This study investigates the internationalization  of small family businesses by classifying the effects of external socioemotional wealth (family reputation) vs. internal socioemotional wealth (family involvement). The study involved 2,704 small family businesses in China, and the results support the hypothesis that family reputation has a positive effect on internationalization, while family involvement has a negative effect on internationalization. Moreover, entrepreneurial spirit reinforces the positive effect of family reputation on internationalization and enhances the negative relationship between family involvement and internationalization. This study contributes by examining the effect of entrepreneurial spirit as a potential balancing factor for the paradoxical influence of internal vs. external socioemotional wealth. To respond to the challenges brought about by economic globalization, internationalization strategies have become crucial or even necessary for many family businesses that traditionally operate in domestic markets. The organizational behaviors of family business differ from other types of firms with different ownership structures because family members usually intend to run the business by creating and preserving socioemotional wealth (SEW), even at the expense of financial gains , is a typical mode of internationalization with heavy resource commitment  and internal  sources for SEW has been explicitly or implicitly proposed in the literature on this subject Block, . Family In other aspects, reputation building offers motivation for the owning family to seek business success. A firm's reputation is defined as the “beliefs of various stakeholders regarding the likelihood that the firm will deliver value along key dimensions of performance  in 2016, which is a nationwide aerial survey on Chinese private entrepreneurs jointly conducted by the All-China Federation of Industry and Commerce (ACFIC), State Administration for Industry and Commerce (SAIC) and Chinese Academy of Social Science (CASS) since the beginning of the 1990s. Each wave of the survey covers about 0.055% of private firms in China mainland and 31 provincial regions, including 22 provinces, four municipalities directly under the supervision of the central government, and five minority autonomous regions.To achieve a balanced representation across all regions and industries in China, a multistage-stratified random sampling method was used in this survey. The sampling procedure was conducted as follows: in the first step, we determined the total number of private enterprises surveyed. This total national sample size was assigned to 31 provinces in mainland China according to their shares of local private enterprises in the national total. Then six cities or counties were picked up for each province, generally including the provincial capital city, one prefecture-level city, one county-level city, and three counties. Then the number of private enterprises surveyed in each city/county and industry are in turn likewise determined according to its share of private number in this province or industry. Finally, private enterprises were randomly selected for each sub-sample. This dataset is by far the best for studying research issues concerning Chinese private enterprises because of its large sample cover. This survey is based on detailed household interviews with the majority owner of each selected private firm , (2), (3), (5), (6), or (8), otherwise equal to 0. Referring to sample statistics, we found that only 9.69 and 5.27% of sampled firms have Foreign Investment and international business expansion, respectively. In the CPES survey, the respondents reported the amount of OFDI. All of the family businesses that self-reported the investment destinations also reported the investment amount, providing an additional validity check of this dummy measurement.The conceptualization of organizational/family reputation “consists of familiarity with the organization, belief about what to expect from the organization in the future, and impressions about the organization's favourability” . These results suggest that it was appropriate to proceed to the factor analysis. One factor was subsequently extracted via principal component analysis with varimax rotation using the Kaiser normalization rotation method, and the total variance explained by this factor was 73.5%. Thus, the three items were averaged into an operating measure of family involvement.Involvement proxied by family ownership and management control is not sensitive in this study, since family ownership is generally high among all the sampled firms. In the survey, the value of family involvement is measured using the following items: (1) The owning family should retain over 50% ownership of the family firm; (2) Strategic decisions about the family business should be made by family members; and (3) The key positions should be occupied by family members. All items are measured using a five-point Likert scale anchored between “strongly disagree” and “strongly agree.” The internal consistency of the family involvement scale is measured using Cronbach's alpha. The three items are highly correlated , confirming that the measuring scale is suitable for the present purposes. The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy value is 0.68, greater than the recommended level of 0.6. Bartlett's test of sphericity is also statistically significant (p < 0.00). The internal consistency of the entrepreneurial spirit scale is measured using Cronbach's alpha; the three items are highly correlated . These results suggest that the scale for entrepreneurial spirit used in this study is relatively reliable.An entrepreneurial spirit is a value that enables an entrepreneur to look beyond accepted boundaries and find innovative ways to leverage the business and improve its practices. In the context of Chinese economic transformation and industrial upgrading, the entrepreneurial spirit is embodied in the pursuit of product innovation, technological innovation, and strategic transformation. Our measurement of entrepreneurial spirit is close to Miller's definition of entrepreneurial orientation as the “behavior of the business characterized by innovation, proactivity and risk-taking” Miller, : 771. EnThis study uses a number of control variables for firm characteristics. Previous research has suggested that foreign investment is essentially capital flight across borders in an attempt to flee a worsening business environment, and it is reasonable to assume that the domestic business environment is a key factor influencing foreign investment decisions. In the survey, the domestic business environment is evaluated using 14 items covering administrative approval, honesty, and efficiency of public officials, fair enforcement of laws, intellectual property protection, personal security, protection of property, infrastructure, business service in the market, interference from local government, financing from banks and private sources, and availability of skilled workers. A factor extracted from these 14 items is used to control for the family business owner's perception of the domestic environment. This study assumes that in firm-level investment strategy, domestic investment is closely linked to foreign investment. International diversification is a strategic consideration within a firm's diversification strategy and may be connected with trends in industry diversification. Therefore, domestic investment and industry diversity are controlled. Education background is also controlled for using dummy variables for high school  and college degree and above, with junior high school and below as the default educational background.Larger family firms may exhibit a greater inclination toward internationalization  is a binary dependent variable, this study applies a Probit model to test the hypotheses , domestic investment  and profit  have positive significant effects on the international expansion of a family business, while business environment and firm size have no significant effects. Slack resources offered by profitability may be important in the implementation of internationalization strategies . Outward foreign indirect investment in industrial fields is encouraged and supported by the Chinese government as a sign of growing Chinese market power, and substantial business expansion in international markets is welcomed by the local government and the public. It is acknowledged that only firms that perform well in the domestic market are in a position to implement a successful internationalization strategy, and foreign investment for business expansion enhances the business reputation and political assimilation of the owning family. A family business with a better family reputation  will thus have greater incentives to expand its business internationally than a family business with a lower family reputation.Model 2 provides the results for the main effect on IBE. The regression results show that family reputation has a significant and positive effect on IBE . The SEWs for the family involvement of the owning family are based on family cohesion and embeddedness in the local social network. The internationalization process is always accompanied by a partial loss of family control associated with the need to leverage external resources and talents. A family business with a high level of family involvement will try to avoid foreign investment that involves a heavy commitment of resources and will accord a higher priority to risk-aversion and SEW . The results for the interaction effect show that the level of entrepreneurial spirit positively moderates the positive incentive of family reputation on IBE. In other words, a family business with a strong entrepreneurial spirit will have more incentive through family reputation to undertake IBE. Hypothesis 3  is thus supported.Model 3 shows the results for the moderating effects of entrepreneurial spirit. The interaction term of family reputation × entrepreneurial spirit, which was added in Model 3, is positive and significant . Thus, an absence of entrepreneurial spirit will place higher importance on the preservation of family capital utilizing an international asset portfolio, which reflects a high level of family involvement. In the social context of the first generation of Chinese entrepreneurs following the opening up and reform of China, higher family involvement implies higher social embeddedness in the local community, which in the presence of strong entrepreneurial spirit places a higher priority on domestic investment than on foreign investment. In other words, the presence or absence of entrepreneurial spirit will make no substantial difference to the IBE for a family business with high family involvement. Hypothesis 4  is thus supported.An interaction term of family involvement × entrepreneurial spirit, added in Model 3, is found to have a significant and negative association with IBE  analysis to check our results. The PSM analysis shows a good level of robustness of the empirical results even after controlling for the self-selection problem for both family reputation and family involvement (see below for details). Tobit models are also used to check the robustness of the empirical results. As shown below, the results of the Tobit models are similar to those of the Probit models, with the same significance. Accordingly, our results can be considered robust.This study aims to identify the causal effect of family reputation and family involvement on the foreign investment of small family businesses. Unlike experimental studies in which sample cases are assigned at random to treatment or control conditions, any sample case can be subject to only one of the potential states of family reputation/family involvement, and we can only observe the outcome (IBE) in the treatment state or control state. Extending causal inference into observational studies is problematic since it is impossible to assign sample cases to treatment and control conditions . As shown in p < 0.01). Differences between the treatment and control groups in both matched and unmatched samples are negative and significant, implying that family involvement has a negative effect on IBE even after controlling for selection bias.In the PSM estimation, the average treatment effect (ATT) of family reputation on IBE is positive and significant  and internal SEW (family involvement) and finds that the orders of priority proposed by external and internal SEW may be quite different. In the context of this study, family reputation places greater emphasis than family involvement on ambitious IBE. More importantly, the effects of family reputation and family involvement are moderated by entrepreneurial spirit. In a family business with high levels of entrepreneurial spirit, the owning family may focus on the preservation of external SEW, which will enhance the effect of family reputation on IBE. In a family business without high levels of entrepreneurial spirit, the owning family may focus instead on the preservation of internal SEW, which will have quite different effects. This study proposes that whether a family business chooses international expansion should be explained in terms of the distinction between external and internal SEW, with careful consideration as to which logic will dominate in a specific diversified business context.This study provides insights into other factors in the choice of IBE. The results in The objective of this study was to analyze the effect of multiple dimensions of SEW on IBE. In a sample of 2,704 small family businesses in China, family reputation  had a positive effect on IBE, while family involvement  had a negative effect. This study also argues that entrepreneurial spirit may change the owning family's priorities in pursuit of SEW, moderating the effect of family reputation and family involvement on IBE. In this sample, entrepreneurial spirit reinforces the positive effect of family reputation on IBE and enhances the negative relationship between family involvement and IBE.This study advances our understanding of the international expansion of family businesses from the SEW perspective in four key ways, theoretically and empirically. First, by classifying SEW into external sources proxied by family reputation and internal sources proxied by family involvement, our study sheds light on the multiple dimensions of SEW and their effects on IBE, thereby contributing to the literature on SEW , and the results might reflect some peculiarities of the national economic and social context. Our findings are very specific to the Chinese transitional context, and caution should be exercised in an attempt to generalize to family businesses in other countries. Third, although it would be interesting to explore the issues raised here using a cross-country dataset, we lacked samples from other countries. The family context is, to some extent, country-specific; family businesses in America and Western Europe may be quite different from family businesses in East Asia. We recommend that future studies undertake a cross-country comparison to detect the similarities and differences among family businesses in a range of cultural and economic contexts. Fourth, our study assumes that intra-heterogeneity among Chinese family businesses is relatively small. However, this assumption may underestimate the wide variations found among local cultures, industries, succession generations, and foundation background. Therefore, exploration of intra-China heterogeneity on this issue is a task for future research.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval were not required for the study on human participants in accordance with local legislation and institutional requirements. The patients/participants provided written informed consent to participate in this study.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


The international terrorism threat urges societies to invest in the planning and organization of psychosocial care. With the aim to contribute to cross-national learning, this study describes the content, target populations and providers of psychosocial care to civilians after terrorist attacks in Norway, France and Belgium.We identified and reviewed pre- and post-attack policy documents, guidelines, reports and other relevant grey literature addressing the psychosocial care response to terrorist attacks in Oslo/Utøya, Norway on 22 July 2011; in Paris, France on 13 November 2015; and in Brussels, Belgium on 22 March 2016.In Norway, there was a primary care based approach with multidisciplinary crisis teams in the local municipalities. In response to the terrorist attacks, there were proactive follow-up programs within primary care and occupational health services with screenings of target groups throughout a year. In France, there was a national network of specialized emergency psychosocial units primarily consisting of psychiatrists, psychologists and psychiatric nurses organized by the regional health agencies. They provided psychological support the first month including guidance for long-term healthcare, but there were no systematic screening programs after the acute phase. In Belgium, there were psychosocial intervention networks in the local municipalities, yet the acute psychosocial care was coordinated at a federal level. A reception centre was organized to provide acute psychosocial care, but there were no reported public long-term psychosocial care initiatives in response to the attacks.Psychosocial care responses, especially long-term follow-up activities, differed substantially between countries. Models for registration of affected individuals, monitoring of their health and continuous evaluation of countries’ psychosocial care provision incorporated in international guidelines may strengthen public health responses to mass-casualty incidents.The online version contains supplementary material available at 10.1186/s12913-022-07691-2. Terrorist attacks cause a significant number of casualties worldwide and seek to create fear in the public , 2. TheiPlanning of psychosocial care in advance is important to efficiently respond to and recover from mass casualty incidents such as terrorist attacks . Their uAlthough international guidelines have been developed, little is known about how different countries actually meet psychosocial care needs after terrorist attacks. Such knowledge is essential to strengthen the public health preparedness and response to such disasters across countries. Given the scarcity of evidence on the best practices for post-disaster psychosocial care, it is particularly important to accumulate experiences and documentation of practices and interventions that have been applied. This study was conducted after a public health workshop on healthcare after large-scale terrorist attacks in Norway, France and Belgium, and sheds light on these countries’ psychosocial care responses . Our oveThis is a country case study of the public authorities’ psychosocial care responses to terrorist attacks in Norway, France and Belgium. The scope was on acute and long-term psychosocial care for the civilian population as outlined on a national level by official bodies in these countries. We focused on the attacks that caused the largest number of deaths in each country in the past decade: the 22 July 2011 attacks in Oslo and Utøya, Norway; the 13 November 2015 attacks in Paris, France; and the 22 March 2016 attacks in Brussels, Belgium. These attacks caused multiple deaths and injuries and exposed thousands to a potentially traumatic event. We reviewed pre-attack plans and guidelines for psychosocial care responses to mass casualty incidents, and post-attack documentation of the actual organization and content of psychosocial care in response to the terrorist attacks under study. The nature and availability of such documentation were unknown beforehand. Consequently, this study is exploratory and descriptive. Data were collected and examined by two researchers from each of the three included countries, next synthesized by all researchers and an additional Dutch researcher with expertise in international guideline development on postdisaster psychosocial care and cross-national comparison of the quality of psychosocial support. The researchers had multi-disciplinary backgrounds in medicine, nursing, epidemiology, public health, mental health, political science, sociology and public administration.The study included documents written in the national languages French, Dutch and Norwegian, and in English.Psychosocial care is a broad term ranging from immediate comfort and practical help through long-term psychological support and specialist trauma care . We searOur focus was on the public authorities’ psychosocial care responses to the attacks and how they documented what was done, by whom and for whom. We did not investigate the treatment of injuries, the emergency medical response beyond psychosocial care, legal aid or financial compensations. Since we did not aim to assess the achievements of the different psychosocial care responses, we did not include observational or qualitative research evaluating the health service utilization after the attacks. Furthermore, we did not examine psychosocial care to professional first responders who intervened in the attacks because of their profession, e.g. from the police, the fire brigade and the military, or medical personnel. The psychosocial care to professional first responders may be outlined in their respective specific institutional crisis plans rather than in general public health plans and may vary according to type of responder. Hence, it was considered too broad to be covered in this study. Those who were struck by the terrorist attacks while they were at work, such as airport personnel in Belgium and Ministry employees in Norway, were considered as civilians.We collected information about certain characteristics of the attacks, such as the total number of fatalities (except perpetrators), fatalities in children (< 18 years old), the reported number of physically injured, the type of attack and location. If this information was not available in the documents listed in  before the attacks occurred. The organization of acute post-disaster psychosocial care and the training of its providers were outlined in a legal ordonnance in the public health code of the French Ministry of Health in 2014, i.e., the year preceding the Paris terrorist attacks , and addThe federal public health services in Belgium updated their psychosocial intervention plan approximately 2 months before the 22 March 2016 Brussels attacks . This plIn the acute aftermath of the Brussels attacks, the local municipalities (communes) were in charge of setting up reception centres, including the possibility to stay overnight, while the federal services were responsible for the coordination of psychosocial care Table  56]. Ev. Ev56]. On the day of the Brussels attacks, a reception centre for the ones close to the victims was opened at a military hospital . RepreseIn all three countries, telephone helplines were available and accessible for the general population, and NGOs such as the Red Cross contributed in the psychosocial care response.Before the terrorist attacks under study occurred, all three countries had national plans or guidelines for the provision of post-disaster psychosocial care. In the immediate aftermath of the attacks, reception centres to provide acute psychosocial care were set up in all countries. Yet, the psychosocial care responses differed in terms of organization and content, particularly in the long-term. Furthermore, the availability and levels of details in the national plans, guidelines and other documentation of the psychosocial care responses varied between countries. The documents from the Norwegian Health Directorate were largely formulated as guidelines and recommendations and included particular descriptions of potentially vulnerable groups such as children and refugees. The documents from the French and Belgian health authorities were formulated as plans rather than guidelines or recommendations. Characteristics of the attacks, the exposed populations as well as the health system and other support systems of the country where they occur may be relevant to take into account when planning and implementing a psychosocial care response.This study covered three large-scale, multi-site terrorist attacks. There were differences between the attacks which may possibly have impacted the psychosocial care responses.The study demonstrates that the geographical context is of importance for the psychosocial care response. Firstly, the resources and availability of professionals trained for providing psychosocial care may vary between urban and rural locations. Secondly, the geographical context may influence the facility of reaching and identifying exposed individuals. All the attacks under study struck the capital of their country, but the 2011 Norway attacks also involved a shooting spree on the small Utøya island in a rural municipality. The geographical limitation of the island made it possible to identify all those who had been directly exposed to the shooting spree on Utøya. This may have facilitated the implementation of a proactive outreach model. In France, the November 2015 attacks took place in various crowded places in the Paris urban area . In this context, survivors who were not seriously injured may have fled the scenes of the attacks before rescue personnel could identify them and offer psychosocial care. Consequently, access to care may for many have depended on self-referral. In this setting, information campaigns on the psychosocial care offers may be particularly important to reach individuals with or at risk of developing health problems after the attacks. This may also have been the case for the two attack sites in Brussels, Belgium (airport and metro station) and for the bombing in Oslo, Norway. Notwithstanding, the bombing in Oslo occurred in the government quarter in the midst of the summer vacation period. Those who were at work in the affected ministries were easily identified. Therefore, it may have been more difficult to identify all the exposed individuals after the attacks in Paris and Brussel.Moreover, previous experiences impact the psychosocial care response. Paris was struck by terrorist attacks in January and November within the same year. Some neighborhoods were heavily affected by both attacks. Consequently, the emergency psychosocial units had recent experiences with providing care in this area upon which they could draw valuable experiences from in the psychosocial care response to the November attacks , 67. In A particular feature of the 22 July Norway attacks in 2011 was that the terrorist survived and had a trial against him beginning 9 months after the attacks, lasting approximately 2 months . The triThe psychosocial care response depends on characteristics of those who were exposed. In the Brussels attacks, two of the suicide bombings occurred at an international airport . A signiIn Norway, there were many adolescents killed during the attacks, and many survivors were adolescents or young adults . The youA key objective of psychosocial care after terrorist attacks is to identify persons at risk and prevent that they develop PTSD or other long-term health problems. Two fundamental questions are how to identify persons at risk and how to follow them up. Proactive outreach and active monitoring depend on the definition of a target population: who should be included in potential screening assessments? With respect to the attacks in Paris and Brussels, we did not find any recommendations of active monitoring with systematic screening assessments in the long-term aftermath of the attacks. Even if there were two target populations that were quite easily defined after the 2011 Norway attacks, one could, as previously mentioned, also have identified individuals at risk of developing PTSD or other health problems that could be eligible for inclusion in systematic screening programs based on the acute psychosocial care provided after the attacks in France and Belgium. Screen and treat approaches have been recommended after disasters, as survivors with mental health problems are often not detected through regular healthcare pathways . Yet, prOne of the objectives of this study was to better understand how the psychosocial care responses may have been influenced by the nature of the health systems. The countries’ health systems differed for instance in terms of gatekeeping and the share of the population with a regular GP. In Norway, there was a principle of lowest effective care with a regular GP scheme where over 99% of the population had a regular GP that served as a gatekeeper for referrals to specialized health care , 54. TheIt was beyond the scope of this study to analyze the roles of the victim support organizations in the provision of psychosocial care in different countries, yet our results indicate that victim support associations played important roles for long-term psychosocial care in all countries, though in somewhat different ways. In France, the victim support associations that were members of the French Victim Support and Mediation Institute offered free psychological consultations to victims of the terrorist attacks . In NorwThere is still a scarcity of knowledge about the most efficient ways of organizing and providing psychosocial care in response to terrorist attacks . Our stuThis study provides new insight into the planned and applied psychosocial care interventions after terrorist attacks in three European countries. Since there is little research on the best practices for post-disaster psychosocial care, it is especially important to synthesize grey literature on practices across countries. Information on the content, providers and rationales of psychosocial care interventions, and whether changes were made when applied after terrorist attacks, may be primarily found in grey literature . The datFurthermore, we aimed at gaining insight into what the national authorities envisaged and required in a psychosocial care response in their country. We therefore assessed plans, guidelines and documentation on a national level and not at lower administrative or geographical levels where there may also be important information on psychosocial care responses. The information we retrieved on psychosocial care differed between countries in terms of the level of details. The descriptions of the psychosocial care responses that we identified were most detailed for the 2011 Norway attacks and least detailed for the 2016 Brussels attacks. It is important to underscore that detailed descriptions do not necessarily mean that the actual care provided was sufficient. Similarly, a lack of detailed descriptions does not necessarily indicate that there was a lack of care. The content and quality of the plans do not necessarily reflect the content and quality of the psychosocial care actually provided. We assessed the plans and other relevant literature on psychosocial care approximately five (Belgium), six (France) and ten (Norway) years after the attacks under study. The time difference might have influenced the availability of literature. Grey literature is often not available in academic databases and might eventually be removed from the web sites of official bodies. It may therefore become more difficult to retrieve as time passes, e.g., as new guidelines or plans are developed. Moreover, recommendations for psychosocial care may change over time; experiences from earlier attacks may have influenced those occurring later. We included one case of terrorism from each country. The responses to the attacks under study may not be representative for the psychosocial care provided after other terrorist attacks or other mass trauma neither in the same country nor in other countries. Furthermore, the data we retrieved on the percentage of the population who had a regular GP were not necessarily comparable. In Norway, the percentage was based on register data, whereas it was based on surveys with self-reported and potentially more inaccurate data in France and Belgium. The latter dated from 2007 and 2008, respectively, and the situation might have changed since. More recent numbers from 2019 indicated that 9.9% of the population in France did not have a regular GP or other regular physician . We haveFinally, this study covered three Western European countries with relatively accessible and well developed healthcare. Although there were differences between the countries under study, the organization, availability and documentation of psychosocial care responses to terrorist attacks may differ further with respect to countries with less developed and less accessible healthcare.Despite the existence of international guidelines on post-disaster psychosocial care, there were important differences between the three studied countries in the psychosocial care responses to large-scale terrorist attacks. In order to build better practices, a mapping of the content and organization of post-disaster psychosocial care in different countries should be established as well as a cross-country framework for monitoring and evaluation research. It is essential to gain knowledge across national borders on the quality and efficiency of different psychosocial care responses to strengthen our preparedness for terrorist attacks and similar mass casualty incidents internationally.Additional file 1. List of the reviewed documents and web sites concerning the psychosocial care responses.


The State of Qatar has made extensive preparation to successfully host the upcoming FIFA 2022 World Cup, a tournament that will be held for the first time in the Middle East and the North Africa region. In preparation for this tournament, a wide-ranging operational strategy is being developed for each of the stadiums separately. This paper looks into the preparation stages of master planning and transport strategy for one of the hosting venues, which is located in Al Rayyan, Qatar. An overview of the Fédération Internationale de Football Association (FIFA) tournament, its assumptions, spatial planning, traffic modeling, Temporary Traffic Management, and the required mitigations from the transport operations perspective alongside the lessons learned are discussed in the paper. Qatar is slated to host the 2022 FIFA World Cup,This paper discusses the approach to conduct a Traffic Impact Assessment (TIA) and the accessibility strategy for the World Cup venues. In this paper, the authors aim to share the experiences and the strategies utilized in transport master planning and operation strategies for FIFA World Cup hosting stadiums in Qatar as an overall process.The following flow chart exhibited in Fig. Traffic Impact Assessment (TIA) deals with demand forecasting, mode choice, public transportation, master planning, and the accessibility strategy for venues hosting major events such as Olympic Games and FIFA World cup.During the FIFA World Cup, it is anticipated that fans occupy not only stadiums but also the designated venues (Fan zones) in public spaces. For instance, in FIFA World Cup  hosted iIn FIFA World Cup  tournamePassenger and travel information for public transportation, parking management, the allocation of resident protection zones and special traffic zones, the designation of bus shuttle services, and promotion of travel by bicycle were included in the FIFA 2006 action plan to facilitate transportation and provide accessibility for such huge tournament with 1.1 billion person-kilometers related to travel.Decker et al.  point ouThus, accurately determining the tournament demand is a critical step toward planning an efficient transport strategy for each of the tournament venues.To prepare for the FIFA World Cup 2022, Qatar has established the Supreme Committee for Delivery and Legacy , the organization responsible for developing the planning and operations and delivering the required infrastructure (Stadiums and non-competition venues).The Al Rayyan Stadium discussed, as a case study in this paper, is one of the venues of the FIFA 2022 World Cup tournament with a net capacity of 41,000 spectators and will host the group and the knockout stage matches. There will be eight (8) venues for Qatar World Cup 2022 hosting 32 teams. The average venue capacity is 47,500 seats. The largest venue hosting the Final Match is Lusail Stadium having a capacity of 80,000 spectators. There are also multiple venues with a capacity of 40,000 seats. The case of Rayyan stadium thus is a relevant representative for transport master plan study and review in Qatar for the FIFA tournament.To successfully deliver the tournament, an accurate estimation of trip generation, modal shares, and parking requirements in consideration of the uniqueness of each stadium is required. SC after extensive modeling and research has derived spectator profile for the tournament. The spectator profile is estimated by calibrating the existing Qatar Strategic Transport Model (QSTM) to match the tournament requirements. This resulting model is known as the Baseline 3 model and includes assumptions based on the confidential inputs from multiple stakeholders with the tournament demand, background demand, and the revised highway network.The Baseline model also accounts for the vehicle occupancies of various user groups . For example, the car occupancy is considered as 2.65 persons per vehicle, whereas the taxi occupancy is 4.0 persons per vehicle, which are assumed based on factors such as past experience and local transportation studies.As for the general arrival and departure profile, it has been assumed that 35% of the spectators will arrive during the peak hour before a match  and 83% will be departing in the peak hour after the match (post-match departure). It is also assumed that 100% of the spectators will depart from the venue within 90 min post-match. The peak hour specified here denotes the peak associated with the match which is an hour pre- and post-match which may not be necessarily the general traffic peak hour.Qatar Match Scenario—Qatar national team playing against another team.Typical Match Scenario—Two international teams playing against each other.The profile of spectators varies according to the teams playing in a match. SC has broadly classified two types of match scenarios;Table Public transport serves as the main and preferred mode of transportation to venues for special events due to their efficient capacity and the ability to utilize the existing infrastructure without major additional constructions. Temporary bus stations could be planned in an open area closer to the stadium. If private cars are allowed near the precinct, it may result in traffic and flow breakdowns and there is a likelihood of a security breach.For the case of FIFA  in GermaBurke and Evans  assessedCurrie and Shalaby  exploredHensher and Brewer  applied An overview of walking and the public transport strategy from the past FIFA tournaments is given below.Designated “World Cup Routes” in FIFA , the dis2The city of Johannesburg in South Africa introduced the Park and Walk during FIFA  World CuFor FIFA  World CuThe West Gate Transportation hub in Johannesburg in South Africa offered transportation services for spectators to reach the stadium during FIFA  World CuIn Cape Town, shuttle services were established and operated between the city’s main transport hub and Cape Town Stadium in Green Point. The services were free for match ticket holders. It was operated from six hours before the game until four hours post-match with the interval of five minutes. To reach the city’s main transport hub, spectators could take shuttle service from the University of Cape Town, which was a designated Park and Ride site in the city. Besides the aforementioned Park and Ride facility, Cape Town designated two other Park and Ride sites, i.e., Camps Bay High School, Kronendal Primary School in Hout Bay.In Brazil, Bus Rapid Transit (BRT) lines were extended to accommodate public transport demand during World Cup 2014. For instance, The Move system was planned for three corridors in the city of Belo Horizonte out of which two corridors were inaugurated in March 2014 serving the Pampulha region where Mineirão stadium is located , route alterations, accessibility to different visiting groups, and traffic safety are addressed.Denver City Council  adopted UEFAIdentification of the outdoor stadium facility and safety measures; andEvaluating the safety awareness to the associated risks for Malay spectators.In the context of safety planning of stadium facilities, few studies discussed the vulnerability of spectators in outdoor stadium facilities during sporting events particularly from the safety point of view. Berlonghi  looked iThey recommended the stadium facility managers to examine the existing sport facilities’ condition within and post the sports events , as the safety awareness among spectators in Malaysian outdoor stadiums seems to be high.VVIPs/VIPs,General Admission Spectators ,Hospitality Spectators,Workforce and Logistics,Information and Technology,Security,Media and Broadcast andCommercial AffiliateFor the case of Al Rayyan Stadium in Qatar for FIFA World Cup 2022, the precinct master plan is divided into multiple zones for efficient and safe operations of different user groups according to the access strategy developed by the Supreme Committee. Some of the user groups who will be served by various zones are:To control the traffic movements, a Traffic Preliminary Zone (TPZ) is designated to help manage traffic flow around the stadium and divert non-essential vehicular trips away from the stadium. The TPZ includes the parking areas and the perimeter roads of the stadium, which are used for screening the vehicles and to allow or reject them entering based on access passes.Temporary Vehicle Permit Checks (VPCs) need to be implemented at all access points to TPZ consequently.A football stadium precinct is tremendously complex in terms of functionality. This is due to diverse multiple operations and activities which happen concurrently.Hence, it is essential that security staff pay attention to the security plan and segregation strategy particularly for rival fan groups, which should be coordinated with the local authorities, and police patrol well before and after ticket checkpoints.A Traffic Free Zone (TFZ), which will be enclosed within the TPZ, is planned to be accessible for selected user groups. Different types of security boundaries and control measures could be employed in the stadium during the tournament. These include security arms and barriers, segregation barriers, hostile vehicle mitigation measures (active and passive), bollards, and gates.Any vehicle entering the Traffic Preliminary Zone has to go through a Traffic Permit Control (TPC). To enter a Traffic Free Zone, it has to pass through a Vehicle Permit Checkpoints (VPC). Any vehicle entering the Stadium Outer Perimeter must be screened at a Vehicle Screening Area (VSA). The scaling of the VSA has been based upon the forecast flow rates. VSAs are established on the Stadium Outer Perimeter to screen all vehicles requiring access .As indicated before, the State of Qatar has made extensive preparation for the FIFA 2022 World Cup in its eight designated stadiums including Al Rayyan Stadium, which will become the new home of Qatar Stars League (QSL) outfit Al Rayyan Sports Club.The aforementioned stadium is located in Al Rayyan Municipality, twenty 20) kilometers west of the capital with the capacity of 41,000 spectators.0 kilometThe largest shopping mall in the country is located next to Al Rayyan Stadium. Hence, the transportation master plan has to deal with the arrangement of public transit for both mall visitors as well as game spectators during the tournament days. Moreover, the transportation master plan considers accessibility to the mall as well, particularly during the tournament duration.In this section, developed strategies for access to the stadium for various user groups, travel routes, and public transit arrangements for buses and metro during the tournament will be briefly explained.For the FIFA World Cup 2022, the accessibility strategy differs according to user groups. Figure The VVIPs who are the Heads of the State and their guests will access the stadium via pre-planned routes and timings with individual security teams and coordinated with the Local Organising Committee (LOC) and the Internal Security Force (ISF) as required. The VVIPs arrivals will be staggered such that no two (2) VVIPs will arrive at the same time to avoid any security lapses.As for the VIP spectators, they will access the stadium via private car or by VIP shuttle bus via the Traffic Free Zone (TFZ) having dedicated and secure parking within/outside but in close proximity of the secured outer stadium perimeter with easy access to the VIP reception areas. Hospitality spectators can access the stadium by private car, bus, and metro.The players and FIFA officials arrive at the site by FIFA buses, as such, it is anticipated a shuttle bus per team plus an official bus for the referee/match officials are allocated. Expectedly this user group arrives at the ground at a specified time in accordance with LOC requirements and would need a dedicated and secured parking area within the stadium precinct.The aforementioned user groups will be accessing the stadium via a dedicated Tournament Route Network (TRN), which is a strategic corridor providing accessibility to the stadium precinct via dedicated event lanes along this corridor. The general public will be prohibited to use these lanes and will be centrally monitored and managed by the security forces.Park and rideMetroTaxiExpress coachGeneral Admission (GA) Spectators comprises all other spectators who do not fall into the hospitality, VIP / VVIP categories. There are four main transport modes to the stadium for General Admission Spectators, i.e.:GA Spectators are usually not permitted to drive a private car to the stadium precinct. Instead, they will park in one of the designated park & ride facilities and access the stadium using the shuttle buses. It is anticipated that a significant proportion of the general spectators will be riding the metro by taking the Doha Metro Green Line and heading to Al Riffa Station and then walk toward the Stadium Precinct (~ 800 m). The average walking distance concerning the local weather conditions is only about 400 m as per the local guidelines. However, it is anticipated that the willingness to walk will be higher among spectators during FIFA World Cup. Given the pleasant weather condition in the months of November and December, it is expected that spectators walk on average 1 km or above to access to and egress from the precinct. In the case of Rayyan Stadium, the pedestrian bridge from the metro station is fully air-conditioned and since the match is scheduled during the winter months of Qatar, it is anticipated that spectators would be easily able to walk this distance.In addition to the Metro, GA Spectators are also likely to arrive at the site via public transport express coaches from the Doha city center. Furthermore, it is expected that a small proportion of the spectators arrive on foot or by bike to the stadium.The Broadcast and Information Technology and Telecommunications (IT and T) user groups may access the precinct beyond the main arrivals and departures periods and will have a minimal impact upon the spectator’s journey to the site.The accessibility strategy needs to take a different approach for the access pattern of media. In other words, the media will require access to the Stadium while the General Admission Spectators are arriving at the site. Therefore, dedicated load zones for shuttle buses need to be located as close as possible to the hosting broadcast compound with additional on-street parking to be provided for Broadcast and Media buses once passenger drop-off has been completed.For FIFA World Cup 2022, public buses and a metro line are two major transit modes offering transportation services from and to the Al Rayyan Stadium. In this section, public transit arrangements for buses and metro during the tournament will be briefly explained.Generally, it is foreseen that the GA spectators will significantly utilize the public transport systems such as the metro and the buses (express coaches and shuttle buses) for the FIFA World Cup 2022. For the case of Al Rayyan Stadium, the Mode Share for the General Admission for bus and coach and metro is forecasted 67% and 40%, respectively. It should be noted that the public transit shares were provided by the Supreme Committee in this study. They were determined based on several studies to reach a sweet spot where the investment in the public transport buses, and metro capacity augmentations are justified. A further increase in public transit infrastructure may not be cost-effective.It is assumed that the express coaches and shuttle buses will be a 50-seater bus with an occupancy rate of 80% totaling 40 passengers. A dedicated Hospitality and GA Spectators coach pick up/drop off zones are provided within the precinct . The three min headway covers the thirty-second allowance for the coach bus to enter and exit the stand based on the standard operations periods, plus, the ninety-second allowance for spectators to board the coach bus with a capacity of 40 passengers per coach. An additional 1-min allowance is assumed to accommodate any further delays, which results in a four-minute headway between services.To streamline the boarding process, each bus stand will have a Spectator Queuing Area, which is designed to hold up to 800 spectators per hour. This steady flow will be ensured by implementing crowd management measures. For a ninety-min  departure clearance time, the stand would need to accommodate up to 1,200 spectators consequently. Assuming a 0.625 sq.m per passenger, each spectator queueing area is designed with an area of 800 sq.m. The below figure presents a typical layout for each bus stand along with its spectator queuing area.Al Rayyan Stadium has been located within walking distance of Al Riffa Metro Station—on Doha Metro’s Green Line. The metro station, Al Riffa Station, is located within a walking distance and has elevated closed walkways. This metro station will be extensively used for both Qatar and Typical Matches to transfer spectators from Doha to the Al Riffa Metro Station and vice versa. Al Riffa Station serves the Mall of Qatar as well.The Green Line of Doha Metro at the Al Riffa station provides access to the south side of the precinct. The driverless metro cars with the interval of 2 min could offer a capacity of 8,000 passengers per hour during peak periods. It is expected that a significant amount of general admission spectators to travel by metro using the Al Riffa Metro Station which will serve Al Rayyan Stadium and Mall of Qatar. Those GA spectators will have access to the stadium on foot from the metro station to the search and screen areas of the venue.Travel routes and accessibility strategies to the stadium precinct are arranged according to the user groups. The VVIPs/VIPs will use a dedicated Tournament Route Network (TRN) to access the precinct. The dedicated VVIP access route will utilize high-security measures and be protected from any public interference. To reach al Rayyan Stadium, there will be two designated routes, the primary route and the secondary route for the VVIPs. The routes will be segregated from the general public and other user groups.The Emir, VVIPs, and VIPs are given the highest priority followed by the Match Officials and the Players, the aforementioned user groups can share the same vehicle route. However, their arrivals within the peak hours will be staggered by security operations so that no dignitaries should be waiting for the departure/arrivals of other dignitaries.In addition to the above-mentioned user groups, Media, Local Organising Committee, Emergency Services, and Tournament Workforce will be given the priority of access and will have segregation of route from the general public. The access routes will be planned to allow accessibility of respective FIFA Constituent group vehicles through the various perimeters around the Stadium and into their relevant parking/load zone areas with minimum interactions with other user groups and pedestrians.Hospitality Spectators; andGeneral Admission SpectatorsThe spectators are placed at the base of the hierarchical chain, albeit they constitute the highest number of users. For the 2022 FIFA World cup tournament, there are two groups of spectators namely;Hospitality spectators are provided with additional complementary services included within their tickets. Hospitality spectators arriving via car to the stadium will be provided with a parking space within the precinct. Furthermore, hospitality spectators will also use the metro and hospitality tournament express coaches from the different parts of the city.General Admission spectators (GA) will travel to the stadium precinct by a range of modes including private car, coach, Metro, taxi, and walking.The routing options should be readily available to the public by utilizing social networks, Variable Message Signs via ITS, and other broadcast radio channels.It is assumed the metro is utilized at its max capacity for both Qatar match and typical match scenarios, transporting a range of user groups. Spectators will walk from the metro station to the precinct, due to its proximity.The transport strategy and the traffic inputs discussed in the previous sections are validated further by a strategic traffic model (Baseline 3 model) in PTV VISUM and at a detailed level, by a microsimulation model in PTV VISSIM. The intention is to examine the operational efficiency of the proposed road network changes and the temporary traffic management measures on mobility, accessibility, and traffic safety. The microsimulation model outputs indicate some operational deficiencies and the presence of bottlenecks, which warrant further mitigations.Wojtowicz and Wallace  emphasizTo provide an easy and straightforward accessibility to approximately 41,000 spectators, visitors, and other user groups to the Al Rayyan Stadium and precinct during FIFA World Cup 2022 matches, implementing a set of temporary traffic management measures, restrictions and road closures will be necessary. This includes closures of main roads to the general public and implementing TPZ and VPC during the match days to cater to the spectator movement. Furthermore, imposing restrictions on left turn and right turn movements from the roads connecting to the main roads of the stadium by using temporary traffic cones is recommended.Rerouting traffic to avoid conflicting flows for the shuttle buses and marking traffic lanes as ‘Bus Only’ lanes to provide priority to the shuttle buses are other operational tactics to improve accessibility to the stadium precinct.For the traffic modeling assessment for the Rayyan Stadium, the Baseline 3 model provided by the SC was updated with the proposed stadium master plan along with the access arrangements. Then, the highway network amendments such as the road hierarchy, traffic analysis zones, signal controls, Park and Ride facilities road and signal capacities, temporary route arrangements, and the tournament specific restrictions, discussed earlier in this section, along with the introduction of new modes, e.g., shuttle buses and tournament express coaches, were inputted to the strategic traffic modeling software (PTV VISUM) to accurately replicate the transport strategy. The model was then run for the traffic assignments, which provides the peak hour traffic flows of the surrounding road network.The peak hour flows were then extracted from VISUM and further operational analyses were undertaken by traffic analysis software such as Sidra (for roundabouts and right in/right outs) and SYNCHRO  to determine the Level of Service (LOS) at the surrounding junctions which range from ‘LOS A’ to ‘LOS F’. As per the applicable standards and guidelines, LOS D or above is considered acceptable for the traffic analysis.In addition to individual analysis of junctions, the entire network study area is further analyzed by VISSIM Microsimulation. To avoid any traffic-related issues during the tournament, besides the LOS criterion, visual checks in the microsimulation will be conducted to identify, if there are any localized bottlenecks, Fig. To realistically represent the traffic flow performance and to mitigate the failing junctions, a microsimulation model was built using PTV VISSIM for the Typical Match  and Qatar Match . These models help determine the capacity requirements of the road segments and junctions and required modifications to the transit services. The VISSIM model is primarily used as an evaluation tool to predict how well the alternative plans perform in fulfilling traffic capacity goals and thus accommodating transport demand.The node evaluation and Level of Service (LOS) criteria for signalized intersections, links evaluation & Level of Service (LOS) criteria for links, and network density analysis are undertaken to make a better evaluation of the network performance. For the operational analysis of the intersections, Average Delay (s), LOS, Average Queue Length (m), Maximum Queue Length (m) were extracted from the microsimulation model for each match type. Based on the aforementioned analysis, it was determined and confirmed that the proposed master plan and the transport strategy will appropriately accommodate the tournament traffic for arrival and departure scenarios, with the exception of certain minor components in the modeled network, as the model demonstrated the majority of the areas within the network perform at an acceptable LOS. However, it was also observed some traffic congestions and blockages within the network, which warranted further mitigation measures such as physical and operational improvements, travel demand management strategies, or a combination of these strategies. The aforementioned measures were examined and then the best performing measures, i.e., Level of Service, operational delays, and density, were eventually recommended. The nature of the mitigations is based on their impacts on the traffic operations; for instance, only minor amendments are required to improve the traffic operations/safety at certain locations. Whereas for some other cases, a major amendment to the existing/proposed infrastructure is needed to achieve the desired traffic performance, flow rates and to ensure the safety of the road users.Given the outcomes of the microsimulation analysis, a set of soft and hard mitigating measures are proposed based on identified traffic bottlenecks and pinch points.Widening the turning radius,Implementing curbs extension,The provision of special road markings to provide clear information,Implementing partial lane closures and,Implementing Reversing lanes: Within the precinct parking the circulatory lanes to the parking areas will be used one directional during the pre-match (IN) and the Post-match (OUT) with an additional lane for emergency vehicle accessThe soft mitigations are temporary in nature and constitute nil to minor construction requirements. In some cases, the soft mitigations would be implemented by the use of the traffic personnel or Intelligent Transportation Systems (ITS). Some of these measures can be outlined as follows:Provision of additional lanes at certain intersections and extension of storage lanes at some access points,The provision of median openings within the divided roads to shorten the clearance times. The turning radius is tested using the Swept Path Analysis to accommodate such maneuvers,Blocking conflicting movements at the surrounding junctions by using concrete barriers and thereby rerouting the traffic to take diversions; andIn a rare case, creating an additional intersection to shorten the shuttle bus travel times to comply with the spectator’s clearance guideline of FIFA.Besides the above-mentioned measures, some mitigations are considered as ‘Hard Mitigations’. These mitigations require medium to major amendments, which are permanent in nature. Such measures include:Based on the aforementioned TTM measures and soft/hard mitigations, it was determined and confirmed by the microsimulation analysis that the proposed master plan and the transport strategy for the Rayyan Stadium will accommodate the tournament traffic demand by evaluating the operational performances against the capacity for all the scenarios. All areas within the microsimulation model were observed to be working at an acceptable LOS (LOS A to LOS D). An example of the soft mitigation and the hard mitigation applied to a typical intersection is shown in Fig. After finalizing the mitigations, a Road Safety Audit (RSA) was conducted on the overall master plan, transport strategy, and the TIA findings and recommendations. RSA is a formal examination of the operational safety of existing or future road infrastructures by an independent and qualified RSA team. It reports qualitatively on potential road safety issues and identifies opportunities to improve operational safety for all road users, with the objective of minimizing the number and severity of personal injury crashes in accordance with a safe system approach. The audit report recommendations were considered and implemented in the TIA.After the completion of the RSA stage, to demonstrate the overall strategy and the flow pattern by illustrating the Last Mile Connectivity and Accessibility, a graphical map is developed. It highlights how various user groups will access the stadium precinct through their corresponding modes from different routes. The Last Mile Connectivity map also displays the information in terms of vehicles and persons for a clear understanding of the traffic flow profiles, which will be served as a crucial guide for various stakeholders such as the security specialists, police, and Internal Security Force (ISF) and is necessary for planning the tournament operations. Figure This study centered on Traffic Impact Assessment (TIA) including the accessibility strategy and master planning for a hosting stadium for the FIFA World Cup 2022 in Al Rayyan, the State of Qatar.The methodology applied in the TIA dealt with forecasting tournament transport demand for various user groups and workforces involved in organizing and operation the World Cup matches such as the local organizing committees, emergency services, media, and playing teams, besides general and hospitality spectators. Furthermore, requirements of the stadium precinct and the surrounding area in order to accommodate World Cup tournament demand in the context of transport master planning were discussed.The paper also explained the accessibility strategy to the stadium precinct for each user group based on their travel mode. To do so, the access route to the stadium precinct is divided into several zones such as Traffic Preliminary Zone, Traffic Free Zone, Vehicle Checkpoints, and Vehicle Screening Area, and relevant strategies for passing through them were clarified.A key strategy used for the planning of the FIFA tournament venues is supposed to utilize the existing infrastructure wherever possible, although this may not hold entirely true with Qatar since the majority of the infrastructure projects were built in order to cater for the upcoming tournament. Nonetheless, it is clearly understood and practiced that the provision of additional infrastructure was minimized and recommended only if absolutely necessary. This was concluded based on the findings of the traffic analysis. Rather than looking at the tournament-specific mitigations, the Traffic Impact Assessment (TIA) recommendations mainly aimed at improving the operational performance, the safety of the road users, and making efficient accessibility.The football stadium precinct is complicated in terms of functionality, crowd management, road, and public transportation operation. The literature review presented in the article outlined some applicable arrangements particularly in the context of mobility and traffic safety for the World Cup and other major tournaments. Therefore, accessibility strategy particularly last-mile connectivity concerning safety, efficiency, and mobility concerns stemmed from huge demand, and past similar World Cup tournaments were elucidated.To conclude, the extended traffic impact assessment discussed in this paper outlines transportation and accessibility strategy components that should be incorporated in the transportation master planning of football stadiums to comply with requirements adopted by the tournament-organizing committees such as FIFA.The specific contributions of this paper could be outlined in the following four merits: (1) to provide a high-level overview of conducting Traffic Impact Assessment to transport & non-transport professionals, (2) to explains how to plan for the special event scenarios for traffic operations, and (3) to outline lessons learned and guidance on types of hard and soft mitigations required during large events and tournaments such as FIFA World Cup.This study can be enriched by undertaking crowd management. During the FIFA World Cup event, which is one of the most-watched sporting events in the world, large crowds of different types can be expected not only in or around stadiums, but also at famous tourist attractions, and public transport stations such as metro, tram and bus stations. Hence, it is important to evaluate the issues, such as capacity issues, existing and potential pinch-points, and bottlenecks as for increased active modes demands. Such study should be undertaken for places where stampedes could occur when demands are suddenly increased particularly at different crowd attracting points. The intention is to make improvements to enhance safety, accessibility to and mobility within such places.Apart from such pedestrian crowd-related issues, which are related to evacuation and capacity of the infrastructure, interactions between pedestrians and vehicles, particularly in the vicinity or outside of stadiums, park and ride spots, metro stations, and touristic attracting points will also largely influence the safety of pedestrians. Such issues should also be considered when planning public spaces for special events.


While the early identification of insomnia in patients with schizophrenia is of clinical relevance, the use of specific compounds to treat insomnia has been studied less in postmenopausal women with schizophrenia. We aimed to explore the effects of melatonin, sex hormones, and raloxifene for the treatment of insomnia in these populations. Although melatonin treatment improved the quality and efficiency of the sleep of patients with schizophrenia, few studies have explored its use in postmenopausal women with schizophrenia. The estrogen and progesterone pathways are dysregulated in major psychiatric disorders, such as in schizophrenia. While, in the context of menopause, a high testosterone-to-estradiol ratio is associated with higher frequencies of depressive symptoms, the effects of estradiol and other sex hormones on sleep disorders in postmenopausal women with schizophrenia has not been sufficiently investigated. Raloxifene, a selective estrogen receptor modulator, has shown positive effects on sleep disorders in postmenopausal women. Future studies should investigate the effectiveness of hormonal compounds on insomnia in postmenopausal women with schizophrenia. Schizophrenia is a severe mental illness, with an estimated prevalence of 1% in the global population . SchizopSleep disturbances have not classically been considered a diagnostic criterion for schizophrenia; however, the vast majority of studies support the notion that patients with schizophrenia suffer from sleep disturbances in at least 80% of cases . In a reIn particular, some researchers report that over half of the patients presenting persecutory delusions may present moderate or severe insomnia , which mGiven the clinical relevance of the identification of insomnia in patients with schizophrenia, an adequate treatment is mandatory. Stummer et al.  reviewedSeveral hypotheses have been tested in order to elucidate the biological underpinnings of insomnia and other sleep disorders in patients with schizophrenia, and to address the potential targets of treatment. A review on the topic reports that the hyperactivity of the dopaminergic system, the dysfunction of the GABAergic system, and signaling in the sleep- and wake-promoting regions of the brain may be implicated , which sGenetic studies have revealed that variants in the promoter region of the melatonin receptor gene, MTNR1A, may be associated with schizophrenia and sleep disorders . In an aOn the other hand, a large amount of research indicates that there is a significant association between the sex hormone levels and the psychopathological symptoms in patients with schizophrenia, even in those patients with patterns of treatment response. Thomas et al.  investigDuring the progesterone phases of the menstrual cycle, the positive symptoms appear to improve, while, in the estrogen phases, the negative symptoms and the general psychopathological symptoms show significant improvements ,19. ThisThe menopausal transition and the postmenopausal period are associated with a significant increase in sleep disorders, such as sleep apnea, insomnia, and restless leg syndrome . Insomni(1)Does the treatment of melatonin improve insomnia in women with schizophrenia at the end of the reproductive lifespan?(2)Does the use of estradiol, progesterone, and other sex hormones make a difference when treating insomnia?(3)Does raloxifene improve insomnia in postmenopausal women with schizophrenia?Thus, the main goal of this nonsystematic narrative review is to investigate the effects of melatonin, the sex hormones, and raloxifene for the treatment of insomnia on postmenopausal women with schizophrenia. The selected studies were chosen on the basis of the following review questions about postmenopausal women with schizophrenia:A nonsystematic narrative review was performed that was based on electronic searches of the PubMed and ClinicalTrials.gov databases, over the last two decades (2000–2021 October), for English, Spanish, German, or French papers that address our three main questions. Papers were included only if they were focused on the treatment effects of melatonin, raloxifene, progesterone, estradiol, or other sexual hormones, on sleep disorders in patients with schizophrenia, and particularly in postmenopausal women.In order to start our search strategy in PubMed, we initially used the following search strategy:  AND schizophrenia. We also searched Clinicaltrials.gov to find trials exploring the effects of melatonin, estradiol, progesterone, raloxifene, and other sex hormones on insomnia in postmenopausal women with schizophrenia. The following search strategy was performed: schizophrenia AND melatonin, schizophrenia AND estradiol, schizophrenia AND progesterone, schizophrenia AND raloxifene, schizophrenia AND testosterone, and schizophrenia AND sex hormones. Additionally, the reference lists from the included studies, as well as Google Scholar, were also evaluated in order to identify further studies.The screening and selection processes were undertaken by two authors (A.G.-R. and J.A.-M.), who scanned all the titles and abstracts and subsequently selected the papers for the further scrutiny of their full texts. The inclusion criteria were as follows: (1) Meta-analyses and systematic reviews that followed PRISMA; (2) Randomized controlled trials; (3) Observational and prospective cohort studies; and (4) Studies focusing on the effects of melatonin, raloxifene, and the sex hormones on insomnia in postmenopausal women. Expert consensus by recognized scientific associations were also included for a further discussion of the findings reported in studies that focused on sleep in postmenopausal women with schizophrenia. The exclusion criteria were as follows: (1) Case reports; and (2) Studies not adequately describing the assessment measures used to evaluate insomnia. In cases where several papers refer to the same works, we included the publication containing the largest sample of patients that tested our questions. After the screening of all of the full-text documents that were accessible to the authors, a total of 20 records were included. Sleep dysfunction has been widely recognized as a common clinical problem in people diagnosed with schizophrenia. Melatonin (N-acetyl-5-methoxytryptamine) is an endogenous hormone that is secreted in the pineal gland, and it has extensively been shown to have neuroprotective and antioxidant properties . A doublSahbaz et al., (2019) investigated the association between the serum melatonin concentrations and the cognitive impairment and circadian rhythms  in 47 paMoreover, a systematic literature review focusing on clinical trials of patients with schizophrenia reveals that melatonin may have positive effects on sleep, the metabolic profile, and tardive dyskinesia . This waA randomized rater-blinded clinical trial was conducted by Mishra et al.  to evaluThe effectiveness of prolonged-release melatonin for benzodiazepine discontinuation was also assessed in patients with schizophrenia and bipolar disorder in a randomized placebo-controlled blinded trial, with 24 weeks of follow-ups . The patIn summary, melatonin treatment seems to improve the sleep quality and efficiency in patients with schizophrenia compared to patients taking placebos. There were no specific mentions of the use of melatonin in postmenopausal women with schizophrenia, which is a potential target population. It has been reported that endogenous and exogenous hormone components interact with sleep regulation in men and women in adulthood . Higher There are animal studies that report that estrogens may influence sleep regulation . In premWithin the field of depression, controversial findings have also been reported with respect to sex hormones and sleep disorders. A systematic review by Morssinkhof et al.  exploredWith all these questions in mind, we explored the potential association between estrogens and sleep disorders in women at the menopausal transition and after menopause, which are periods characterized by a decline in estrogen levels.It is a well-established fact that estrogens are dysregulated in major psychiatric disorders, such as in schizophrenia. A review of the field reveals that estradiol has organizational and activational effects via genomic and nongenomic mechanisms . In partThe effects of estradiol and other similar compounds on sleep disorders in postmenopausal women with schizophrenia have not been investigated. There are more studies available on the effects of selective estrogen receptor modulators (SERMs) in postmenopausal women with schizophrenia, which will be addressed in the following sections. In a study by Huang et al. , the serIn postmenopausal women with schizophrenia, the effects of progesterone or other similar compounds have not been tested. Although brexanolone—a synthetic allopregnanolone—has been demonstrated to prevent depression-like behaviors in animal models, the psychotropic properties of progesterone have not been evaluated in postmenopausal schizophrenia .The menopausal transition and postmenopausal stages in women are associated with an increased risk of sleep disturbances, which are partly explained by the influence of testosterone and the testosterone-to-estradiol ratio . The mosDehydroepiandrosterone sulfate (DHEA-S) is mainly produced by the ovaries and the adrenal system. Dihydrotestosterone, a primarily peripheral product of testosterone metabolism, is also an androgen precursor in women. A study by Buoli et al.  investigRaloxifene is a selective estrogen receptor modulator (SERM) that shows a high binding affinity to the estrogen receptor, and that acts as an estrogen agonist in bones and lipids, and as an antagonist in the uterus and breasts . FurtherNatale et al.  conducteThe effect of adjunctive raloxifene for postmenopausal women with schizophrenia has been reported in recent meta-analyses ,48. Zhu While it has been extensively reported that raloxifene exerts a positive influence on sleep disturbances in healthy postmenopausal women, research that is focused on postmenopausal women with schizophrenia is scarce.This nonsystematic narrative review focuses on the following issues with regard to postmenopausal women with schizophrenia: In the first step, we tried to elucidate whether the treatment with melatonin is capable of improving insomnia in women with schizophrenia, at menopause and beyond. As a second objective, we investigated the use of estradiol, progesterone, and other sex hormones for the treatment of insomnia in these populations. Finally, we investigated whether raloxifene—a selective estrogen receptor modulator—may be a potential treatment for insomnia in postmenopausal women with schizophrenia, as it has been extensively explored to treat psychopathological symptoms.The first question was addressed because several findings in animal models seem to indicate that melatonin may be useful for treating patients with schizophrenia. Melatonin treatment attenuated the schizophrenia-like symptoms in the mice and reduced the histopathological alterations . MelatonIn our review, we found that the serum melatonin concentrations were associated with cognitive impairment and the circadian rhythms  in patieIt has been hypothesized that estradiol, progesterone, and other sexual hormones exert an effect on the central nervous system, and this has been evaluated in animal models of schizophrenia ,22. FurtThe third question focuses on the use of selective estrogen receptor modulators (SERMs) in postmenopausal women with schizophrenia. The research on the use of SERMs has been restricted to the effects of raloxifene on the psychopathological symptoms and the cognitive domains ,57. Few The use of estrogen modulators as adjunctive treatments has yielded promising results in the studies of postmenopausal women with schizophrenia . In the The categorization of insomnia into primary and secondary conditions has been extensively described in the scientific literature. Although sleep disturbances have not been considered a core feature of schizophrenia, the clinical relevance of sleep has been highlighted by several authors . PatientOther biological pathways should also be investigated in postmenopausal women with schizophrenia, for instance, the adrenaline–noradrenaline balance. Kornstein et al.  exploredThis review has several limitations and strengths that should be clarified. The first limitation is that it is a narrative review rather than a systematic review. It is a nonsystematic narrative critical review of the literature on the topic of the effects of melatonin and the sex hormones on insomnia in postmenopausal women with schizophrenia, rather than an attempt to provide an all-encompassing review of the literature. This method allowed us to include papers in the field that have helped to answer the three questions we addressed at the beginning of the review. Another limitation of our review is that we could not separate primary and secondary insomnia in the included studies. The papers focusing on postmenopausal women with schizophrenia do not adequately describe insomnia according to these categorizations. However, melatonin and other sex hormone compounds were administered as adjunctive treatments. Despite the limitations we mention, the present study has several strengths. This is the first review integrating the use of melatonin and sex hormones, together, as potential treatments for women with schizophrenia in the postmenopausal stages. To the best of our knowledge, this is the first review addressing this issue in this specific population of women.A large amount of research indicates that sleep problems are prevalent and severe in patients with schizophrenia. In our review, we focused our search on the use of melatonin and sex hormones for the treatment of insomnia in postmenopausal women with schizophrenia. Melatonin treatment improves the quality and efficiency of the sleep of patients with schizophrenia, compared to treatment with a placebo. However, to the best of our knowledge, there were no specific mentions with regard to the use of melatonin in postmenopausal women with schizophrenia, who are our target population.Estrogen and progesterone pathways are dysregulated in major psychiatric disorders, such as in schizophrenia. However, the effects of estradiol and other similar compounds on sleep disorders in postmenopausal women with schizophrenia has not been sufficiently investigated. Raloxifene, a selective estrogen receptor modulator, has been found to exert positive effects on sleep disorders in healthy postmenopausal women. Although raloxifene may be effective for treating psychotic symptoms in postmenopausal women with schizophrenia, the specific effects on the sleep of postmenopausal schizophrenia populations is still understudied. Future studies should investigate the effectiveness of hormonal compounds on insomnia in postmenopausal women with schizophrenia.