.Major priorities for research include:Hosting a hackathon in the African region: leveraging the database of innovators from continent through several innovation hubs and accelerators across the continent, WHO AFRO shall call for innovations that are suitable for the African region context to help respond to the current COVID-19 response.Online innovation market platform for COVID-19: develop a web-based platform for collating innovation submissions for COVID-19. The platform will be accessible to Member States to identify appropriate innovative solutions that they will adopt and scale in their respective countries. A review committee will be constituted to periodically review the science and maturity of the innovations, and their potential impact to develop a pipeline fit for adoption and scale in the Region.Case studies for innovations developed in other countries globally: implement a systematic approach to identify the innovations that were developed in other regions, for instance in China and Europe. Perform implementation research and gain knowledge on whether those solutions can be adapted to the current African context.Early investigations of COVID-19 cases in countries: engage with countries to introduce the five WHO standard protocols for early investigation of COVID-19 cases in the Region. Give orientation to countries that indicate interest on any or all the five protocols. Provide both technical and financial support on the implementation of the selected protocols.Research on priority questions around COVID-19: facilitate the setting up of research teams for the response. Share the research priorities with country response teams and partners, facilitate coordinated research actions, Facilitate the use of generic protocols and finally, mobilize resources to support implementation of research protocols in countries.In collaboration with partners, such as the African Academy of Science (AAS); the European and Developing Countries Clinical Trial Partnership (EDCTP); the Coalition for Epidemic Preparedness and Innovations (CEPI); among others, we have taken steps to develop clinical trial regulatory oversight capacity over the years. For instance, the African Vaccine Regulatory Forum (AVAREF) was established as a mechanism to assure the quality of reviews through the technical support of WHO, African experts and other experts, as needed. The WHO in African region has also produced guidance documents for use by countries in building their research infrastructure.There are some major research outcomes that have contributed to change in the way we do things in the region that WHO has been involved in. For example, WHO was at the center of the development of the AFR meningitis A vaccine which has exclusively been used in Africa and has stopped outbreaks of meningitis due to this serotype ,6. WHO iWith respect to Ebola vaccine, WHO played major roles, from supporting the research, to conducting the trial in Guinea in 2015. A randomized trial for the vaccine began during the West Africa Ebola outbreak in 2015. With support from WHO, the government of Guinea and WHO took the unusual step to lead the trial, when no other organization was positioned to run a trial in Guinea during the complex emergency. During the current Ebola outbreak in the Democratic Republic of the Congo, more than 236,000 people were vaccinated with rVSV ZEBOV GP donated by Merck to WHO, including more than 60,000 health and frontline workers in the Democratic Republic of the Congo and in Uganda, South Sudan, Rwanda and Burundi. Furthermore, for the past five years, WHO has consistently convened experts to review the evidence on various Ebola vaccine candidates, informed policy recommendations, and mobilized a multilateral coalition to accelerate clinical evaluations. The EMA review was unique in that WHO and African regulators actively participated through an innovative cooperative arrangement put in place by WHO, which will help accelerate registration for the countries, most at risk .With respect to diagnostics, WHO in the African Region has major strides. For example, WHO supported evidence informed tools and policy development and at least 20 new technologies were developed and evaluated in the last decade . FurtherWe would like to reiterate that research is critical for our work as an organization. It is a core function of the WHO in shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge. We consider research critical for progressing on the UHC and SDG agenda, and more importantly protecting the people against health emergencies and pandemics like the COVID-19. Consequently, the WHO has taken steps to strengthen capacity for research in the region. The results of these efforts may take time to manifest but will surely do as we persist in our drive, with support from our partners.The authors declare no competing interests.


In the recent years, the progress in genetic analysis and next-generation sequencing technologies have opened up exciting landscapes for diagnosis and study of molecular mechanisms, allowing the determination of a particular mutation for individual patients suffering from hereditary red blood cell-related diseases or anemia. However, the huge amount of data obtained makes the interpretation of the results and the identification of the pathogenetic variant responsible for the diseases sometime difficult. Moreover, there is increasing evidence that the same mutation can result in varying cellular properties and different symptoms of the disease. Even for the same patient, the phenotypic expression of the disorder can change over time. Therefore, on top of genetic analysis, there is a further request for functional tests that allow to confirm the pathogenicity of a molecular variant, possibly to predict prognosis and complications  and, in the best case, to enable personalized theranostics (drug and/or dose) according to the disease state and progression. The mini-review will reflect recent and future directions in the development of diagnostic tools for red blood cell-related diseases and anemias. This includes point of care devices, new incarnations of well-known principles addressing physico-chemical properties, and interactions of red blood cells as well as high-tech screening equipment and mobile laboratories. Thus, there is a need to establish the prognosis and possible complications of particular disease states and to determine an appropriate treatment. This is not restricted to the selection or combination of particular drugs but also the dose of these drugs. The concept of personalized theranostics addresses this issue but requires new approaches to become effective.There is a demand for novel diagnostic assays and devices from several perspectives. (i) Since we are still facing huge economic differences across our planet, there is a need (and a market) for low-cost diagnosis of common and rare red blood cell-related diseases. This includes sickle cell disease, thalassemia, malaria, and other less common hereditary and acquired hemolytic anemias. (ii) Scientific progress and the omics era allowed to unravel new diseases. This covers so far undiagnosed red blood cell diseases as well as identifying new pathogenetic variants in previously phenomenologically defined diseases. However, the huge amount of data obtained need to be interpreted, and often variants predicted at Given the rarity and the heterogeneity of this group of disorders, the interest of pharmaceutical companies and device maufacturers in developing drugs and technological devices, respectively was limited in the past. The strong possibility not to reach a sufficient volume of requests, the approach to rare disorders, in particular the congenital ones, was scanty up to some years ago. Funding initiatives for rare diseases, especially by the European Commission (within the 7th Framework Program and Horizon 2020) boosted research in the field of rare anemias, and this will continue within the coming years (Horizon Europe). A consensus document highlighting major achievements in diagnosis and treatment of blood disorders, including rare red blood cell disorders, and identifying the greatest unmet clinical and scientific needs has been recently prepared by more than 300 experts belonging to the European Hematology Association (EHA) .There are many requirements that should be taken into consideration in the development of a point of care device. It is important that the test performed will be rapid, user-friendly, easily interpretable, sensitive and specific . Another aspect that should always be considered in the development of point of care diagnostic devices is their size. They need to be transportable and in the best case being pocket size. Furthermore, such devices need to be affordable, although the threshold for the market price is different depending on the socio-economic environment of the patient(s). In particular, one of the technical developments of the past decade is in favor of such developments: the smartphones (and tablets) are ever improving mini-computers with innovative interaction interfaces that often “only” require particular sensors and the complementary software to turn into a diagnostic device. Even smartwatches (or fitness watches) already measure routinely heart rate and other health-related parameters start to become routine read-outs such as oxygen saturation  or blood pressure. It is worthwhile to mention that most point of care devices work completely non-invasive or at least only require such small amounts of blood that can be taken by finger prick avoiding venous puncture e.g., . ExampleA very special test for sickle cell disease was recently developed. The test is utilizing filter paper and, thus, costs less than 0.05€ per test .As outlined in the introduction, although the identification of a molecular lesion is mandatory in genetic disorders to confirm the diagnosis, clinical observations reveal that the genotype/phenotype correlation is not always possible and that other genetic/epigenetic factors (other than the molecular defect) may contribute to the clinical phenotype. This is particularly evident in case of intrafamily clinical variability in presence of the same mutation, or in clinical variability in the same patient during his life . TherefoAn example addressing cell deformability is the LoRRca  . The insA neat concept to test red blood cell stability based on a bead mill and spectral measurement of hemoglobins was developed by Blaze Medical Devices . Although the concept was convincing , the devYet another example is a table top device called MeCheM  that was developed by Epigem Ltd.  within the project CoMMiTMenT . It is a microfluidic device that can challenge red blood cells chemically or with functional surfaces, while red blood cells are microscopically observed. Although it is not yet on the market, it is under investigation in several hematologic laboratories within Europe and in a clinical trial testing the efficiency of Memantine for the treatment of sickle cell disease .The opposite of point of care devices are machines or procedures that are so complicated and/or expensive that they are exclusively established in expert centers or even in specialized research laboratories. For these devices/procedures, it is sometimes hard to distinguish between the generation of new knowledge and diagnosis—at least this borderline is fuzzy. An example of such a device is an automated patch-clamp robot that in the past proofed to be useful for the investigation of red blood cells . An imagin vitro erythropoiesis, which was refined and optimized considerably also in the past decade. Although bioreactors for an automated and controlled differentiation from peripheral stem cells to erythrocytes are under development , each case seems unique and worth to be described and deeply characterized. Networking activities to recruit similar cases and to joint expertise and collaborations is utmost important in this field e.g., . However2+ , the effin vitro . Taking in vitro  and (ii)in vitro . HoweverPoint of care, artificial intelligence, and personalized theranostocs are probably the major keywords that characterize current and future developments in diagnostic devices for red blood cell-related diseases, in general, and for rare anemias, in particular. From a conceptual point of view, genetic analysis is well established, and decrease in the size of devices and significant cost drops will increase the spread and the regular use of this diagnostic tool. In line with this, a targeted analysis of a defined (group of) protein(s) will be replaced by a full genome analysis. However, functional analysis  on top of gene characterization will become increasingly important. This may go far beyond the samples given above and is likely to include further miniaturized assays of well-known tests such as the investigation of cell density distributions or measurements considering filterability properties.Both authors wrote and approved 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.


One important concern around the spread of respiratory infectious diseases has been the contribution of public transportation, a space where people are in close contact with one another and with high-use surfaces. While disease clearly spreads along transportation routes, there is limited evidence about whether public transportation use itself is associated with the overall prevalence of contagious respiratory illnesses at the local level. We examine the extent of the association between public transportation and influenza mortality, a proxy for disease prevalence, using city-level data on influenza and pneumonia mortality and public transit use from 121 large cities in the United States (US) between 2006 and 2015. We find no evidence of a positive relationship between city-level transit ridership and influenza/pneumonia mortality rates, suggesting that population level rates of transit use are not a singularly important factor in the transmission of influenza. Concern about the role of public transit use in the spread of contagious respiratory diseases is long-standing, widespread, and very timely. The literature on the epidemiology of influenza, in particular, dates back to the early 1900s and has historically demonstrated that mortality from season influenza and pneumonia is concentrated among older adults and among those with pre-existing health conditions . It alsoOne source of such increased exposure is hypothesized to be the use of public transit . Public Based on our review of the literature, few studies have directly examined the potential role of public transit use in the spread of contagious respiratory diseases. In a study of influenza-like illness and time spent in the London Underground, Goscé and Johansson 2018) found that incidence was higher in areas where commutes to Central London involved more contact with other riders; however, the authors included only one year of data and did not directly measure the share of people in each borough who ride the underground; instead, they simply controlled for car ownership  found th. By contWhile transportation of any type is clearly associated with the spread of disease from one geographic area to another, the role that public transportation plays in the transmission of disease within a local area is complex and difficult to study. One way to examine the full impact of mass transit on the spread of influenza is, therefore, to examine data aggregated to the city level, exploiting the considerable variation in the use of public transit across American cities. Therefore, we draw from a decade’s worth of city-level influenza/pneumonia mortality and census-based transit-use data to examine the relationship between community level use of public transportation and mortality from influenza/pneumonia. It is important to note that we are not examining whether influenza rates are higher among those who take public transit relative to those who do not; rather, we are assessing whether community transmission of severe influenza, including to those who never take transit, is greater in areas where transit use is higher.The Centers for Disease Control and Prevention (CDC) report aggregate data on deaths where influenza and pneumonia is the underlying or contributing caused listed on death certificates . We dowDatasets were merged based on city, state name, and year to construct a city-year data set, excluding city-years where no data were present (n = 1201). We used negative binomial models to estimate influenza/pneumonia death counts (summed together), with an offset term for the population and robust standard errors clustered on city. The baseline model included the percent of residents using public transit to commute to work, the age distribution , and the flu year modeled as a set of dummy variables. The adjusted model added census division areas (of which there are nine) to control for climate-related factors, and city-level percentages of bachelor’s degree or higher, non-white, below poverty, unemployed, and male. To test the robustness of the model, we repeated the analysis for each individual year and used linear and Poisson distributions in place of the negative binomial specification. Because transit use is highly correlated with population density, and both factors might be expected to contribute to the spread of influenza, we also conducted a sensitivity analysis controlling for population density.Since cities may differ in their health care infrastructures, we conducted sensitivity analyses with two indicators designed to capture the quality of and access to the healthcare system. First, we obtained influenza vaccination rates for adults 65 years old and older from the CDC’s Behavioral Risk Factor Surveillance System for approximately 90 overlapping metropolitan statistical areas . VaccinaTo examine city-specific effects of changes in transit, we ran the analysis for the full period using fixed effects for each city, identifying the relationship between changes in transit use and changes in flu across the full period. Because there was very little change in transit use among cities over this period, we also identified the 10% of cities with the largest absolute increase and the 10% of cities with the largest absolute decrease in transit use between the two time periods (2006–2010 and 2011–2015) and plotted the association between the average death rate in the first three years of the data (2006–2008) and the last three years of data (2013–2015) to determine whether there was an appreciable change in the death rate. To counter the fact that pneumonia cases make up a larger portion of deaths in our rate and that these deaths may be driven by hospital rather than community acquired infection, we created a ratio of deaths from October 1 –March 30 and from April 1 –September 30. Since flu deaths primarily occur in the fall and winter, whereas pneumonia deaths occur all year round, this ratio represents a proxy for flu vs. pneumonia deaths in a given city and year [Throughout, we report the incidence rate ratio (IRR) for transit ridership and its associated confidence intervals. Coefficients and standard errors for the full model are provided in the In 2015, influenza/pneumonia death rates ranged from 0.65 per 100,000 in Springfield, MA to 329 per 100,000 in Dayton, OH  and publIn the baseline negative binomial model, the death rate was negatively associated with percent transit . For eveWhen we looked at the 10% of cities with the largest increase in transit use  and the 10% of cities with the largest decrease in transit use  between the two time periods, death rates in the early period appear highly correlated with death rates in the later period for both sets of cities  . The corIn 100 simulations of the data using the adjusted negative binomial model, the IRR ranged from 0.988 to 1.000, with a mean of 0.994. Approximately 99% of all IRR were below 1, implying that the risk of death was reduced the majority of the time .Using historical influenza/pneumonia and transit data in the US, we did not find any evidence supporting the hypothesis that greater use of public transit at the city level is associated with local influenza and pneumonia mortality rates. These findings are consistent with prior studies of the relationship between transit use and influenza –10, but This study has several limitations. First, we merged datasets from various sources based on city names, however, the geographic boundaries of these cities could be defined differently, meaning the percent of influenza/pneumonia deaths and other covariates could be under or overestimated. Second, this is an ecological study with outcomes and predictors measured at the city-level; therefore, findings should not be interpreted in terms of individual risk. Third, commuting to work is only one aspect of how public transportation is used in a city; there could be meaningful differences in other types of use  that vary between cities and could influence influenza/pneumonia rates. Fourth, we could not separate influenza from pneumonia deaths, many of which are driven by hospital/healthcare acquired infections, not community transmission, creating noise and potentially bias if these infections are not equally spread within the population. That being said, we found good concordance between the CDC’s assessment of flu season severity  and our In conclusion, our research does not address the question of whether, within a city, those who use public transit are at greater risk than those who do not. However, despite widespread concerns about the role of public transit in diffusing respiratory disease, our findings suggest that the rate of utilization is not a singularly important factor in the local prevalence of influenza.S1 Appendix(DOCX)Click here for additional data file.S1 File(XLSX)Click here for additional data file.


The rapid spread of the Coronavirus disease 2019 (COVID-19) has forced most countries to take drastic public health measures, including the closure of most mental health outpatient services and some inpatient units. This has suddenly created the need to adapt and expand telepsychiatry care across the world. However, not all health care services might be ready to cope with this public health demand. The present study was set to create a practical and clinically useful protocol for telemental health care to be applied in the context of the current COVID-19 pandemic.A panel of psychiatrists from 15 different countries [covering all World Health Organization (WHO) regions] was convened. The panel used a combination of reactive Delphi technique and consensus development conference strategies to develop a protocol for the provision of telemental health care during the COVID-19 pandemic.The proposed protocol describes a semi-structured initial assessment and a series of potential interventions matching mild, moderate, or high-intensity needs of target populations.Telemedicine has become a pivotal tool in the task of ensuring the continuous provision of mental health care for the population, and the outlined protocol can assist with this task. The strength of this protocol lies in its practicality, clinical usefulness, and wide transferability, resulting from the diversity of the consensus group that developed it. Developed by psychiatrists from around the globe, the proposed protocol may prove helpful for many clinical and cultural contexts, assisting mental health care providers worldwide. The Coronavirus disease 2019 (COVID-19) pandemic has placed the world in an exceptional situation, forcing communities and governments to make fast decisions. The World Health Organization (WHO) has highlighted the importance of measures aimed at delaying the spread of the virus . These ivia this approach , upper middle income , and high income countries .via telephone hotlines. The following protocol was created with this limitation in mind. Still, whenever possible, video conferencing should also be made available to the public.There are some contexts where video conferencing is available for specialists and the population. However, while it would be ideal for everybody to have access to the tools and the necessary digital literacy to liaise with mental health providers online, this is not always the case. An actual means available for the wider population and mental health care providers in most contexts involve phone calls (landline or mobile), primarily via telephone hotlines or helplines. But before making this service widely available, these departments should first organize the necessary resources, including human resources. This organization should include securing the contact information of, and/or an open line of communication with, available hospitals, ambulance services, and any other potentially necessary resource . Depending on availability, this organization should also include securing up-to-date information about COVID-19, public health measures, essential services, and any financial assistance available to the population in times of quarantine. It should also include setting up a filing system for records, if these were to be used.We recommend mental health departments to provide an entry point to mental health care The service would require, ideally, a coordination team, a technical support team, and mental health care providers (from here on referred to as providers). The coordination team should be responsible for ensuring resources, both material and human resources, including technical support. In case that not all members of the providers team were mental health specialists, the protocol we are presenting offers a guide for when to refer the call to these specialists. All providers should possess the appropriate and necessary competencies in terms of mental health care. In regard to the provision of telemental health care, it might be necessary to organize brief training at the service, either through professional associations, by inviting national or international consultants, or even through active learning under a self-training scheme. There may be contexts where it would be the same providers who are in charge of coordinating the service. Still, it is advisable for them to organize first the necessary resources, according to the service capabilities.via video conferencing, the artificiality of eye contact through a screen (Providers should be aware that telepsychiatry carries some additional challenges in regard to establishing rapport. This is due to the loss of nonverbal cues during the interaction, the lack of physical closeness, and, in cases where it is conducted a screen . ProvideWhen contacted for the first time, providers should conduct an immediate assessment and intervention, tailored to each person’s needs to the best of the provider’s capabilities. via follow up calls and further communication should be scheduled with this population. People experiencing a psychiatric emergency or a situation that places them or others at risk of harm require third-line interventions, which include immediate contact with a mental health specialist or an emergency service.As an outcome of this initial assessment, callers will then be matched to one of three potential lines of intervention Table 4.All interventions should follow the criteria of appropriateness and evidence-based efficacy. It is highly recommended for providers to review and follow, according to the provider’s and service capabilities, the best practice guidelines provided by either local or international entities, e.g., those published by the American Psychiatric Association and the American Telemedicine Association , and othThe rapid progression of COVID-19 and the non-pharmacological interventions adopted to reduce the spread of the virus have led to increasing difficulties in the provision of mental health care. As a result, telemedicine has become a pivotal tool in the task of ensuring the continuous provision of mental health care for the population. It is extremely important for mental health services around the globe to prepare and take action ; the proThe strength of this protocol lies in its practicality, clinical usefulness, and wide transferability, resulting from the diversity of the consensus group that developed it. Country representatives from a wide range of social, cultural, and economic contexts contributed to the development of this protocol. As such, it represents a valuable tool with a likely wide transferability across different regions and contexts. Nevertheless, it should be acknowledged that there is a potentially high degree of resource allocation needed to apply these recommendations, which may indeed limit its transferability to some contexts. Therefore, further studies are recommended to ensure a match between the here proposed protocol and country/context-specific conditions or to guide all necessary adjustments before it is implemented locally. Moreover, both these studies and/or the implementation of the present protocol in any mental health service should abide by specific local health regulations and the institutions’ ethics committees.Still, the proposed protocol could help mental health providers to identify and address the mental health impact of physical distancing and misinformation during the COVID-19 pandemic, two key issues highlighted in the literature . FurtherThe literature also suggests that it may prove beneficial to develop targeted telepsychiatry interventions for different populations during the pandemic . ParticuAs suggested by other authors , 26, 40,The mental health impact of the COVID-19 pandemic has forced mental health services around the world to adapt. The adoption of this protocol can complement existing guidelines during the pandemic in those contexts where telepsychiatry was well established already, but most importantly, it can also provide a starting point to those where telepsychiatry has played a marginal role until now. These are particularly difficult moments in time. However, they also offer the opportunity to advance the way in which mental health services worldwide support the population, and this protocol also highlights the importance of acknowledging and harvesting the knowledge and expertise of early career psychiatrists around the globe in that task.The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.RRam developed the trigger questions and topics and wrote the first draft of recommendations and article with the support from LO. All authors contributed to the article and approved the submitted version.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.