A considerable number of qualitative studies have been published in recent years on the issues that the quantitative studies have limitations on. This study aimed at performing a meta-synthesis on qualitative studies on Road Traffic Injuries (RTIs) with a scoping review approach.This meta-synthesis study was conducted as a scoping review in 2019. The Arkesy and O’Malley framework was applied which has six steps of identifying the research question, identifying the relevant studies, selecting the studies, charting the data, data analysis and reporting the results, and consultation exercise. The required data were gathered by searching the relevant keywords in databases of PubMed, web of knowledge, Scopus, Cochrane Library, Science Direct, Google scholar, Sid, IranMedex. Extracted data were analyzed by the Content-Analysis method.Finally, 30 studies were included. Extracted data summarized in five main themes and 17 sub-themes. The main themes were: consequences , the needs of survivors , risk factors , barriers of prevention , and prevention solutions  of RTIs.This study combined the methods of the scoping review and the meta-synthesis to mapping all qualitative studies on the RTIs, with this approach, this study provides extensive and practical information for policy-makers, managers, practitioners, and researchers in the field of RTIs. Also, by applying this approach, the gaps in the existing knowledge and areas in need of further research are identified.The online version contains supplementary material available at 10.1186/s13690-020-00493-0. Road Traffic Injuries (RTIs) are the main cause of morbidity and mortality in the world nowadays . The bigQuantitative studies have been published on various aspects of the RTIs. Although the quantitative studies were brilliant in this area and have helped the prevention of the RTIs, they are faced with some limitations in some aspects. So the researchers used the qualitative methods besides the quantitative ones . The quaConsidering the characteristics of the qualitative studies, in recent years a significant number of these studies have been performed on some aspects of the RTIs that the quantitative studies were faced with serious limitations on those aspects , 11. SumStep one: Identification of the research questionThis was a meta-synthesis study performed as a scoping review in 2019 with the aim of the analysis of published qualitative studies on RTIs. The framework by Arkesy and O’Malley was used which is the first methodological framework to manage the scoping review studies. The framework is published in 2005 and includes six steps: identification of the research question, identification of the relevant studies, selection of the studies, data charting, data analysis and reporting the results, and consultation exercise .Step onWhat are the main approaches of the qualitative studies on RTIs?What are the main methods of data collection in qualitative studies on RTIs?What are the most important aspects of RTIs studied in qualitative studies and what are the results?The research question was what are the characteristics and results of the qualitative studies on RTIs. The question is specifically divided into the following:Step two: Identification of the relevant studiesInclusion and exclusion criteria: All qualitative studies on the RTIs from January 2000 to March 2019 were eligible to include in the analysis. The language was limited to English and Persian. Those studies on injuries of accidents other than road traffic accidents , those studies that assessed the RTIs and other injuries at the same time, short communications, and conference abstracts were excluded.Step three: Study selection/screeningThe required data were gathered by searching the keywords of road traffic injury, road traffic accidents, road traffic crashes, motorcycle accident, motorcycle crash, motorcycle injury, motor vehicle injury, motor vehicle crash, motor vehicle accident, qualitative, interview, phenomenology, focus group discussion, grounded theory at the databases of PubMed, web of knowledge, Scopus, Cochrane Library, Science Direct, Google scholar, Sid, IranMedex  flow diagram  was usedStep four: Categorization of the dataAfter screening, the reporting quality of the studies was assessed by two researchers using the Critical Appraisal Skills Program (CASP) checklist. The checklist includes 10 items. The first two items are screening questions. The appraisal of the study would continue only if the answer to at least one of these two questions was yes. For the next eight questions the three options of Yes, Can’t tell, No were marked for which the scores of three, two, one were assigned respectively . So the Step five: Conclusion, summarization, and reporting the resultsTo extract the data, the data extraction form was developed in MS Word 2010. Data for three papers were extracted as a pilot. Then the form was revised. The intended data included: author(s), year, country, study purpose, participants, the approach of the study, data collection method, study findings (themes and sub-themes).Step six: Providing practical recommendationsThe gathered data were analyzed by the content analysis method. Content-Analysis is a widespread method for the analysis of qualitative data through the identification, analysis, and reporting of the patterns (themes) within a text –18. CodiAfter extracting and reporting the study results, based on the study findings and the opinions of the research team, practical recommendations were made in terms of research methodology and also for the policymakers and managers.Of the 4623 retrieved records, 1825 were duplicates. At the title and abstract screening, 2752 records were removed. The full-text review also resulted in the removal of 16 papers so finally, 30 papers were included in the synthesis , change in roles of the family members such as the breadwinner role of the mother of children due to injury of the father), and cut or reduction of family income.One main social consequence of the RTIs that was highly mentioned was the limitations of the social relations of the injured people. Moreover, the accidents due to the low safety of the vehicles and roads can result in distrust of the people in government actions.One of the most obvious consequences of RTIs is financial consequences. It includes damages to the vehicle, damages to road facilities, treatment and care costs of the injured people, costs of losing the productivity of the people in the society, paying the blood money, and other costs.Every RTIs due to the mentioned consequences creates some needs in the injured individual and his/her family. One of these needs is the social needs of the injured people which include social support by the government, charities, family, and friends in terms of financial, mental, spiritual, and legal supports. Another need after an RTI is the need for healthcare which includes emergency care right after the accident, specialist and quality care at the hospital, rehabilitation care, and mental care.The other main theme was the risk factors of the RTIs which had three sub-themes of general risk factors (five items), risk factors for motorcyclists (five items), risk factors for children and adolescents (four items). Table The barriers to the prevention of the RTIs were in three categories of general barriers (five main and 13 sub-main), pre-hospital barriers (three main and 10 sub-main), emergency, and hospital barriers (two main and five sub-main). Table Solutions for prevention of the RTIs and reduction of their consequences were categorized in five dimensions including increasing safety (three items), rules and regulations (four items), education (two items), increasing equipment (five items), and scientific solutions (two items). Table Results of the quality appraisal of the included qualitative studies showed that the average quality score of them was 21.6 in the 8–24 range. One issue that did not receive sufficient attention in the studies was the ethical issues , needs , risk factors of the RTIs , barriers of prevention of the RTIs , and solutions of prevention of the RTIs .The RTIs not only cause physical and financial problems, but also cause some mental problems due to losing family members, feeling guilty, feeling ashamed, being an encumbrance, and fear of the future. The physical problems usually get better by healthcare or the person becomes adapted to the problems. But the mental problems such as long-term depressions bring more suffering for the person and have more severe consequences . A meta-Another consequence of RTIs is financial issues. The high social and economic costs of the RTIs have challenged the policymakers of the countries , 58. TheOne of the main needs of the victims of the RTIs is the need for social support because they cause the victims to be socially isolated , 68. NumOne of the most important categories of the risk factors identified in this study is the risk factors of the motorcyclists. According to the National Highway Traffic Safety Administration (NHTSA), the risk of death of the motorcyclists is 34 times more than other vehicles. This number is eight times for severe injuries . Most ofAs it is mentioned, the risk factors identified from qualitative papers in this study were general risk factors, specifically for motorcyclists and children and adolescents. Yet quantitative studies have identified specific risk factors for other groups of people such as the elderly, pedestrians, and bike riders. The literature shows that these groups are also vulnerable to RTIs –96 and sThe study by Khorasani Zavareh et al. (2009) showed that there are several barriers to the prevention of the RTIs in Iran. The main theme of the study was the lack of a systemic approach to the prevention of the RTIs and the sub-themes were human resources, transportation systems, and organizational coordination . A reporThe existence of a leading organization with sufficient authority and tools is one of the most important solutions for the prevention of the RTIs. Several organizations are involved in RTIs and their prevention, of which the main ones are the ministry of transportation, ministry of industry, ministry of health, traffic Police, forensic medicine organization, Central insurance organization, ministry of Justice, ministry of interior, the red crescent organization, and the EMS. At the countries that are successful in reducing the burden of the RTIs, usually, there is a leading organization that has the stewardship of the activities around the RTIs , 102. FoAnother important solution that was emphasized in several studies is establishing an on-time and effective registration and reporting system. The experiences of the countries indicate that the health sector can play an effective role in designing and implementing the recording and reporting system of the RTIs –108. In Although with the best of our knowledge this is the first study of scoping review and meta-synthesis on qualitative studies on the RTIs, it has some limitations. The main limitation of this study was limiting the search of the literature to English and Persian languages because there might be some good studies in other languages that are not included in the synthesis. Subjective interpretation of the findings is another limitation of this study. Petticrew et al. (2013) noted that the results of meta-synthesis should be more interpreted by policy-makers and users . But in This study combined the methods of the scoping review and the meta-synthesis to mapping all qualitative studies on the RTIs to summarize the vast literature into five main themes and 17 sub-themes. The main themes found in this study were: consequences of the RTIs, needs, risk factors, barriers of prevention, and solutions for the prevention of the RTIs. With this approach, this study provides extensive and practical information for policy-makers, managers, practitioners, and researchers in the field of RTIs. Also, by applying this approach, the gaps in the existing knowledge and areas in need of further research are identified. However, this method is a new method and more studies are needed to become more mature with this method.➢ Psychological and social effects of traffic accidents.➢ Policy-making, management, and organizational tasks of RTIs prevention.➢ Qualitative studies to investigate RTIs prevention issues in high-risk and vulnerable groups .➢ Qualitative studies to further investigate the provision of high-quality health care services to traffic accident victims➢ Carrying out qualitative studies on experiences, high-risk behaviors, and prevention of traffic accidents with the participation of drivers of public and heavy vehicles➢ A qualitative study with policy-makers and senior managers on macro-level issues of traffic accident prevention .➢ Application of qualitative studies in designing, implementing, and evaluating RTIs prevention interventions and policies.Based on the results of this study, the following topics are recommended for future qualitative studies:Additional file 1. Complete search strategy in PubMed databases for identifying the qualitative studies on Road Traffic Injuries (RTIs) published between2000 to 2019.Additional file 2. Results of the quality appraisal of qualitative studies on Road Traffic Injuries (RTIs) published between2000 to 2019.


Indoor Air Quality (IAQ) is one of main topics of Public Health on which international institutions and countries are taking action. With regards to healing architectures, several studies have reported data analysis and case studies to improve users’ health , but there are not enough regarding volatile organic compounds (VOCs). Regarding chemical pollution of indoor air, the Scientific Community has highlighted that there are several factors that affect the IAQ, in particular the design and management, and energetic efficiency, of inpatient wards. Several stakeholders, from the designers to the managers, are responsible for the indoor air in healing environments. Supported by analysis of the State of the Art and the main factors that influence the heterogeneous scenario of inpatient wards, the paper presents three check-lists, designed for supporting the stakeholders during the design phase, or for the daily procedures and maintenance activities, for pre-assessment of factors that affect chemical pollution, and for the definition of strategies to be applied. In fact, in such environments IAQ assumes a particular meaning and importance, both for the vulnerability of the patients and for the long time spent by the sanitary staff. The multidisciplinary approach emphasizes the continuous need for interdisciplinary knowledge and skills aimed at finding solutions able to protect users’ health status , especially in the field of the indoor air issue. Several stakeholders are responsible for health promotion in indoor environments, starting with the decision makers and the designers during the design process, to the managers and the users who will manage, work, use and live in the spaces .Referring to the factors that affect the Indoor Environmental Quality (IEQ), the Indoor Air Quality (IAQ) is an issue already discussed in the 1980s ,3,4,5, aAmong the indoor environments, IAQ in “Architectures for Health” requires great attention for guaranteeing healthy indoor air and well-being, in particular for protecting patients and staff against Hospital Acquired Infections (HAIs) and occupational diseases ,8. In faTherefore, during the design process of hospital settings and their management, it is necessary to guarantee healthy spaces, starting with (a) the support of managers, medical and non-medical staff, maintainers and service providers, and (b) the design of hospital planners in relation to the layouts, the material selection, the rooms’ dimension, the engineering plants, etc., which can highly affect the performances of the facility and its processes ,11. In fIn general, the IAQ within hospitals is a complex and dynamic system, in which physical factors, and biological and chemical contaminants generated in indoor environments, as well as those in the outdoor air that come into the building via natural ventilation  and, primarily, mechanical ventilation  play a role. The quality of the management and maintenance of engineering plants , the cleRegarding the chemical composition of indoor spaces, there may be threats to the air quality from a range of indoor and outdoor sources ,26,27,28Currently in the European Legislation, VOC concentrations and IAQ for generic indoor environments are limited via acts and norms in some countries, as Settimo and D’Alessandro  investigNowadays, for assessing chemical pollution, it is necessary to monitor activity, but this is not always possible to set it up immediately, and data analysis requires a long time. Therefore, the aim of the paper is to give rise to three check-lists for reducing chemical pollution in inpatient wards, for supporting designers, hospital planners, medical directors and managers, to be applied during the design phase, and for the application of daily procedures and maintenance activities in the defining of strategies for healthy performances. The focuses of the check-lists are related, referring to the current trends in hospital design, and to facilities with mechanical ventilation and/or mixed systems .The inpatient ward is a low–medium care environment, with the presence of hospital staff and users with weak health conditions. Typically, a traditional inpatient ward has about 28–32 beds with support services for medical activities and hospital staff, such as a nursing station, the head nurse office, several storages, a medical room, doctors’ offices, a kitchenette, a workers’ dining room and users’ restrooms .In this functional area, one of the most important pathogen sources is related to the respiration of a potentially infectious user and related medical activities; most of the inpatients spend a lot of their time in beds, while medical staff spend a lot of their time in a ward, depending on the activities to be carried out ,33,34,35In general, they may be exposed to a wide range of chemical pollutants emitted from several products, such as finishing materials, furniture and disinfectants, and regular control plans, etc. .The configuration of the inpatient room, as well as the design and health-related trends, is affected by: (a) environmental factors, dimensional space and design features; (b) managerial factors, related to medical procedures, training and health education, maintenance and cleaning activities, etc.; (c) social factors, guaranteeing hospitable spaces for users . With reSince of the scientific literature reports give very different outputs and results, and the resulting work from the analysis conducted by Gola ,42 is diOutdoor and indoor microclimatic factors, which refer to the outdoor air, the solar exposure and indoor microclimatic parameters, such as temperature, relative humidity, air velocity, air change, etc. Although these factors can vary, they have a great influence on the IAQ and the performances of materials in the room and air fluxes.Management activities, which refer to the management and maintenance activities, ventilation systems, cleaning and disinfectant activities, control plan, etc., carried out in the room and in the functional units and/or in the entire facility. They can highly affect IAQ, but their emissions can be controlled through the applications of strategies, and at the same time they can be changed if their actions are dangerous for users.Design factors, which refer to all the components that characterize the inpatient room . In general, their emissions are constant, although in relation to their life, the emissions may decrease over the time.Human presence, which refers to the presence of users, their health status, and the medical activities carried out in the inpatient room. Their presence and application can vary, and therefore they can affect the indoor air in different modes.Starting from an analysis already conducted by Gola et al. , it is pAs emerges from an analysis of the several factors, to overcome the criticisms related to the design of healing environments, interdisciplinary knowledge needs to be taken into account, including: the needs of users  related to their activities and therapies; nosocomial infections; applications of the technologies and ventilation systems (HVAC) needed to carry out the ordinary and specialist healthcare disciplines; risk analysis techniques for several functional units, including events caused by incorrect application of procedures; acceptable residual risk values and related sharing and management procedures .In addition, designers, in collaboration with healthcare professionals, should design the healthcare settings according to the different uses, support the healthcare organization in identifying the most optimal solutions , and elExposure of hospital users to chemical pollutions is related to several aspects, related to product formulations, how and where the products are applied, the methods of use, the degree of aging of the various components, the type of maintenance activity, etc. . As someStarting from the application of several case studies and the evidence given by a detailed analysis of the scientific literature , IAQ is As the World Health Organization (WHO) and several Institutions have already highlighted, for understanding the real performances and the IAQ, it is proper to do several monitoring activities for an adequate data analysis, and for the investigating of the factors that affect this issue ,52. AlthFor this reason, for supporting designers and medical directors, the research team produces check-lists for the pre-assessment of chemical pollution in inpatient rooms, during the design phase, daily procedures and maintenance activities.These check-lists aim to be useful tools for the pre-assessment and prior verification of strategies and decisions to be applied, and, when these cannot be verified, to have an awareness and take action for avoiding possible risks for the hospital users regarding chemical pollution. They become a preliminary tool to define a future and broad protocol for supporting the healthcare organizations in the strategies to be applied.These lists refer to several criteria, considered as factors that affect IAQ  the State of the Art, several research projects and investigations, and the systematic reviews by scientific international researchers, supported by reports promoted by the research group Study for the Indoor Air Pollution of Istituto Superiore di Sanità  in Italy . The lisThe aim of this check-list is to investigate and verify the design features of the room , its configuration and its installations. The check-list is particularly useful for designers and hospital planners during the design process.The general scope of this list is to highlight possible deficiencies in the design phase, and to implement the project of the room through design strategies. This check-list is strongly related to the design of new healthcare facilities, or the renovation of an existing hospital. In this phase, the decision makers have a great responsibility, because it is possible to already define the management strategies, supported by the healthcare organization, for obtaining the best performances of the rooms, as well as of the cleaning and maintenance activities.Starting from the answers, and in particular the negative ones, it will be possible to define strategies and solutions for improving the use and performances of the environmental unit for the medical activities.In general, the check-list focuses on healthcare facilities with mechanical systems, responding to the current trends in hospital design.As The check-list aims to highlight some criticisms, related mainly to negative answers, for identifying strategies and solutions to be applied, where possible, because each hospital project is different.The following list  suggestsThe check-list has the aim of investigating and verifying the daily procedures, the room occupancy and its performances. The aim of this list is to highlight possible deficiencies in medical and human activities, and to implement the procedures through management strategies.Although design strategies require hard interventions, the check-list permits one to consider several factors and plan alternative actions related to the ventilation system (HVAC) and its efficiency, cleaning activities and detergents, a series of more specific activities of sanitation and disinfection, medical activities, and procedural adoption of prudential and adequate behavior.Starting from the answers, and in particular the negative ones, it will be possible to define strategies and solutions for improving the use and performances of the environmental unit for the medical activities.In general, the check-list focuses on healthcare facilities with mechanical systems.As The check-list aims to highlight some criticisms, related mainly to negative answers, for identifying strategies and solutions to be applied, where possible, because each healthcare project is different.The following list  suggestsThe check-list has the aim of investigating and verifying the condition of the room after the maintenance activity and/or intervention.The aim of this list is to highlight possible deficiencies of the room and procedures before occupation of the room by users, and to apply management strategies.The type of interventions can be different , i.e., hard or soft interventions in the room. In relation to complexity, the strategies may concern natural ventilation or HVAC systems and efficiency, medical activities and management procedures, the planning of cleaning and disinfection, activities’ assessment, and actions related to air monitoring for both chemical and biological agents.Starting from the answers, and in particular the negative ones, it will be possible to define strategies and solutions for improving the use and performances of the environmental unit for medical activities.In general, the check-list focuses on healthcare facilities with mechanical systems.As The check-list aims to highlight some criticisms, related mainly to negative answers, for identifying strategies and solutions to be applied, where possible, because each activity requires different attentions.The following list  suggestsIt is clear that IAQ is a very broad topic, in which any variable can affect the performance of air in indoor environments. In fact, design and management strategies which may be adequate in relation to different procedures can decrease or increase the quality performances of the inpatient room, and the comfort of users ,84.Although current monitoring activities and data analyses are more reliable, the check-lists become useful tools for a pre-assessment and prior verification of strategies and decisions to be applied, and when they cannot be verified, they help one to have awareness and take action for avoiding possible risks to the users.The multidisciplinary approach, supported by design, chemical and healthcare issues, demonstrates the need for interdisciplinary of knowledges and skills aimed at finding solutions able to protect the health status of users . It is cThe hospital system should be rethought, giving attention to the pollutant emissions, and providing buildings that, from the design phase up to the building’s realization and functioning, can maintain the safe conditions of the indoor environment ,69,90. IThe paper aims at the elaboration of strategies for health promotion in hospital wards, from the chemical pollution point of view. In any case, it is possible to consider improvements, all the time, to the contents of the check-lists, thanks to the support of several research groups, the data analysis and monitoring activities supported by scientific methodologies, such as those of Gola et al. and Śmiełowska et al. ,76, whicThese activities help the healthcare organization and hospital staff, with a view to preventions and the planning of interventions into the activities and the use of sanitizing or disinfectant substances related to medical activities, and also helping them to be ready in the case of epidemics , particularly regarding the activity of disinfection .Among the future perspectives, the new challenge is to investigate the correlations between the chemical and biological pollutants, and their effects on IAQ and the quality of the healthcare facility.


Sensors. The authors contacted the publisher regarding the robustness of the results. The selection of weight parameters was not sufficiently rigorous, resulting in doubts concerning the scientific validity of the theoretical models and simulation results.The journal retracts the article , cited aSensors. The extent of the error is significant and, therefore, in accordance with the journal’s procedural requirements, this article is retracted.Adhering to our procedures, an investigation was conducted by the Editor-in-Chief with the editorial office of The authors agreed to this retraction and apologize for any inconvenience caused.


The article presents data on a new scheme of complex treatment and rehabilitation of emigrants with psychogenic, endogenous and organic depressive disorders, as well as the results of comparative analysis of the effectiveness of this scheme, compared to the traditional one.The use of the proposed treatment scheme also allowed to reduce the severity of anxiety, indicators of the severity of psychopathological symptoms, improve the quality of life among emigrants suffering from depressive disorders of different genesis.The received results allow us to recommend the scheme we have developed for implementation in the complex treatment of emigrants suffering from depressive disorders of psychogenic, endogenous, and organic genesis. The problem of emigration in Ukraine is one of the most pressing state and social problems. Emigration is one of the most massive social processes in the world, which has shown a pronounced tendency to increase in recent years. Based on the information from Ukrainian embassies abroad, the Ministry of Foreign Affairs reports that up to 2.5 million citizens are employed outside the country. The data of the Ministry of Social Policy of Ukraine obtained based on the analysis of the labor market, made it possible to determine the volume of labor migration, which is approximately 3 million persons . AccordiIn recent years, due to Russian aggression towards the East of Ukraine, there has been a tendency for a rapid increase in the number of Ukrainian migrants. If the intention to emigrate was present in 12.3% of the respondents in 2005, the percentage was already 65.0% in 2015 .Migration is seen as an important factor in influencing a person’s mental health. Some authors believe that emigration provokes manifestation or exacerbation of endogenous mental illness. At the same time, the issues related to the peculiarities of the depressive disorders in emigrants have not been studied sufficiently. In particular, the manifestations of depression concerning the emigration factor have not been investigated, which significantly complicates the development of targeted therapeutic approaches to the treatment and prevention of depressive disorders in this population category. This study was based on the research and analysis of clinical-psychopathological phenomenology of depression to develop the system of measures for treating depressive disorders in emigrants.Migration is accompanied by the transformation of the whole system of socio-psychological relationships, including interpersonal, family, parental, labor, and leads to significant tension of psychological mechanisms, which finally can lead to depressive and anxiety disorders, somatization, and post-traumatic stress disorder. The process of adaptation of migrants in a recipient country can be challenging and require a fundamental psychological and sociocultural restructuring, defined by the term “stress of acculturation” , 9.N.V. Kondrashova believes that the interdisciplinary nature of the migration problem necessitates the use of a set of research methods based on the implementation of ethno-sociological and cultural approaches, which ensures obtaining the results that objectively reflect the current state of the problem, makes it possible to predict the development of this process and to give scientifically substantiated recommendations .According to N.S. Palagina, the problem of adaptation of forced migrants has a complex interdisciplinary nature, while the socio-psychological aspect of the adaptation of migrants is not enough investigated. In the process of social and psychological adaptation of migrants, there are significant changes in the personal plan manifested in decreased self-esteem and level of aspirations, deformation of value orientations, and social attitudes. The author highlights that most of the forced migrants are non-adapted, which is manifested in the hypothymia type of response, the chaotic nature of the activity, in trend to take a protective position, externality and escapism, a decreased emotional state, emotional tension, and a tendency to groundless concern about minor issues, irritability, and anxiety. The situation of forced migration can be characterized as a crisis and even extreme, the one that poses a threat to health and life. At the same time, the success of the socio-psychological adaptation of migrants is determined by psychological and non-psychological conditions, in particular, socio-demographic affiliation, personal characteristics, life experience, degree of similarity, and differences between cultures, the communicative potential of the subject, creativity, and others. In the process of socio-psychological adaptation of migrants, there are clearly revealed phases (stages) that characterize the dynamics of adaptation processes and the success of adaptation in general. A comprehensive program of assistance, which includes a system of social, psychological, and educational measures, can optimize socio-psychological adaptation by main indicators, such as adaptation to the sociocultural environment, emotional stability, social frustration, and mental state .L.A. Shaygerova emphasizes that the complex process of adaptation in the situation of migration leads to changes in the identity of the migrant’s personality that reach a crisis level. The crisis of identity among migrants manifests itself in the different profound transformations of its contents, occurring on the personal and group levels. So, the overcoming of the identity crisis is an essential condition for the successful adaptation of the individual in the situation of forced migration. However, it often reaches such depth and strength that personal resources are not enough and the person requires psychological help for overcoming it. Such help is the correction of violations of the motivational and necessity sphere, restoring of positive identity, integrity, and integration, development of constructive strategies for overcoming, building up and integrating into the content of the personality’s identity of the values and elements of the host culture .It is evident that the nature of emigration – forced or voluntary – is extremely important for the negative impact on the psyche of an individual. R. Rice and D. Bhurra et al. emphasize that the problem of forced migration, which has a powerful negative impact on the state of migrants’ mental health, has recently become a result of political instability, poverty, terrorism, and other negative social factors . From thZ.H. Lepshokova notes that the characteristics of the ethnic identity of the migrants are related to certain acculturation strategies: the expressiveness of the national identity of the migrants is positively related to the separation strategy, the expressiveness of the civic identity – with the strategy of assimilation. At the same time, the integration strategy is positively associated with all components of the psychological well-being of the individual and with a high level of sociocultural adaptation of migrants. Assimilation, separation, and marginalization strategies have a predominantly negative relationship with the components of mental well-being and mental health (anxiety and depression) .Emigration is considered as a factor provoking a manifestation or exacerbation of endogenous mental illness -19. EmotNumerous studies have found that the situation of migration determines the high dissatisfaction of the individual with life changes and leads to the development of depression, psychosis, paranoid and schizoid disorders.C.A. Zaiontz et al. note that migration is a factor that provokes, exacerbates and participates in the formation of a psychopathological picture of some severe mental disorders, especially affective disorders; the authors consider it necessary to study the level of sociocultural integration and psychological support of migrants in recipient countries .B.L. Zhong et al. report significant psychoemotional stress experienced by migrants, especially difficulties of adaptation in the new social environment, intense work, farness from the family, and financial difficulties .R.A. Yaskevich et al. emphasize the peculiarities of older migrants’ adaptation severity; in addition to the exacerbation of somatic diseases, in the period of adaptation, depressive symptoms can be seen in most individuals. The women have depressive symptoms 1.8 times more often and anxiety disorders 3.2 times more often than men. The authors recommend the use of a special rehabilitation psychotherapeutic program for such migrants .M. Shen et al. note that the presence of depressive and anxiety disorders in migrant parents affects the normal functioning of the whole family and causes behavioral disorders in children .N.S. Mahajan et al. emphasize that emigration is a risk factor for psychosis. The most common diseases are mood disorders - women have a greater prevalence of a major depressive episode with melancholic symptoms, while manic episodes are more frequent in men. In this case, mental disorders are especially prevalent among the second generation of emigrants, which is associated with the effects of migration stress, discrimination, and acculturation in the early years of life .B.L. Zhong et al. report a greater risk of a major depressive disorder during the life of labor migrants . SimilarM.E. Beutel et al. point out that, despite the actuality of the problem of emigration in Germany, the studies of the migrant’s mental health are extremely insufficient. Based on large-scale research , the authors found a high prevalence of depressive disorders, anxiety disorders, and suicide among first-generation migrants, while the mental health of the second generation of migrants did not differ from ethnic Germans; their socio-economic status was also high .M. Schouler-Ocak indicates that migrants suffer from specific psychiatric disorders , and the prevalence of mental disorders in this population is greatly increased .D. Bhugra et al. showed that migrants are more prone to mental illness, a fact that should be taken into account in public health and social policy programs.The mental health of migrants has become a key problem in current healthcare issues in EU member states. H.J. Salize et al. indicate that mental health services in the recipient countries are not able to provide adequate psychiatric care to migrants because of a growing stream of mental illnesses, limited health resources, the reduced number of trained professionals, and new legal requirements. Several studies substantiate the need to involve a variety of state and community structures that provide language, cultural and social adaptation of migrants with free access to mental health services in the system of psychiatric help.The experience, gained by migrants in combat zones, crisis regions, and during escapes, increases the risk of primary and secondary traumatism with further psychiatric disorders. In addition to post-traumatic stress disorder, major depressive disorders, anxiety disorders, and psychosis are more likely to occur in migrants than in the general population. Recent studies have shown that around half of forced migrants suffer from mental illnesses such as depression, post-traumatic stress disorder, and anxiety disorders. In Germany, about 5 thousand sessions of psychotherapy are held annually, which is only 4% of the need.Treatment and rehabilitation approaches for depressive disorders of migrants are currently in the stage of active formation. Understanding the importance of correction of depressive symptoms among migrants has motivated scientists from different countries to find new methods of treatment and prevention of depressive disorders in this category of patients.Looking at the life-threatening clinical manifestations, complications and the presence of high suicidal danger, it is clear to see that severe depression belongs to the category of urgent pathologies. The leading deontological requirement for the provision of medical care to patients with depression is the most rapid possible achievement of the therapeutic effect with the appointment of individually adequate intensive care. It requires a comprehensive multivariate assessment of the patient’s condition, including the operative diagnosis of depression and comorbid states, clinical- psychopathological and syndromal evaluation of depression, characteristics of its course, comorbidity and pathogenesis. The authors highlight the need for complex treatment using different medication groups, non-drug therapy with subsequent supportive treatment for reducing the symptoms of the current episode and preventing exacerbations, as well as a prophylactic treatment to avoid relapses.It is evident that migrants need special therapeutic approaches to the treatment of depressive disorders, taking into account the socio-psychological characteristics of this contingent of patients. However, analyzing the modern scientific literature on pharmacological therapy of depressive disorders in emigrants (remigrants), it should be noted that this problem remains practically not resolved. Somewhat more studied are measures for psychosocial therapy of affective disorders in emigrants and remigrants.Specialists of the European Psychiatric Association have formulated recommendations for reducing the risk of migrants’ mental disorders.In the public sphere, a clear policy that takes into account employment, provision of housing, the satisfaction of the physical and intellectual needs of migrants, with appropriate resources that has to be freely available to migrants, provision of the system of social-psychological support of migrants by skilled personnel, adequate information policy, collection and analysis of the necessary information have been implemented.In the field of mental health, the availability to physicians for necessary information, cultural awareness, and training should become an obligatory part of professional competence; it should be the part of training plans for medical staff that provide psychiatric and psychological help to migrants and the range of medical (psychiatric) services should be sufficient and cover all main areas, being provided with all necessary resources. Much attention is paid to the importance of psycho-educational activities, which include giving practical advice to migrants all the necessary knowledge about illnesses. Such information should be problem-oriented.The psychological assistance to emigrants for effective psychological adaptation is determined by the following directions: changes in the living conditions of the emigrant according to his educational and professional level, the change in the hierarchy of needs and in the system of meaningful goals, as well as the increase of intrapsychic adaptation in the process of psychological correction.Cognitive-behavioral therapy (CBT) is one of the most promising psychotherapeutic directions in the treatment of depressive disorders. CBT refers to a group of interventions that are among the best-known empirically-supported treatments for depression. CBT is based on the premise that inaccurate beliefs and maladaptive information processing (forming the bases for repetitive negative thinking) have a causal role in the etiology and maintenance of depression. This ‘cognitive model’ posits that when maladaptive thinking is corrected, both acute distress and the risk for subsequent symptom return will be reduced . At the Thus, the analysis of modern scientific literature devoted to the problem of depressive disorders in emigrants and remigrants shows that its development is not enough. The contradictory nature of the scientific data of the influence of factors of emigration and remigration on the emergence and the course of depressive disorders, the lack of programs of complex pharmacological and psychosocial correction, causes the relevance of further research of the clinical, psychopathological and psychiatric aspects of this problem, as well as the development of modern approaches to integrated treatment and rehabilitation of emigrants and remigrants with depressive disorders.Based on this research, the scheme of integrated treatment and rehabilitation of emigrants with psychogenic, endogenous, and organic depressive disorders was developed and implemented in the health care practice. A comparative analysis of the effectiveness of this scheme and the traditional one was conducted.The proposed treatment and rehabilitation schemes are based on the principles of integrated, individualized, and differentiated approaches to ensuring the phases and continuity of treatment and rehabilitation measures. Its goals are to stop, as quickly as possible, the manifestations of depressive disorders  and ensure maximal restoration of the ability to work, social functioning of the patient, prevention of relapses of depressive disorders, providing early socialization and social adaptation, taking into account specific features identified at emigrants and reemmigrants, with the involvement of family and public organizations. Targets of therapy are clinical manifestations of depressive disorders , social maladaptation and disorders of microsocial communications, pathological behavior patterns associated with the presence of depressive disorders, as well as factors of emigration and remigration.A comparative assessment of the effectiveness of the proposed treatment and rehabilitation scheme relative to the traditional one was done by comparing clinical and psychological and psychometric data, as well as indicators of quality of life.The proposed scheme is implemented in four stages related to the continuity of treatment and diagnostic measures.•The first stage – diagnosis. It includes clinical and psychopathological evaluation of the existing psycho-emotional disorders in the patient, analysis of anamnestic data, clinical symptoms, dynamics and prognosis of the disease, the relationship of clinical and socio-psychological factors.•The second stage – complex treatment. Includes a complex of biological therapy and psychotherapy aimed at reducing depression, normalization of the psycho-emotional state, social adaptation and rehabilitation. Differentiated psychotherapeutic correction of emigrants includes the use of rational psychotherapy, cognitive-behavioral therapy and group psychotherapy. In emigrants with psychogenic depressive disorders, psycho-educational therapy could also be used. The criterion of the effectiveness of therapy is a stable (at least two weeks) normalization of the psycho-emotional state, the absence of clinical signs of depressive disorder, the development of an adequate emotional response to real-life circumstances, including emigration, giving up destructive patterns and developing constructive patterns of behavior.•The third rehabilitation stage is aimed at the formation of a stable adequate emotional and behavioral pattern, maximum adaptation and rehabilitation of the patient, prevention of relapses of the depressive disorder. The drug therapy is similar to the one used in the treatment stage, with the correction of doses of medications, depending on the current state of the patient. Differentiated psychotherapeutic work includes the use of cognitive-behavioral psychotherapy in emigrants and a combination of cognitive-behavioral therapy, family psychotherapy and autogenous training in remigrants. At this stage, there are also measures for social rehabilitation and the readaptation of the patient.•The fourth stage - prophylactic - is aimed at maintaining the normal psycho-emotional state, effective resistance to stress, and prevention of relapse of depressive disorder. Medication therapy includes the treatment of the main disease in depressive disorders of the organic genesis and the seasonal prevention of endogenous depressions. Psychotherapy, the use of techniques of self- regulation, and measures for social adaptation could be used as well.In groups of emigrants that suffer from depressive disorders, the proposed scheme of dynamics therapy showed a higher efficiency, compared with the traditional scheme in terms of recovery and improvement of the general condition, reduction of psychopathological symptoms, and increased quality of life.The obtained results allow us to recommend the scheme we have developed for implementation in the complex treatment of emigrants suffering from depressive disorders of psychogenic, endogenous and organic genesis.The authors declare that there is no conflict of interest.


Urban shrinkage is currently spreading at global level. At the same time, the scale of urban shrinkage is not limited to urban agglomerations, metropolitan areas, or big cities, but begins to expand to a vast number of small towns. Over the years, the characteristics, models, and mechanisms of shrinkage in large cities have attracted the attention of scholars; however, the problem of shrinkage in small towns has not been fully discussed. In China, small towns are located at the margins of cities and are the first part of the countryside; hence, they are the link and the bridge between urban and rural areas, and a space carrier to solve the diseases of big cities and for rural rejuvenation as a whole. However, in the process of rapid urbanization, some small towns have experienced urban shrinkage, mainly through a decline in township enterprises and the deterioration of the living environment, which has restricted their role in coordinating the spatial support of urban and rural development. Therefore, a correct understanding of the shrinkage of small towns has considerable theoretical and practical guiding significance. We focused on the towns of the Jilin Province as the research unit, and combined township population, economy, land use, and employment indices to establish an urban shrinkage index, identifying the status, spatial distribution, and influencing factors of small towns shrinkage in the Jilin Province. Moreover, we analyzed the similarities and differences of small towns shrinkage between the Jilin Province and developed countries. The results show that small towns shrinkage in the Jilin Province shares similar characteristics with developed countries, as well as important differences in aspects such as population migration, low-level industrial structure, and administrative division adjustments. Since there was no negative index in the original data, we adopted the calculation method of the positive index. The specific formula used is as follows:ij is the original index, which represents the value of index j of year i of a small town; and max(jX) and min(jX) are the maximum and minimum values of the index j across all years, respectively.Where Then, we used the entropy method to calculate the weight of the evaluation index and the urban shrinkage index. The specific formulas used are as follows:m is the number of research units; n is the number of indices; jW is the weight of the index j  and slightly shrinking towns (-0.069836 - -0.000402) by applying the natural breaks using ArcGIS.Where  index j ; Sij is r value, which reflects the degree of linear correlation between two variables. The value of r is between , and the higher the absolute value of r, the higher the correlation. The Pearson correlation coefficient was calculated as follows:Small towns shrinkage is a complex process, influenced by several factors, and caused by factors such as population, economy, location, and nature. In order to measure the relationship between small towns shrinkage and these factors, following existing research , we intrN is the number of shrinking towns; X is the selected index; and S is the urban shrinkage index of shrinking towns.Where Small towns in the Jilin Province are facing an extensive shrinking trend. From 2003 to 2017, 284 of the 414 towns in the Jilin Province, accounting for about 68.60% of the total, had a growth trend, while 130 towns, accounting for about 31.4% of the total, were facing a shrinkage trend. Among these, the slightly shrinking towns accounted for 27.29% of the total, and the significantly shrinking towns accounted for 4.11% of the total. The geographical location of the significantly shrinking towns was relatively remote and far away from the main traffic arteries, core urban areas, and county towns, so they were relatively less attractive to the population. In the Jilin Province, the slightly shrinking towns were mainly agricultural and resource-based towns. The agricultural towns dominated by agricultural production drove the lack of urban economy and employment capacity, and led to the loss of population in townships. Resource-based towns are towns with mineral, forest, and other natural resources exploitation and processing as the leading industry. Due to the implementation of natural forest protection policies and the decline of recoverable mineral resources such as coal and oil, the economy of resource-based towns was in recession, unemployment and poverty were increasing, and towns were shrinking. Hence, it may be concluded that, from 2003 to 2017, about 3/10 of the towns in the Jilin Province experienced different degrees of urban shrinkage, and the majority of these towns had a slightly shrinking trend. Shrinking towns generally faced population loss, economic recession, and lack of industrial support.The concentration of shrinking space in small towns in the Jilin Province was relatively evident . From thThe spatial distribution of small towns shrinkage in the Jilin Province was significantly affected by the agglomeration and diffusion effect of central cities. Changchun was in the primary stage of diffusion, and traditional industries, information, and innovation began to move to the periphery. Under the influence of function diffusion in the central urban area, the shrinkage degree of small towns in the inner suburbs of Changchun decreased. At first, the urban function diffusion of Changchun did not affect the outer suburbs, which made the shrinkage of small towns in the outer suburbs more severe than that in the inner suburbs. However, the development of other central cities in the Jilin Province was in the agglomeration stage, attracting the industries, population, and talents of small towns in the inner suburbs to the central cities, and forming a typical "siphon effect", depriving the development opportunities of small towns, and resulting in the fact that shrinking towns were mainly distributed in the inner suburbs of the central cities. The agglomeration and diffusion effect of central cities would continue to act on small towns in the Jilin Province for a period of time in the future. The current spatial pattern of shrinking towns would continue for a long time.Small towns shrinkage was the result of the comprehensive influence of all factors investigated. Considering the possibility to collect and quantify data, as well as the comparability between towns, we focused on 6 aspects  and 14 influencing factors of small towns shrinkage in the Jilin Province . The PeaSmall towns shrinkage in the Jilin Province was generally small in scale; this is consistent with the characteristics of small towns shrinkage in developed countries –43. By tSmall towns in the peripheral regions of the Jilin Province were seriously shrinking, as well as small towns located in the periphery of large cities and in backward areas of the Jilin Province. Compared with small towns in the periphery of large cities, small towns in geographically peripheral regions were more vulnerable to economic and social recession, in a similar way as for shrinking towns in Germany and France. The peripheral small towns in Germany shrank significantly. Location had a clear influence on the development of these towns: the more peripheral the towns, the higher the population decrease , 44, 45.The mining resources-based small towns in the Jilin Province had a strong shrinkage, in line with the shrinkage of resource-based small towns in developed countries. The initial development of mining towns in the Jilin Province relied mainly on the mining industry, and the development of the town's economy was highly dependent on these resources. In recent years, the exploitable resources of these towns in the Jilin Province have been facing exhaustion, and replacement industries have not been formed. The primary sector in resource-based towns had a small scale, while the secondary and tertiary sectors were insufficient, and their ability to absorb employment was poor. In 2010, the mining industry employed only 4,576 people in the townships of the Jilin Province, indicating a significant shrinkage of small towns. When mines were closed or reduced in size, due to changes in the resource industry and the depletion of recoverable resources, Australia's resource-based mining towns also failed to find suitable alternative industries. As a result, the economy shrank and population loss intensified , 48, 49.The public facilities in the shrinking small towns of the Jilin Province were gradually aging, in a similar way as for shrinking towns in Europe , 50. DueThe following six main differences between small towns shrinkage in the Jilin Province and in developed countries have been identified:The function types of shrinking towns in the Jilin Province were more diverse, while those in developed countries were relatively uniform. The economy of the shrinking towns in the Jilin Province was mainly based on agricultural product processing, industrial and mining resources, trade, and forestry. The functional comprehensive towns, as well as the tourism-based towns and the port towns at the border with other countries, also showed a certain shrinkage. The economy of the shrinking towns in developed countries was mainly based on the agricultural, mining, and manufacturing sectors. In the United States, the towns with strong agricultural and mining sectors recorded the fastest population outflow . In JapaThe shrinkage of small towns in the Jilin Province was mainly affected by population migration, and was less affected by population age structure, as happened in developed countries. The shrinking towns in the Jilin Province were less attractive to population, and emigration rate was increasing, especially among young and educated people, who pursued a higher quality of life. The outflow of population from the province was mainly directed towards Beijing, Tianjin, Shanghai, and Shandong . The popThe shrinking towns in the Jilin Province were characterized by a low-level industrial structure, while these in developed countries were mainly affected by deindustrialization under the background of globalization. The low-level industrial structure of small towns in the Jilin Province was mainly composed of resource-based industry and agricultural product processing industry. Resource-based industries were characterized by a high dependence on mineral resources, the lack of deep processing of resources, a short industrial chain, the lack of technological advantages, the lack of technology and product correlation among industries, and by a poor industrial development flexibility. Once entering into resource exhaustion, and market and technology competition, the industrial system of small towns would be "paralyzed". The production capacity of the enterprises processing agricultural products was low, resulting in low agricultural economic benefits and low added value of agricultural products. In developed countries, due mainly to economic globalization and deindustrialization, traditional industries such as textiles, metal manufacturing, and shipbuilding gradually lost their competitiveness in the global economy. A large number of traditional manufacturing industries were constantly shifting to overseas developing countries. Some towns, especially in the United States and Japan, lost their leading industries , 47, 56.The development of shrinking towns in the Jilin Province was affected by the overall decline in the development of Northeast China, while some shrinking towns in developed countries were subject to post-socialist transformation. Small towns in the Jilin Province were an important component of the old industrial base in Northeast China. In recent years, the economy of Northeast China has gradually been overtaken by the rapid economic development of the Pearl River Delta, the Yangtze River Delta, and the Beijing-Tianjin-Hebei region. The economic and industrial focus of China has been moving southward, and the regional functions in Northeast China and their competitiveness have gradually declined. As a result, shrinking towns have lost their appeal to businesses and population, and the prospect of economic development gradually declined. On the contrary, the shrinkage of small towns in Central and Eastern Europe in the 1990s was mainly due to the post-socialist transformation. The socialist system was generally concentrated in the larger cities and established a relatively stable economic base in the small towns in the periphery, which became regional administrative and manufacturing centers. The socialist transformation had a serious impact on the economy and society of these countries, especially on small towns, which lost relatively more development opportunities and economic prospects than big cities .The main strategy of shrinking towns in the Jilin Province was still focused on attracting investment and economic growth, while the development direction of shrinking towns in developed countries shifted towards adopting a strategy of smart decline, consisting in pursuing fewer people, fewer buildings, and less land use , 58. In The adjustment of administrative divisions in the Jilin Province was the most important and characteristic cause of urban shrinkage. With the rapid development of urbanization, the administrative divisions of the Jilin Province have been adjusted frequently, including turning counties (cities) into districts or into cities, merging villages and towns, and including the combination of administrative districts and boundary adjustments. In China, the spatial definition of urban population is also directly linked to the administrative division system. When two towns are merged, although the urban population in the two towns increase, the per capita economic level does not significantly improve –61. SincUnder the background of resources depletion in the old industrial bases and the decline of traditional industries in Northeast China, small towns in the Jilin Province have experienced urban shrinkage through population outflow, the decline of township enterprises, and the deterioration of the living environment. The development of most small towns is in a “maintenance” state, and shrinkage has become a prominent feature of the development of small towns, especially resource-based towns, which show a distinct “absolute shrinkage” feature. The spatial distribution of shrinking towns in the Jilin Province was highly concentrated along the northeast-southwest axis and followed a core-edge structure. The average population size of shrinking townships in the Jilin Province was considerably lower than that of growing townships. Population migration, industrial development, employment level, and adjustment of the administrative division were the key factors restricting the development of towns.There are several similarities between the shrinkage of towns in the Jilin Province and that in developed countries, related to aspects such as population loss, the decay of the town’s material space, the decline of the economy and social culture, and the exhaustion of resources in resource-based towns. There are also significant differences between the Jilin Province and developed countries. In the Jilin Province, the phenomenon of town shrinkage was shorter in time; moreover, it involved a large number of different types of shrinking towns, which were widely geographically distributed and held significant spatial differences. The shrinkage of small towns in the Jilin Province was mainly due to population migration, low-level industrial structure, and administrative division adjustments. Small towns in developed countries were more likely to shrink because of the industrial restructuring caused by deindustrialization and globalization, as well as because of an aging population and a decline in fertility rate (in Japan and in Europe), poverty and isolation under the background of suburbanization (in the United States), climate change , and post-socialist transformation (in Europe).The formation of urban shrinkage in the Jilin Province cannot be separated from its special development background. First, as one of China's traditional old industrial bases, Jilin Province's traditional industries are mainly resource-based industries. There are many resource-based cities and towns, which are widely distributed in the Jilin Province. The land area, population, and local GDP of resource-based cities and towns account for 70%, 50.6%, and 49%, respectively, of that of the Jilin Province . The JilThere are significant differences in the historical background and political system of small towns shrinkage between China and developed countries, and the shrinkage of small towns in developed countries provides a good basis for the study of the shrinkage of small towns in China. Urban shrinkage is not necessarily a bad thing, and not all shrinking towns will go into decline. Shrinking towns can enjoy economic prosperity , and theThis research used the entropy method and the Pearson correlation coefficient to identify shrinking towns by using multi-dimension indices, to quantitatively explain the factors influencing shrinking towns in the Jilin Province, thereby providing a new perspective for the quantitative study of urban shrinkage. However, this research has the following limitations: 1) The research object of this research is the township, which is similar to the concept of small town in developed countries. However, the concept of small town in China does not entail a clear population limit, therefore the number of identified shrinking towns may be higher than that in developed countries. 2) This research is limited by the urban statistical data. The temporal coverage of the yearbook data on townships is limited, and it is difficult to obtain multi-dimensional data of unified indicators for several years; therefore, it is necessary to further mine the available data on small towns in the future. 3) Due to limitations in urban statistics, this research did not analyze the utilization efficiency of public facilities in shrinking towns, which will be the focus of future research.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.


The mediation category underlay theanalysis.an integrative review, which included theoretical and methodological studiespublished in the following databases: COCHRANE Library, EVIPNet, HealthSystems Evidence, LILACS, PDQ-Evidence, PubMed, Rx for Change, and SciELO,in addition to mediation category indicated the need forthese theories not to be restricted to the micro-context, but to incorporatethe elements of the social macro-structure to which they are connected.19 references were included, published between 1997 and 2018. It is aninnovative proposal to direct the process of evaluating health programs,interventions, and/or policies, with the democratic participation of theparties involved, such as users, workers, managers and researchers; itproposes to elaborate theories about what works, for whom, in what context,and how. The It is indicated that the realist evaluation is to be conducted in 21 stages.It takes into account qualitative and procedural methods, which makes itpowerful for understanding human and social relationships in the contextanalyzed. Theories that come from evaluating the functioning of the programsanalyzed have greater explanatory chances if they are built by reference tothe social totality. On the other hand, it is knownthat assumptions about the success of this type of intervention must be betterunderstood through evaluation processes, since they occur concretely within thescope of social relationships, allowing to ascertain the plausibility of theintervention and assist the evaluators in deciding what should beprioritized..Procedural monitoring, with access by the team of evaluators to intermediateoutcomes, is considered essential in the evaluation of complex healthprograms..The evaluations indicated for complex interventions involve stages that range fromthe identification of health needs to the design and implementation of the programsand policies. In addition, it is necessary that the evaluation process takes intoaccount the discussion of the political priorities and considers collecting data atdiverse moments, to capture changes over time..The traditional models for assessing public programs and policies do not have suchattributes. Coming from predominantly positivist frameworks, they focus on theinterests of the organizations and institutions, the logic of human resources, andthe cost-benefit ratio. In this perspective, the structure is vertical, with theevaluator playing a central role and being generally external to the context of theevaluation.. The realistic review, which shares the same theoretical perspectivewith the realist evaluation, argues that the best evidence must come from atheoretically oriented and locally situated process.The realist evaluation aims to overcome this traditional approach. In this sense, itinvolves qualitative and quantitative components, based on theory, to promote theimplementation of policies and programs in specific contexts. The re process..A literature review mapped the concepts of the realist evaluation as applied tohealth systems research, based on primary studies that used this evaluationmethodology. The authors recommend greater clarity regarding the definitions ofmechanisms and context, two elements considered structural in the realistevaluation, in addition to the outcome.Thus, this review aims at identifying and analyzing the concepts of the realistevaluation and the recommended methodology for its implementation in the healtharea.The question in this review is the following: What are the concepts and stages of therealist evaluation used in the health area? It was formulated using the PICostrategy , with theelements delimited as follows: P - Without delimiting the population; I - Conceptsand stages of the realist evaluation; Co: Health area., thus stimulating the exposure and understanding of theoretical andmethodological frameworks about certain phenomena of reality. The development stagescan be systematized in eight steps, according to the literature in the area: (1)Creating a group to conduct the IR; (2) Preparing the introduction; (3) Formulatingthe question and the objective; (4) Describing the methodology; (5) Analyzing andinterpreting data; (6) Presenting outcomes; (7) Interpreting and discussingoutcomes; and (8) Disclosing outcomes.The integrative review (IR) was chosen because it constitutes an appropriatemethodology to contribute to the synthesis of the review of theories andmethodologies, thus soutcomes.In this sense, once the first phases that demanded meetings of the responsible groupwere overcome, in stage 4 only theoretical and methodological studies, bothpublished and of the gray literature, were included, which analyzed and/or proposedtheories and/or methodologies of the realist evaluation. The search was carried outin August 2019 and included references published in Portuguese, English, andSpanish, in any year, and indexed in the databases until July 2019.Teses-CAPES and Google Scholar. Theexpression “Realist evaluation” was chosen as it was the most sensitive searchstrategy, enabling the mapping of the largest number of potential references on thetheme. On the other hand, it guaranteed sufficient specificity. This expression isnot a MeSH term, as it is a relatively new term. Manual searches and among thereferences of the references included were also carried out.To search for scientific and gray literature, the expression “Realist evaluation” inEnglish or Portuguese was used in the following databases: COCHRANE Library,EVIPNet, Health Systems Evidence, LILACS, PDQ-Evidence, PubMed, Rx for change, andSciELO, in addition to After identifying the studies, the references were selected by title and abstract,full reading, inclusion/exclusion, and data extraction by the team of fourreviewers, with at least two of them working independently. Data extraction wasperformed using an instrument composed of the following items: (1) Title; (2) Year;(3) Authors; (4) Country of origin of the lead author; (5) Area of knowledge of thefirst author; (6) Objective of the study; (7) Definition and purposes of the realistevaluation; (8) Theoretical reference framework; (9) Stages of development of therealistic review; and (10) Summary of the text selected.The evaluation of the methodological quality of the studies included was not carriedout, as the object of study was of the theoretical type, and there was no inclusionof empirical studies., with the essential conceptual elements of the realist evaluation beinganalyzed according to the mediation category.From the point of view of collective health, the theoretical approach of historicaland dialectical materialism was adopted in this study, with tThe authors of this article declare that they have no conflict of interest.428 references were identified from data sources, manual searches, and references ofthe references, as shown in After excluding duplicate and unavailable publications and selection by title andabstract, 47 references were analyzed in full. In total, 19 references wereincluded, as shown in It should be noted that the studies were published between 1997 and 2018, with nine(47%) starting from 2011. The studies were published by authors from the UnitedKingdom, Australia, Canada, Sweden, United States, and Singapore, in the followingareas of knowledge of the first author: Primary Care, evaluation, Education,Nursing, Philosophy, Business, Rehabilitation, Technology Development, Sociology andSocial Policy, and Social Research. The figure below presents the integrativesynthesis of the definitions and purposes of the realist evaluation:.It was identified that the concepts presented by the different authors are congruentwith each other. The realist evaluation is a methodology structured according to thephilosophical assumptions of realism, which aims to address the complexity of thehealth interventions, considering the influence of the social relationships andorganizational structures. It is a theory-oriented approach that focuses theevaluation on obtaining answers about what works, for whom, in which context, andhow,,,-30.. The mechanisms are the way the subjects interpret and act regardingthe intervention and are not always explicit, whereas the context is represented bythe characteristics of the conditions in which the interventions were introduced.Finally, the outcomes are the consequences of activating different mechanisms indifferent contexts, which produce clear theories or structured theoretical models, toexplain how interventions promote the expected outcomes.The realist evaluation considers the Context-Mechanisms-Outcomes (CMO) articulationto understand the underlying dispositions that make up the studiedsituation,15. Tcontexts,17, woutcomes., assuming that different contexts produce different outcomes, eitherbetter or worse(-). The CMO configuration has the potential to introduce a broad and complete picture ofwhat is happening, in order to elucidate the essential elements that enabled theuse, or not, of interventions, programs, and/or public policies, assumior worse-16. .Another innovative aspect is the purpose of understanding the configuration ofoutcome patterns obtained by implementing the interventions. The realist evaluationstudies aimed to present the changes resulting from the implementation ofinterventions and how such measures were produced and introduced to modify thecontext and balance of the underlying mechanisms,20.. In this sense, programs/interventions/policies are evaluated based onthe changes produced in the individuals, subgroups, and contexts involved, inaddition to identifying the social and cultural resources that are necessary tosustain the changes. For the realist evaluation, it is necessary to: (1) formulate a theoryabout the program, interventions, and/or policies assessed; (2) formulate andprioritize evaluation questions around the theory; (3) plan, design, and conduct theevaluation based on the theory; (4) identify the constructs postulated in thetheory; (5) determine the efficacy or effectiveness of the program, interventions,and/or policies assessed, and explain cause and effect associations between thetheoretical constructs and the factors that affected the outcome pattern. Theseprinciples are situational and do not constitute strict criteria, since theirapplication depends on the nature of the program assessed, the objective of theevaluation and the individuals who will use it.In order to understand the investigated reality, the realist evaluation must beginwith theories, which will be tested and refined in a cyclical and iterative way,being structured in the form of proposals about how the mechanisms occurred incontexts to produce outcomes,-,,27. I changes. For thl use it.. The choice of the data collection methods must be guided by thetheory, in order to test the assumptions/theories and to unveil the patterns andregularities of the program, through observations, data collection, data analysis,among others. In complex programs, random sampling, randomized clinical trials orquasi-experimental projects may not be able to identify elements that interfere withthe participation of those involved in the program, because the intervention hasunexpected processes that cannot be predicted in advance for statistical purposesand do not capture outcomes and contextual elements.In this way, the evaluation allows for a circuit that can be guided by differentstrategies for understanding the reality under study,,,21. Tg others,27. Ielements,27.. This process should follow an emancipatory perspective, which requiresthe participation of other stakeholders in the evaluation, in the identification oflocal history, and in the transformative actions in which the practiceoccurs. Emancipation is in this sense understood by the author as a process inwhich those involved identify needs for changes in the practices, reflect on suchpractices, and seek to promote cultural changes, based on the needs identified inthat context. Analyses and changes are related to the local cultural dimension ofthe social relationships. The political and economic dimensions are not considered in theauthor’s perspective.In this sense, it is necessary to include the evaluator in the process, who has thetask of understanding and testing the theory studied,19. Teoccurs. Emanciionships. The po.The emerging realist evaluation is one of the evaluation categories found and isdescribed as the one that aims at social improvement by implementing programs andpolicies. The evaluator engages in the process of creating knowledge with theparticipants, believing that public discussion informs society for making sociallyresponsible decisions. Therefore, the evaluation is not a condition for deciding onthe merit of a social policy, but it supports democratic decision-makingprocesses,25..The critical realist evaluation derives from critical realism, an approach that isadvocated for implementing evidence-based innovation in health. In this perspective,it is highlighted that the evaluation is inherent to the implementation process andnot something out of place to measure outcomes. The critical realist evaluationemerges more explicitly to show that it is part of the broader implementationprocess considering the conditions that promoted or hindered the changes..In short, the realist evaluation has the potential to support decision-making and thecreation of public policies, as the outcomes are presented according to thedifferent contextual realities of pre-existing social structures, to generate achange that includes structures, culture, and social relationships,,26.The integration of the stages was possible without the need to overcomecontradictions, since all the papers found are based on the same epistemological andtheoretical-methodological frameworks, with some non-conflicting variations, as isthe case with the emerging and critical realist evaluation. Thus, from the CMOconfiguration, the stages for conducting the realist evaluation were integrated andshown in Using the studies included and the analysis category, the specific guidelines foreach stage were described, considering that the stages can occur in an overlappingand iterative way.1. Definition of the theory and of the evaluation questions:Formulate theories about the program . The understanding of the theory allows for the development ofexperimental configurations of mechanisms and contexts. Consider that theexplanation of reality by the theory will occur in all the stages of theevaluation;context). The unaluation;2. Title: Identify the document as a realistic synthesis orevaluation;aluation;3. Abstract: Include brief details about: the policy, program orinitiative under evaluation; program configuration; purpose of the evaluation;evaluation question(s) and/or objective(s); strategy; data collection,documentation, and analysis methods; main findings and conclusions;clusions;Introduction:4. Presentation of the study theme: Explain the purpose of theevaluation with secondary data;ary data;5. Theory of the program: Describe the initial program theory (ortheories) that underpin the program, policy, or initiative;itiative;6. Evaluation questions, objectives, and focus: Indicate thequestion(s) and specify the objectives for the evaluation. Describe whether and howthe program theory was used to define the scope and focus of theevaluation;aluation;Methods:7. Justification for using the realist evaluation: Explain why arealist evaluation approach was chosen and (if relevant) adapted; adapted;8. Description of the program policy, initiative or productassessed: Provide relevant details about the program, policy orinitiative assessed;assessed;9. Evaluation locus: Describe and justify the reason for choosingthe place where the evaluation took place;ok place;10. Description and justification of the evaluation design: Adescription and justification of the evaluation design  must be included, at least briefly or as an appendix, inthe document that presents the main conclusions. If this does not happen, theomission must be justified and a reference or link to the design must be provided.It can also be useful to publish or avail for free  any document or original evaluation design document, if any;, if any;11. Data collection method: Provide details and justificationsabout the method choices, which can be quantitative or qualitative: which ones wereused, why, and how they contributed to develop, support, refute or refine theprogram theory. Quantitative methods are mostly used regarding the context, forexample, group comparison; Qualitative methods contribute to the exploration ofhypotheses and to the identification of unforeseen elements of the context andoutcome. The semi-structured qualitative interview is the most common and availablemethod of data collection, either alone or in combination with other methods. Itusually contains exploratory questions based on the program assessed and acting asinstruments to extract the proposals of the general investigation;tion,,-28;12. Definition of the participants: Describe how the participantsin the evaluation were defined, invited and engaged, and how they contributed to thedevelopment, support, refutation or refinement of the program theory. The stakeholders are considered the main data sources, as they haveexperience in specific phases and processes within the program assessed;m theory. The stassessed;13. Data analysis: Describe and justify which method of analysiswas used, how the program theory was developed, supported, refuted and refined, andwhether the analysis changed during the evaluation. There is not just one suitable analytical method, as it depends on thetheories proposed and on the availability of data. In the realistic program theory, different outcome patterns areexpected to exist for different groups or contexts within the program, and theanalysis tests these theories;aluation. There  of data. In thetheories;14. Ethical approval: Indicate whether the realist evaluationrequired and obtained ethical approval from the relevant authorities, providingdetails as appropriate. Explain the reason if it is not necessary to conduct theevaluation.aluation.Results:15. Details of the participants: Report (if applicable) whoparticipated in the evaluation, details of the data they provided, and how the datawas used to develop, support, refute or refine the program theory;m theory;16. Main results: Present the main results, linking them to thecontexts, mechanisms, and configurations of outcomes. Show how they were used todevelop, test, or refine the program theory;m theory;Discussion and final considerations:17. Theory test: Review and understand the possible CMO patternconfigurations to refine the theory and promote knowledge;18. Summary of the outcomes: Summarize the main outcomes withattention to the evaluation questions, purpose, the program theory, and thestakeholders;eholders;19. Strengths, limitations, and future directions: Discuss thestrengths of the evaluation and its limitations, including considerations of all thestages in the evaluation processes. In many evaluations, there will be anexpectation of providing guidance on future directions for the program, policy orinitiative, its implementation and/or project. The particular implications of therealistic nature of the outcomes must be reflected in these discussions. Considerthat future directions support public policies, being important politicalinstruments for social research;research;20. Discussion and main conclusions: Compare the outcomes withexisting literature and list the main conclusions that are justified by the dataanalysis. If appropriate, offer recommendations consistent with a realisticapproach;approach;21. Funding and conflict of interests: Indicate the source offunding (if any) for the evaluation, the role played by the funder (if any), and anyconflicts of interest of the evaluators.aluators..The aforementioned stages, integrated from the studies gathered in this review, allowguiding the development, as well as the preparation, of the final report of arealist evaluation,,28.It was assumed in this work that the potential of the realist evaluation lies in itsability to capture the interactions inherent to the CMO complex..This type of evaluation highlights that the outcomes found in a given evaluationprocess are not linearly transferable to other realities, as they depend on theinteraction of particular social processes..The interactions, as analyzed by the mediation category in this work, represent thearticulation between the parts of a complex totality and, at the same time, themovement between the singularity and the totality, formed by socio-historicalstructures, constituted by interactions with dynamic and contradictory movements,and not only by the Cartesian sum of the parts..The mediation category carries both an ontological and a reflective dimension sinceit exists independently of the social subject, and can support individuals’reflection processes about a certain reality, captured by its essence and not onlyin the appearance realm.. In the realist evaluation, part of the underlying mechanisms, whichcan interfere with the outcomes of a given project, depends on the reflection ofthis social being on the proposed intervention and on the reality in which it isinserted.Mediation constitutes the ontology of the social being that is based on the ownmovement of the categories of reality, and not on logical ideal concepts, beingpresent in the sociability of the social being. Therefore, it is sustained in theperspective of the relationship between man and nature and, in this way, thetransformation of nature by man (work) is a condition of human existence. In the.This field of mediations takes shape in the particularity in which the dialecticbetween the universal and the singular occurs. It is in this mediation field thatthe singular facts are related to the laws of universality, which is configured fromthe reality of the singular. The individual, being the smallest unit of the socialtotality, has infinite variations and, therefore, has great complexity andparticularities.. In the realist evaluation, the context is located in the particulardimension since, depending on its conditions, there will be or there will not be theactivation of underlying mechanisms, which may influence the outcomes of theintervention proposed by a given program, policy or service.The particular represents the expression of the categories of mediation between thesingular individuals and society. In the. Thus, the mediation category helps to apprehend the movement of thehidden social being in individuals and, therefore, supports the understanding of theunderlying mechanisms addressed in the realist evaluation.It starts with the understanding that the social being and its dynamic complexesexpress themselves in a particular way. In the sphere of universality, there are thegreat determinations and tendency laws of a given social complex. Laws anddeterminations that, in the sphere of singularity, are hidden by the dynamics offacts. Thus, .In this perspective, mediations are instrumental categories by which the action isimplemented, they are a way of objectifying the practice. The mediations areexpressed by the set of instruments, resources, techniques, and strategies that thesubject becomes aware of in order to penetrate the plots of reality as a possibilityto transform it..Regarding the limitations, realist evaluations of property demarcation and educationprograms in penitentiaries, initially described by the creators of the realistevaluation, were not based on theoretical frameworks or totalizing theories thatexplained what the root is of the problems that lead to the creation of theseprograms. Nor was it discussed, for example, how society is organized and the modeof capitalist production, which are generators of social inequalities. Thus, in itsorigin, the realist evaluation showed certain pragmatism when looking for cause andeffect relationships..Other limitations concern the philosophical dimension of critical realism, whichemphasizes that the production of several authors who follow the critical realistictheory is restricted to non-historical abstraction by not using any tools that makeit possible to understand how objective social structures can be transformed and howto carry out the transformation. Thus, it states that critical theorists do notalways make assumptions about the object of investigation when analyzing socialrelationships, which makes the starting point of investigation arbitrary. In thisperspective, the causal mechanisms are self-referenced and the structures only existas a result of human behavior and that the causal powers would thus berelational.. It has been argued that the use of dialectic alters the researchstrategy for critical realism in several ways. First, it demonstrates the need toabstract causal powers through dialectical connections and contradictions that areinherent to diverse interconnected totalities. Second, historical analysis becomes akey moment in this dialectical procedure in order to overcome a common dualism incritical realistic thinking between structures in closed systems and contingentmechanisms in contingent historical events. Society is seen as an interconnectedhistorical totality, so that concrete events are themselves moments of thattotality. Thus, the mechanisms are considered moments of dialectical connections intotalities and moments of specific dialectical contradictions. It is verified thatthe dialectic reshapes the debates about the relationship between the parts and thewhole.Such limitations are still under discussion, even by one of the main theorists ofcritical realism - Roy Baskar - who has sought to add the dimensions of historicityand totality, and the dialectic, considering the contradictions ofreality. It hasThis IR made it possible to map the scientific production of the health area on theconcepts, purposes, and stages of the realist evaluation. The studies included didnot present theoretical discrepancies, allowing for the epistemologicalreconciliation of the concepts and methodology of this approach. The integration ofdata enabled the presentation of 21 stages for the development of the realistevaluation of complex health contexts.Thus, it can be said that, by analyzing the outcomes of a given intervention, basedon the understanding of the interactions that occur in the reality of socialrelationships, the realist evaluation ends up identifying its potential fortransformation and the elements that interfere in the outcome of theinterventions.From the milestones of the mediation category, however, there is a need for thesetheories to be elaborated incorporating the elements of the social macrostructure towhich the mechanisms are connected.For collective health, this has essential implications for research and healthpolicies because taking social totality as a reference expands the explanation aboutreality and, consequently, the possibilities for transformation.


Between electric gloom,angels and demons dressed in plastic bluehave dragged me through the darkness,to the infinite black stone,where the origin and the end of time are lost.There, in the immense dark solitude,and in the imposed silence of word and thought,She, in my breath, gazed at mewith her eyes of fire,frosty and timeless,without any mercy,without any mercy.


Human Genome Variation (HGV), the second official journal of the Japan Society of Human Genetics, and worked diligently to increase its profile. For the last 6 years, the editorial committee has been successfully managed under his strong leadership. This open-access journal, launched in 2014, has attained a unique position in the human genetics/genomics research community. On behalf of the Editorial Board of the HGV, its authors and readers, I sincerely want to thank Professor Tokunaga for all his contributions to the journal.It is with great pleasure that, from 1 January 2020, I have taken over the role of Editor-in-Chief from Professor Katsushi Tokunaga, who founded HGV as a member of the Editorial Board, I have seen and experienced the success of this unique open-access, online-only journal. An innovative feature of the journal is a curated database of the underlying data from Data Reports, which is growing into an important resource for the human genetics/genomics community. The rapidly changing field of genomic technologies, especially next-generation sequencing and genome editing, are revealing more and more genetic variants responsible for or associated with various human diseases and traits. HGV aims to provide a coherent link between a published paper and the underlying data deposited in an accompanying database. This open-access database of variations and variability can be searched, filtered and variously used to further the progress of genomics research. Articles published in this journal are also fully open access, allowing for the widest dissemination, visibility, and impact of authors’ research. The intended audience for this journal is researchers, scientists, clinicians, genetic counsellors and those interested in human genetics/genomics, from all sectors and from around the world. We warmly welcome submissions from the scientific community. We assure authors submitting to the journal of efficient and respectful handling of their manuscripts and, in particular, of a shorter submission to decision time.During the years that I have been associated with HGV, and also very proud to be working with an outstanding internationally diverse team of Associate Editors, members of the Editorial Board, reviewers, and the supporting staff in Springer Nature. As the new Editor-in-Chief, I will strive to continue to improve and enhance the quality and reputation of HGV. I welcome suggestions, discussions and thoughts from the readers, authors, reviewers, and editors to help me to understand and rectify any problems with the journal.I am truly honored to assume the responsibility of the Editor-in-Chief of I am enthusiastic about this opportunity and look forward to working with you over the coming years.