Mental health problems have become a public health problem that needs to be solved in China. However, medical resources for mental healthcare remain insufficient and unevenly distributed. The Chinese central government has taken many measures to address this issue over the last decade. This study aimed to evaluate the changes in equity in mental health bed allocation from 2011 to 2020.The data of this study came from the China Health Statistical Yearbook (2012–2021) and the China National Administrative Division Information Platform. The annual growth rate was used to evaluate the time trends of mental health beds. The Lorenz curve, Gini coefficient and Theil index were used to assess equity in the demographic and geographical dimensions. The distribution of mental health beds was visualized on a map using geographic information system (GIS) software.The total number of mental health beds in China increased steadily from 2011 to 2020. At the national level, the Gini coefficient and Theil index all exhibited downward trends over time. The mental health bed allocation in terms of the demographic dimension was relatively equitable, with Gini values all less than 0.3; however, the Gini coefficients by geographical area were all more than 0.6, indicating inequity. Intraregional contribution rates were higher than interregional contribution rates, which were all above 60%.The overall distribution equity of mental health beds improved from 2011 to 2020. The equity of mental health beds in terms of population size is superior to that in terms of geographical area. Intraregional differences are the main source of inequity. In particular, differences within the western region need to be given attention. Thus, the findings from this study emphasize that the demographic and geographical distributions and all influencing factors should be considered when the government makes mental health resource allocation policies. Mental health, ignored for far too long, is crucial to the overall well-being of individuals, societies, and countries. In recent years, mental health issues have become more prevalent, impacting people of all ages and financial levels worldwide. GloballThe reduction in the mental disorder burden in China is essential and urgent. However, the resources provided to tackle the enormous burden, such as financial investment, 5, profThe Chinese government has prioritized ensuring that all citizens’ right to health is protected. Over the past ten years, it has implemented corresponding measures to enrich mental health resources and address health resource maldistribution. First, Mental health beds are a pivotal component of mental healthcare resources. How to optimize the allocation of mental health beds has been a concern of policymakers and scholars in different countries–17, inclTherefore, in cases of nonuniform distributions of mental health care needs across regions, we aimed to evaluate the trend of equity in mental health bed allocation in not only demographic but also geographic terms in China over the last ten years, from 2011 to 2020. The Lorenz curve, Gini coefficient, and Theil index were used in this study. The findings of this study may help reflect the impact of the government’s efforts to improve health resources and provide a theoretical foundation for policymakers to take appropriate measures to optimize the allocation of mental health beds.We collected data from 2011 to 2020 to track the changes in the allocation of mental health beds in China. All data referred to are available in the public domain. The mental health beds and demographic data were extracted from the China Health Statistics Yearbooks 2012 to 2021, while tChina has 34 provincial-level administrative regions (hereafter collectively referred to as provinces), as shown in Fig. For a descriptive analysis of the demographic and geographic distribution of mental health beds, we calculated the densities of mental health beds per 10,000 population and per 10,000 square kilometres at the provincial and regional levels. The annual growth rate (AGR) of mental health beds from 2011 to 2020 was computed as well. The formula of the AGR is as follows:where B represents the quantity of mental health beds in 2020, A represents the quantity of mental health beds in 2011, and m represents the number of years.The Gini coefficient has been used in a wide variety of resource allocation contexts to measure inequity, including income, wealth, credit availability and energy. It is aThe Gini coefficient is an absolute indicator with a universal grading scale. It takes a value from 0 to 1, with a higher value indicating greater inequity. GeneralG represents the value of the Gini coefficient; Xi is the cumulative percentage of population or geographic area in the ith province; Yi is the cumulative percentage of mental health beds in the ith province; and n is the total number of provinces.In formula 2, The Theil index is another common measure of inequity that has some advantages over the Gini coefficient. The Gini coefficient can only describe the degree of equity, while the Theil index can be used to analyse the source of inequity. HoweverPi represents the proportion of the ith province’s population (area) out of the total population (area); Yi represents the proportion of health resources owned by the ith province out of the total number of mental health beds. The total Theil index can be decomposed into the intra-Theil index and inter-Theil index. Formula 4 and formula 5 are used to calculate the intra-Theil index and inter-Theil index, respectively.In formula 3, Tintra means the differences in mental health bed allocation in the region; Tinter means the differences in mental health bed allocation between regions; Pg represents the proportion of the gth region’s population (area) accounting for the total population (area); and Yg represents the proportion of mental health beds owned by the gth region accounting for the total number of mental health beds. k means the total number of regions. The contribution rates of Tintra and Tinter can be calculated by dividing the total Theil index.In the above formulas, All statistical computations were conducted in Microsoft Excel 2020 , while ArcGIS software  was used to map the geographical distribution of mental health beds.Table As shown in Table When stratified by region, the largest annual growth rate of mental health beds per 10,000 population and per 10,000 square kilometres was seen in the western region. The highest number of mental health beds per 10,000 people was in the western region. The highest number of mental health beds per 10,000 square kilometres was in the eastern region. The eastern region obtained the highest number of mental health beds per 10,000 people from 2011 to 2015. The western region replaced it as the first from 2016 onwards, with a rapidly increasing number of mental health beds (Fig. Figure Moreover, Gini coefficients, as shown in Table Table Demographically, in 2020, the Theil index of mental health beds in the eastern region was the smallest, and the largest index was in the western region. This finding means that the allocation of beds in the eastern region is the most equitable, and that in the western region is the least equitable. The Theil index in the eastern region declined from 0.058 to 2011 to 0.014 in 2020, which means that the allocation of beds was improving in the eastern region. T in the central region increased from 0.013 to 2011 to 0.024 in 2020, which means that the allocation of beds worsened in the central region. T in the western region did not change much.The inequity within these regions were the main cause for the overall inequity. The interregional Theil index for mental health beds declined from 0.008 to 2011 to 0.005 in 2020, and the corresponding intraregional Theil index dropped from 0.042 to 0.028. Despite slightly decreasing trends of both the intraregional and interregional inequity indices of mental health beds, the intraregional Theil indices continued to account for approximately 85 -95% of the total Theil index during the study period. This finding shows that the inequity within these regions were the main cause of the overall inequity. Next, we continue to decompose intraregional differences (Table Based on area, in 2020, the allocation of beds in the eastern region was the most equitable, while it was the worst in the western region. The Theil index between regions tended to decrease gradually, indicating that interregional inequity narrowed. Moreover, the inequity within regions worsened as the intraregional Theil index increased from 0.538 to 2010 to 0.614 in 2020. As shown in Table The Chinese government attaches great importance to health care. In recent years, a series of measures have been taken to promote the development of the mental health system. This study shows that the number of mental health bed resources in China increased steadily from 2011 to 2020, and the density of beds increased as well. The implementation of a series of medical reform measures, particularly the Mental Health Prevention and Control System Construction and Development Plan, which was launched by the National Development and Reform Commission, the Ministry of Health, and the Ministry of Civil Affairs in 2010, is closThe policy initiatives mentioned above have shown good results. However, there remains a disparity in the allocation of mental health beds between China and high-income countries. According to the data of the World Mental Health Atlas 2020, the allocation level of mental health beds in high-income countries is 5.1 per 10,000 people, while CIn this study, the Gini index was used to reflect the overall equality, while the Theil index was used to decompose the sources of inequity. To gain more insight, we evaluated the equality of mental health beds based on both population and geographic area. We found that equity in resource allocation has been improving annually over the past decade. According to population allocation, overall equality is relatively fair. Nonetheless, it is in a highly inequitable state according to geographic area. This result is not surprising since most resource planning programs were based on population allocation, with few focusing on geographic areas. Correspondingly, the equity of resource allocation by population was much better than that by geographical area. Many scholars have reached the same conclusion, 30. HowFrom the perspective of inequity decomposition, mental health bed resources in China are unevenly distributed across regions, and intraregional inequity is the main contributor. The findings are consistent with those of previous studies on the allocation of healthcare resources in terms of expenditure, facilitThe Chinese government has taken many initiatives and achieved great results in addressing the huge burden of mental disorders. However, China’s mental health service system development and service delivery still face many difficulties. In addiIt is important to recognize the limitations of this study. First, the research object of this article is the mental health beds in 31 provinces in China. We did not further subdivide mental health beds into different categories. Future studies need to be conducted by focusing on specialized mental health bed categories, such as public and private, profit and nonprofit, mental hospitals, mental health beds in general hospitals and community residential facilities. Second, this study mainly analyses the equity of mental health bed resource allocation from the perspective of demography and geography, without considering the actual mental health status and mental health service needs of different regions. Future studies should consider more factors to comprehensively evaluate mental health bed allocation. Third, in addition to mental health beds, health service indicators, especially the number of health professionals and the amount of public expenditure, should be emphasized in the allocation plan of mental health beds.This study’s results show that the total number of mental health beds in China has increased steadily over the past 10 years. However, large gaps still exist in the distribution of mental health bed resources between different regions. The equity of mental health bed resources by population is better than that by geographic area, and the disproportionate distribution of the mental health bed resources within different regions was the main source of inequity. Policymakers need to consider the geographical accessibility of health resources to ensure that people have access to available mental health services. The equality of the allocation of mental health beds within different regions, especially the western region, needs to be optimized.


Road traffic crashes are among the leading causes of death and disability in the world, particularly in low and middle-income countries. This study aimed at to conduct a social marketing formative research to inform the development of a campaign to manage driving speed on the intercity roads of Iran. To carry out the social marketing formative research, a qualitative and quantitative study were conducted. Also, a literature review of the speed management strategies was carried out and an analysis of traffic accident data and speeding violations was performed in selected provinces during 2019 and 2020. Based on the findings of the qualitative study, perceived sense of lack of speed control, poor monitoring system, and law enforcement are the main reasons drivers exceed the speed limit. They mostly suggest using punitive levers and more stringent law enforcement practices for speed management. Literature reviews also confirm that to successfully develop an effective speed management plan a set of measures should be implemented together, including road safety engineering, raising awareness, social marketing strategies, and finally strict law enforcement. The overriding findings of the formative research revealed that to persuade Iranian drivers to respect the speed limit, the messages of the campaign should focus on strict law enforcement in the selected corridors.In the minds of the Iranian audience, strict law enforcement is of paramount importance for a speed management strategy to work; hence it should be taken into consideration when tailoring the campaign messages. From the findings of the present study, it can be concluded that to manage speed on intercity routes in Iran, a social marketing campaign is needed to encourage compliance with speed limits. This is to say, every 24 seconds one person dies in a road crash.2 Approximately 63% of vehicles are in LMICs, yet 93% of deadly accidents happen in LMICs3 As the world population grows and with more use of motor vehicles, particularly in LMICs, it seems that the rate of deaths and injuries caused by road crashes in LMICs will rise in the coming years. This is a problem with proven solutions.Road traffic crashes (RTCs) are among the leading causes of death and disability in the world, particularly in low and middle-income countries (LMICs).5 There are two approaches to avoiding RTCs: the traditional approach and the systemic approach. In the traditional approach, human error is thought to be the greatest contributor to fatal crashes. Therefore, the main focus of this approach has been to change the behavior of drivers, reduce human error and thereby prevent injury crashes.7 However, the systemic approach tries to prevent deadly crashes from happening by building and managing a safe system in which responsibility falls on the shoulders of both drivers, road designers, and managers.8 The Safe System Approach (SSA) has been promoted by the WHO as an effective measure to improve road safety and has been adopted in many developed countries.9 The SSA reframes the way in which road safety is viewed and managed. The SSA aims to eliminate fatal and serious injuries for all road users.10 Therefore, since safe speed acts as one of the main pillars of the SSA it should be specifically administered for each road, in such a way that crashes do not lead to death or severe injury.11RTCs are a multifaceted problem, which can be broken into road-related factors, vehicle-related factors, and human factors.12 The death toll caused by road traffic accidents in the WHO Eastern Mediterranean Region countries has risen from 17.9 per 100,000 in 2013 to 18 per 100,000 in 2016, and speeding has played a major role in many of these crashes and deaths.1Data show speeding amplifies both the number and severity of crashes; hence speeding plays a significant role in more than one-third of deadly road crashes.14 It is estimated that if effective speed management strategies in Iran were successfully implemented, and the driving speed across the country's road network fell by 10 km/h, the number of deadly road crashes would decrease by 40%.15Driving over the speed limit is the biggest road safety problem in many countries, particularly in LMICs, including Iran.The speed management pilot project, based on the SSA and result-oriented management, will be implemented in three Iranian provinces: Khorasan Razavi, Isfahan, and Markazi. The present study is a part of the speed management pilot project, which was carried out with the support and advice of the Eastern Mediterranean Regional Office (EMRO) of the WHO.16 In the field of health, SM has been further defined as the customer-oriented use of commercial marketing principles and techniques to develop programs, interventions, and evaluations aimed to change health behaviors.17In this project, the social marketing (SM) approach acts as a theoretical basis for designing the speed management intervention based on the SSA. SM, along with education and enforcement, is considered as the three main ways to change behavior. SM is at the forefront of audience-centered behavioral models, and its main objective is applying commercial marketing to shape the voluntary behaviors of target groups to boost their well-being and social welfare. In this approach, participants’ desires and needs are assessed, and then interventions are designed and implemented to decrease barriers or to reinforce the benefits of an idea, a behavior, or a social action to promote them.18 Examining the current behaviors of the target group and the relevant factors shaping them can accordingly help planners and managers have a clear picture of the target group and their problems to design and implement tailored intervention programs.The present study was conducted based on Social Marketing Assessment and Response Tool (SMART). This model has seven stages, in this study, three stages of formative research including audience analysis, market analysis and channel analysis were used. In SM formative research, a comprehensive analysis of behaviors is conducted for providing a comprehensive picture of the current patterns and trends of current audience behaviors.19 Therefore, by listening to drivers who violate legal speed limits and collecting their ideas, one can understand decision-making processes about complying with speed limits. The results of this research help the behavioral intervention designers to understand how best to persuade drivers to voluntarily avoid speeding.According to the exchange theory in SM , if certain measures are adopted to change drivers’ perception of the benefits of speeding, in such a way that drivers think of speeding as a costly behavior, they would be more likely to refrain from driving at illegal and unsafe speeds.20 taxi drivers' views on risky driving behavior,21 reducing aggressive driving, reducing alcohol-impaired driving crashes,22 the "Drugged Driving Kills project: Why Drive High?”23In many countries of the world, SM has been considered as the basis of addressing driving problems, such as decreasing risky driving behaviors,25 Moreover, despite having passed training sessions, these drivers do not respect the speed limit. Given the fact that driving at the speed limit does not require special skills and drivers can easily adhere to these limits instead of exceeding them, educational interventions are not particularly effective in encouraging drivers to respect the speed limitations. This study aimed at to conduct a SM formative research to inform the development of a campaign to manage driving speed on the intercity roads of Iran.It seems that a majority of the drivers in Iran drive too fast, despite having enough information about the authorized speed and the consequences of speeding, as well as despite having the skill to drive without violating the speed limit.This article reports the application of the SM formative research to obtaining ideas for speed management intervention design. To do this, the following steps were carried out: a qualitative study, a cross-sectional survey, and an analysis of traffic crash data and speed violations in selected provinces. Besides, worldwide intervention strategies were reviewed to draw on other countries' best experiences. The qualitative studyStudy design26 A qualitative study was conducted based on the SM approach and its core concepts, particularly the SM mix namely product, price, place and promotion (4 Ps).16 The 4 Ps of marketing are the key factors that are involved in SM interventions. Marketing mix is a set of controllable tools that, by combining them, it will be possible to respond to the target market and audience group.17The directional content analysis approach was used to conduct a qualitative study. This method is usually classified based on the theory-based inductive method, and its differences with other methods are based on the role of theory in them.The purpose of the qualitative study was to obtain the opinions of the interviewees as to why drivers violate legal speed limits, the obstacles to respecting speed limits, appropriate methods to persuade drivers to comply with the speed limits, effective communication channels, and suitable places to convey campaign messages to drivers. Participants and Data collection27 Individual interview questions were tailored with an emphasis on the marketing mix. These questions include:In each of the pilot provinces, two officials from the Department of Highways and Road Transport, two officials from the Traffic Police, and two members of non-governmental organizations working in the field of road safety answered questions in the form of semi-structured-in-depth telephone interviews. In addition to interviewing these individuals, telephone interviews were conducted with selected drivers in the target provinces. In total, in-depth interviews were administered with 15 experts in the field of speed management and eight selected drivers in the target provinces. These people were selected purposefully. Department of Highways and Road Transport and Traffic Police in each provinces introduces key informant people. Telephone interviews were held by the second author of the article. The basis of data collection in qualitative studies is to achieve data saturation.1) What is your general opinion about the current state of driving speed in the country? 2) What factors do you think to encourage drivers to exceed the speed limits? 3) If drivers in Iran wanted to follow the speed limits, what do you think would prevent them?4) How do you think drivers can be persuaded to adhere to the speed limits? 5) In your opinion, what options are available to communicate with drivers and leave an impact on their driving habits? 6) Where do you think are the most suitable places to make an influence on drivers? Data analysis28 Data analysis performed simultaneously with data collection and carried out by using directed content analysis in three phases, namely preparation, organization, and reporting. After each telephone interview, the audio file was transcribed by the interviewer. The collected data were analyzed using MAXQDA software version 10. Two Researchers examined the qualitative data separately and assigned their preferred codes to the participants' responses at the sentence level. After the coding was completed, the two researchers reviewed each other's codes and resolved issues of disagreement through discussion. In cases where no agreement was reached, a third party assisted.Directional qualitative content analysis was applied to categorize the interviewees' answers to each question.The analysis of traffic accident data and speeding violations in the selected provincesThe information available in the databases of institutions dealing with traffic crashes and speeding violations in selected provinces of the country were consulted to determine the specific target audience and intercity corridors suitable for the administration of the pilot study in the campaign designing. Having granted the consent of the country's officials and officials in the selected regions, the required data were provided to the research team. Cross-sectional study29 According to the TPB, the behavioral intention is the most proximal determinant of human social behavior.30 This theory has been applied to driving behaviors such as aggressive driving,31 texting while driving,32 using mobile phones while driving,30 and driving while drunk.33The cross-sectional study was done to a deeper understanding of the factors affecting speeding among drivers in the selected provinces. To do this study, we applied theory of planned behavior (TPB). The TPB is a psychological theory that links beliefs to behavior. The theory maintains that three core components, namely, attitude, subjective norms, and perceived behavioral control, together shape an individual's behavioral intentions.34 The questionnaire was translated and localized by a member of the research team to be used among drivers in Iran. After this, the questionnaire was compiled into an electronic version, and drivers were asked to answer it using a link. Finally, the quantitative survey was completed by 164 drivers in the selected provinces. Data obtained from the cross-sectional survey were analyzed using SPSS version 16.Data was collected by using TPB questionnaire. The questionnaire was developed by Boissin and et al. to determine the factors affecting speeding among new generation of Omani drivers.Speed management literature reviewA global literature review of the speed management strategies was carried out to benefit from successful experiences in other countries. With this objective in mind, search operations by using the keywords "driving speed management" and "reducing driving speed" were performed on Google Scholar and PubMed databases, as well as Persian data base Magiran, SID, and IranMedex. All articles published in English or Persian from 2000 to 2020 were searched in these databases. Papers that aimed at driving speed management were selected. Ethical ConsiderationsAt all stages of the study, participants were given a full explanation about the objectives of the study and voluntary participation. After that their informed consent was obtained and data were collected. Participants were assured that their information would remain confidential. This study aimed to conduct SM formative research to inform the development of SM campaign to manage driving speed on intercity routes in a selected number of provinces in Iran. In the following sections, the findings of each step of the study are presented. The findings of the qualitative studyIn this stage, 23 people, including drivers and people working in the field in the three target provinces were interviewed. Almost all the interviewees stated that most drivers do not respect the speed limit on intercity routes. Respondents' answers to the question of why drivers exceed the authorized speed limits are summarized in The respondents believed that suitable places for the implementation of the speed management project were: gas stations, roadside welfare complexes, toll booths, roadside shopping malls, road police stations, highways and road transport stations, along the roads, city exits, and road stations in summer and new year travels. When asked about the proper communication channels for conveying campaign messages to drivers, the respondents mentioned television and radio with an emphasis on television, billboards, posters and brochures, cyberspace, and the Internet, respectively.Almost all experts and drivers believe that the monitoring system and law enforcement are not properly administered in Iran. Drivers feel that no one is monitoring them on the road. They also believe that in terms of being subjected to punishment there is no difference between a driver who respects the speed limit and a driver who does not. In general, the findings show that speeding violations in Iran are not met with strict law enforcement.Findings of data analysis regarding traffic accidents and speed violationsThe analysis of data regarding the traffic accidents and speed violations on intercity routes in selected provinces revealed that the following routes are suitable for the project administration: Isfahan-Morche Khort-Meymeh-Delijan route and Najafabad-Tiran-Daran route in Isfahan province, Kahak-Sabzevar-Neishabour route, and Chenaran-Qoochan-Farooj route in Khorasan Razavi province, Saveh-Tehran freeway route and Arak-Salafchegan route in Markazi province. The analysis of these data also indicated that a suitable target group for the implementation of the pilot project includes male drivers aged between 20 to 50 who own a private car. Results of the literature review of speed management strategies36 Successful and effective speed management practices depend on strong political support, regular and systematic monitoring of road safety levels, and continuous evaluation of executive actions.14 Furthermore, any speed management intervention should be implemented based on accurate assessments of the current situation as well as available resources and technologies so that the plan remains active over time.35 Another important finding of the literature review was that intervention programs based on educational and SM, engineering, and law enforcement should be conducted in conjunction with each other.37 The literature recommends that, in LMICs, low-cost solutions to fit with existing resource limits and technology could be used.5 The next step after that is to design and implement educational awareness campaigns and SM programs with an emphasis on speed limits to inform drivers that exceeding speed limits is not wise behavior as they will face punishment and legal fines.38 Finally, active law enforcement should be administered for drivers who do not comply with the speed limits.39A total of 18 studies was were reviewed. Results of the literature review show that making a significant change in the average driving speed is not feasible without conducting long-term and continuous intervention measures.41 Also, it is of paramount importance to follow up on delays in the payment of driving fines so that their preventive role is observed. Moreover, some studies show that removing speed cameras from a specific road leads to higher driving speeds on that route.41Law enforcement can be seen in almost all strategies used for speed management. Also, the use of speed cameras is one of the most widely used methods in speed management programs. One notable finding was that when speed cameras are used as a speeding detection system, it is necessary to promptly inform drivers of their violations and a fine ticket is sent to them.42 Therefore, speed management interventions should be designed in such a way that most drivers accept them. Speed management interventions also show that in designing the intervention programs, it must be clear why drivers do not adhere to the speed limits. In other words, designers of speed management interventions need to know the motivations of drivers exceed legal speed limits.Besides, the results of the literature review show that the use of different speed management strategies often depends on road characteristics and drivers' attitudes toward these strategies, as well as the economic and technological capabilities of the country.The quantitative study findings The mean and standard deviation of the age of the respondents was 35/92 and 7 years, respectively.The items that always or most often reminded drivers to respect the speed limit were: traffic signs (70%), observing a crash scene (68%), speed detecting signs (65%), crashes involving family and friends (58%), family members (45%) and speeding fines (43%). Quantitative survey findings also showed that encountering a crash scene (68%), speed signs (66%), family members (66%), traffic signs (65%), and crashes involving relatives and friends (60%) are among the factors that always or oftentimes encourage drivers to drive at the speed limit. The factors that help drivers to respect the speed limit are speed cameras (77%), stationary police cars (76%), police patrol cars (70%), imperceptible speed monitoring system (60%), text messages containing police warnings (64%) and getting pulled over by the police (63%), respectively. Insights for SM campaign development• Analysis of data on road accidents, drivers of vehicles involved in accidents, and speeding offenders determined that male drivers between 20 and 50 years of age who drive a private car are the best and most suitable target group for the project. Also, by determining two corridors in each of the three target provinces of the program, the location of the campaign was determined.• Regarding the specific target group and the selected routes for the campaign, it should be noted that these drivers are traveling in the selected corridors for a short time and the intervention plan is designed according to these limitations. Drivers entering the selected corridors of the program will be informed about the differences between these routes and other routes and will be warned that in these routes, legal consequences of speeding violations are serious.• Findings of the quantitative and qualitative studies also support that speed management plans in Iran ask for legal and regulatory measures to be strictly applied and drivers who do not follow the rules should face the consequences. Since law enforcement is highly prominent in the minds of the Iranian audience, it should address in the messages of the SM campaign. • To gain the attention of drivers, campaign messages should highlight the differences between selected corridors with other roads and paths. Also, for many drivers and experts, highlighting the legal and health consequences of speeding, particularly getting pulled over by the police and facing penalties, suffering injuries, and even death in a crash are effective reminders to respect the legal driving speed. For this purpose, four messages were specifically tailored to encourage drivers to respect the speed limit. The main contents of the messages are speed control by the fix and mobile cameras, stopping the offenders by the Police, heavy fines of offenders, and more mortality and morbidity. Therefore, without improving the law administration process and strictly monitoring it, one cannot expect any improvement to come from the SM campaign. Strict law enforcement by the police plays a key role in completing and advancing the speed management intervention plans based on the SSA.• The SM campaign should influence the minds of drivers and encourage them to drive at the permitted speed. In this persuasion, the main focus of the program and its components is to highlight the health and legal consequences of driving at illegal speed. • The aim of the campaign is to improve the behavior of drivers and reduce the percentage of drivers who drive at illegal speeds. After preparing all the stages of the program, a two-week period can be used to inform and justify the drivers entering these selected routes. This opportunity is used to explain the program in general, how it is implemented, goals, and when the program will start, in order to provide a mental background for the implementation of the program.• The success of the project depends on the appropriate support of legislators, policymakers and managers, as well as the participation of drivers. In order to create a commitment to support and implement this program, it is necessary to involve them.39 signs indicating the speed of drivers,42 increasing the number of fixed and mobile speed control cameras43 have been used in different countries.The aim of the present study was to gain insights to guide intervention development. To do this, SM formative research was applied. According to opinions of interviewees, highlighting the consequences of speeding, especially being stopped by the police and being fined, getting into an accident and being injured in an accident, and even dying, are good reminders to respect the speed limit. Therefore, these items should be considered in designing the campaign. In many other studies, reminders have been used to comply with the speed limit. For example, speed limit flashing lights,43 In Italy, a highway was selected for speed management intervention.44 In Tehran, in order to reduce dangerous driving behavior, the drivers of the two regions with the most violations were selected.20By determining two corridors in each of the three provinces and considering male drivers aged 20 to 50 who drive in these corridors, the specific target group of the social marketing campaign was formed. The designers of the intervention for speed management in Ghana also identified the areas where the most speed violations were committed.14 In this regard, many intervention programs have used a set of legal and engineering measures combined with behavioral interventions.47 For example, in designing a public campaign called "Safe Speed", the focus was firstly on informing drivers of the dangers of speeding and the role of speed cameras. Later, drivers were informed that speed cameras have been installed in different areas.40 Another SM campaign, called Wipe Off 5, was designed to support the intensification and expansion of the police actions in controlling speed measures.45 In the speed management intervention plans in Canada, a series of legal and educational measures were taken to ensure drivers comply with the new speed limit.42The findings of quantitative and qualitative studies emphasize the need for legal and regulatory measures to identify drivers who drive fast and deal with them. In line with the findings of the present study, Gupta has also mentioned in designing social marketing campaign that a set of measures including consolidating legal action, seeking support for legislation, police training, and developing a SM campaign for speed management should be taken into consideration.49 Moreover, positive attitude and higher perceived behavioral control towards speeding were the important predictors of the intention of respect to the posted speed limit. In line with the results of a quantitative study, among Indonesian and Omani drivers, speed intention is directly influenced by attitude. Attitudinal messages were used in the design of speed management interventions in these two countries to reduce driving speed.51Results of the online survey indicated that Iranian young drivers often do not follow the speed limit and are interested in speeding. This finding in consistent with similar studies. In Australia, Oman, Turkey and most of other comprise young drivers drive too fast are the target group for many speed management interventions.This study must be viewed in light of limitations. The focus of the study was on speed management on intercity roads, and this issue should be taken into account when interpreting and generalizing the results. Also, the research team was supposed to make a field visit to the studied provinces, but it was not done due to the epidemic of Covid-19. The literature review was not systematic and restricted to the scientific-reviewed paper and Google Scholar and PubMed databases. However, with these limitations in mind, according to the results of the formative research, it can be recommended and concluded that male drivers aged 20 to 50 who drive their private cars were the most appropriate target group for the project. Moreover, by defining two corridors in each of the three target provinces, the audience of the SM program was formed. The SM approach intends to leave an impact on drivers and encourage them to drive at the speed limit. In this encouragement, the main focus of the program and its components is on highlighting law enforcement, as well as highlighting the health and legal consequences of speeding. AcknowledgmentSpecial thanks to Dr. Hala Sakr Ali, Violence, injuries and disabilities, (WHO), Regional Office for the Eastern Mediterranean, and Dr. Lori Mooren, Safety and Communications, Sydney, Australia.


The recent decision to remove race-based calculations of kidney function for candidates on the national waitlist approved by the OPTN Board has set the tone towards a more equitable assessment of prospective transplant and donor candidates . The chaIn greater detail, there remains a disparity in providing equitable access to racial minorities , especiaEvidence is lacking regarding ethnicity and organ donation in Europe. In fact, data collection is not generally undertaken and standardized, based mainly on self-identification or recorded country of birth. Furthermore, the discrepancy between national methodologies limits access to data for various minority groups, which in turn renders not only national, but also gathered European data collection less reliable than and less comparable to what happens in the USA . AdditioIn the UK, non-white ethnic minorities, comprise 11% of the population, 7% of organ donors, 35% of people awaiting a kidney transplant and 21% of people who died on the waiting list , with miDemographic characteristics of donors , recipieRace is a variable often considered in eGFR calculations, with the potentiality to overestimate renal function in Black patients, causing about 16% misclassification of kidney disease stage , and thuAs a result of health inequality, Black and Asian minority people in need of a kidney transplant wait for longer in comparison to their Caucasian counterparts . This haTo possibly meet the organ donor offer, LDKT not only represents the best opportunity of success in terms of definitive renal replacement therapy, but it also allows pre-emptive treatment of kidney failure. Since LDKT is unfortunately a precious resource not available for everyone, educational campaigns aiming to expand living organ donation should target these minority backgrounds, and content related to risks for the altruistic act of donation by Black and Asian candidates should cover topics related to the effects of donor and recipient races on the respective health outcomes.What is then the available evidence on the effect of race on living kidney donors, and the impact on recipients’ outcomes? As previously stated, data on post-donation eGFR might be affected by the formulas used in the calculation, so they remain heterogenous and inconclusive, therefore a more accurate analysis could focus on the percentage change in eGFR or slope eGFR in longitudinal observations  or in a per se, should not be a barrier to increase the living donor kidney pool: on average, 88% of the entire living donor pool of this international cohort are Caucasian, but with the help of the previous mentioned educational campaigns, up to 40% of Black and Asian minorities have proven to be a realistic target to contribute to the living organ donor pool   < 0.001 . There h < 0.001 ; howeverFinally, if we look at what happens to Black kidney transplant recipients, in a recent meta-analysis we demonstrated no significant difference between the 1-year mortality in comparison to Caucasians , as wellIn conclusion, Black deceased donors are more likely to experience CKD compared to Caucasians, mainly in view of the trends present in the general population.This should not be considered a barrier to the expansion of the living donor pool and the possibility to offer LDKT to candidates of Black and Asian minorities should instead be concrete and actively incentivized.The new proposed OPTN/UNOS race-neutral eGFR calculations  might beWe believe that future studies need to focus on how to overcome this barrier in consideration of the current organ donor shortage, to minimize the effect of race in kidney function and provide equitable access to individuals of different socio-racial backgrounds. We also strongly support the omission of adjustment for ethnicity in the eGFR formulas, in agreement with current research looking at new endogenous filtration markers and interventions to eliminate racial and ethnic disparities, supporting consideration in health outcome differences due to health inequalities rather than race.Transplant and Nephrology Societies should favor this new policy change to intervene on the long overdue negative impact of race on eGFR, with the aim to reduce delayed referrals for transplant and delays in qualifying for waiting time and for donor’s eligibility. Equity in health means “equal opportunity”  and thus


Overconsumption of energy provided by energy-dense, nutrient-poor (EDNP) food and drinks increases the risk of unhealthy weight gain and of obesity-related health outcomes. The aim of this study was to develop a nutrient profiling model for classifying EDNP food and drinks and to estimate the amount of discretionary energy for EDNP food and drinks in a recommended diet. A stepwise approach was used first to develop a nutrient profiling model for classifying EDNP food and drinks and then to estimate the amount of discretionary energy in a recommended diet using diet modeling. The nutrition profiling model comprised 24 macro- and micronutrients and energy density. The model classified 67% of 1482 foods and 73% of 161 drinks correctly as EDNP food and drinks compared with an expert-adjusted model. Sweets, chocolate, cake, cookies and biscuits, sweet and salty snacks, sugar-sweetened and artificially sweetened drinks, and alcoholic drinks were classified as EDNP food and drinks. The estimated amount of discretionary energy for EDNP food and drinks was 4–6% of the energy requirements for 4–75-year-old Danes. It seems prudent to have special attention on EDNP food and drinks in dietary guidelines and future public health initiatives to avoid overconsumption of energy. Findings from the Global Burden of Disease Study 2015 show that the prevalence of overweight and obesity among children and adults is a large and increasing public health problem around the world ,4,5,6,7.Data from Euromonitor 2018 show that people in Western countries have a high consumption of EDNP food and drinks, and Denmark holds the world record in consumption of candy. On average, people in the Scandinavian countries, the Netherlands, the USA, England, and Italy buy between 32 and 51 kg candy, chocolates, cake, ice cream, dessert, and snack bars each year [Despite the relevance of reducing the intake of EDNP food and drinks, there exists no internationally agreed definition of EDNP food and drinks or how to classify these food and drinks. They are often referred to as food and drinks that are high in fat, added sugars, sodium, and alcohol while containing low levels of nutrients. In the Dietary Guidelines for Americans 2020–2025, they are referred to as “Limit Foods and Drinks Higher in Added Sugars, Saturated Fat, and Sodium, and Limit Alcoholic Drinks” , and in For people themselves to be able to limit the intake of discretionary food and drinks, it is essential that they know which food and drinks are classified as discretionary, and the maximum amount of EDNP food and drinks that may be included in a recommended diet.The aim of this study was therefore, first, to develop a nutrient profiling model for classifying EDNP food and drinks and then to estimate the amount of discretionary energy for EDNP food and drinks in a recommended diet to inform official dietary guidelines and future public health initiatives.First, a nutrient profiling model, including 24 macro- and micronutrients and energy density, was developed and used to score 1482 foods and 161 drinks in an attempt to classify EDNP food and drinks. Second, the classification of EDNP food and drinks was used in modeling recommended diets and estimating the amount of discretionary energy. The study design is illustrated in Four key terms were used in the current paper: EDNP food and drinks were defined as food and drinks that contain a lot of energy per serving but few nutrients. Core food and drinks were defined as food and drinks that, in appropriate amounts, contribute to a healthy and varied diet that satisfies the nutritional needs and supports overall good health. Discretionary energy was defined as the maximum amount of energy that can be used for EDNP food and drinks in a recommended diet. A recommended diet was defined as a healthy and varied diet that meets the Nordic Nutrition Recommendations 2012 and the official Danish Dietary Guidelines 2013 ,14.The method for developing the nutrient profiling model consisted of three overall steps summarizing the approach suggested by Scarborough et al. (2007)  and the The development of the model involved testing 1482 foods and 161 drinks from a comprehensive food list. The food list was developed for the most recent Danish National Survey of Diet and Physical Activity (DANSDA 2011–2013) and therefore contains a wide selection of the most common food and drinks that Danes consume. The list of food and drinks includes both single foods and composite foods such as burgers and smoothies. Foods and drinks were scored separately, as drinks generally have a much lower nutrient and energy density than foods. Information about nutrient content originates from analyzed data retrieved from the Frida database 4, which was published on 2 August 2019 .We used the across-the-board approach to score food and drinks in absolute terms as the aim was to assess the nutrient profile of each food or drink. As no single food contains all nutrients in the quantities that a person needs, the authors decided to include a wide range of qualifying and disqualifying nutrients in the model. These include 24 macro- and micronutrients where reliable food data have been published . FurtherEnergy density is defined as energy per gram of a food or drink and may be used as an indicator of the risk of overconsumption of energy. The cut-off value for energy density for foods was set at 900 kJ/100 g, corresponding to a high energy density according to the World Cancer Research Fund/American Institute for Cancer Research . Foods wWe decided to weigh qualifying and disqualifying nutrients and energy density equally in the model, i.e., with ⅓ each, since it was not possible to find scientific evidence for prioritizing the scores for qualifying and disqualifying nutrients and energy density. The model calculation is illustrated in The actual calculations of the scores were performed in Microsoft Excel 2016 and checked in SAS, SAS Institute Inc. Cary, NC, USA (Version 9.04).The cut-off value for classifying EDNP food and drinks was selected pragmatically by the nutrition expert group. The expert group consisted of the authors who have expertise with the development of nutritional profiling models and estimation of discretionary energy using dietary modeling ,20. To dAfter the classification of all food and drinks with the nutrient profiling model, quantitative criteria of agreement between the expert-adjusted model and the nutrient profiling model were estimated. After classifying food and drinks with the nutrient profiling model, exceptions and reclassifications of food and drinks were made. This resulted in an expert-adjusted model for food and drinks.Model validity was measured by sensitivity and specificity analyses. These analyses were performed with the selected cut-off value. Core food and drinks with a score above the cut-off value were considered true positives, while those with a score less than or equal to the cut-off value were considered false negatives. Similarly, EDNP food and drinks below the cut-off value were true negatives, while those above were false positives. The number of food and drinks in these four categories is the predicted classification.The classification of food and drinks by the expert-adjusted model was included as a response variable, and the nutrient profiling model score was included as a prediction variable.The sensitivity ratio aims to test if the proportion of food and drinks classified as core foods or drinks by the profiling model also belong to the food and drinks classified as core by the expert-adjusted model. The specificity ratio aims to check if the food and drinks classified as EDNP by the profiling model also belong to the food and drinks classified as EDNP food and drinks by the expert-adjusted model. An ideal nutrient profiling scheme will result in a sensitivity ratio and a specificity ratio equal to one.Finally, the receiver operating characteristic (ROC) curve was used to investigate the cut-off value and balance between false negatives and false positives. Key parameters were calculated in IBM SPSS Statistics, IBM Corp., New York, NY, USA version 25.To examine how much energy is available for EDNP food and drinks in a recommended diet, dietary intake patterns were modeled to provide suggestions for healthy and nutritionally appropriate diets at different energy levels. The modeling was conducted on the eaten diet and not the raw ingredients as the Nordic Nutrition Recommendations 2012 refer to nutrient intake . The dieCriteria were that the recommended diets should meet the Nordic Nutrition Recommendations 2012  and the Furthermore, the goal of the recommended diets was the recommended intake of dietary fiber and macronutrients as a percentage of the total energy intake (E%) and an intake of 10 vitamins and 8 minerals corresponding to the Recommended Intake (RI) or higher. The recommended diets were designed for use by individuals in specific age and sex groups. The RI is intended to be used for diet planning for groups of individuals in specific age and sex groups .The number of age groups necessary when considering differences in the energy and nutrient requirements between groups.The variation in energy requirements within an age and sex group constitutes a maximum of 10% (maximum 1 MJ/day) compared to the average energy requirement in the age and sex groups.A sufficient number of participants from DANSDA 2011–2013 for the diet modeling.Age and sex groups for the recommended diets were determined from the variation in energy requirements according to the Nordic Nutrition Recommendations 2012 and taking into account:The energy requirement in each age and sex group was set as the average of the lowest and highest energy requirements within the group and was based on a moderate activity level determined by pedometry in the Danish population .Each food or drink group was based on actual intakes in Denmark and composed of the same proportions as they are eaten or drunk by different sexes and age groups. The nutrient profiles for each composite food group were therefore different depending on age and sex. A total of 38 food and drink groups were formed.The recommended diets were constructed by performing a nutrition calculation for the different age and sex groups based on the composite food and drink groups and the amounts of food and drinks stated in the dietary guidelines per 10 MJ adjusted to the different energy levels. For the remaining food and drink groups that were not included in the dietary guidelines, the intake from DANSDA 2011–2013 was maintained. If nutrient goals were not met, the modifiable elements were main food group or subgroup amounts, including/excluding certain foods.The maximum amount of energy for EDNP food and drinks was estimated as the difference between the energy content of the modeled recommended diets and the total energy requirement for each age and sex group.In the official Danish Dietary Guidelines 2013 and the Nordic Nutrition Recommendations 2012, the goal for the total diet is that the content of added sugars and saturated fat should be less than 10% of energy. Therefore, the robustness of the estimated amount of discretionary energy was tested by examining the influence on the diet content of saturated fat and added sugars if the entire discretionary energy was used for single foods or drinks that contained a lot of saturated fat and/or added sugars such as chocolate or hard candy.The amount of discretionary energy was also calculated for persons with a low or high level of physical activity. The calculations were conducted on the assumption that the proportion of the energy requirement that can be used as discretionary energy at the different activity levels was the same as for a moderate physical activity level.A decrease in the model scores of 2 points was seen for every 5th percentile from the 95th percentile (score = 90) down to the 30th percentile (score = 61). From the 25th percentile (score = 54) and down, the score dropped by 7 points for every 5th percentile, indicating a substantial drop in the nutrient value of the foods. In order not to overestimate the number of EDNP food and drinks, the nutrition expert group selected a score of 40 as the cut-off value. All foods and drinks with a score above 40 were classified as core foods, while food and drinks with a score ≤40 were classified as EDNP food and drinks.Some food and drinks were manually reclassified from EDNP food and drinks to core food and drinks and vice versa. This was done to make it easier to communicate what types of food and drinks are classified as EDNP to the Danish population, but also to make the classification less sensitive to changes in the nutrient composition of single products. Some fatty meat products, cheese products, sweet breakfast cereals, and a single fish product were moved to core foods, where the most foods were placed. The reverse was also the case, i.e., some cakes, desserts, and ice cream products were classified as core foods by the nutrient profiling model and were moved to the EDNP food and drinks by the nutrition expert group.Four EDNP food groups were reclassified as core food groups and one core drink group as EDNP drinks by the nutrition expert group independent of the model scoring: (1) vegetable oils were reclassified as a core food group due to their beneficial fatty acid composition, aligning with the official Danish Dietary Guidelines; (2 + 3) visible sugars and fat spreads were reclassified as core food groups as they are primarily used as ingredients and only consumed in small amounts, e.g., on bread or in coffee/tea; (4) water was reclassified as a core drink because it contributes to the fluid balance without providing unnecessary calories, aligning with the official Danish Dietary Guidelines ; (5) artThe food scoring interval of the 1482 foods was from 18 (chocolate bar) as the lowest value to 96 (Brussels sprouts) as the highest. Most foods scored between 60 and 90 (core foods), while approximately 14% scored 40 or less (EDNP foods). For drinks, a significantly larger proportion (40%) scored 40 or less (EDNP drinks).Vegetables (including legumes), fruits and berries, composite dishes, fish, and potatoes scored the highest. Fat- and sugar-rich foods such as candy, chocolate, sugar-free candy and chocolate, cakes, biscuits, snack bars, ice cream, desserts, and snacks  scored the lowest .Drinks such as water, tea, and coffee with and without milk scored the highest (70–89), and sugar-sweetened soft drinks, cordials, energy drinks, and sports drinks as well as alcoholic drinks  scored the lowest (14–31) of the total 161 drinks. Food and drinks with a score below 40 were classified as EDNP food and drinks and are shown in p < 0.001) indicates that the model is good at classifying foods as core and EDNP foods.As shown in As shown in p < 0.001) indicates that the model is good at classifying drinks as core and EDNP drinks.The test result from the ROC procedure of 0.89  and might have saved some of the reclassification carried out by the nutrition expert group.The recommended diets are illustrated in As shown in Zero intake or as low an intake as possible of sugary drinks is recommended internationally to prevent the development of obesity and the risk of obesity-related diseases ,4,7,23. The robustness tests showed that a predominantly one-sided choice of fatty discretionary foods such as chocolate makes it difficult to comply with the nutrition recommendation for saturated fat if the amount of discretionary energy is too large. As the amount of discretionary energy should comply with nutrition recommendations, we believe it is sensible to convey the robustness-tested amount of discretionary energy to the public. In Physical activity does not significantly increase the amount of discretionary energy. By going from a low to a high level of physical activity, there is room for approximately one extra portion of EDNP foods or drinks (data not shown).The results show that the nutrient profiling model classified around 70% of 1643 foods and drinks correctly as EDNP compared with an expert-adjusted model. The specificity of foods was 67% and the sensitivity 94%, while the specificity of drinks was 73% and the sensitivity 97%. Candy, chocolate, cake, cookies and biscuits, sweet and salty snacks, sugar-sweetened and artificially sweetened drinks, and alcoholic drinks were classified as EDNP food and drinks. The estimated amount of discretionary energy for EDNP food and drinks was 4–6% of the energy requirements for 4–75-year-old Danes.Studies assessing healthy and less healthy food and drinks with nutrient profiling models and estimating discretionary energy in a recommended diet are sparse. Anyway, we compared our main findings with the relevant studies.The authors are not familiar with other studies that have classified EDNP food and drinks with a nutrient profiling model. Quinio et al.  found a Although a nutrient profiling model may be useful to classify food and drinks, it cannot stand alone. It is necessary to make pragmatic decisions and exceptions for some food and drinks, such as ASD.ASD were placed among EDNP drinks, although the profiling model classified them as core drinks. The available evidence does not directly support the role of ASD in promoting or preventing weight gain or metabolic abnormalities . EvidencFurthermore, ingredients such as fats and sugars were also reclassified as core foods after the scoring with the nutrient profiling model because they are regarded as ingredients in food preparation in Danish food culture. We believe the nutrition profiling model and the approach to estimate the amount of discretionary energy may be useful for other nutrition researchers when defining EDNP food and drinks. However, exceptions and reclassifications of some food and drinks will most likely be necessary when adopting the approach for other food cultures.The 4–6% of the energy in a recommended diet that may be used on EDNP food and drinks is consistent with the WHO’s recommendation and the EFSA’s opinion on dietary sugars, emphasizing the additional health benefits of reducing the intake of free sugar to less than 5% or as low as possible of the total energy intake ,32. ReceDenmark, the USA, and Australia have used a similar diet modeling and a comparable method to estimate the amount of energy for EDNP food and drinks . HoweverThe authors decided to communicate discretionary energy as portions of EDNP food and drinks where each portion corresponds to a fixed amount of energy. The Dietary Approaches to Stop Hypertension (DASH) diet is an example of a recommended diet in the USA ,9. In thThe safest amount of discretionary energy in the recommended diet is the one tested for robustness. Unlike for fruit and vegetables, fish, and whole grains, there is no recommendation to vary the intake of candy, chocolate, soft drinks, or alcoholic drinks; therefore, it is important that the amount of discretionary energy is robust, so it is possible to choose favorable EDNP food and drinks freely.The disease burden in Denmark shows that obese people have a shorter life expectancy, higher sickness absence, and a greater disease burden . TherefoIt is a strength that the nutrient modeling of the recommended diet was based on real intakes of food and drinks consumed by the Danish population, making the recommended diets more credible.There are several limitations in the present study. The approach and method of the nutrient profiling model may appear complex. However, the nutrient profile scoring is based on simple calculation rules with no complex statistics that are easily performed in an Excel sheet or in statistical software programs. The scoring of nutrients and energy density in the model follows simple principles and calculation rules, as shown in It may also be seen as a limitation that expert judgement overrules the classification by the nutrient profiling model of some foods and drinks. However, exceptions were also made by other well-known nutrient profiling models such as the Nutri-Score, where alternative nutrient criteria and/or pre-determined cut-off scores are considered for certain cheeses, fats, and beverages ,26. In oAs the present nutrient profiling model could be used to inform dietary guidelines, it is also important to align with other foods and drinks highlighted in the dietary guidelines such as water and plant-derived fats. A point for consideration for future development of the model could be how to handle exceptions. One suggestion could be to exclude exceptions, e.g., according to dietary guidelines before scoring. Still, this is also a subjective decision.The values in the food composition tables used for the nutrient profiling model are average values with large variation, which may result in some inaccuracy both in the nutrient profiling and in the suggested amounts in the recommended diets. Furthermore, missing values for vitamins were found, especially for alcoholic drinks and artificially sweetened candy. However, since alcoholic drinks and artificially sweetened candy contain few vitamins, they were kept in the model. We also applied the same weighting of all 24 nutrients which may be a weakness in the model, although it is not possible to do it in a different way based on the existing knowledge. The model will not necessarily be suitable for classifying fortified foods in their present form, and these should probably be assessed separately. Another limitation was how the cut-off value was set. The cut-off was selected by the nutrition expert group, guided by the scores, the curve of the scores, and the types of food groups below and above the value. The ROC procedure showed that the cut-off of 40 was set too low as a score around 53 probably would have reduced the reclassification of food and drinks. However, there was no objective way of setting the most accurate cut-off. The setting of upper and lower cut-off values for energy density is also a limitation. As there is no common or standard definition of the energy density of high-energy-dense foods, we choose a cut-off value published by the World Cancer Research Fund/American Institute for Cancer Research in 2007 . For driThe present study is the first to classify food and drinks that may be defined as EDNP according to a nutrition profiling model and nutrition expert judgement. Candy, chocolate, cake including cookies and biscuits, sweet and salty snacks, and sugar-sweetened and artificially sweetened drinks, as well as alcoholic drinks, were classified as EDNP food and drinks. Our study may be viewed as a starting point and inspiration towards an international discussion on how to define EDNP food and drinks. Furthermore, the amount of discretionary energy that may be used for EDNP food and drinks in a recommended diet was estimated to be 4–6% of the energy requirements for 4–75-year-old Danes.It seems prudent to have special attention on EDNP food and drinks in dietary guidelines and in future public health initiatives to avoid overconsumption of energy and prevent overweight. EDNP food and drinks classified by the nutrition profiling model and the estimated amount of discretionary energy may be used to inform dietary guidelines. If people are to limit their intake of EDNP food and drinks, they must know what is classified as discretionary food and drinks, and the amount of these food and drinks that may be included in a recommended diet.


Together with the “law of entropy”, two of the main reasons for the risk of burnout among physicians who work in emergency departments around the world are the variety of clinical issues presented by patients and the absence of guidelines for managing most of them.Medicina, entitled “Emergency medicine and emergency room medical issues”, was planned on this basis, and physicians around world were invited to contribute papers regarding any type of clinical experience in this field.For this reason, to be an active worker in the emergency room is one of the most complex types of role experienced in the health system. This Special Issue of Of course, this being a Special Issue born in the COVID-19 era, several articles focus on various aspects of the outbreak of this disease. The management of emergency rooms during the outbreak changed all around the world, as protective equipment, isolation rooms and contumacial areas were measures adopted in the first wave of the pandemic , with coOf course, cardiovascular diseases also occupy a relevant place in research conducted by scholars around the world. Useful information regarding the use of a mobile cloud 12-lead ECG transmission system for patients with acute coronary syndrome that aims to optimize the time for the “first medical contact to ballon (FMCTB)” and revascularization is provided in . On the Of course, to perform an etiological diagnosis of a rare infectious disease in the emergency department is very difficult and, when possible, it is frequently associated with atypical clinical manifestations. Several intriguing case reports from this field are reported in the present Special Issue, focusing on the origins of bacterial pericarditis ,20.Hematological abnormalities are also a matter of discussion in the daily clinical practice of emergency departments for both children  and adulPoisoning plays a significant role in several cases. Thus, the identification of rare clinical presentations or side effects of drugs or external agents always represents a difficult clinical scenario in the emergency room ,24.Furthermore, several life-threatening diseases such as cardiogenic shock or severe pulmonary embolism, of which clinicians have started to gain substantial clinical experience, are now being treated with extracorporeal membrane oxygenation, which represents a new frontier for emergency departments .However, although acute illnesses affecting non-surgical areas are fascinating, trauma also represents a significant area of hard work in emergency departments. The usefulness of magnetic resonance imaging has been underlined several times in the history of medicine, although this radiological support is unfortunately not available in all emergency departments ,27. Conv


Poland has implemented two major organizational changes in recent years to improve cancer care. In 2015, a dedicated ‘fast pathway’ to diagnostics and treatment was implemented for patients suspected of having cancer. In 2019, the National Oncology Network began pilots in four regions of care pathways for cancer at five sites. Neither has been evaluated—no baseline information was collected, and what assessments were undertaken were limited to process measures. While the 2019 initiative was at least piloted, a national rollout has been announced even while the pilot is still ongoing and when concerns about certain aspects of the model have been raised. Given that cancer is the second largest cause of death in Poland and that cancer outcomes are worse compared to Western European averages, there is a particular need to ensure that models of care are informed by the evidence and adapted to the realities of the Polish healthcare system. Although the incidence of all these cancers is below the European Union (EU) average, death rates are higher (both age standardized) [After cardiovascular disease, cancers are the second largest cause of death in Poland, accounting for 23% of all deaths in 2018 [The explanations are, however, unclear, as cancer registration covers only about 10% of the population, and most published data on survival are now quite old . HoweverHistorically, management of solid tumors in adults has been largely centralised on the Institute of Oncology in Warsaw and its two regional branches , but in reality, provision has been fragmented ,7,8. TheSince the mid-2000s, several attempts have been made to improve health outcomes for cancer patients, including the adoption of the two National Programmes for Cancer Diseases Control mentioned above. However, as these programs made the implicit assumption that the organization of cancer care in Poland was largely appropriate, their focus was on strengthening preventative measures, including increasing participation in cancer screening programs and improving access to diagnostics and treatment, rather than on improving the organization of care. The closest that Polish policy has come to addressing this issue were the introduction, in January 2015, of a dedicated ‘fast pathway’ for patients with suspected cancer to enable them faster access to comprehensive diagnostics and treatment ,10 and tIn this perspective piece, we describe these two measures and assess whether they have contributed to improving cancer care in Poland. We begin by describing both policies in detail, including their implementation, followed by the problems they encountered before concluding with recommendations for moving forward.A fast pathway for patients suspected of having cancer was introduced in 2015 as part of a package of measures to reduce waiting times for diagnostic investigations and specialist consultations . The patThe pathway starts with a visit to a primary care or outpatient specialist doctor who assesses the patient and—if a cancer diagnosis is suspected—issues the patient with a Diagnostics and Oncology Treatment (DiLO) card. This card entitles the patient to fast-track access to necessary diagnostics and then to treatment within guaranteed maximum waiting times: 28 days from the visit to the primary care doctor to basic diagnostics, 21 days from the specialist consultation to in-depth diagnostics, and 14 days from the multidisciplinary Concilium  to the sBox 1The concept of a multidisciplinary concilium was created as a means to provide integrated high-quality cancer care appropriate to the patient’s needs. It comprises a clinical oncologist, radiotherapy specialist, oncological surgeon, and (for blood cancers) a hematologist. It meets once the initial diagnostic phase has been completed. Other specialists may also be included, depending on the type of cancer, and further support may be provided by other health professionals, such as nurses, psychologists, physiotherapists, and clinical geneticists. It also includes a care coordinator who supports the patient when making appointments, ensures the flow of information among the various healthcare providers and with the patient, manages their medical records and their DiLO card, and liaises with their primary care or specialist outpatient provider on discharge.Source: Based on .Even before it was enacted by Parliament, this ‘oncology package’ faced criticism from healthcare providers and those commenting on health policy . They weOnce the implementation had started, operational shortcomings quickly became apparent, although some were addressed in subsequent legal amendments . For exaIt Is difficult to say whether the reform led to any improvement in terms of waiting times or enabled earlier diagnosis. For example, only 17.4% of basic diagnostics and 7.9% of in-depth diagnostics were completed within the maximum waiting limits in 2016 . The totThere are also difficulties in assessing progress toward a greater role for PHC, as opposed to specialist ambulatory care. Only about a third of referrals to the fast pathway came from PHC in 2015 , a figurAn unintended consequence of the introduction of maximum waiting times was the increased fragmentation of cancer care ,17. ThisThese concerns have been around for some time. A national audit covering the period from January 2015 to May 2016 reported wide variations in the quality of cancer care among providers . For exaThe shortcomings described above resulted in new proposals for improving cancer care and culminated in the adoption of the National Cancer Strategy 2020-30 , which rThe concept of this Network draws on experiences from other countries in Europe, in particular Norway, France, and the United Kingdom . It seekThe activities of the Network are to be coordinated and managed by the National Oncology Council . The CouAllocation to one of the three levels is based on resources and volume of activity and, for the two lower levels, the demonstration of formal cooperation mechanisms with higher levels. Those at the 3rd reference level will function as the Regional Coordinating Centres, responsible for deciding where each patient will receive treatment, depending on their site and stage of cancer. Providers with expertise in a particular area can qualify as competence or excellence centers . In addition, local cooperating or satellite centers  will provide services such as day-case chemotherapy, post-treatment monitoring and care, and rehabilitation. This is to enable care to be provided close to patients’ homes, consistent with developments in countries such as Norway and the UK . These pSince early 2019, this model has been piloted in two regions , with one more region joining in October that year (Podlaskie in the northeast) and a further one in April 2020 (Pomorskie in the north) . The aimProviders participating in the pilot implemented standardized patient pathways for these five cancers, with standardized protocols and documentation. Standardized documentation was also introduced for pathology and radiological findings, with standardized templates for patient data to be used in multidisciplinary conciliums, which for the first time in Poland includes information about the stage of cancer. Quality monitoring covers the timeliness of diagnostic tests and treatment, completeness of diagnostics, and 35 quality indicators  see Tab, which cCare coordinators, previously used only during the treatment phase, were brought in from the start of the patient’s journey. Their responsibilities were formalized, with defined responsibilities and procedures for working with medical staff, including standardized checklists to ensure that all the necessary data were gathered before the concilium, and access to IT support in monitoring patient progress along the pathway. Dedicated call centers were introduced to provide information about cancer care. Patient satisfaction was monitored with a survey that asked about timeliness, complexity, ease of access, and general experience of care.The pilot was originally meant to run for 1.5 years until the end of 2020. This was extended until the end of 2022 due to the COVID-19 pandemic but also due to problems interpreting the results. Official data published at the end of 2021 show mixed results across the four regions see , with poOn 4 February 2021, on World Cancer Day, the Polish government announced that it would prepare a draft law on the National Oncology Network by the end of March that year to be implemented on 1 January 2022, effectively rolling out pilots across the whole country. Indeed, despite the lack of any final assessment of the pilot, the draft was published and submitted for public consultation. This was based on a preliminary assessment of the pilot prepared by the Polish Cancer Society, but that report has so far not been published for public scrutiny. While many of the changes tested in the pilot are welcome and have the potential to significantly improve the quality of cancer care in Poland, the draft law has also attracted criticism.One source of concern is that the pilot, and now the draft law, focuses mainly on hospital care, neglecting preventive activities and the early detection of cancers, despite concerns that many cancers are detected too late to be treatable. While the new cancer units are meant to provide preventive services alongside diagnostics and treatment, this is no substitute for community prevention and is unlikely to have a wide-enough reach. Cancer prevention could be more effective if it were provided within PHC, but the Regional Coordinating Centres lack any means to influence the provision of services at the PHC level. It is also unclear if this would have made any difference, as PHC providers in Poland are generally not very effective in providing preventive services, and recent plans to strengthen preventive services at the PHC level  have beeOther commentators are concerned that the new model may be too difficult to implement in the Polish context. For example, some analysts argue that the uneven geographical distribution of human and infrastructure resources makes it impossible to establish reference facilities in all regions. For example, surgery for lung cancer is only provided in a few centers. The exclusion of providers not meeting the quality criteria for the Network may reduce fragmentation of care and improve quality, but creates problems for patients currently served by these providers, who may face longer journeys. A certain degree of flexibility may thus be needed to adapt the model to the current circumstances, at least initially. While the draft law gives providers 2 years to implement the new quality requirements, this may not be long enough to establish reference facilities in all regions.The 2015 reform that introduced the fast cancer pathway also failed to adequately consider the realities of the Polish healthcare system. One example is the intention to increase the role of primary care in cancer diagnosis, which faces the challenge of an already high burden falling on PHC doctors and associated financial and staff shortages ,33. The The piloting of the National Oncology Network offers the opportunity to introduce necessary fixes before the Network is implemented across the whole country. Rushing in with the legislation while the pilot is still underway, without a thorough assessment or addressing concerns that have already surfaced, defeats the aim of having a pilot in the first place and risks introducing mistakes on a larger scale.However, as mentioned earlier, a thorough assessment of the pilot may be difficult. There were no baseline data and little comparative data outside of the pilot. This highlights the broader problem of the lack of data to underpin decision making in the Polish healthcare system. Reliable and sufficiently granular data on the incidence, stage of cancer progression, treatments, and waiting times for various services are largely missing. Some information is collected in the National Cancer Registry, but as noted above, coverage is limited and often delayed. Providers focus instead on reporting process information on services necessary for financial settlements with the public payer—the National Health Fund (NHF). Such data are then used to construct the maps of health needs (which were introduced in 2016 as a decision support tool), including cancer care. This creates a bias toward the existing structure of service provision and distribution of resources, such as the focus on hospitals, diverting attention from the relatively less well-developed but much-needed outpatient services and prevention ,34. SincMetrics and indicators collected within the National Oncology Network represent the beginnings of the first system of quality assessment of cancer care in Poland that can support evaluations at the national, regional, and provider levels. This is a welcome development, and it may help drive real change and a gradual departure from the status quo.Despite all their shortcomings, the testing of reforms via pilots, such as through the National Oncology Network pilot, is a welcome development in Polish health policy. It was only in 2017 that a legal amendment  introducCancer is a major health problem afflicting the Polish population. Improving cancer outcomes by better prevention, detection, treatment, and post-treatment services are of paramount importance. Given the various problems with the provision of cancer services in Poland, reforms are much needed. The measures assessed in the National Oncology Network pilot, such as the introduction of reference levels, strengthening of care coordination, introduction of standard patient pathways for diagnostics and treatment, comprehensive monitoring of quality indicators, and many others, hold promise. However, they must be carefully designed, adapted to the needs and reality of the Polish healthcare system, and carefully and transparently evaluated. For example, focusing attention on hospital treatment and neglecting prevention will not lead to improved health outcomes if cancers continue to be detected too late for treatment to be effective. Additionally, basing decisions on one pilot site, which is already known to deliver high-quality cancer care even before the introduction of the pilot, dismisses the realities in the rest of the country, where resources and quality of care are worse and where the piloted solutions may not be implementable. A lack of transparency about the results makes it difficult to optimize proposed solutions and risks introducing mistakes that will have real consequences for the patients.As in other countries, politics exerts considerable pressure on Polish health policy. There is thus pressure to keep the promises made on 2021 World Cancer Day before definitive evidence on the effects of the pilot becomes available. This should be avoided. Doing something just for the sake of it may waste already scarce resources without bringing much value to cancer patients. All indicators collected in the pilots should be published and subjected to public debate, allowing experts, patients, and other stakeholders to work out joint solutions—either in the form of revisions to the proposed draft law on the National Oncology Network or otherwise—that can be effectively implemented in all regions. These should focus not only on hospital treatments but encompass the entire patient pathway, as well as health promotion and disease prevention activities, and not only the current configuration of resources but also how to improve them going forward. The new National Cancer Strategy addresses many of these concerns, and policymakers should focus on implementing all its elements, not only the National Oncology Network, while fine-tuning the latter. After little progress has been made in improving detection and treatment pathways over the past few years, Polish patients deserve better.