In Europe, the mental health law legal framework has had several changes throughout the years to achieve and develop new reforms, better mental health care, and protect the human rights of patients. The UK national data shows rising detention rates and the disproportionate use of the legal framework among people from black and minority ethnic groups. At the national level, compulsory admissions are lower in Italy; it also shows that it has increased in the last few years in both countries. The lack of ethnic national data, especially in Italy, limited the ability to understand compulsory admission, discrimination, and stigma in mental health. The present study aims to compare the legal framework of mental health law and compulsory hospital admission in Italy and the UK. A review of each country’s latest amendments to mental health law and the number of compulsory hospital admissions was conducted to understand the impact of changes in mental health care. According to the currently prevailing orientation, it would be desirable to adopt tools aimed at reducing stigmatization, developing international standards, producing guidelines, as well as raising awareness of the ethical challenges imposed by compulsory admissions.Compulsory hospital admissions of patients with mental disorders are defined as admission to a psychiatric hospital without consent. England and Wales further consider the admission of an incapacitated person . The criIn such a context, the present study aims to compare the legal framework of compulsory admissions between Italy and the UK, reviewing national databases and the latest changes in legislation. For this purpose, a narrative literature on the updated epidemiological data and relevant national documents has been conducted.2.Reports from around the world highlight the need to address discrimination and promote human rights in mental health services. For this purpose, careful discipline of coercive practices such as hospitalization and forced treatment, restraint , or isolation is essential.The United Nations Convention on the Rights of Persons with Disabilities (CRPD) marks a paradigm shift in the way disability and mental illness are conceptualized. It places the person at the center of the decisions that concern him and considers individuals as holders of rights based on equality with others. Such an approach to disability has profound implications for legal capacity legislation as well as its implementation. The CRPD recognizes the challenges outlined and calls for major reforms for the promotion of human rights through a fundamental paradigm shift in the field of mental health that includes the rethinking of rules, laws, systems, and services . Since tApproximately 50 million people with mental illness live in the European Union (EU). The restriction or deprivation of legal capacity to which many of these people are subjected constitutes an obstacle to the possibility of living independently and making free decisions about life. The CRPD has become an integral part of the legal order of the signatory countries, creating legal obligations regarding the prevention of discrimination and the protection of equality. Most existing laws on legal capacity share several common features; in fact, to limit the legal capacity of an individual, the presence of an intellectual disability or a mental health problem should be associated with a second criterion connected to the “impossibility” of the person to look after his own interests.Despite many steps forward at the international level, the protection of mental health remains an issue rarely recognized as important. Safeguarding mental health deserves greater attention from society and states to guarantee individuals the best possible care. Achieving such a goal involves investing in policies and programs aimed at the active involvement of people with mental illness; in the same way, it is crucial to keep the concepts of mental health and physical health united to be able to proceed with an adequate allocation of resources.2.1.In 1978 the Italian mental health care system underwent a radical change with the gradual closure of all the Mental Health Hospitals. The reform developed Departments of Mental Health nationally, delivering outpatient and inpatient care, running semi-residential and residential facilities, and having small psychiatric units in general hospitals.Law 180 established four principles: (a) a gradual phasing out of mental hospitals; (b) the establishment of general hospital psychiatric wards for acute admissions, each having a maximum of 15 beds; (c) the restriction of compulsory admissions; and (d) the setting up of community mental health centers providing psychiatric care , 7.The main principle of Law 180 is that patients with mental disorders have the right to be treated the same way as patients with other diseases, which means: (a) acute mental health conditions have to be managed in psychiatric wards located in general hospitals, (b) treatments should be provided voluntarily, and compulsory admissions kept only for specific circumstances, and (c) compulsory admissions need to be formally authorized by the Mayor and can only be undertaken in general hospital psychiatric wards  . FinallyThe Major has 48 h to complete the authorization and inform the municipality and patient of the admission. The compulsory hospital admission lasts for seven days, allowing the patient’s care, promoting voluntary treatment or less restrictive forms of compulsory intervention such as non-hospitalization . CompulsDespite the promulgation in 1978 of law 180 and of law 833 , in Italy, there has been a lack of planning for years, especially in the field of organization of services. Such a shortage was partly due to the general difficulties associated with the implementation of the National Health Service.Between 1994 and 1996 the reform process was reactivated, and the proposed intervention strategy provided a crucial framework to finally initiate a systematic reorganization of the services dedicated to psychiatric care. The main changes were (a) the establishment of the Department of Mental Health to guarantee unity and integration of psychiatric services within the same territory, (b) the identification of organizational components of the Department , and (c) the activation of primary and secondary liaison care services. Due to ongoing uncertainties and delays by many regions, the Parliament, through repeated legislative interventions , introduced sanctions in the absence of operative interventions for the closure of psychiatric hospitals and the activation of mental health departments.The Law 81/2014 outlined the closure of judicial psychiatric hospitals. The closure of judicial psychiatric hospitals, which ended in February 2017, involved their replacement with facilities called Residences for the Execution of Security Measures, with a limited number of beds in general hospitals.2.2.The Mental Health Act 1983 (MHA) is the law in England and Wales under which a person with mental health problems can be admitted, detained, and treated in a hospital against their wishes . It tellThe Mental Capacity Act (MCA) was introduced in 2005 and was amended in 2007. The MCA is a legal framework that allows actions and decisions on behalf of vulnerable individuals who lack the mental capacity for self-determination . The ActPeople taking action without a patient’s consent must attempt to keep to a minimum the restrictions they impose on the patient’s liberty, having regard to the purpose for which the restrictions are imposed”  and a specially trained Approved Mental Health Professional (AMHP) who is a non-medical professional  and agrees on the application of legal criteria for compulsory admission.“The patient suffering from mental disorder of a nature or degree which warrants the detention of the patient in a hospital for assessment for at least a limited period; and is in the interests of he/she own health or safety or with a view to the protection of other”  were highest, compared to the White group. The “Any Other Ethnic Group” had the second highest rate of compulsory admission  followed by the “Any Other Mixed Background” group .Unfortunately, there is a lack of ethnicity data in the national database regarding compulsory admission in Italy. Several studies in Italy have shown a higher rate of compulsory admission among migrants. A study conducted in a large metropolitan context demonstrated a prevalence of compulsory admissions in migrants more than double with respect to natives (23.24% versus 9.11%) . Another4.The principles of mental health law in different countries and the epidemiology of compulsory treatments raise concerns about patient care, treatment, and mental health services.Interestingly in Italy, most of the information about ethnic groups and compulsory hospital admission is related to migrant studies and are not collected as part of a national database, which is more commonly seen in the British national database. The lack of ethnicity data, especially in Italy, limited our ability to understand the broader experiences of many minority communities regarding compulsory admissions. As studies have shown that compulsory admission rates are higher in migrants and minority ethnic groups, there are ongoing discussions about stigma towards mental health and ethnic inequalities in mental health services are ongoing.Aside from ethical issues, the scientific evidence regarding compulsory treatment is currently heterogeneous. On the one hand, growing evidence demonstrates the long-term benefits of compulsory treatment with an improvement in symptoms, a reduction in suicidal ideation, relief from exacerbations of serious psychiatric illnesses and increased motivation to initiate treatment . On the Compulsory and coercive medical treatment profoundly affects the personal sphere of the individual, putting his integrity and dignity at risk. The absence of clear and uniform data makes this phenomenon difficult to analyze and monitor, particularly regarding the operating procedures carried out in the specific case. Compulsory hospitalization legislation must respect patients’ fundamental rights, reduce mental health stigma, increase awareness, and address discrimination and inequalities in mental health care. The legislative activity, therefore, must guarantee the utmost attention to the protection of personal freedom and health in the interest of the person and of the community . In esseThe improvement of the operating methods cannot be separated from comprehensive data collection and active surveillance of the procedures in place. The best approach to the subject must necessarily be based on a close relationship between science and law to obtain legislation that is as evidence-based as possible. To make the combination possible, the data must be of high quality, available , and monitored globally. In such an operational context, the role of scientific dissemination is crucial. The goal must be to guide the investments of time and money in political strategies oriented toward health decisions guided by the best scientific evidence available. So, monitoring the phenomenology of compulsory admission is desirable to recognize a chronological and socio-economic context; in other words, scientific activity is fundamental for orienting decisions in legal and health matters. From this perspective, the implementation of epidemiological data on compulsory hospitalization and BAME is of considerable importance to better understand social demographics and improve mental health care and patients’ rights. Healthcare professionals should by now be accustomed to maintaining an Evidence-Based approach in clinical practice. However, evidence-based medicine is not unanimously recognized and accepted as the best way forward in-patient care. Scientific publishers, journals, researchers, authors, science communicators, journalists, and communicators should share virtuous training and in-depth courses, defining methods and languages of scientific communication. Only through the sharing of intent will knowledge and the correct interpretation of scientific evidence be able to guide decisions in such a delicate matter. The attention and understanding of scientific evidence are essential so that political realities and decision-makers can adequately take charge of health policies. Concerning global social inequalities, particularly in terms of health determinants and health response to evidence, the incentive for systemic change is crucial. Frequently, the constant change in socio-economic and cultural contexts favors the simultaneous dissemination of qualitatively very different evidence, making the scientific dissemination of certainties and uncertainties very difficult. The insufficiency – if not even the complete absence – of strategies to prevent or counter misinformation on issues related to mental health and compulsory hospitalization requires the implementation of direct actions against misleading content. In light of the considerations made, not only the reliance on evidence-based medicine but also the convinced support of an evidence-based policy must be considered desirable.Finally, it is important to consider further research, education, and multidisciplinary work aimed at continuously improving patient care and addressing racial and ethnic inequities for more culturally appropriate mental health services.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.LA: Conceptualization, Writing – original draft. MP: Conceptualization, Writing – original draft. MS: Conceptualization, Methodology, Writing – review & editing. RL: Methodology, Writing – review & editing. FM: Writing – original draft. SD’E: Methodology, Writing – review & editing. PF: Supervision, Writing – review & editing. VF: Supervision, Writing – review & editing.


Perspectives of the core competencies of nurses are varied among postgraduate-year nurses, which makes it challenging to establish training programs and develop evaluation instruments. Particularly critical for nurses is the ongoing acquisition of competencies throughout life. Sometimes this acquisition is funded by the healthcare system, but the key question is how the system leverages this acquisition and ultimately how it translates into patient care. This study seeks to explore nurses’ key competencies acquired through continuing education from the perspective of two groups of postgraduate nurses with different levels of experience and with different objectives to be assessed. An NGT procedure was applied to the group discussion. The participants were recruited according to basic factors such as the number of years of professional experience, their level of education, and their preferred professional status. Thus, seventeen professionals participated in the study, representing two public hospitals in the city. Following the NGT procedure, the competencies identified from the thematic analysis were scored and ranked to achieve a consensus. Eight core issues were derived in the novel group concerning transferring the competencies to patient care quality: holism, care work, organizational barriers, specialization, no transfer, confidence, knowledge, and instrumental tools. Four core issues were derived when asked about the relationship between the resources invested and the organizational and professional development of the nursing staff: professional development, positive learning, negative learning, and recognition. In the more experienced group, seven issues were derived from the first issue raised: continuous learning, quality, confidence, holism, safe care, autonomy, and technical issues. Additionally, six issues arose from the second question: satisfaction, autonomy, creativity, productivity, professional development, and recognition. In conclusion, the perceptions of the two selected groups are negative when it comes to assessing the extent to which the competencies acquired in lifelong learning are transferred to the patient and the system evaluates and recognizes these competencies for improvement. Healthcare organizations should constantly be searching for ways to improve service quality and its impact on patient care and on the global population in general. Governments seem to devote a large portion of public funds to the training of these professionals, but the question remains: to what extent does this investment in continuous training reach the patient, and does the system allow professionals (nurses) to apply it?The COVID-19 pandemic has highlighted the shortcomings, in Spain and throughout Europe, in the surveillance field and how difficult it is to manage a health crisis without a robust management model of public health [In the period 2020–2022, the activity of nursing professionals increased in complexity and difficulty; together with more demanding patients, this has led to dissatisfaction, stress, and exhaustion. With all certainty, this trend will continue during the coming years. Society must assume responsibility for the importance of healthcare provision to these professionals, which should imply increasing financial resources for the profession and reducing the barriers encountered by nurses, e.g., in aspects related to fewer opportunities for continuous training by their organizations, the high cost of training, loss of motivation, shortage of staff, family issues, and limited involvement of management teams. Consequently, nurses must understand the relationship between the acquisition of competencies through continuous learning and the improvement of patient care and professional practice. Competence is defined in a variety of ways. Many professions have their core competencies. Nursing competency includes the crucial abilities required for fulfilling one’s role as a nurse. Therefore, it is important to clearly define nursing competency to establish a foundation for the nursing education curriculum. However, while the concepts surrounding nursing competency are important for improving nursing quality, they are still not yet completely developed. In , the autAccording to a review of the international literature on nursing, competency can follow three theoretical approaches: behaviorism, trait theory, and holism . BehavioIn Spain, there is no obligation to take a given number of hours of continuous learning once the nursing professional has obtained their degree. However, in some regions, a climate has been created that favors continuous learning with an accrediting legislative system, supported by the consideration of the time of attendance at training courses organized by the social partners as working time .Because no patients were involved in the study, ethical approval by the hospital ethics committee was not required, but the process of ethical considerations was taken into account with the study participants, just as it is taken into account in other nonhealthcare settings. The investigator explained to the participants the purpose of the research as well as the procedure to be followed on the days of the NGT session. The consent form was distributed to the group of participants because the sessions were recorded, thus protecting their rights.The relationship between continuous learning and results has barely been studied, especially in Spain. Thus, ref.  reflectsIt is clear that the literature that analyzes the competencies acquired through lifelong learning after graduation is inconclusive and scarce when it comes to transferring this to quality and organizational aspects. Previous research shows how the investment in continuing education does not translate into the health system taking advantage of it to improve the quality of care for the patient; it remains an acquisition of competencies that the health professional uses personally without being supported by the health organization, despite the fact that in many cases it is the health system itself that financed this continuing education. Ref.  analyzesRef.  investigIn the 1990s there was an open debate about the need to determine whether the acquisition of skills through continuous training improves care practice by basing the evaluation of performance on results instead of on the training process itself. Studies that measured the impact on care practice seem to establish a causal relationship between lifelong learning and care. However, [In light of the nursing literature, it is difficult to conclusively prove a relationship between the quality of patient care and continuous training for competencies acquisition. However, the need for strong associations among certain variables is gradually being incorporated. These variables are, primarily, the individual competence needs of the professional, the context in which they work, the nature of the continuing training, and the maintenance of a professional career. In the following decades, the concern with continuous training and its efficacy continued, although much of the fragmented research displays a tendency to evaluate isolated programs without analyzing overall needs and results. On the other hand, the establishment of the obligation, as some groups defend, would not necessarily guarantee the acquisition of certain competencies, nor the improvement of nursing practice; it would simply establish the imperative of measuring results even when it is expensive and difficult, given that patients do not definitively perceive the competences of the nurses in their care practice.Ref.  highlighGiven that the studies have not established a relationship between continuing education and actual improvement of clinical practice, long-term evaluations must be proposed in a broader way and should include a qualitative perspective.Our purpose is to characterize, as a first step, the utility, the impact on patients and institutions, and the influence of the competencies acquired in a holistic sense in the continuous learning after graduation. In the academic field of nursing in Spain, nurses finish their degrees and begin to take a series of courses in a more or less impulsive or reflective way. This is maintained throughout their professional life, with ups and downs determined by work, family, or personal issues. Such courses and seminars are sometimes funded by the national health system, and at other times the nurses are privately funded. This study describes nurses’ experience of working as members of different unit practices in two public hospitals in Aragon (Spain). Our study set out to gain a deeper understanding of the lived experience of a group of nurses working in two public hospitals. The global research question is: What is the effect of nurses’ lifelong learning (in terms of competencies acquisition) on healthcare organizations’ performance? The following research questions were proposed to fulfill this goal: Is it possible to transfer competencies acquisition to patient care quality? Is the system capable of harnessing that potential for its own benefit?The results are used to highlight and offer some practical reflections about public/private investment in lifelong programs and to balance their purposes.Although there seems to be a constant concern for continuing education to acquire competencies that have an impact on the patient and on the healthcare system in Spain, despite the fact that university training is good, it is not mandatory to take continuing education hours. On an individual basis, sometimes financed by the professional and sometimes by the health system itself, professionals continue to acquire both health and organizational competencies to impact their day-to-day work and professional development. However, there is a climate of dissatisfaction, since training serves only to obtain more points and to consolidate jobs, but in no case does the system evaluate or enable mechanisms to transfer all this intellectual capital to the hospital environment. Given this situation, a group of nurses from one of the hospitals analyzed was concerned about analyzing in greater depth the reasons for these aspects.A descriptive qualitative design was chosen to better understand the subjects of the research questions from the perspective of the nurses themselves (and other process stakeholders). This study adopted a consensus-building approach using the nominal group technique (NGT). The study was undertaken between September and November 2021. The study settings are two hospitals that both belong to the local government health system inside of the national healthcare system. One of the hospitals is a teaching hospital with more than 800 hospital beds and is located within the city; it is considered the head of the health sector of the region. The other hospital is not a teaching hospital, has more than 250 hospital beds, and collects patients from smaller localities around the city. Both hospitals collect the professionals described in the sample. These two hospitals are each a reference in their category of clinical and nonclinical hospitals and were therefore considered a good case study for the research. The participants were nurses working in two of the top five hospitals in the region. A purposive sampling strategy was used to ensure that the participants were committed members of the hospital at different stages. Clinical nurse specialists in each hospital provided mailing lists of potential participants, who were invited to participate via an e-mail providing general information on the study’s nature and purpose. Additional nurses were recruited via direct contact during an online meeting and by snowballing. In total, 17 nurses agreed to share their experiences. The participants in this study included different levels of training after graduation according to the Spanish education system in nursing professionals: graduates in nursing, postgraduates in nursing with a master’s degree, and postgraduates in nursing with a Ph.D.Novice group (A): (1) possessed a registered nurse degree; (2) had less than five years of experience as a nurse; (3) half of the sample had a graduate degree and the other half had only a nursing degree.Experienced group (B): (1) had served as a nurse for more than ten years; (2) one of them had a postgraduate degree; (3) one of them was at the end of their professional life; (4) one of them had served as a head nurse for more than five years.The participants were 17 nurses working in two public hospitals in the city of Zaragoza, Spain. A purposive sampling strategy was used to ensure that participants were experienced members of the hospital at different stages. Regarding the selection of experts, a previous study profile was constructed, consisting of basic factors such as age, gender, level of education, and employment status. In the present study, two groups were established according to their age and professional experience, because nurses work immediately upon finishing their studies (or even before). Group A was formed of 10 nurses  with a maximum age of 40 years. Four of them have postgraduate training (master), one has a doctorate in nursing, four do not have postgraduate training, and one is a specialist nurse. To provide seamless training from basic education to postgraduation clinical practice, many studies have focused on evaluating the nursing competency of university graduate nurses with less than five years of experience. Group B was formed of seven nurses  over 40 years old. Only one of them has postgraduate training, with a doctorate. Two are in primary care, one of them being a coordinator. The male nurse is retired so has a complete vision of working life, and the rest are working in the hospital. The clinical nurse facilitator (the researcher) provided a mailing list of potential participants, who were invited to participate via e-mail, in which they were given general information on the study’s nature and purpose. The questions revolved around the nurses’ day-to-day experiences in the workplace; supplemental questions were also used to obtain more information. The sample of four discussion groups to four individual interviews seems to be considered adequate for data saturation as the majority of issues across the data were identified. In qualitative research, three to six groups are considered sufficient when the interviews are not stratified by any characteristics of the participants . As the The principal investigator set a date for the NGT sessions and then invited the potential participants via phone or e-mail, which included notification of the inclusion criteria for participation. Only those who fit the criteria were recruited. They were given two weeks to make the decision to participate and sign the consent form. Until they completed the consent forms, they were not divided into groups for the sessions. The rounds took place in a room of the health facility next to one of the selected hospitals. The novice group took about 60–80 min to complete. The most experienced group took about 40–60 min to complete. The rounds were recorded, and the audio files were kept for two years and then deleted and disposed of. The questions revolved around the participants seeking solutions to a problem without a record of explicit or structured information, but the solutions are the responsibility of the expert participants or those affected by the problem. Participants’ responses were classified and prioritized in order of importance through consensus. Following the nominal group methodology ,12, the Has the quality of care for your patients improved in any way after receiving continuous training? This question seeks to answer the research question: Is it possible to transfer the benefits of competency acquisition to patient-care quality? How do you think that the time and money invested (direct and indirect costs of training) in the courses taken after finishing “basic” training have influenced your skills and professional development within the public health institution? This question seeks to answer the research question: Is the system harnessing that potential for its own benefit? Four sessions were held, and the data were obtained in the order of priority, seeking consensus, since each participant represented a group. Diversity and heterogeneity were sought while avoiding bringing together opposing parties. Subsequently, individual votes generated scores allocated to the acceptance of the various solutions.To analyze the data, the qualitative, cyclical, thematic data analysis process described by ,12 was fThe present study proposed to use a group diagnostic method with the nominal group technique, as an alternative to obtaining a diagnosis of reliable training needs, as it considers the context of the labor system and includes the opinion and analysis of those involved in the phenomenon being studied.Each group was individually conducted with one round for each question of the NGT, which process consists of six core tasks: definition, ideas generation, ideas registration, ideas clarification, selection, and prioritization. Step 1: The study purposes, group task, and the NGT procedure were explained to the participants so that they knew the explicit process and understood that each member had an equal opportunity to present their own opinions. Step 2: The group members wrote down the core competencies that they believed to be the most critical for patient care after training (in the case of question 1). Step 3: The members in each group took turns naming one core competency that they had noted, without repeating one that had already been named. After the first round, additional rounds could occur until every member had expressed all of their opinions. During this step, group members had to respect the right of others to speak and could not judge or debate, no matter what idea was being presented. Step 4: Core competencies with similar definitions were combined and simplified through group discussion. Step 5: A vote was taken on each of the core competencies identified in Step 4. An eight-point response from 1 (less important) to 8 (very important) depending on the group and research question was used for each group member to vote for the core competencies. Then, the total score of each core competency was calculated. Finally, in Step 6, each group ranked their core competencies based on the total scores. The group NGT took about 40–60 min to complete.The steps were repeated in each of the groups (A and B) for the two proposed questions. Group A resulted in eight competencies for question 1 and four issues for the second question. In the case of group B, the first question resulted in seven competencies and the second in six issues. Both cases were categorized in order of importance. This study requested ethical approval and was fully approved by the Institutional Review Board in both hospitals. The process of ethical considerations was taken into account with the study participants, just as it is taken into account in other nonhealthcare settings. The principal investigator explained to the participants the purpose of the research as well as the procedure to be followed on the day of the NGT session. The consent form was distributed to the group of participants because the sessions were recorded, thus protecting their rights. The audio files were kept for two years and then deleted and disposed of. The regulations governing research in Spain do not require ethical permission for interview studies that do not involve patients, do not cause harm, and do not involve intervention in the physical integrity of the patient. Informed consent was obtained from all respondents before each interview, and participant data were protected by law. This research also includes the following concepts: social value, scientific validity, equitable selection of subjects, and a favorable risk-benefit ratio.Eight subthemes emerged from question 1 and four from question 2 in group A. In group B, there were seven subthemes from question 1 and six from question 2. The nurse preceptor group, responding to question 1, originally proposed eight competencies that lifelong learning had led them to develop. Core competencies were identified and acquired with the improvement of patient care after continuous or permanent training. RQ 1: Is it possible to transfer the competencies acquired to patient care quality? In a second round, these competencies were prioritized and the group highlighted some institutional problems that negatively affected the patient transfer. RQ 2: Is the system capable of harnessing that potential (continuous learning) for its benefit?Concerning question 2, which asks for perceptions of the relationship between the investment of resources and professional and organizational development, the panel of experts identified four items that in the second round were prioritized as follows: positive learning (39 scores), negative learning (22 scores), professional development (19 scores), and recognition (19 scores). These items represent the effect on organizational performance . RQ 1: Is it possible to transfer the competencies acquired to patient care quality? In group B, the first question regarding the improvement of the quality of patient care after training produced seven core competencies identified and acquired for the improvement of patient care after continuous or permanent training. Competencies : PersonaRQ 2: Is the system capable of harnessing that potential (continuous learning) for its benefit?As for the second question in group B , the iteSome important conceptual differences were observed between the two groups. Although both perceived the acquisition of the holistic vision of the patient, in group A, the participants made clear that it came from their academic training, while in group B they considered it a paradigm shift, acquired later with care practice and the skills learned via continuous training. It is also interesting to observe that group A talked in terms of skills, tools, and professional development, while group B spoke in terms of safety, patient autonomy, and humanization of care.This study, using the NGT method, explores the perspectives of nurses regarding the core competencies acquired with continuous learning, especially their perceptions of how the health system—and specifically its working units—takes advantage of the investment of these professionals in their organizational performance. This analytical study matches a holistic view of competency as a cluster of elements. Possessing professional knowledge and clinical skills is a basic requirement for all healthcare professionals ,14. In tIn the older group, a reflection was offered from the experience of continuous training throughout their professional life. Problem-solving competence was increased and reflected in daily practice with continuous training. The specialization of care in patients with specific characteristics translated into higher quality care, with more unified and systemic care. The competence of autonomous learning is reinforced when the quality of care is transferred, mainly in the safety and autonomy of the patient to complete the treatment successfully. The reaction to developing more technical or human skills when patient care is considered was much debated, but again there was no consensus, and it was the least valued competence. How the institutions or clinical units take advantage of lifelong training is difficult to quantify via a cost-benefit analysis. The nominal technique offers the perceptions of these professionals in a certain environment. In the least experienced group, continuous training serves to improve indicators of optimization of time and resources and encourage research in care as well as developing more efficient care (results). However, it was observed that there is no correlation between the improvement of patient care (results) and professional development because the institution considers only the number of courses taken as a quality indicator to improve its position when choosing certain clinical units, so quality indicators of the use and transfer of that training (results) are not attended to. The perception of the nurses focused more on a transfer at the level of personal development rather than on professional growth.The most experienced group value the investment of direct and indirect costs in time and money in personal satisfaction, they feel more qualified with better resources, and after years of experience, they are very careful when choosing the training that interests them, not for the consolidation of a job position. However, continuous training has not allowed them to have greater autonomy due to institutional organizational barriers.NGT is a quick and effective method for obtaining a consensus of ideas or values. In this study, NGT was used to explore the perceptions of a group of nurses on the core competencies acquired in the continuing education process and on how best to transfer them to patient care and, at the same time, to the medical institution. The two groups participating in the study identified several competencies that are acquired through continuing education and that are transferred to patient care depending on the degree of experience of the participating group. Thus, in the less experienced group, eight key competencies were identified: holism, care work, organizational barriers, specialization, nontransfer, confidence, knowledge, and instrumental tools. In the more experienced group, there were seven patient-transferable competencies identified: continuous learning, quality, trust, holism, safe care, autonomy, and technical issues. When asked whether the healthcare system takes advantage of the acquisition of these potential competencies and how it is materialized, group A (newcomers) reflected this in four items: professional development, positive learning, negative learning, and recognition. The group with more years of working life reflected it in six items: satisfaction, autonomy, creativity, productivity, professional development, and recognition. The conclusions of this study can serve as a guideline for preparation courses and can facilitate the development of evaluation instruments or scales for preceptor training.


Work-related mental health problems are a major and growing public and occupational health issue. Although prevention of work-related disease is a central task in the work of occupational physicians, implementation of preventive tasks can still improve. The aim of this paper is to present the development of an intervention to support occupational physicians in the execution of preventive tasks and a protocol for its evaluation.An intervention to support occupational physicians has been developed making use of the implementation mapping protocol. The intervention was based on barriers and facilitators for the execution of preventive tasks, input from stakeholders, and evidence-based strategies from literature.The intervention consists of three peer group supervision meetings directed to preventive tasks. During these meetings, occupational physicians will receive materials and will use goal-setting to formulate their own action plans. The IM-PROmPt-study  is a two-armed cluster randomized controlled trial, comparing peer group supervision directed to the implementation of preventive tasks for occupational physicians with usual peer group supervision. The evaluation will include an effect and process evaluation to examine if the intervention is successful in supporting OPs to implement preventive activities, specifically aimed to prevent work-related mental health problems.The intervention is expected to lead to more knowledge and awareness of the value of prevention among OPs, anticipated to lead to both organizational and individual gains.ISRCTN registry; ISRCTN15394765. Registered on 27 June 2023.The online version contains supplementary material available at 10.1186/s12889-023-16858-3. Work-related mental health problems are a major and growing public and occupational health issue. The proportion of workers in the European Union reporting exposure to risk factors that could negatively affect their mental health increased from 25.0% to 2007 to 44.6% in 2020 . MoreoveIn a study on sick leave data in the Netherlands, it was found that one episode of sick leave due to stress-related complaints lasted on average 101 working days. This accounted for on average 19,151 euros on the side of the employer. Burn-out had the highest number of lost working days and associated costs, with on average 163 working days and associated costs of 30,770 euros . Both thMany governments and institutions have developed policies, laws, and guidelines to prevent work-related  health problems of the working population. In the Netherlands, the Dutch Working Conditions Act ensures that all workers are able to work healthy and safely. In the amended Working Conditions Act, prevention of disease and sick leave became an even more central issue as of July 1st, 2017. Among others, a basis contract was introduced. This contains the rights and obligations for employers, employees, and occupational health professionals, and states the requirements for the contracts between occupational health and safety services (OHS) and employers –7. ExampAn evaluation of the revised Dutch Working Conditions Act has shown that whilst more than half of the OPs 62%) indicated that the amended law has allowed them to give more attention to preventive activities, only 17% experienced a reasonable difference and 5% a large difference 2% indica, 9. ThusTo contribute to the prevention of work-related mental health problems in the Netherlands, the aim of this study is to develop strategies to improve the adoption and implementation of preventive tasks in practice by OPs. In this study, the following tasks are defined as being preventive: open consultation hours, workplace visits, preventive medical examinations, periodic occupational health examinations, risk inventory and evaluation, advising about occupational health policy, and consultation with other occupational health professionals. The aim of this paper is twofold: (1) to describe the development of strategies and an intervention for the implementation of preventive tasks by OPs targeting work-related mental health problems and (2) to describe the protocol for a cluster randomized controlled study (RCT) to evaluate the effectiveness of this intervention and the process of implementation.This manuscript is based on the implementation mapping (IM) protocol by Fernandez et al. , and desThe aim of the needs and assets assessment was to identify all actors involved in the implementation of preventive tasks by OPs, and to identify barriers and facilitators for the implementation in practice . To idenThe aim of the second step was to develop matrices of change objectives with the roles for the different actors, the adoption and implementation outcomes for each of the actors, and the corresponding tasks to achieve these outcomes (i.e. performance objectives) . These mTo collect input for the matrices, an interactive session was organized with a group of 19 stakeholders, including OPs, representatives from occupational health services (OHS), representatives from employer and employee organizations, and representatives from several occupational sectors. Before the session took place, the stakeholders were asked to rate the nine themes of barriers as identified in step 1 on importance and changeability on a scale from 0 (unimportant/unchangeable) to 5 (very important/changeable). Facilitators for the implementation of preventive tasks were often the opposite of the barriers. For example, organizing meetings with a multidisciplinary team of  professionals could help facilitate the execution of preventive tasks, while a lack of multidisciplinary collaboration could hamper this execution. Therefore, the stakeholders were not asked to score the facilitating factors. During the session, possible solutions and strategies to overcome the barriers for the implementation of preventive tasks by OPs were discussed.Using the information from this session, implementation outcomes and performance objectives  methods to influence the earlier identified determinants, and to develop strategies that are based on these theoretical methods . For thiIn addition, the CFIR-ERIC strategy matching tool was used to come up with strategies and methods from literature . This evThe aim of the fourth step was to produce protocols, activities and materials needed for the implementation of preventive tasks, using the strategies proposed by stakeholders and collected from literature . For theThe last step of IM aims to evaluate the intervention. Therefore, a cluster randomized controlled trial (RCT) will be conducted to evaluate the effectiveness and the process of the intervention. More specific, the following research questions will be addressed:What are the effects of the intervention on the execution of preventive tasks aimed at the prevention of work-related mental health problems and behavioural determinants of OPs?What are the experiences of OPs and other stakeholders with the process of implementation of the intervention?Based on literature, a list of more than 100 barriers and facilitators for the implementation of preventive tasks by OPs was created and grouped into nine themes: (1) Insufficient knowledge about prevention among employees, employers and OPs; (2) Insufficient multidisciplinary collaboration; (3) (Lack of) knowledge and skills of OP; (4) Costs-benefits of preventive tasks for the employer; (5) Insufficient resources, facilities and time for OP; (6) Familiarity, accessibility and findability of OP among employer and employee; (7) Laws and regulations are not known by employers; (8) Insufficient cooperation between occupational and curative health professionals; (9) Lack of trust in OP because of  dependence on employer. An overview of these themes and an explanation of each can be found in appendix 1.According to the stakeholders consulted, the most important barriers were: insufficient knowledge about prevention among employers and employees; insufficient multidisciplinary collaboration; and lack of knowledge, interest or skills of OPs about preventive tasks see Fig. . At the An example of a matrix of change objectives for OPs, including the behavioural outcomes, performance objectives and personal determinants, can be found in Table Based on the ratings of the stakeholders as to the importance and feasibility of the earlier proposed strategies, an idea prioritization-matrix was created, see Fig. After using the CFIR-ERIC matching tool, a list of possible strategies was created from literature to tackle the identified themes of barriers and facilitators. Appendix 2 shows a full list of these ERIC strategies and for which barriers these strategies are helpful to overcome .For the intervention, we will use the existing peer group meetings. Within a period of six months, three meetings will be organized with a total of approximately five working hours, in which prevention of mental health problems is the central topic. The chair of each of the intervention groups will be trained and guided in facilitation during the course of the intervention. OPs will be provided with materials, which includes information about work-related mental health problems and ideas about how to incorporate preventive tasks more in their daily practice. Making use of the materials and following different steps, OPs will formulate their own goals with regard to execution of preventive tasks targeting work-related mental health problems to be achieved during the course of the intervention. Advice and input from fellow OPs play an important role in formulating the goals. In short, the peer group supervision groups will focus on 3 important aspects: (1) An interactive introduction into the topic of prevention of mental health problems; (2) Formulating personal goals with input from colleagues; (3) Sharing best practices with regard to prevention. Table To evaluate the implementation of the developed intervention, a two-armed cluster randomized controlled trial (RCT) will be conducted. The design of a cluster-RCT has been chosen, because the intervention will be delivered at a group level . The OPsThis study will be performed in accordance with the ethical guidelines and regulations laid down in the Declaration of Helsinki. Moreover, this study will be reported in adherence with the CONSORT Guidelines . This stThe study population consists of OPs and will be recruited in two steps. First, we will recruit peer group supervision groups via the Netherlands Society of Occupational Medicine. Second, we will recruit individual OPs within each participating peer group and ask whether they want to participate in the evaluation. Thus, an individual OP can decide not to participate in the evaluation, but could still participate in the specific prevention-oriented peer group supervision meetings. OPs will be excluded from participating in this evaluation when: (1) They have an upcoming retirement or long-term leave (e.g. pregnancy leave) during the follow-up of this study (i.e. 12 months), or (2) They work fewer than 16 h per week as an OP. The latter requirement is to ensure OPs have enough time available to focus on their preventive tasks and change something in their working habits.The sample size for this study was based on estimating an effect on the primary outcome, the self-reported percentage of time spent on preventive tasks. Using a one-sided Pearson’s chi-squared test of proportions at alpha = 0.05, assuming 0.1 and 0.25 of the total percentage of working hours per week being assigned to prevention tasks in the control and in the treatment groups, respectively, 80 participants were needed in each group to achieve a statistical power of 0.8. Considering a loss to follow-up of 20%, this study would require a sample size of 200 individual participants, of which half in the control and half in the intervention condition. Taking into account that each peer group consists of approximately eight people, this corresponds to approximately 25 peer groups. This analysis was done using the procedure power in SAS, version 9.4, and in consultation with an experienced statistician.After each individual OP has given their written informed consent for participating in the evaluation and has filled in the baseline questionnaire (T0), randomization will take place at the level of the existing peer groups. Participating groups of OPs will be randomly assigned to (1) the peer group supervision plan directed to the implementation of preventive tasks targeting work-related mental health problems (intervention groups) or (2) the usual peer group supervision condition (control groups). The control groups will be put on a waiting list and receive the peer group supervision materials after the 12 months follow-up of this study. To avoid bias, the randomization process will be executed by two independent researchers. Researcher 1 will assign consecutive numbers to each participating peer group. A computer-generated randomization will then be performed by researcher 2, in order to assign each number to either the intervention or control group. This way, allocation to either one of the groups cannot be influenced. Because of the intervention, blinding for allocation on the level of the participant (OP) is not possible.“I regularly visit the workplace to monitor the interaction between work and health and to evaluate opportunities and risks.” or “I give my employers solicited and unsolicited advice about preventive tasks, to prevent and limit health threats” [The primary outcome is the execution of preventive tasks aimed at the prevention of work-related mental health problems. This will be assessed by means of the self-reported number of hours spent on each of these tasks, and the self-reported percentage of time spent on prevention, absence and reintegration guidance, and other tasks (e.g. teaching responsibilities). Moreover, OPs will be asked if they would like to spend more time on prevention . If they want to spend more time on prevention, they will be additionally asked on what specific tasks . Furthermore, questions derived from an existing questionnaire of the Netherlands Society of Occupational Medicine will be used . This quthreats” .Secondary outcomes are the attitude, social influence and self-efficacy of OPs (ASE) ; perceivData on potential confounders will be collected by questionnaire as well. These include both sociodemographic factors and organizational characteristics:Individual characteristics of the OPs: age, number of working hours per week, number of years work experience, being self-employed.Organizational characteristics: sector, and if they are working for Small and Medium Enterprises (SME) or larger organizations.Data at baseline, 6 months (T1) and 12 months follow-up (T2) will be presented using descriptive statistics. To investigate the effectiveness of the intervention, differences between the intervention and control group in the outcomes at baseline, T1 and T2 will be analysed making use of longitudinal linear or logistic mixed models. If necessary, baseline differences between the intervention and control group will be adjusted for. Consistent with the design of the cluster-RCT and to avoid bias, analyses will be performed following the intention-to-treat principle. This means that all participants randomized will be kept in the groups they were randomized to, regardless of the intervention they received in practice . For theThe process evaluation provides insight into the process of both the implementation of the intervention and the translation of this into their daily practice. We will create a questionnaire for OPs and conduct semi-structured interviews with both OPs and the chair of peer groups assigned to the intervention.Acceptability refers to the degree to which OPs perceive the intervention as agreeable or satisfactory. This will be included in the questionnaire by asking what participants liked and did not like about the peer support group meetings. The adoption is simply defined as the uptake or intention to use the intervention. This will be assessed by asking why someone decided to participate in this study and if participation did meet their expectations. Appropriateness is defined as the perceived relevance or fit of the intervention to address the issue of lacking implementation of preventive tasks. Costs are the costs associated with the implementation effort, including costs of materials and average hourly wage of OPs. For this, administrative data will be used. Feasibility is about the extent to which the intervention can be successfully used within, for example if it was feasible to work on one’s personal goals. Fidelity measures the degree to which the intervention implemented as intended [Penetration is defined as the integration of a practice, but can also be defined as the reach, i.e. the number, proportion and representativeness of participants [ustainability is the extent to which the execution of preventive tasks is institutionalized within the organisation [In the questionnaire for OPs, we will use the taxonomy proposed by Proctor et al. (2011) which focuses on eight implementation indicators: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration and sustainability . Acceptaintended . This inicipants , 26. Finnisation .In addition, we will link the process and effects to determine if better implementation of the intervention within the peer groups leads to better outcomes with regard to prevention after 12 months. In the effect evaluation, OPs will be asked if they were successful in implementing the preventive tasks and reaching their formulated goals. We aim to determine if OPs in peer groups with higher fidelity have better effects and spend more time on preventive tasks. This will be done making use of sub-group analyses.Furthermore, during the interviews OPs will be asked for their reasons for using the implementation plan/strategies, how they used it, satisfaction, barriers and facilitators for the implementation of preventive tasks, and intentions with regards to continuation of the preventive tasks . The intAlthough preventive tasks should be a central part of the work of OPs in the Netherlands, implementation of preventive tasks is insufficient. To improve the uptake of preventive tasks by OPs, insight is needed into the barriers and facilitators for the utilization of preventive tasks, and into strategies how to overcome these barriers. Making use of literature and stakeholder opinion, and following the Implementation Mapping protocol, we developed an intervention to stimulate OPs to implement preventive tasks in their current practices. The evaluation phase will include an effect evaluation and process evaluation. The aim of this evaluation phase is to examine if this intervention is successful in supporting OPs to implement preventive activities, specifically aimed to prevent work-related mental health problems.More knowledge and awareness of the value of prevention among OPs can ultimately also lead to more knowledge and awareness among employers and employees about work-related mental health problems and preventive measures. It is therefore anticipated that better implementation of preventive tasks by OPs will lead to reduced numbers of work-related mental health problems and to both organizational and individual gains. For OPs, better execution of preventive tasks might not only make the work more varied and attractive, but may also lead to more job satisfaction. For employees, more prevention might contribute to increased awareness, increased job satisfaction and improved workplace culture . Since nIf the intervention described in this paper has proven to be effective in supporting OPs in their preventive tasks, widespread implementation of the intervention is anticipated. For this, an additional implementation and dissemination plan will be developed. Moreover, the form of the intervention  may also be applicable to prevention of other work-related health problems or relevant themes other than prevention. The process evaluation can help to understand if and how the intervention can be improved in order to do so.The chosen study design of a cluster randomized controlled trial is a suitable design since the intervention will be delivered at group level . HoweverBesides these limitations, this study also has some advantages. So far, most research has been limited to only the identification of barriers and facilitators to the implementation of preventive tasks by the OP. Research into the development and evaluation of strategies or interventions that tackle these factors is lacking. Moreover, most studies on the role of the OP focus on absence and reintegration guidance, and not on stimulating the preventive role of OPs. This study fills this research gap. An advantage of using the IM protocol is that we systematically work towards the development of an intervention to support OPs in the execution of their preventive tasks. Another strength is the use of both knowledge from research and literature, as well as practical knowledge from the stakeholders involved. In addition, the strategies used in the intervention are evidence-based and translated to the Dutch context and context of this research. In doing so, we adhere to the existing structure and method of peer support groups. This way, our implementation protocol is not only scientifically relevant, but also fits to practice. The evaluation of this study will focus on the effectiveness and process. This makes our evaluation more comprehensive and will allow us to learn from the implementation process to eventually improve the intervention, before implementing on a wider scale.Below is the link to the electronic supplementary material.Supplementary Material 1


Although global food consumption costs more in terms of impact on human life than money is spent on it, health costs have not been consistently quantified or included in food prices to date. In this paper, a method to determine the external health costs of nutrition and dietetics is developed by employing the cost-of-illness (COI) and true cost accounting (TCA) approaches. This is done exemplarily for the reference country Germany. The results show that 601.50 € per capita and 50.38 billion € in total external health costs are incurred annually due to nutrition. Overall, most costs are accrued through excessive meat consumption (32.56% of costs), deficient whole grain intake (15.42% of costs), and insufficient uptake of legumes (10.19% of costs). Comparing the external health costs with the external environmental costs in Germany, it can be seen that of the total annual costs of around 153.86 billion €, 67.26% originate from environmental impacts and 32.74% from impacts on human life. In order to achieve the 17 Sustainable Development Goals and to increase family as well as public health, there is a need to internalise these external costs into actual food prices. Intense droughts, water scarcity, severe fires, rising sea levels, melting polar ice, and declining biodiversity are just a few examples of the consequences of global climate change. Since the 1800s, humans have been the main reason for these extreme events . The SDGGHG emissions represent an example of an externality, which is defined as any action that affects the welfare or available opportunities of an individual or group and is neither directly paid for nor compensated   Food Systems Summit shows that food externalities amount to USD 20 trillion per year, which corresponds to more than twice the global food consumption. While USD seven trillion is the result of environmental costs, the bulk of the costs of USD eleven trillion is attributable to impacts on human life . Of this, an average of 57% is due to direct healthcare costs and 43% to indirect costs such as informal care and losses in labour productivity. The high proportion of unpriced health externalities makes sustainable and healthy food less affordable for consumers and less profitable for producers than comparatively unhealthier alternatives; hence, representing one main reason for global malnutrition. For example, 690 million people were undernourished in 2019, and ten million die every year due to unhealthy eating habits. Global nutrition guidelines could save five million lives and 79 million life years per year. Moreover, according to this study, up to USD 735 billion in health costs could be saved if such guidelines were introduced .The COI approach was used to calculate the potential cost savings due to healthier diets. COI studies aim to identify and measure all the costs of a disease  by consiIn the scientific literature, no concrete, calculated health premiums or discounts for certain foods exist. The reason for this absence is both the difficulty to measure food products externalities in general as well as large uncertainties. The latter is due to incompletely captured fields of influence as well as fundamental uncertainties in the primary literature, in trade datasets, in modelling the strands of influence, and in monetising external costs. Specifically, estimates of health costs from food vary due to differing approaches and assessment methods, as well as inconsistent standards and guidelines , as thisFurthermore, data sources and data collection in combination with the high complexity of the underlying value chains represent a key challenge. One of the main reasons why health and social components have not yet been sufficiently taken into account in corresponding approaches such as TCA to date is the main focus of companies on improving the natural capital base in impact assessment to improve shareholder value creation. The center of attention lies in reducing carbon emissions, as this is also a global focus, above all visible in the example of the 2030 Agenda. However, impacts on the oceans or workers’ health, for example, are hardly addressed. Therefore, a transdisciplinary approach is necessary to consider health and social consequences along the entire value chain .The mentioned problem areas have the consequence that currently no uniformly quantified nutrition manual that can be utilised to determine concrete price premiums for the health effects of food has been published .One solution to this problem is the Planetary Health Diet (PHD), which was designed for a global population of about 10 billion people in 2050. The basic ideas are a shift to healthy diets and sustainable food production   , a tax oIn summary, the vast majority of studies deal with the environmental costs of food and only a few focus on calculating the health costs of food. The COI approach is predominantly used for internalising health costs, in which direct and indirect costs of diseases are taken into account. Up to now, however, either the total global health costs have been calculated or only those for a group of countries, subdivided according to income. A specific health premium per kilogram was calculated for red and processed meat only, whereby here again a high level of aggregation was applied at the country level. To date, no methodology has been elaborated that determines the country-specific health costs of individual foods or their ingredients and, thus, creates reference values for potential price increases. Therefore, in this paper, we aim to develop a true pricing approach using the COI and TCA approaches to calculate the specific external health cost premiums of selected dietary risk factors for a reference country. Finally, different implementation options and their advantages and disadvantages will be discussed. Thus, this study answers the following research question: how high are the external health costs of food consumption?In this section, we first describe the methodology to calculate health premiums, which represent external costs to date, for foods by dietary risk factors. In the first step, an approach is developed to quantify and monetise the quantity-standardised health costs of the harmful quantity for individual dietary risk factors. In the second step, the methodology is extended to include an approach for determining the concrete health premiums of individual products. Finally, we explain the calculation and sourcing of the input data.Before starting the method, a reference country is defined for which the health costs are determined in the following by utilising the procedure illustrated in Then, relevant diseases through food are selected based on Afshin et al.  (pp. 195d) and those for specific dietary risk factors , the DALY rate (q) of the individual diseases (d) is calculated, by which the percentage of the respective disease burden caused by the individual dietary risk factors is obtained.From the general DALYs of the diseases (DALYdir) and indirect costs (cind) of the selected diseases are determined for a given year (y) and the values are summed up. Here, one can distinguish between three cases concerning the data situation.Then, using the COI approach already mentioned, the direct  and on population figures (py). In the following calculation, it is assumed as an example that the data on direct costs originate from the year 2010 and the data on indirect costs from the year 2011. Thereby, the costs are standardised to the year 2010.In the second case, data on both types of costs are available for different years. Here, an adjustment is needed with regard to inflation and population size in the summation. This requires information on consumer price indices  and indirect per capita costs  exist, but only the total direct costs (cdir) for one year are available.In the third case, data is available on both cost types, with one cost type being calculated from the ratio of total costs to per capita costs of the other cost type. In the following calculation, for example, it is assumed that both the direct , the inflation-adjusted per capita costs of the selected diseases are first multiplied by the calculated DALY rates, resulting in the per capita health costs of the respective diseases of the individual dietary risk factors .In order to ascertain the per capita health costs of the individual dietary risk factors , one needs the average daily intake of the respective dietary risk factors in the reference country  and their daily recommended intake . The former is retrieved from a global database listing the intakes of all dietary risk factors [In order to be able to calculate the quantity-standardised health costs of the harmful quantity that is consumed deficiently or excessively of the respective dietary risk factors on average in the reference country  by calculating the difference between the values just determined.Now we detect the specific harmful amount of the dietary risk factors that is consumed too little or too much per capita daily , which is estimated by the PHD at 2500 kcal per day [p,cal). From these values, the quantity of the product that would be required if one were to cover the daily requirement exclusively with it is calculated .In the first case, for the individual ingredients, one needs a reference number of kilocalories consumed daily  to obtain the total amount of the dietary risk factor that would arise when the daily requirement is completely covered with the product .This is then multiplied with the amount of the dietary risk factor contained in the product .Subsequently, the daily recommended intake of the respective dietary risk factors already determined is needed, and is subtracted from the total amount of the dietary risk factor when the daily requirement is completely covered with the product. This shows the harmful amount contained in the product when the daily requirement is fully covered by it . This value is now divided by the reference number of kilocalories consumed daily, which yields the average share of the product in daily consumption in the reference country .The average consumption of the product group in the reference country per day is then determined and the kilocalories of the specific product standardised on this per day is calculated  by multiplying the harmful amount of the dietary risk factor when the daily requirement is fully covered by the product with the share just determined. This value indicates how many grams of the dietary risk factor one would consume excessively on average per day in the reference country if one were to rely exclusively on this product within the product group. Although the standardisation is not needed to arrive at the same final result, this intermediate step is included in the method for better and easier understanding.Then, we calculate the average unhealthy amount of the dietary risk factor of the product in the daily consumption in the reference country  by dividing the number of kilocalories of the product by the average consumption of the product group in the reference country per day and multiplying it by the quantity just calculated.This is then adjusted to the quantity of the product (np) by multiplying the amount of the dietary risk factor of the product in daily consumption in the reference country by the quantity-standardised health costs of the harmful amount of the dietary risk factor.The last step is to calculate the specific health premium for the product .In the case of under-consumed product categories, the harmful quantity calculated above is divided by the daily recommended intake of the respective dietary risk factor to obtain the quantity quota, which represents the basis for internalising health costs (lr). Here, the average daily intake is extracted directly from studies by national or supranational authorities or, if this is not possible, from databases. If aggregated values are not available, the average is determined using population statistics. The underlying data is explained in more detail in the following subchapter.In the case of over-consumption, the harmful quantity calculated above is divided by the average daily intake of the respective dietary risk factor in the reference country to obtain the quantity quota, which represents the basis for internalising health costs (hr). This is used to calculate the quantity of the product that causes external benefits or costs .Now we determine the specific amount of the product category or dietary risk factor (mr) is calculated by multiplying the quantity of the product category that causes external benefits or costs by the quantity-standardised health costs of the harmful quantity for the dietary risk factor.In the last step, the specific health premium for the product category  is utilised, which contains the direct as well as the indirect expenses for the year 2015 . Here, dNumerous studies exist for T2DM, all of which include direct costs. A distinction is made between overall, diabetes-specific, and diabetes-associated direct costs. According to Jacobs et al. (2017)  , which includes estimated daily intakes of all dietary risk factors for any country . In GermDifferent sources are also required to determine the daily recommended per capita intake of the respective dietary risk factors.For sodium, the suggestion of the German Nutrition Society (DGE) is utilised. It recommends a daily intake of 6.00 g of salt, which corresponds to 2.30 g to 2.40 g of sodium   is used   that are consumed deficiently or excessively of the dietary risk factors per capita daily and the quantity quota which represents the basis for internalising health costs (lr/hr) are calculated there.The just mentioned quantity quota is required when calculating the health premiums for dietary risk factors that are available as product groups. In addition, there is a necessity for a concrete quantity for which external health costs are internalised. In this paper, in the first step, premiums and discounts are calculated for one kilogram of the respective dietary risk factor. In the second step, this is adjusted to the quantities of selected foods. Furthermore, information on the prices of the specific products is required. This study examines some products of Edeka, a large German retailer. Here, apples , minced To calculate the health premiums of dietary risk factors as individual ingredients, the daily consumed reference number of kilocalories already addressed in In this paper, the health premiums due to sodium are calculated for four products as examples. For these products, one needs the selling price, the specific number of kilocalories, and the amount of sodium contained. Here, we determine corresponding health premiums for the types of salami from Edeka already mentioned above and for gouda , as wellFinally, the health costs for certain food products from the Penny-market are determined and applied to a study that already calculated the influence of external environmental costs on corresponding products . The valResults show that EUR 601.48 per capita health costs occur annually in Germany due to dietary risk factors. The six largest dietary risk factors account for 72.48% of the costs, which is why we focus on these factors in this paper. The total annual external health expenses of CVD, T2DM, and neoplasms caused by dietary risk factors are approximately EUR 50.38 billion based on the most recent population status as of 1 January 2022. Over-consumption occurs when the amount that is actually consumed exceeds the recommended amount, while under-consumption refers to the opposite. Of CVD health costs from dietary risk factors, 38.89% are the consequence of over-consumption, while 61.11% are attributable to under-consumption. Legumes with 17.20% and whole grains with 17.07% account for the highest share of the resulting total CVD health expenses. Red meat and sodium turn out to cause the largest shares of health costs due to over-consumption with 11.32% and 9.80%, respectively.T2DM occurs mainly because of excessive consumption of dietary risk factors. Of the health costs, 70.27% are due to over-consumption, of which 84.22% are ascribable to red and processed meat. Excessive consumption of the two types of meat thus poses the greatest risk for dietary T2DM. The remaining 29.73%, which occur due to undersupply, are mainly caused by deficient consumption of whole grains and fruits.Neoplasms result predominantly from an undersupply in the diet. Thus, 67.44% of the health costs are attributable to under-consumption, of which 37.02% are traced back to a too low daily intake of whole grains. The remaining 32.56% largely arise from red and processed meat. Excessive consumption of the two types of meat is responsible for 87.98% of the health costs from neoplasms due to over-consumption.In summary, CVD and neoplasms are predominantly caused by an undersupply of food. In both cases, too little consumption of whole grains is elementary. T2DM is mainly a consequence of over-consumption of food, with red and processed meat being the main contributors. Red and processed meat also contribute largely to the health costs of neoplasms and especially red meat to the health costs of CVD.For dietary risk factors as whole product groups, we calculate health premiums for each kilogram, which are presented in To illustrate the concrete impact of internalised health costs on food, we ascertain the price changes of selected products from Edeka, one of the leading retailers in Germany, in With the information on the quantity-standardised health costs of sodium, the average daily reference number of kilocalories and the data on individual products, their specific health premiums are obtained. The inflation-adjusted external ecological cost premiums of certain products from the above-mentioned Penny-market in some cases differ greatly depending on the production practice. Thus, the organic and conventional variants of the same product entail different environmental cost premiums. Since the production method has no significant influence on the extent of external health expenses, the cost premiums and discounts for the organic and conventional variants of the product are assumed to be identical. In the following, one kilogram is always applied as the reference quantity. The environmental surcharge for conventional gouda is EUR 4.69, while that for organic gouda is EUR 3.49. For both, the health expenses amount to EUR 0.16. For conventional mozzarella, the environmental cost premium is EUR 3.04, and for organic mozzarella EUR 2.29. The health costs of both variants come to EUR 0.01. Conventional mixed minced meat should become more expensive by EUR 10.35, and organic mixed minced meat by EUR 12.39 with the internalisation of external environmental costs. The health cost surcharge is EUR 7.51. Conventional apples should become higher priced by EUR 0.19, and organic apples by EUR 0.13 when internalising environmental costs. For conventional bananas, the environmental surcharge is EUR 0.21, and for organic bananas EUR 0.16. If health costs are internalised, both fruits just mentioned become cheaper by EUR 0.68, which corresponds to overcompensation of ecological costs.This effect can also be observed with price reductions. Here, too, the percentage price decrease is greater for the conventional variants than for the organic variants. Thus, the price of conventional apples would drop from EUR 2.31 to 1.83 per kilogram (79.08% of the current price), while that of the organic variety would decline from EUR 3.47 to 2.92 (84.20% of the current price). The price per kilogram of conventional bananas would diminish from EUR 1.09 to 0.63 (57.67% of the current price), and the price per kilogram of organic bananas would decrease from EUR 1.79 to 1.27 (71.15% of the current price).Now that the external health costs of food in Germany resulting from nutrition have been presented and the impact of internalising these expenses on consumer prices has been evaluated, the results and the uncertainties will be discussed.First, we describe, explain, and discuss the dealing with uncertainties based on the input data breakdown in This paper uses a variety of data from different sources, each of which is subject to uncertainty. In measuring the burden of disease on life, a tool from the University of Washington is employed . This prIn determining the costs of the selected diseases, aggregated costs for the super categories of diseases are used in this study. Concerning CVD, there is no subdivision into individual subcategories such as ischemic heart diseases or stroke. In neoplasms, the different types of cancers are not differentiated. As a result, the costs of illness cannot be calculated in a fully differentiated way for each dietary risk factor. Because of the coarser granulation, the total costs are higher than the sum of the individual costs in a more disaggregated view. This problem is counteracted in this study by using the DALY rate, as this normalises the costs to the over category under consideration.Furthermore, significant uncertainties arising from the heterogeneous sources regarding the age of the data and the data contained exist, which is particularly important when calculating the costs of diabetes. Numerous studies are published containing varying direct costs, most of which are more than ten years old. In this paper, the study with the highest sample size was selected, as it is the most representative. It represents almost all people with T2DM in Germany, and its result is similar to that of the Costs of Diabetes Mellitus (CoDiM) study, which analysed data from the same year from about 1.5 million insured people and came up with a per capita cost of EUR 5239  , assignable to the lack of national and international guidelines   , organicAs already illustrated, the majority of diseases occur due to an undersupply of food. Consequently, there should be an incentive to consume more of it. Based on the calculated results, under-consumed food becomes cheaper when both health costs and environmental costs are internalised, because the impact of health externalities exceeds that of environmental externalities. However, for over-consumed food, both types of costs add up, whereby the share of environmental costs is greater than that of health costs for animal-based and dairy products used in the aforementioned study .The Boston Consulting Group (BCG) estimates the total environmental external costs of agriculture in Germany at around EUR 90.77 billion in 2018 . AdjusteThus, in comparison, the production increases in Germany, which leads to higher environmental costs, while, because the diseases examined here are in general mainly caused by an undersupply of food, there are fewer external health impacts on human life, explaining the dominance of environmental costs over health costs in Germany.The results illustrate that an integrated internalisation of all external costs from food consumption leads to incentives for a healthier diet. Food that is taken in deficiently becomes cheaper for the consumer, and food that is taken in excessively becomes more expensive. In the process, poor production methods and the resulting environmental costs or benefits increase or decrease the calculated health costs. Thus, the side effects of economic activity are monetised and become part of prices. The market is equalised, and a shift to healthier and more sustainable diets is motivated.In this study, a methodology is developed to determine the health costs of individual foods and their ingredients for the reference country to, thus, create reference values for potential price increases or decreases. In our framework, first, a new type of DALY rate is introduced to determine the percentage of the diseases CVD, T2DM, and neoplasms of the most influential dietary risk factors in their total numbers in Germany. This rate is used in the next step to calculate the per capita health costs of the individual dietary risk factors using the COI approach. By determining harmful levels of dietary risk factors, quantity-standardised health costs are calculated, and concrete health premiums or discounts for individual ingredients as well as individual products are determined.We find, that EUR 601.50 per capita in total health costs are incurred in Germany per year due to nutrition. Almost one third of these is caused by an over-consumption of meat, thus, highlighting an excessive meat consumption as a main driver of health costs in Germany. Further results underline the insufficient consumption of grains, legumes, and fruits, as well as the excessive consumption of sodium as significant drivers of health costs.This thoroughly answers the research question formulated in the introduction.Overall, 48.78% of health costs in Germany are due to an oversupply of food, while 51.22% are caused by an undersupply. While both globally and in Germany most DALYs are incurred by an undersupply of food, the proportion in Germany is significantly lower than in international comparison, which is primarily due to Germany’s high consumption of meat. Comparing the calculated health costs of minced meat, apples, bananas, gouda, and mozzarella to the environmental costs calculated by Michalke et al. (2019) , an inteIn summary, the costs of nutrition through impacts on human life, which to date are not included in market prices and thus not compensated, can be quantified and monetised by applying the methodology developed in this paper. By pricing food appropriately, the 17 SDGs could be advanced by improving the health aspect in particular. For this, an international application in addition to the calculation of health costs through this method for Germany is required for a globally healthier diet and an equalisation of the market.