Evidence has shown that SMS text message-based health education is effective in improving exclusive breastfeeding. However, there is limited evidence on the development and design of SMS messaging intervention targeting fathers and mothers.This is the formative assessment and intervention design for a larger trial targeting both fathers and mothers for breastfeeding support in Tigray, Ethiopia. A total of 42 parents of children less than 2 years of age were involved in the design process that also included nutrition experts. We recruited 128 expectant couples to the intervention  who continued for 3 months postnatally.Sixteen messages were developed specific to feeding in the antenatal and postnatal periods. These messages were revised with parents and experts and pretested with parents. Over 4 months 87% of fathers and mothers received 3 or more SMS text messages. All fathers and 97% of mothers read the weekly SMS text messages. Almost 90% of mothers and fathers indicated their willingness to continue to receive SMS text messages related to infant feeding.Development of SMS based breastfeeding interventions should involve the target population in content design. The role of experts and target population in the co-design process is also crucial. Breastmilk is considered the ideal source of nutrition for infants and foundation for health growth and development. For optimal feeding, the World Health Organization (WHO) recommends breastfeeding initiation within the first hour after birth and exclusive breastfeeding for 6 months, with continued breastfeeding to 2 years , 2. BreaThere are a range of modifiable determinants which impact maternal breastfeeding practices. These are primarily psychosocial and include; maternal intention to breastfeed, attitudes, self-efficacy to perform breastfeeding, and social support during lactation . These pThere is growing evidence showing the acceptability of mHealth interventions promoting breastfeeding , 9. HoweThe intervention was developed as part of a study exploring the use of a mHealth intervention targeting both mothers and fathers to improve exclusive breastfeeding to 3 months. It took place in Mekelle, the capital city of the regional state of Tigray in February 2018 to March 2019. This was a three-phase process, phase-1: formative assessment; phase-2: co-design of SMS message and pretesting; phase-3: acceptability testing. The detail of the design is described below.The formative assessment for the intervention included exploring the attitudes, knowledge, beliefs, barriers, and enablers of exclusive breastfeeding as well as experiences of mobile phone use, perceived benefits of using a mobile phone, as well as timing, and frequency preferences for receiving SMS text messages for mothers and fathers. Focus group discussions (FGDs) were undertaken with mothers (two groups), and fathers (two groups), resulting in a total of 42 participants. All mothers and fathers had a child less than 2 years of age, access to a personal mobile phone, and were able to read and understand the local language (Tigrigna) and who had provided informed written consent were eligible to participate. Either the mother or the father was included in the FGD but not both. Details of methods and data analysis are described in the formative studies , 18.Codesign is a process that involves all stakeholders throughout the design process . This ishttp://www.frontlinesms.com). This system was used to send the messages using the EthioTelecom (Ethiopian Telecommunication) network, the sole-provider of telecommunications in Ethiopia. This software was installed on a personal computer and was connected to a mobile phone with a local SIM card, which helped to access the local network. The use of the FrontlineSMS was to enable the sending of bulk SMS. FrontlineSMS text messaging had been used in a previous breastfeeding intervention [After development of the SMS text messages, the messages were uploaded into a freely available bulk SMS software, FrontlineSMS . Descriptive statistics were conducted to describe message delivery and satisfaction for fathers and mothers.The content of the SMS breastfeeding education was developed after conducting an explorative qualitative study with fathers and mothers who had a child less than 2 years of age. Sixteen weekly messages for fathers and 16 messages for mothers were developed that were tailored to the antenatal and postnatal periods  of fathers, and 55% of mothers shared the SMS text messages with their partners’ , and mothers-only arm , compared to the control group where only 60% of participants achieved exclusive breastfeeding [One of our formative assessments indicated the increased acceptability of SMS text messages for breastfeeding education if they were from experts . As the tfeeding .The study has significant strengths including that it is one of only a few that involve fathers and mothers. In addition, all the important components of design and implementation were incorporated, including the involvement of the target population in the content development, co-design, pretesting, and implementation. However, there are limitations. A cost–benefit analysis was not undertaken and so costs associated with the SMS intervention were not analysed. In addition, this study was conducted in a state capital city, so that the findings may not be able to be generalized to rural areas.In conclusion, the development of SMS based breastfeeding interventions should involve the target population  in content design and in the co-design process to improve intervention efficacy. In addition, pretesting and incorporating feedback improves the acceptability and readability of the SMS text messages. Involving all those steps improved the acceptability and engagement of participants with the intervention. Co-designing interventions and paying attention to factors that could influence intervention acceptability and suitability ensures interventions are fit-for-purpose and improves their effectiveness in changing behaviours that influence health, in this case breastfeeding.


Patients with anorexia nervosa (AN) often refuse treatment despite their extremely low nutritional status. This study investigated the methods of assessing the mental capacity of patients with anorexia nervosa (AN) who refuse treatment by physicians in Japan, the United Kingdom (UK), and the United States (USA). It also identified the key points of the assessment.A questionnaire survey using a case vignette was conducted among physicians  who treat eating disorders.A total of 23% of physicians in Japan, 32% in the UK, and 35% in the USA reported that they believe patients with AN lack the capacity to make appropriate decisions. Physicians who considered patients with AN to have an impaired mental capacity placed significantly more emphasis on the level of psychopathological values, which are values caused by AN (and can be changed by recovery) that affect the ability to be rational, when assessing the mental capacity of these patients. Conversely, physicians who considered patients with AN to have full mental capacity placed significantly more weight on the ability to express a choice or preference.It may be necessary to add the level of psychopathological values to the assessment of the mental capacity in relation to obesity fears and emotional disturbances of Patients with AN because emotions caused by psychopathological values strongly influence decision-making. By considering the level of psychopathological values, it may be feasible to reflect the actual situation during the assessment of the mental capacity of those who refuse AN treatment, thus making it more likely to overcome ethical dilemmas.The online version contains supplementary material available at 10.1186/s40337-022-00633-7. This study investigated the method of assessing the mental capacity of anorexia nervosa (AN) patients who refuse treatment in Japan, the United Kingdom, and the United States. Approximately one-third of clinicians who assessed patients with AN declared that those patients showed impaired decision-making capacity when refusing treatment. Clinicians who considered patients with AN to have impaired decision-making ability tended to focus on the level of psychopathological values when assessing their mental capacity.The online version contains supplementary material available at 10.1186/s40337-022-00633-7. Anorexia nervosa (AN) patients often refuse treatment despite their extremely low nutritional status, which requires immediate treatment. However, informed consent must be obtained from the patient before performing therapeutic actions. Therefore, treatment refusal by patients with AN causes an ethical dilemma for physicians. For example, if patients refuse treatment when it is necessary, then prioritization of the protection of life by physicians can infringe on the self-determination of these patients. Legal disputes and ethical debates regarding whether coercive treatment should be administered to patients with AN who refuse treatment have occurred .One of the important keys to assessing patients with AN who refuse treatment is determining whether the patient has the mental capacity to make appropriate decisions. Regarding the ethics of coercive treatment in the field of psychiatry, coercive treatment can be justified only when the patient's capacity to provide consent is impaired and severe danger to health or life cannot be prevented by less intrusive means . If patiMental capacity is generally evaluated according to four elements: understanding; appreciation; reasoning; and expression . An asseOften, patients with AN may not demonstrate obvious impairment in these four factors, even when they refuse treatment. However, it is impossible to consider that patients with AN have impaired mental capacity without finding impairment in terms of the four aforementioned factors. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) is one of the gold standards for assessing the mental capacity . A smallFor those with AN, the assessment of mental capacity using the MacCA-T has been noted to focus heavily on cognitive function and focus little on the values of the patients , 9–12. TA case involving a patient with AN who refused treatment was developed, and a questionnaire survey was conducted to assess the mental capacity of that patient  as members of eating disorder-related societies, such as the Academy of Eating Disorders, and those who treated eating disorders. In the UK, a web-based survey was conducted among physicians registered in Doctors.net.uk  who are members of eating disorder-related societies, such as the British Eating Disorder Academy, and who treated eating disorders. The web survey was conducted through a survey company that solicited responses until more than 80 responses were collected, assuming that the maximum response rate in Japan was 40%. In both the USA and the UK, three announcements encouraging participant in the survey were provided over a 6-week period.p < 0.05 was considered statistically significant.A chi-squared test was conducted to determine the significant difference in the proportion of responses among the three countries regarding the presence of mental capacity, reasons for the lack of mental capacity, and respect for self-determination. When significant differences were found among the three countries, a chi-squared test and Bonferroni's correction were conducted. For the items that were important for assessing the judgment ability, Fisher’s direct method was used to examine the differences in the response rates. All analyses were two-tailed, and Fifty-three responses were obtained from physicians in Japan who specialize in treating eating disorders (25% response rate). There were 21 psychosomatic physicians, 25 psychiatrists, and 7 adolescent medicine physicians. Psychosomatic physicians were trained in the field of internal medicine and received additional psychiatric-psychosomatic training. Both psychosomatic physicians and psychiatrists mainly treat eating disorders in Japan. Most physicians had 10 to 19 years of experience, but some had more than 30 years of experience. Most physicians treated between 50 and 99 patients per year, whereas some treated up to 199    Table .Table 3RRespondents who answered that the patient had not lost mental capacity were asked whether they would respect this patient’s self-determination to refuse treatment. In the USA and the UK, 67% and 44% of physicians, respectively, responded that they would respect it, whereas only 18% of physicians in Japan agreed that they would; this was a significantly lower percentage compared to that of physicians in the USA and the UK : ability to process reasonable information; ability to understand medical information given; ability to appreciate medical information as it relates to oneself; ability to express a choice or preference; and consciousness of disease. Physicians who rated patients with AN as lacking mental capacity emphasized the following factors (in order of importance): ability to understand medical information given; ability to weigh competing factors; ability to process reasonable information; level of psychopathological values; and consciousness of disease. Whether physicians rated the level of psychopathological values and ability to express a choice or preference as important resulted in a significant difference between the percentage of physicians who rated the patients as having the ability to make decisions and the percentage of physicians who rated the patients as not having the ability to make decisions Table . The levThis is the first study of how physicians treat and assess the mental capacity of patients with AN in Japan, the USA, and the UK. Patients with AN often refuse treatment, although this may seem irrational from a general perspective. Mental capacity is generally evaluated using four elements, understanding, appreciation, reasoning, and expression , and mosAs a result of asking physicians whether they respect the patient’s decision to refuse treatment, approximately two-thirds of physicians in Japan, half of physicians in the UK, and one-third of physicians in the USA said that they do not. When patients with AN have mental capacity and refuse treatment, these physicians have higher regard for their ethical duty of beneficence to protect the patient's life than for their ethical duty of respect for autonomy . In particular, physicians in Japan showed significantly less respect for self-determination than those in the UK and the USA, which may be attributable to the fact that in Japan, in addition to long-standing paternalism , 17, thePhysicians in Japan were significantly different from their counterparts in the USA and the UK in terms of which items they focus on when assessing the mental capacity of patients with AN. Physicians in Japan focus on short-term memory, ability to express a choice or preference, ability to understand medical information given, ability to appreciate medical information as it relates to oneself, ability to process reasonable information, and ability to weigh competing factors when assessing mental capacity. Of these, ability to express a choice or preference, ability to understand medical information given, ability to appreciate medical information as it relates to oneself, and ability to process reasonable information are components of the four mental capacity factors identified by Applebaum and Grisso . Short-tPhysicians in the UK tended to place significantly more emphasis on short-term memory and ability to weigh competing factors when assessing the mental capacity than those in Japan and the USA. This may be because the Mental Capacity Act in the UK uses the following factors that refer to memory retention and the weighting of information to evaluate the mental capacity: understand the information relevant to the decision; retain that information; and use or weigh that information as part of the process of making decisions .The difference in the emphasis placed on the factors of importance when assessing mental capacity was examined among physicians in the UK and the USA who reported that patients with AN who refuse treatment have mental capacity and those who reported that they do not have mental capacity. The results showed that physicians who thought the AN patient did not have mental capacity placed significantly more importance on level of psychopathological values than physicians who considered that the AN patient did have mental capacity; however, physicians who thought the AN patient had mental capacity placed significantly more importance on the ability to express a choice or preference than physicians who thought that the AN patient did not have mental capacity. No differences were found for other items.Most items used to determine mental capacity are items from the aforementioned mental capacity assessment tool commonly used and items provided by the Mental Capacity Act . No diffThe ethical attitude of physicians who value patient autonomy may lead to patients with AN being considered to have the mental capacity to make decisions whenever possible. As a result, physicians who assess mental capacity may place more weight on whether patients with AN express any preferences or choices.Because patients with AN tend to be considered to have mental capacity when evaluated using the usual method of assessment , 15, wheIt may be necessary to add levels of psychopathological values to the assessment of mental capacity in relation to obesity fears and emotional disturbances of patients with AN. For example, patients with AN often experience severe anxiety when their weight increases, even if that increase is small, and they may refuse life-sustaining tube feeding and intravenous infusion because they contain fat or sugar. Elburg et al.  reportedThis study had some limitations. First, the Japanese survey was mailed to physicians who were members of the Japanese Society for Eating Disorders, and the UK and USA surveys were web-based surveys of physicians who were members of academic societies and registered with medical networks. Although responses were obtained from physicians who treat patients with AN in all three countries, it is undeniable that the difference in survey methods may have affected the results. Second, the small sample size resulted in problematic representativeness. Third, the survey was a multiple-choice questionnaire that may have overlooked the possibility that physicians who treat patients with AN may place importance on mental capacity evaluation items that were not included as response options. Fourth, the use of the vignette for this study did not result in physicians making decisions based on a robust clinical assessment; instead, they made decisions based on an extremely limited understanding of the patient. The study results and differences observed may reflect idiosyncratic responses of the physicians to the case presented and not usual clinical practices, thus limiting the generalizability. Fifth, the vignette used in this study was simple and did not contain detailed clinical information. Therefore, each physician could have had different impressions of the case presented in the questionnaire, which may have influenced their answers. Sixth, the generalizability of these results is limited because the Japanese survey did not have a high response rate, and the response rates for the UK and USA surveys are unknown. Finally, because this was a vignette-based study, there were limitations to the interpretation of the results. For example, it is not possible to distinguish whether physicians chose coercive treatment as a result of their assessment of the lack of mental capacity when considering the psychopathological values of the patients, or whether their assessment of the lack of mental capacity was the result of considering psychopathological values in response to paternalistic acts. Qualitative research performed through interviews with physicians would be beneficial to address these issues.Qualitative studies that perform interviews with physicians are needed to determine how physicians assess the mental capacity of patients with AN and how they make decisions when patients with AN refuse treatment. Additionally, further studies using several vignettes and different patient characteristics and more clinical details would provide a richer data set for analyses. Furthermore, it may be necessary to conduct a survey focused on which psychopathological values are important and why they are considered important.The results of mental capacity assessments of patients with AN performed by experienced physicians are inconsistent. In addition to the conventionally used items, the level of psychopathological values was found to be a key factor in the evaluation of mental capacity. Because the evaluation of mental capacity is an objective of the psychiatric evaluation, variations among the conclusions reached by physicians are undesirable. Patients with AN considered to have impaired mental capacity by psychiatrists have poorer treatment responsiveness . The assAdditional file 1. Vignette Case and Question about factors of mental capacity.


Despite the high number of cases initially reported in Europe (the first region outside Africa to report mpox cases), the outbreak was quickly contained using effective contact tracing, treatment, and targeted preventive measures that kept serious outcomes to a minimum. The same did not happen in the Americas. Out of the 74 mpox deaths reported worldwide, 54 happened in the Americas, and the region has the highest disease burden. The Americas house six of the ten most affected countries globally , from which more than 57,000 confirmed cases were reported as of January, 2023. In this special issue of The Lancet Regional Health – Americas, we present a collection of papers that explore the clinical, psychological, political, and humanitarian aspects of the current emergency in the region, with a special focus on Brazil and Mexico, and call for unified efforts that aim at a global elimination of mpox, leaving no region behind.Since May 2022, mpox disease (formerly monkeypox) has been reported across all six WHO regions, accounting for emerging sexually transmissible infection (STI). Although surveillance data remain incomplete, most confirmed cases outside Africa have been among men who have sex with men (MSM) and the available information suggests an important intersection between mpox, HIV, and other STIs. The global pattern was reproduced in two case series from Brazil and Mexico, the first detailed reports from Latin American countries. In Brazil, Silva and colleagues found that 89·7% of confirmed cases in Rio de Janeiro were reported by MSM, 53·2% were HIV-positive, 21·2% had syphilis, and 33·0% had other STIs. In a Mexican cohort, Núñez and colleagues found that 97·6% of confirmed cases were reported by MSM, and 52·9% were HIV-positive. The overlap between mpox and other STIs is a silver lining as it can provide impetus for the implementation and strengthening of combined, targeted actions to increase diagnosis and treatment for several co-occurring STIs in high-risk groups. Sadly, the current outbreak has been linked to high levels of stigmatisation of the disease, discouraging suspected cases from seeking diagnosis and treatment, hindering public efforts to eliminate transmission, and fomenting misinformation and discrimination. Similar issues were faced in the early 1980s during the HIV epidemic, and it is unacceptable for us to repeat the same mistakes.The epidemiology of the ongoing outbreak suggests most transmissions happened through sexual contact, establishing mpox as an Nsoesie and Vu cite the case of Georgia, USA, where in August, 2022, Black residents made up 79% of the positive mpox cases but only 45% of the recipients of the mpox vaccine Jynneos. In Brazil, the lack of leadership commitment to the emergency may have favoured the explosion of cases. Homophobic declarations by then-President Bolsonaro during the worst moments of the outbreak cemented the stigmatisation of the disease, and the country now has a shortage of the only nationally approved treatment (Tecovirimat) and delayed arrival of vaccine doses. In this special issue, Scheffer and colleagues and Gadelha and colleagues discuss the case of the mpox response in Brazil and propose actions that could help the region overcome the health emergency. Reduced access to emergency-approved antivirals and the smallpox vaccine (MVA-BN) is a recurrent issue for all Latin American and Caribbean (LAC) countries that rely on externally provided drugs and vaccines and undermine public campaigns to contain the outbreak and eliminate transmission. The PAHO Revolving Fund has secured some of the third generation vaccines through Bavarian Nordic to be made available for LAC countries and called for more collaborative action to stop the outbreak in the region.Efforts to contain and eliminate mpox in the Americas are underway, but with varying degrees of success. Some decline in reported cases among MSM in the USA appears to be linked to effective communication and engagement with key communities, paired with vaccination of at-risk populations and case-contacts. However, similar to the early days of the COVID-19 pandemic, the lack of disaggregated data may hide the disproportionate impact and unequal access for certain groups. end of PHEIC for mpox in 2023. This is based on the current global trend that weekly cases have declined more than 90% from the peak in August, 2022; however, the global picture is not an homogeneous one. If we look at the Americas alone, weekly cases continue to increase in several countries, and the region is the only one still considered at high risk under WHO assessments. Although the global trend indicates that the situation seems to be moving towards resolution, eliminating mpox must be an international effort. Achieving zero new cases in Europe does not solve the problem if American and African countries remain a reservoir of viruses. Neglecting the endemic circulation of mpox in Africa for the past two decades is probably the main reason we are now battling a multicountry health threat. Looking at the emergency through each region's lenses is important for an equitable and population-centred response. With this special issue, we call for a unified response that aims for global mpox elimination to prevent history from repeating itself. No one is safe until everyone is.The multicountry mpox outbreak was declared a Public Health Emergency of International Concern (PHEIC) on July 23, 2022, and the WHO director-general, Dr Tedros Adhanom Ghebreyesus, hopes to be able to declare the


In line with the commitment of the Malaysian government and Ministry of Health to prevent the brain drain of specialists from public hospitals, they have been permitted to perform dual practice within the public hospital setting (DPH) since 2007. DPH allowed them to hold jobs in both public and private practices within the same public hospitals that they are affiliated to, permitting these specialists to treat public and private patients. Nevertheless, the information regarding DPH in Southeast Asia region is still limited. This narrative review provides insight into the implementation of DPH in Malaysia. It highlights that DPH has been well-governed and regulated by the MOH while serving as a means to retain specialists in the public healthcare system by providing them with opportunities to obtain additional income. Such a policy has also reduced the financial burden of the government in subsidizing healthcare. However, as in other countries with similar policies, multiple challenges have arisen from the implementation of DPH in Malaysia despite its positive achievements and potentials. This paper concludes that proactive governance, monitoring, and regulation are key to ensure the success of DPH. Globally, the retention of specialists in the public healthcare sector remains a major problem. The exodus of specialists from the government sector to the private sector is considered perilous to the public health sector since their skills and expertise are highly demanded to perform complex procedures to ensure the best treatment outcomes for patients . They plAllowing specialists to take up dual practice is one of the common policy interventions to overcome attrition in low- and high-income countries . Dual prIt is crucial to distinguish the different types of dual practice to appreciate different arrangements implemented in numerous settings. In general, dual practice can be classified based on the locations of healthcare professionals attending to private patients as follows: (i) ‘outside’: in a separate private setting; (ii) ‘beside’: in a private ward or clinic physically connected with a public facility but run as a private business; (iii) ‘within’: in the same public facility but outside public service operating hours at extra fees, or (iv) ‘integrated’: in the same public facility with informal payment and no time restrictions ,12. In tFull-time public servants who are solely dedicated to the public sector are no longer the norm. Dual practice is not limited to high-income countries and has also been widely adopted in low- and middle-income countries (LMIC) ,10,11,13Multiple reasons for specialists taking up dual practice have been identified. According to Ferrinho et al. , the extBoth positive and negative consequences of DPH have been reported in the existing literature ,6,14. OnIn general, there is no single best method in the management of dual practice, with different strategies being adopted by governments . In someInterestingly, the characteristic of DPH is viewed as one of the better option to facilitate the regulation of dual practice as it could be more easily controlled and governed ,6,13,27.In Malaysia, public specialists are allowed to perform both the ‘outside’  and ‘within’ types of dual practice [Full Paying Patient (FPP) Service]. Under the FPP, patients are treated by their specialists of choice in first-class wards and charged at full rate without receiving any government subsidies for the treatment . AlthougMalaysia is an upper-middle-income country with a two-tier health system. The public healthcare sector is funded predominantly through general taxation in co-existence with a market-driven private health sector that consists of mostly physician-owned clinics and hospitals . All citThe 67th World Health Assembly adopted the Global Strategy on Human Resources for Health: Workforce 2030 with the aim to ensure universal availability, accessibility, acceptability, coverage, and quality of the health workforce through adequate investment to strengthen health systems and implementation of effective policies . To pursApproximately 60% of the specialists in Malaysia serve in public hospitals . They arThe Malaysian government has introduced multiple strategies to retain specialists in the public health sector, including offering financial incentives. Financial incentives play an important role in influencing individuals’ choice of workplace and have always been applied to address workforce shortage in healthcare worldwide ,39. WhilIn many LMICs, seeking additional incomes by taking on fee-for-service private patients is common among healthcare workers ,17. ResoAccording to Rahim and Mwanri , there iPerkhidmatan Pesakit Bayar Penuh di Malaysia’ . Literature searches were conducted using electronic databases (PubMed and Google Scholar) to identify peer-reviewed publications, including empirical evaluation, policy analysis, and reviews published from January 2016 to October 2021. Additional articles were also identified from bibliographies and grey literature. Websites of the MOH and research institutes were also explored. Due to a limited number of peer-reviewed articles available, this review was based mainly on grey literature, including official reports, press statements and guidelines. The documents meant for internal circulation in the MOH were not included in this review. Overall, the analysis in this review led to an overview of the operational policy, the scale of implementation, regulations, uptake, outcomes, and major challenges of the FPP Service in Malaysia.This was a narrative review ,49 focusThe former Prime Minister of Malaysia pointed out that “The Government is not able to provide high remunerations for medical specialists. As such, the Government has agreed to set up private commercial wings in Government hospitals, to enable serving doctors to enjoy better remunerations and thereby, continue to serve with the Government. Through these measures, the Government also hopes to attract specialists who have left the service to return and serve in Government hospitals. In addition, this will enable those seeking better medical treatment to obtain such treatment at reasonable charges in Government hospitals. It will also enable our government hospitals to be promoted abroad, in line with the objective to encourage health tourism.” . Such anThe FPP Service was launched in 2007 . It was The implementation of FPP Service started at only two tertiary hospitals, namely the Putrajaya Hospital and the Selayang Hospital, which are also known as the pioneer FPP hospitals ,34. The The Guidelines for Implementation Fee Order  (Full Paying Patient) 2007 (Revision 2015) was developed to guide the FPP Service at the operational level. The guidelines cover the basic service operation from registration to payment, qualification of specialists to participate in the service, code of ethics, patient management and monitoring mechanism . The scoRegistration is made mandatory for medical specialists who would like to take up the FPP Service. The registration criteria include being a Malaysian citizen and have completed three years of specialist gazettement or as a subspecialty specialist . All FPPThe types and rate of fees that can be charged on patients under the FPP Service are listed under the Fees  (Full Paying Patient Service) Order 2007 (FPP Fee Order) ,50,52. TThe FPP revenue collected by the hospital is divided into portions payable to the FPP specialists and the government ,54,55 T. The govThe FPP Service is regulated for the number of specialist engagements with patients, amount of incomes, time spent, and the number of patients treated ,32. In gA qualitative study by Amir et al.  revealedA steady growth in the number of specialists registered for the FPP service has been observed ,50,60. AThere was a significant rise in FPP patients’ encounters from 2015 to 2019 following expansion of the FPP Service to another eight hospitals  60]. In. In60]. In a quantitative study conducted by Liyana et al. , FPP patFun et al.  reportedThe FPP Service has generated a sizeable revenue and created an alternative source of income for the government since it was first implemented in 2007 . The amoFollowing the public announcement for FPP Service implementation, there were major concerns from the public that this scheme would divert the attention of specialists from their public duty and compromise the quality of services received by public patients . The MOHThe challenges faced by hospital authorities were briefly reported by Amir et al. . In a stSeveral public specialists declined the opportunity to join FPP Service due to existing workloads, work exhaustion, or family commitment. Some felt comfortable with their current income or already had established work outside of the public hospital, while others were concerned with ethical issues and felt that the FPP guideline was unclear and that there was lack of administrative support from the hospital administration . The samApart from that, the report by the National Audit Department  and a feLastly, FPP only remunerates the specialists but not nurses, medical assistants, radiographers, and other support staffs. They are only allowed to claim standard overtime payment for their out-of-office hour work . This haTo the best of our knowledge, this was the first review on the implementation of DPH in Malaysia, which covered the policy, practices and evaluation. It started with the information regarding the history of DPH in the country, followed by the extent of the implementation, governance, and regulation. We also discussed motivations for the uptake, achievement, and challenges of DPH based on the limited literature identified.It is noted that the FPP service is only available in 10 out of 146 public hospitals in Malaysia to date. The implementation of FPP Service reveals that the distinctive realms between public and private healthcare are progressively blurry in this country. FPP Service is a reflection that the Malaysian mixed public-private healthcare system has evolved to improve individual wellbeing by offering a greater choice of provider and care options, as well as faster access for elective treatments .Conceptually, DPH is likely to improve the employer attractiveness of the public sector . TherefoA portion of the revenue generated from DPH could be reinvested on public hospitals to improve the healthcare quality and alleviate the budgetary pressure . EmpiricMost of the challenges of the FPP Service are associated with the sharing of infrastructure and workforce. Ideally, the FPP service must be delivered effectively without compromising the level of responsiveness to patients seeking subsidized healthcare ,14. As aDPH is complicated and reported to add additional burden to hospital administration , similarThis review also highlighted the achievements of the FPP Service in ten public hospitals and suggested DPH expandability to other hospitals in Malaysia. Nevertheless, the concerns about the widening of health inequalities caused by DPH ,22,73 shUndeniably, dual practice is a complex phenomenon with ambiguous effects on the healthcare sector’s performance . In geneDual practice policy and regulatory response continues to be a topic that generates wide interest among researchers ,13,26,46This article provided an overview of the FPP service as the DPH in the Malaysian public healthcare system using a narrative review approach, also known as “unsystematic narrative review” of relevant sources of data as described in previous publications . This reAs shown by our analysis in Malaysia, the organization and regulation of FPP service is a complex process. Conceptually, DPH such as FPP renders certain benefits but at the same time comes with multiple conundrums. In Malaysia, the FPP Service in ten public hospitals has been well-governed and regulated by the MOH. Though currently there are limited number of FPP hospitals, evidence thus far indicated that it has some potential to retain specialists in public healthcare. It offers additional incomes to specialists and generates extra revenue for government. DPH offers a unique arrangement for public specialists as it enables them to attend to patients in public hospitals, including those who opt out of subsidized healthcare. It is crucial not to overlook the possibility of unequal treatment of public patients with the expansion of DPH in Malaysia so that the vision of universal health coverage will not be derailed. Proactive governance and robust systems of monitoring and regulation are key to ensure the FPP Service in the Malaysia public healthcare sector is sustainable and support patient choice, workforce attraction and retention. Our review also revealed that despite the increasing scale of DPH in Malaysia, there remains a big gap in the relevant literature, especially in the local context. Scientific study and further analysis from different perspectives, for example the impact of this policy on patients’ health and financial implications are warranted to better understand the impact of this type of dual practice in Malaysian public hospitals.


Several factors that follow the development of society affect physical inactivity, which primarily includes the development of technology and digitalization and the increasing choice of unhealthy lifestyle habits. However, certain shifts in the fitness industry have been noted in the last decade. The development of wearable technologies and artificial intelligence is one of the leading fitness trends and undoubtedly represents the future of the fitness industry. On the other hand, the significant influence of social media and networks affects the development and attitudes of people related to physical activity. Therefore, this review paper evaluates the advantages and disadvantages of wearable technologies and artificial intelligence, the positive and negative effects of social networks, and points out the problems accompanying these new fitness trends. The development of fitness trends follows humanity's needs, and one of the biggest challenges is incorporating these novelties in a mission to improve physical activity levels worldwide. Physical activity (PA) is a generator for the improvement of quality of life. PA provides a broad spectrum of health benefits, including the decreased risk of early death, coronary heart disease, stroke, hypertension, type 2 diabetes, cancers, weight gain, risk of dangerous falls, anxiety, and cognitive decline , 2. MoreHowever, people do not engage in this minimum amount of PA recommended. At this moment, we are facing the pandemic of physical inactivity (PI) and obesity . Around Several factors influence these results of creating inactive, sedentary community, including the development of technology, digitalization, decrees in motivation, decrease of active commuting, higher rate of depression and anxiety, to name a few. In addition, the consequence of growing levels of PI might be caused by system-level factors  influencing PA behavior. It must be recognized that our obesogenic and PI-promoting environments partly cause inactivity. One of the leading challenges of society is how to motivate people and create adherence and discipline to exercise more and change their lifestyle behaviors. Different factors can influence adherence and motivation to exercise. Interestingly increasing influence of Social networks (media) can perhaps represent the silver bullet in closing the gap between PI and PA. Recently, Lakićević et al.  publisheSince 2006, the American College of Sports Medicine (ACSM) has administered an annual worldwide survey of fitness trends . This isExcluding wearable technologies, performing new and challenging workouts could increase your enjoyment and interest while enhancing new abilities. Moreover, the need for novelty may represent a need for something that stands out of the routine . ExercisFollowing modern trends, there are some indications that fitness and physical exercise are changing. There is a certain shift in fitness trends. Based on ACSM leading fitness trend list , wearablThe use of wearable technologies has been widely tested in the last 10 years, while the results of these studies have demonstrated mixed effectiveness. Few studies evaluated the effectiveness of wearable devices' on weight loss outcomes and the practice of PA. In the study by Fazzino et al.,  a signifOne of the concerns of wearable technologies and smartwatches is their accuracy in measuring PA. This leaves room for improvement, but on the other hand, the current accuracy of the device is at a high level considering the general population's needs. The precision in step counting and self-observed steps using wearable technologies differed slightly, while smartwatches were even more accurate . The acArtificial intelligence (AI) and associated computational techniques have recently become the new frontier in developing the landscape of fitness, health care, and promotion of PA . For exaSocial media and social networking platform usage have exponentially grown in the last 10 years. Social media can be defined as “websites and computer programs that allow people to communicate and share information on the internet using a computer or mobile phone“ . In addiA youtuber can be defined as someone who makes and appears in videos on the website, while an influencer can be defined as someone who affects or changes other people's behavior . FitnessEarlier media models involved passive consumers theory, where consumers simply absorb media content . HoweverPrior research reports that higher exposure and greater attention to health in the media could lead to broader knowledge concerning a healthy lifestyle and healthier behavior , 48. ConContent designed to promote PA, healthy lifestyle habits, and a positive attitude toward fitness are likely to impact the viewer/consumer of online content positively. However, increased attention and careful consideration are advisable while using social networks and youtube channels to inspire the transition toward healthy behaviors. It is a mistake to assume that watching fitness channels can increase PA. Moreover, it could even reduce the intentions of the viewers to exercise .PI was defined as a global pandemic in the 2012 Lancet series on PA and health. PI has hazardous health and economic consequences. One of the most important challenges to modern societies is increasing awareness of PA's importance and a healthy lifestyle. However, there is no silver bullet for PA promotion. Although many efforts have been made to promote PA, the global level of PI is still high. Therefore, it is essential to establish some goals that will follow the needs and development of modern society. On the one hand, the growing influence of influencers and social networks on the promotion of PA is a good strategy, while on the other hand, a cause for concern. The question is how to limit the influence of influencers due to the possible harmful effects of the content of their channel and the accuracy of the information itself. On the other hand, leading healthcare organizations should take the initiative and start educating fitness influencers who impact a considerable number of people, thus providing Internet users with more accurate information. In the end, the development of AI does indeed represent the future of fitness, and we will be able to assess the real benefits and consequences of these technologies in the assessments that lie ahead.With this short review additional questions arise and need to be answered:(1) How can wearable technologies be popularized and implemented in PA interventions worldwide?(2) How can social networks implement PA advertising/ promotion strategies at scale?(3) How can the next wave of technological improvements such as AI be integrated into large-scale PA promotional programs.Enhancing global health by increasing PA will demand both advancements in knowledge and a more significant commitment of resources.VŠ, NT, and PD: conceptualization and writing–original draft preparation. MR and NT: methodology. IM, SP, MR, and NT: writing–review and editing. PD: visualization and supervision. VŠ and PD: funding acquisition. All authors have read and agreed to the published version of the manuscript.This work was supported by the Provincial Secretariat for Higher Education and Scientific Research (142-451-2597/2021-01/2).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


A growing body of research demonstrates that economic conditions and racial and ethnic disparities result in excessive overuse of emergency departments (EDs) by a small group of socioeconomically marginalized residents. Knowledge and understanding of these issues on the part of the healthcare team can promote equality by providing structurally competent care. This study aims to identify the major social and structural factors related to patterns of ED visits by Arab and Jewish patients in Israel, where access to health services is covered by universal national health insurance.A cross-sectional study was conducted using questionnaires of ED patients in a tertiary care medical center in Jerusalem. The hospital is the largest of the three EDs in Jerusalem with over 90,000 adult patient visits a year. The sample was stratified by ethnicity, including 257 Jewish patients and 170 Arab patients. The outcome variable was repeat visits for the same reason to the ED within 30 days.There were differences between Jewish and Arab patients’ social and structural characteristics, including health status, socioeconomic status, feeling of safety, and social support. There were also significant differences in some of the characteristics of health service utilization patterns, including ED repeat visits, language barriers when seeking healthcare in the community, and seeking information about medical rights. The variables associated with repeat visits were different between the two groups: among the Arab patients, repeat visits to the ED were associated with concerns about personal safety, whereas among the Jewish patients, they were associated with poverty.The study illustrates the gaps that exist between the Arab and Jewish population in Israel. The findings demonstrated significant differences between populations in both health status and access to health services. In addition, an association was found in each ethnic group between different structural factors and repeat ED requests. This study supports previous theories and findings of the relationship between structural and social factors and patterns of health services utilization.The online version contains supplementary material available at 10.1186/s12939-022-01698-1. The Emergency Department (ED) is an important interface between the hospital and the community. As the ED serves all residents with medical needs, the patient population reflects the religious, linguistic, cultural, and economic diversity of the neighborhood and city . Social Gaps and disparities in health exist in Israel similar to anywhere in the world. Braveman defined health disparity  as “a particular type of difference in health or in the most important influences on health that could potentially be shaped by policies. It is a difference in which disadvantaged social groups  systematically experience worse health or greater health risks than more advantaged groups” . In IsraInequalities are reflected in social factors . These factors are affected by determinants that stem to a large extent, from structures such as economic systems, health policies, laws, and regulations. Examples of these determinants include the availability of resources to meet daily needs; discrimination; exposure to crime; public safety; and residential segregation .structural competency  and Jews [n = 10]), the questionnaire was revised. The interview, using the final structured questionnaire, was conducted in Hebrew or Arabic by an interviewer fluent in one of the languages. The questionnaire was written in Hebrew and translated into Arabic by a professional translator. The translation was then compared to the original and edited by native Arabic speakers.Following a pilot with 12 patients  for the same medical reason, within 30 days. The independent variables included: age, gender, marital status, language, ethnicity, health status, sense of safety, previous year primary care physician (PCP) visits, chronic diseases, chronic medications, chronic pain, education, employment, social support, use of welfare services, exposure to physical or emotional violence, illegal drug use, and alcohol use. Additional variables referred to characteristics of recurrent visits and the usage of health services in the community.Sample size was calculated based on a similar study from the United States  using Wip < 0.05. Initially, descriptive statistics of the sociodemographic and health characteristics of the study participants were performed, followed by a univariate analysis of health services utilization patterns for the entire study population, and then stratified analysis for each of the research groups (Arabs and Jews). T-test, chi-squared, and Mann–Whitney tests were used according to the type of the variable. For the construction of the multivariable models, correlations between independent variables that were significantly associated with the outcome variable were examined. Multivariate models for each of the research groups were calculated using logistic regression. A model with the best fit was selected in reference to the significance of the model constant, Nagelkerke R-squared, likelihood ratio test, Hosmer–Lemeshow, and ROC analysis.Data processing and analysis were done using IBM SPSS Statistics for Windows, Version 25.0 . Statistical significance was determined as Demographics and health characteristics are presented in Table There were no significant differences found between Jews and Arabs regarding age and gender. Significant differences were found regarding marital status and the number of children: more Arab patients were married and the median number of children was higher, as compared to Jewish patients.In terms of health status, there were significant differences between Jews and Arabs. Jewish patients reported better health statuses compared to Arab patients. They had fewer chronic illnesses, required fewer medications on a regular basis, and reported less chronic pain.In terms of education and socioeconomic status, there were significant differences between the study groups, with lower levels on both variables in the Arab group compared to those of the Jewish group. No significant difference was found in employment rates. The percentage of Arab patients who did not speak Hebrew  was significantly higher than the percentage of Jewish patients who did not speak Hebrew. Most of the Arab participants in this study held the status of permanent resident in Israel, distinct from the status of citizen.Significant differences were found in terms of feeling safe and having social support. A greater proportion of Arab than Jewish patients used welfare services, and a greater proportion likewise reported having experienced physical and mental violence, expressed concern about their safety, and felt they had fewer social support resources. Regarding illegal drug use, a significant difference was found, whereby a greater proportion of Jewish patients reported having used drugs sometime in the past or present. Regarding alcohol use, not enough information was reported.There were significant differences in some of the characteristics of health service utilization. A greater proportion of Arabs than Jews reported encountering language barriers when seeking healthcare in the community. A higher percentage of Arab participants did not seek information about medical rights, compared to the Jewish patients, who reported seeking information but encountered difficulties. A small percentage of Arab participants reported that their family physicians were not fluent in Hebrew, meaning they were unable to read hospital discharge letters written in Hebrew.No significant differences were found between the groups in the percentage of people who gave up community healthcare services because of financial constraints . There was also no significant difference between the groups for those who did not have a designated family physician in the community (7% of Arabs and 12% of Jews do not have a designated family physician).The characteristics of ED utilization patterns in the two study groups are shown in Table The characteristics of the current visit to the ED were similar between the two groups in terms of how they arrived at the ED and the time lapse between the emergency and the arrival. Most patients arrived independently (not by an ambulance); there were no reports of delays at military checkpoints, and in both groups, only a small minority reported that it took them more than one hour to arrive. Also, there was no difference as to who referred the patient to the ED. Most respondents came to the ED after consulting with a professional . However, there was a significant difference between the groups regarding prior medical consultation. A higher percentage of Arab patients than Jewish patients had visited another medical center (such as an HMO clinic or a community urgent care clinic) before arriving at the ED. There was no difference between the groups’ reports regarding experiencing discrimination in the ED. There was a significant difference between the groups in terms of their patient experience in the ED, with a higher median satisfaction found in the Jewish group.In terms of the frequency of ED visits over the last year, there was no difference between Jewish and Arab patients. However, when comparing repeat visits over the previous month, there was a significant difference: a higher rate of Arab patients than Jewish patients returned to the medical center over the previous month for the same reason (16.9% vs. 9.3%).Given the multiple differences found between the Jewish and Arab patients regarding the characteristics of the ED visits, we conducted a separate analysis for each group, to determine the relationships between the patient characteristics and the dependent variable: repeat ED visits within one month for the same reason. The findings are shown in Table The results revealed similar trends in the two groups in terms of the following patient characteristics: employment, health status, concern for personal safety, frequency of visits to the PCP, and foregoing community healthcare services due to financial constraints.In both groups, unemployed participants were more likely to visit the ED more than once in the last month. The worse the self-reported health status was, the more likely the patients were to return to the ED. However, in the Arab group, this relationship was not statistically significant. The trend was also similar among chronic medication users, who were more likely to return to the ED than were their counterparts. Mostly among Arab patients, concern for personal safety was positively associated with repeat visits. In the Jewish group, the trend was similar, but the association was not statistically significant.Frequent PCP visits (more than 10 times a year) in both groups were related to repeat visits to the ED. Deferring healthcare services because of financial constraints was also associated with a high rate of repeat ED visits in both groups, but the association was not significant in either.Regarding other variables, we found different trends in the two groups. The use of welfare services was related to repeat visits only in the Arab group. In the Jewish group, a lower socioeconomic level was significantly related to repeat visits to the ED. In the Arab group, by contrast, the direction of the association was not consistent.No other variable was associated with repeat ED visits. This includes the variables of age, gender, and marital status.r > 0.7).We chose to include in the multivariate models the variables that in the univariate analysis were found to be significantly associated with the dependent variable. Before introducing the variables in the multivariable model, we examined collinearity to verify that there were no strong associations between the variables  with health status and frequent visits to a family physician. Among the Arab patients, this pattern was associated also with concerns about personal safety, whereas among the Jewish patients, it was associated with poverty.The study found significant differences in sociodemographic characteristics of the Jewish and Arab ED visitors, including differences in their economic status, education levels, and employment rates. Also, differences were related to the degree of knowledge about national welfare services, concerns for personal safety, and the availability of social support. These data reflect the existing gaps between Jews and Arabs in Israel, in general, and in Jerusalem in particular .Consistent with other studies , 23, we Considering the relationship demonstrated in previous studies between structural vulnerability and ED repeat visits , 17, we There was a difference between Jews and Arabs in terms of repeat visits, with significantly more recurring visits among the Arab patient group (16.9% vs. 9.3%). In the hospital where the study was conducted, the rate of general repeat visits as of 2017 was 14.1% , indicatAmong the Jewish patient group, when controlling for other variables, repeat ED visits were associated with perceived poor health, poverty, and frequent visits to a family physician. These findings are consistent with findings from previous studies that examined factors associated with frequent ED inquiries , 33. As Poor economic status and lack of employment have been associated in previous studies with repeat ED visits of various populations –39. The In Israel, there is a national health insurance law that provides medical insurance to all Israeli residents, including the Arab residents of East Jerusalem . It seems that despite the existence of insurance, the financial situation still influences repeat ED visits. The claim that lack of health insurance influences health status is supported by several studies , but notElalouf Commission) stated the following: “The government and its institutions must recognize social (poverty) determinants of health and declare reduction of health inequality as a strategic goal.” The commission’s recommendations included, among other things, opening information centers to enable healthcare users to exercise their rights as well as providing discounts on medications for treating chronic conditions of patients who live in poverty. Another recommendation was to provide healthcare workers with comprehensive information on the association between poverty and health  an unavoidable necessity, which provides those affiliated with the various HMOs reasonable access to services.” . That isChernichovsky et al., 2017  discusseAmong the Arab participants in the current study, the only variable associated with repeat visits, when controlling for other variables, was a concern for personal safety. Using this measure revealed a significant difference between the two groups, with the Arab participants expressing greater concern about their safety than did their Jewish counterparts.The relationship between referral patterns and concern for personal safety has been examined following the discussion in the US regarding the misuse of healthcare services and its association with lack of safety reported by vulnerable groups , 44. An The findings of this study help to bridge the gap of knowledge regarding factors associated with repeated ED visits among Arab and Jewish patients in Jerusalem. The study contributes to the understanding of the association between social and structural factors and the use of health services and strengthen the knowledge about structural inequalities and structural vulnerability of minority populations.Buchbinder linked repeat ED visits with low socioeconomic status, explaining that staff structural competency plays an important role in preventing repeat ED visits associated with poverty-related reasons . When thAlongside the advantages of the study which seeks to examine the structural determinants in the unique context of emergency medicine in Jerusalem, there are some limitations. First, the data for this study were gathered using a structured questionnaire, parts of which had not been used previously and therefore had not been validated before. The questionnaire was constructed based on previous qualitative exploratory research. Following a pilot survey of several ED visitors—Jews and Arabs—the questionnaire was examined by experts and a reassessment of the research tool was made. However, this is the first study in which this questionnaire was used.In the data analysis, we included both study populations, Arabs and Jews, as separate groups. It is important to note that each one of the groups consists of diverse subgroups with unique characteristics. The analysis presented in the study did not take those into account. For example, utilization patterns among the ultraorthodox may differ from the rest of the Jewish population. Similarly, there may be differences between Christian and Muslim Arabs. These differences between the subgroups may affect the associations.Since the study was conducted in only one hospital in Jerusalem, its findings may represent only the caregivers and patients of this hospital, and might not be valid for other hospitals serving different populations. However, as discussed above, most of the findings that emerged in the present study were consistent with those in the established literature.In this study, a convenience sample was used. However, there was an attempt to sample participants in all shifts to reduce selection bias. Data were collected from patients who were already in the hospital’s ED. Hence, information about the chain of events that preceded the participants’ arrival at the ED could not be sufficiently examined. This study did not find any differences in means of access to the ED; however, people who typically encounter barriers to emergency medical services might not have had access to this ED and were not present at the time of the study, so no information could be obtained. This absence may pertain to people without medical insurance or those who live beyond the military checkpoints. In addition, the study did not examine the outcomes of repeat visits for the patients.This study found associations between social and structural factors, and the ED referral pattern. The pattern of repeated visits to the ED for the same reason within a month was associated in both ethnic groups with health status and frequent visits to a family physician. Among the Arab patients, repeated visits to the ED were associated also with concerns about personal safety, whereas among the Jewish patients, it was associated with poverty. In addition, many differences between Jewish and Arab patients were found in terms of both sociodemographic and socioeconomic levels, as well as in the pattern of ED use. These findings illustrate the existing gaps and the vulnerability of disadvantaged populations, which affects their use of healthcare services.Knowledge and understanding of these issues on the part of the healthcare team, in tandem with solutions formulated at the institutional and political levels, can promote equity by providing structurally competent care. Promoting the recognition of structural forces is the first step in developing better understanding, discourse, and practice in the clinical setting –51. ThisKey recommendations drawn from the study include the need to formulate a policy that will ensure that disadvantaged populations have better access to medical specialists and their services in the community; the need to strengthen these populations’ knowledge of, access to, and understanding of their medical rights; and the need to use the translation services provided by the Ministry of Health and the hospitals after adapting them to the particular demands of the ED workflow. In future studies, it would be interesting to examine these issues and conduct comparisons with other minority groups, such as the ultraorthodox Jewish community, elderly, or people with disabilities, who were not addressed in this study.Additional file 1. Questionnaire items.


Artificial intelligence (AI) based on the perspective of data elements is widely used in the healthcare informatics domain. Large amounts of clinical data from electronic medical records (EMRs), electronic health records (EHRs), and electroencephalography records (EEGs) have been generated and collected at an unprecedented speed and scale. For instance, the new generation of wearable technologies enables easy-collecting peoples’ daily health data such as blood pressure, blood glucose, and physiological data, as well as the application of EHRs documenting large amounts of patient data. The cost of acquiring and processing health big data is expected to reduce dramatically with the help of AI technologies and open-source big data platforms such as Hadoop and Spark. The application of AI technologies in health big data presents new opportunities to discover the relationship among living habits, sports, inheritances, diseases, symptoms, and drugs. Meanwhile, with the development of fast-growing AI technologies, many promising methodologies are proposed in the healthcare field recently. In this paper, we review and discuss the application of machine learning (ML) methods in health big data in two major aspects: (1) Special features of health big data including multimodal, incompletion, time validation, redundancy, and privacy. (2) ML methodologies in the healthcare field including classification, regression, clustering, and association. Furthermore, we review the recent progress and breakthroughs of automatic diagnosis in health big data and summarize the challenges, gaps, and opportunities to improve and advance automatic diagnosis in the health big data field. Nowadays, AI has been widely researched and achieves great success in recent years, and the heart of AI technologies is machine learning (ML) algorithms  Volume, Velocity, Variety, Veracity, and Value, health big data have five additional special features shown in  as follo(1) Multimodal: healthcare data consist of text data, image data, and numerical data.(2) Incompletion: There is a gap between medical data collection and treatment, which cause disease information reflection not enough. At the same time, recording data manually would have deviation, incompletion, and expression uncertainty due to subjective cognition.(3) Time validation: There is progress between the patient’s treatment and the disease outbreak. For example, electrocardiogram (ECG) and electroencephalogram (EEG) are time signals which have strong time-validated properties.4) Redundancy: There are many same records stored in the healthcare data system. Take EHRs for example, physicians who serve in community hospitals often input multiple records due to unfamiliar computer operations, especially in China.5) Privacy: It is inevitably related to the patient’s private information when researchers process healthcare data. Disclosure of patients’ privacy information will hurt patients’ lives.The rest of this paper is organized as follows. Section II introduces big data technologies like Hadoop, Spark, and Storm. The artificial intelligence technologies in health big data are described in section III. Section IV summarizes this paper.In the big data era, the traditional data management framework which is based on a relational database management system (RDBMS) is challenged by the increasing data deluge. The old framework is unable to deal with the growing amount of unstructured data. Therefore, new technologies were developed to serve the need for big data management, in the aspects of file systems and programming models. These technologies aim at providing scalability as well as fault tolerance, to handle the huge volume and heterogeneity of big data . Big datAlthough Moore’s law promised that the storage capacity of computer chips doubles roughly every 18 months or so, current magnetic storage technology relies on a million atoms per bit, and the quantity of data grows much faster . It is iAs a pioneer in the attempts of providing users with high-performance services with a distributed file system, Google File System (GFS) achieved great success and its concepts were inherited by a lot of its successors. It features work division between control and storage servers, and replication of the same data, to provide performance and reliability in this way . Its basThe highlight of this architecture includes that the control flow is separated from the data flow which leads to higher performance and that the replicas of data offer both reliability and efficiency under good management. Meanwhile, this system also has limitations in supporting small files, for its specific design purpose to support Google’s own service.Some successors of GFS are generally different implementations of the same idea, for example, HDFS  and KosmIn conclusion, after many years of development, distributed file systems are relatively mature, and it is a prevailing trend to develop a customized DFS for a certain field.As scalability and performance are two of the key requirements of a big data system, parallel computing must be implemented to offer these features. However, traditional parallel programming models fail in migrating to big data systems which consist of a massive number of servers over a wide area. In recent years, a lot of programming models were proposed to provide solutions to this specific need.As the forerunner in distributing heavy computations across thousands of machines, MapReduce abstracted two basic operations from a broad variety of real-world tasks . The mapMany programming models have been proposed afterward. Some provided considerable improvement to the MapReduce model. Microsoft developed Dryad  in whichIn the big data era, various public hospitals and private healthcare providers are producing large amounts of data that are difficult to process. Therefore, powerful automatic artificial intellectual algorithms are needed for the analysis and processing of useful information from healthcare data. This information is very precious for healthcare specialists and physicians to apprehend the cause of diseases and for providing better and cost-effective treatment to patients. To improve prediction accuracy, there are various artificial intelligence technologies such as classification, regression, clustering, and association used in healthcare data analysis to increase the healthcare provider’s capability for making the decision in regard to patients health. There are large amounts of research resources available regarding artificial intellectual application in health big data which are presented in subsequent sections with their advantages and disadvantages.One of the data analysis tasks is classification, which divides data into target labels. Each data point is predicted into the target label by a pattern classifier. For instance, hypertension patients can be classified into three stages of stage 1 hypertension, stage 2 hypertension, and stage 3 hypertension  on the bIn the ML domain, SVM as a supervised classifier is widely used for classification . It is wA decision tree (DT) is a common ML method for constructing prediction models from data. The models are obtained by recursively partitioning the data space and fitting a simple prediction model within each partition . Due to A neural network (NN) is based on a biological nervous system having multiple interrelated processing elements known as neurons, functioning in unity to solve a classification problem. Rules extracted from the trained model help to improve the interoperability of the learned network . Er et aBayesian decision theory is a basic method under the statistic framework, and it is extended easily to do classification tasks . Liu andThe application of classification analysis methods in medicine is getting more and more advanced, not only is it used extensively in disease diagnosis, but also there will be more breakthroughs in disease treatment options in future, and all of these expectations become more apparent in the near future.Regression analysis is a statistical method to determine the quantitative relationship between two or more variables. Based on observational data, regression analysis could establish appropriate dependencies between variables and analyze the inherent rules of data . It is wRegression analysis can accurately measure the degree of correlation between factors and the degree of the regression fit to improve the effectiveness of prediction, which is of great significance in medical diagnosis. More recently, regression analysis is one of the most frequently used analytical techniques in disease diagnosis and etiology analysis .Clustering is an unsupervised learning method that is different from classification. Clustering is a process of classifying data into different classes or clusters, so objects in the same cluster have a large similarity, and objects between different clusters have a large degree of dissimilarity . ClusterCluster analysis is essentially finding a statistic that objectively reflects the affinity of an element and then classifying the elements into categories based on this statistic. Cluster analysis decomposes the symptoms of chronic diseases and is used to assess the quality of life in chronic diseases, such as lung cancer; cluster analysis is very effective in assessing these diseases.Apriori, Predictive Apriori, and Tertius). Further rule-mining-based analysis was undertaken by categorizing data based on gender, and significant risk factors for heart disease were found for both men and women. Association is one of the most vital approaches to data mining that is used to find out the frequent patterns, and interesting relationships among a set of data items in the data repository. Frequent patterns are patterns that appear frequently in a dataset. The initial motivations of the association rules were raised for the issue of the market basket analysis. The association process analyzes the customer’s shopping habits by discovering the association between the different items placed in the “shopping basket” by the customer. The discovery of this association can help retailers understand which goods are frequently purchased by customers at the same time, so as to help them develop better marketing strategies . AssociaUsing the association analysis method to discover the relationship between the attributes in the medical dataset, especially some general factors such as age and smoking habits, and the measured body organ function indices related to the possibility of disease, the doctor can accurately determine the possibility of disease through the patient’s characteristics, which is very meaningful for medical diagnosis, and the future application of the association analysis method to predict diseases and develop treatment plans based on vital signs.In summary, AI as a role in healthcare big data, its effects on the development of the medical industry, applications of AI in medicine, challenges, and promises of both AI and big data with respect to healthcare, and prevailing techniques  and tools for performance optimization of healthcare big data can be used by the medical industry.This paper investigated the application of AI technologies in health big data based on a data elements perspective. Traditional data management framework, which is based on a relational database management system (RDBMS), is hard to deal with a growing amount of healthcare data. Big data processing frameworks like Hadoop  are employed in the data preprocess stage to accommodate big data and accelerate computing efficiency. We found that there is no single ML method that gives consistently good results for all kinds of health big data. The performance of ML methods depends on the type of dataset that researchers have taken for doing the experiment. To get the higher performance of ML method, most of the research combined many artificial methods to complement the deficiency of each one called hybrid method or integrated method or assemble method.In addition, it is well known in the AI field that feature selection and extraction are very important factors that affect the performance of artificial methods. Features are extracted and selected on the basis of healthcare/medical domain knowledge and optimal techniques in normal conditions. For healthcare providers and medical providers, AI technologies are widely utilized to make effective decisions in regard to how to enhance patients’ health, how to provide healthcare service at low cost, and how to remind physicians to avoid misusing drugs and misdiagnosing.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.HX analyzed the methods and penned the manuscript. HC, LX, and HL gave important suggestions. QT, LF, and HFC participated in discussions and provided some literature resources. HC revised the manuscript. All authors contributed to the article and approved the submitted version.