The bundle of forest landowners’ rights largely varies from one jurisdiction to another. On a global scale, the diversity of forest management regime and property rights systems is such that finding comprehensive and standardised approaches for governance analysis purposes is a challenging task. This paper explores the use of the Property Rights Index for Forestry (PRIF) as an analytical tool based on five rights domains  to assess how regulatory frameworks impact the owners’ forest property rights. We show that PRIF is a reliable index for various governance arrangements, considering its ability to score forest owners’ freedom to decide in case studies that range from the Amazon area (Brazil), Misiones province (Argentina) and Quebec (Canada) to community-managed Nepalese and Mexican forests. PRIF scores obtained in these diverse governance arrangements confirm that the governance of forests held by entities other than the state is driven by two factors: the owner’s ability to exclude the public from the use of his/her own resource and the owner’s freedom to decide on the forest management goals. These factors explained 66.44% of the variance in our sample and should be considered as the main potential drivers while implementing any new international or national policy. Despite having a few limitations, the PRIF is a promising governance indicator and has been proven to perform well for various socioeconomic and legal contexts. They produce a variety of goods and services, ranging from public to private goods in an economic sense11, forest ownership is defined as a multi-layered system that interrelates distinct features, including the character of the owning entity , the nature of ownership that distinguishes between different property regimes, and the general institutional setting impacting the allocation of property rights (who can use the resource and under what conditions). Around the world, 22% of all forest area is privately owned by individuals, businesses, and communities, representing 887.7 million hectares worldwide. Meanwhile, public forests account for 73% of global forest area, 2% of which is managed by indigenous communities12.In a broader system approach14. Private property is owned by a specific individual or private legal entity, while public property is owned, in the name of the citizens, either by the state (state property) or by local or regional administrative entities . Common property is owned conjointly by tenants. The common property regime is the institutional arrangement defining the conditions for the management and use of the resources that are used collectively16, pp. 15–16.The legal owners of the forest resources can be individuals, legal persons, communities, the state or other public/private institutions, corresponding to the main distinction usually made between private, common, and state property regimes respectively17. Thus, characterising forest ownership entails the identification of the responsibilities (rights and duties) of actors that possess the sum of operational property rights  and collective choice rights . This characterization was first defined by Schlager and Ostrom18 and increasingly used in literature25. A reliable legal and institutional governance setup is a prerequisite for successful forest management, irrespective of the forestland ownership category29.Being an owner implies having rights but also duties towards others. Rules and oversight are necessary to establish and enforce a property rights system36. To assess these rights is a challenging task as some of them are enforced by government (de jure rights) while others arise only from resource-use cooperation and are therefore not recognized by law (customary rights)40. Customary tenure arrangements are often informal and based on locally recognized rights without formal legal recognition. Still, as long as the legal entitlements are embedded in the constitutional setting of any country, the assessment of the rights based on a de jure situation provides an understanding of the role of the state in regulating the activities that can be performed by landowners.Property rights can be seen as social relations, defining the titleholder of something of value against all others2. This is reflected in different national and regional regulatory frameworks, defining what the forest owner and other resource users may or may not do in relation to forest goods and services25. Understanding these differences, from a cross-country comparative perspective, provides insights into the opportunities and challenges of implementing international and cross-sectoral policy objectives and commitments related to forest management.The bundle of rights granted to landowners and their enforcement may vary between countries as a matter of social, historical, and economic settings41. At the core of the RRI resides the bundle of rights approach proposed by Schlager and Ostrom18. The RRI reports assess how far the communities can access forest resources (access rights), harvest timber or other forest products , make decisions regarding forest management (management rights), exclude outsiders from their forests (exclusion rights) and lease the resource, sell it or use it as collateral . However, the concept of RRI does not provide a frame for cross-country comparison and is limited to structuring the description of the diversity of institutional government-led arrangements to recognize the rights of Indigenous peoples and communities to forest resources. A specific index to depict the property rights situation globally has been developed by the Property Rights Alliance. Their Property Rights Index comparatively ranks countries on their legal and political environment, physical property rights, and intellectual property rights42, without distinguishing between the various types of natural resources, and being concerned only with private property rights.Since 2005, The Rights and Resources Initiative (RRI) has been using an analytical framework to assess the impact of national laws that relate to the forest tenure rights of indigenous peoples and communities in Latin America, Asia and Africa43 have calculated an original property rights index in forestry (PRIF), designed to make a link between property rights distributions and the corresponding rule-of-law across different countries. In the initial study, PRIF values were calculated at the level of the legislation applicable in 31 European jurisdictions (countries and regions). The article pointed to important differences in the degree of freedom that forest owners have across Europe ranging from 84.7 degrees of freedom in the Netherlands to 38.4 in North Macedonia. In a subsequent paper, the PRIF index was used to identify the impact of the legal changes in property rights distribution in the last two decades, pointing out the stability of rights in most of the Central, Western and North European countries and the impact of the institutional changes in the Eastern European Countries43. The PRIF index has been used as an appropriate governance indicator in European reports and in large-scale assessments of the use of forest resources in Europe44. However, the applicability of the PRIF index to legal regimes outside of Europe was never tested. Besides, the PRIF is primarily designed for private forest owned by individuals, not considering other modalities of ownership, such as community forests. The extension to community forests could help to understand how governance works for this form of ownership that represents 28% of the developing world’s forests45 and is subject to increased vulnerabilities due to climate change and rapid societal transformation47.In the case of Europe, the bundle of rights approach has been used in the case of individual private forest ownership. Nichiforel et al.51. Thus, the main research objective of the paper is to test the applicability of the PRIF in different institutional contexts, including different ownership forms and different regulatory frameworks. A subsequent research objective is to identify the impact of expected freedom limitations and particularities of each case study on the scores of the indicator and its categories. As an example of this hypothesis, variations are expected to be found in PRIF values linked to fewer management rights when analysing regulatory frameworks with stronger emphasis on forest protections, fewer alienation rights for community forests or greater exclusion rights for private forests. This study explores the methodological implications for further developing the PRIF as a universal analytical framework applicable across different forest institutional contexts and property regimes.In this study, we aim to test whether the categories and indicators analysed by the PRIF are universal enough to be adapted to any jurisdiction with different property rights arrangements and policy goals (production as well as protection). For this purpose, we tested the PRIF on a sample of five jurisdictions: two from South America , two from North America  and one from Asia , with a total forest cover of approximately 69.1 million haWith the objective of testing the limits of the PRIF index, a broad mix of jurisdictions was selected so as to comply with at least two out of the four following criteria: (i) jurisdictions are not located in the European continent, (ii) jurisdiction are global forestry benchmarks for production and/or environmental importance, (iii) jurisdictions have forest management regimes with various policy or forestry objectives, (iv) jurisdictions are selected to represent diverse forests ownership categories.12 and the world’s largest forest product trade balance52, respectively. Canada also complies with our third point, as the country’s legislation allows for two types of forest management regime, as it will be explained further on. Also on this point, we selected the intermediary conservation classification in Misiones (Argentina), where there are three forest management classifications, according to the environmental protection status of the area. Lastly, for their diversity of forest ownership, we selected Nepal and Mexico, allowing us to test the capabilities of the PRIF index with community forests in two different continents and institutional contexts.All selected jurisdictions fulfil the first criterion. To fulfil the second criterion, Brazil and Canada were selected, as they consist of the second biggest forest area50. Thus, this case study will serve as an example of the impact of forest protection legislation on the assessment of the PRIF indicators.Argentina is a federal state divided into 23 provinces. Since the enactment of Law 26.331 in 2007, Argentina’s native forests have been divided into three categories, corresponding to different levels of conservation goals. Forest management is most flexible in low-priority conservation zones (green category), and wood extraction is forbidden in high-priority conservation zones (red category). Meanwhile, the intermediate level (yellow category), the one selected for analysis in this paper, allows for limited sustainable use, tourism, harvesting, and scientific research. The state analysed will be Misiones, which comprise 1.6 million hectares of native subtropical forest, 59% of which belongs to the yellow category49.Brazil is a federal country formed by 26 states and a federal district. In this paper, the selected state was Amazonas, and the study only considers the management of “Reserva Legal” (RL). The RL is an area in which all rural landowners are obliged to have forested land, and its size varies according to the biome where the plot is located. In the Amazon Forest biome, landowners are obliged to have 80% of RL (permanent forest state), while the other 20% of the land can be changed at the owner’s discretion. The RL can be managed as long as land use does not change and follows Brazilian forest management laws. The exact amount of RL in the Amazonas state is not known. Using the data of the national rural land register (CAR) and knowing that all of the land situated in the state is in the Amazon biome, shows that there is a total of 68.2 million hectares of agricultural land in the state, meaning that there should be, roughly, 54.56 million hectares of RL in the studied state48. Forestry laws in this province distinguish between non-producers and producers, each having specific forestry regulations. “Producers” are owners who possess a forested area of at least 4 hectares who chose to follow a forest management plan certified by a forest engineer, allowing them to apply for forestry subsidies. This case represents 29,674 owners and 39% of the private forest in Quebec53. Meanwhile, “non-producers” are private forest owners that did not apply for the producer status, therefore, not being obliged to submit a forest management plan and, consequently, not having the possibility of applying for forestry subsidies. The study compares the legal distribution of rights for both categories of private forest owners (producers and non-producers) to identify the reliability of the PRIF methodology in capturing different institutional approaches of private forestry existing also at the sub-national level.Canada is a federal state composed of ten provinces. In Quebec, our selected province, the total amount of private forest represents 11.7 million hectares divided between 133,700 ownersejidos and comunidades). Forests held by local, tribal and indigenous communities totalled 42.06 thousand hectares in 201551. The ejidos have legal personality and fiscal obligations toward the State. The comunidades have the right to common lands for the economic sustenance of the entire communal land. Another form of common property defined by the Mexican constitution is the ejido, in which the members of a community are entitled to a portion of land to live on, a portion of land to cultivate and a portion of communal land. The internal rules of the ejido regulate the use, access, and conservation of the territory, as well as the rights and obligations of the ejidatarios. The general framework of property rights is similar between these two types of common property; thus, the study integrates the ejidos for the de jure assessment of the PRIF. The smaller differences with comunidades are presented in the results section.Mexico is a federal state in which the 1917 Constitution establishes three levels of government: the federal Union, state governments, and municipal governments. Currently, the General Law of Sustainable Forest Development, integrated into the Mexican Constitution regulates land management to achieve equitable development in the country and the promotion of agricultural, livestock and forestry activities. Article 27 sets guidelines for land tenure and property rights and establishes three property regimes: private property , public property  and social property  that modifies the decision-making powers of local and provincial government. However, the new forest law enacted in 2019 was not implemented through subsequent legislation at the time of the analysis. Thus, in the meantime, this analysis is based on the national and centralised laws that were currently prevailing in 2020. Nepal has two forest ownership types: private forest and national forest55. The community forests are part of the National Forests in which the management is done by local users, forming a User Group (UG), and has been an ongoing practice in Nepal since 197856. According to the latest FRA report12, community forests accounted for 2237.67 thousand hectares in 2018. All the rights are given to the UG to manage the forest, but the land belongs to the state and its ownership cannot be changed by the group57. Article 67 of the Forest Act analyses how these rights are addressed in the law. In total, the forest area analysed by this study adds up to almost 70 million hectares . In its initial application, the indicators were assessed only for private forest ownership and for forests not located in protected areas, thus covering the usual practices regulated by the forest-specific legislation in a jurisdiction. “Jurisdiction” refers to a particular geographic area governed by a defined legal authority and can be a country if the forest legislation is unitarily applied at a national level or can specifically differentiate the areas where the forest legislation is set at subnational levels. Considering that each PRIF indicator contains a set of predefined alternatives based on the legal stipulations, we have checked the forest-specific legislation in the analysed non-European jurisdictions to see if the existing alternatives can also be found in these new jurisdictions. The list of alternatives was sorted by order of increasing restrictions on forest owners’ rights and were weighted from “no restrictions” (100 degrees of freedom) to “fully restricted” (0 degrees of freedom). Maximum or minimum degrees of freedom are theoretical possibilities for some indicators, but this method facilitates the weighting of the intermediate alternatives.The PRIF is based on 37 indicators Appendix  that werThe PRIF values were calculated for the legal regime applied to forest management in four federal states and one country from three different continents. Due to the structure of the legal system of each country, jurisdictions were analysed at a state or province level  or at a national level . When analysing the legislation of federal states, if no specific law was found regarding the matter under analysis, national state law was used instead, which happened with some frequency in Brazil, and sometimes in other cases. Only the legislation applicable to regular forest practices was considered, thus excluding special situations of forests from strictly protected areas or other restrictive zoning systems. For Argentina—Misiones, the legislation applicable for the yellow protection category was considered since this category provides for the economic utilisation of forest resources as opposed to strictly protected areas (red protection category).43. It thus results in an evaluation of each indicator as addressed de jure in the forest regulatory framework. If there was no legislation for a specific indicator, the selected alternative was considered as “not regulated”, a situation that was also identified in the initial construction of the PRIF.The analysis of the legal texts (mainly the forestry laws of the studied countries and regions) aims to identify the legal provisions corresponding to each of the 37 PRIF indicators. To quantify the different levels of freedom in each jurisdiction, the authors used the multiple-choice assessment questionnaireFor the comparability of the interpretation of the legal text in the framework of the PRIF alternatives, a working group was set up with all country data providers, thus allowing for a common reiterative process in identifying the proper alternative for each indicator in each jurisdiction. The process took place in February 2020.Only one indicator is integrated into the PRIF to analyse the distribution of access rights based on whether there is any restriction for the forest owners to enter their own forests (I1).Argentina-Misiones and Brazil-Amazonas impose no restriction on the forest owners to enter their private forests; in the quantification of indicators, this means that the forest owners have the highest level of freedom regarding access rights assessed with 100 degrees of freedom. In Canada-Quebec, the ministry can impose restrictions under exceptional conditions, for example when lives are at risk because of forest fires. Freedom is scored at 90 degrees, as such restrictions are imposed only in exceptional circumstances and for the safety of the owners themselves.ejidos and comunidades, however, access can be limited if the rights are transferred to commercial entities by the decision of the communities. This situation falls under the indicators’ option with 80 degrees of freedom (“owners can negotiate the access restrictions and refuse them”). Nepal has the highest restrictions among the compared jurisdictions, as the officer in charge can prohibit the entrance of all individuals to the forest, including community forest members for a certain period57. This type of restriction is linked to the alternative “temporary imposed restrictions—owner cannot negotiate this” in the assessment of the indicator, which is considered as giving only 55 degrees of freedom of access to forest owners.In the case of the analysed common properties, access may be limited to different extents. In Mexico, access and transit are not restricted for the members of To assess the state involvement regarding the rights of an owner to harvest forest products and in what quantity, 11 indicators were used: six dealing with timber products and the other five with non-wood forest products (NWFPs).Withdrawal rights for timber are largely influenced by the freedom of decision-making regarding the amount of timber to be harvested (I2). Thus, in four cases, this indicator provides no decision-making freedom to forest owners as the amount of timber is decided only by means of forest management plans . In Nepal, a forest management plan is compulsory to harvest timber and to collect non-wood forest products, while in Mexico, forest technicians authorised by the governmental agency set the forest management plan that needs to be endorsed by said government agency. In Brazil-Amazonas, timber withdrawal is highly regulated, and owners’ rights are assessed with 15 degrees of freedom. In the case of Quebec, producers are obliged to follow a forest management plan (0 degree of freedom) while the non-producers can decide on the amount of timber to be harvested in the framework of general requirements, thus having the highest decision-making power of the analysed cases (90 degrees of freedom).Regarding the approval of timber harvests (I3), restrictions to harvest apply in Nepal and approvals are needed for the other countries. In Nepal and Quebec, the owners can perform the harvesting by themselves (I6), in Brazil the owner is free up to a certain limit provided for in the law and, in Argentina-Misiones and Mexico, the owners need a licence to perform harvesting activities. This is reflected in the level of bureaucracy required to issue harvesting permits (I7) which is assessed as being a highly bureaucratic process in Argentina-Misiones and Brazil-Amazonas, rather bureaucratic for the community forests in Nepal and Mexico and a very easy procedure in Quebec, both for producers and non-producers.Considering the six indicators concerning withdrawal rights for timber, a large variation between the case studies was found in terms of the decision-making freedom of owners, non-producers in Quebec having the highest level of freedom (86.66) and user groups in Nepal the lowest (32.5) Fig. .Figure 1Withdrawal rights for NWFPs present similar patterns to those for timber harvesting, with the highest value for the non-producer owners in Quebec 61) and the lowest in Nepal (30). Except for the non-producers in Quebec, results are quite homogeneous, with low scores for NWFPs  and commercial use (I9) without any restrictions, but producers must act according to the forest management plan. In Argentina and Nepal, extracting NWFPs is allowed only in accordance with the management plan. In Brazil-Amazonas, general restrictions are provided for in the legislation, but no approval or planning are needed. In Mexico, all members of the communities and res nullius) in Quebec, to the state of Brazil-Amazonas and Mexico, and to the hunting association in Argentina-Misiones. In Nepal, game is considered to belong de jure to the community forests, nevertheless, the members of the community cannot influence hunting activities. This situation is valid for all the case studies, hunting activities (I11) being strictly regulated, and owners having limited or no influence on it. In Mexico, the state, through technicians endorsed by SEMARNAT agency, establishes the hunting control rules. Ejidos and communities must respect endangered species, but hunting is allowed for subsistence and for animals used in traditional rituals. This de jure alternative identified for the community forests in the Mexican case study is a particular situation which was not considered in the initial designation of PRIF; nevertheless, the scoring for this category corresponds to the original PRIF alternative where “the owner can decide the amount of game to be hunted in the framework of an imposed maximum/minimum limit or state approval”.Game (I10) is considered to belong to nobody (Grazing (I12) is forbidden in Nepal, and no legal provisions were found in the text of laws of Argentina-Misiones and Quebec. For Brazil-Amazonas, general legal limitations apply while in Mexico the owners can make use of common lands for grazing, but the state can implement grazing rules in biodiversity rich forests.Management rights have been evaluated with 13 indicators, divided into 3 sub-categories: rights for land use change, management planning, and implementation of forest management operations.In the subcategory of land use change, both ownership categories from Canada-Quebec have total freedom, scoring 100 for the 3 indicators used in this subcategory. Meanwhile, Nepalese communities can only change forest land use when a portion of the land is donated to people in need, though the land still cannot be ploughed (I13). When the issue concerns the obligation of reforestation after clear cuttings (I14) and natural disasters (I15), Mexico has the lowest degree of freedom out of the six cases studied, not only having to reforest and maintain biodiversity after harvesting but also being obliged to restore and take conservation actions after natural disasters.Management planning rights are low overall, Quebec-producers having the lowest score in the subcategory (23) considering their obligation to have a management plan, followed by Argentina (34). Only Nepal and Quebec Non-producers obtained over 50 degrees of freedom. Even then, Nepalese owners have limited rights regarding management planning. For example, it is only in Nepal that even the harvesting of brushwood needs the authorities’ approval in any circumstances (I16).A full forestry management plan is needed for final felling (I17) in Mexico, Argentina, Brazil, and Quebec producers, the latter also not having any influence on the determination of goals in the FMP (I18). As for who is authorised to design the FMP (I19) Mexico has the lowest degree of freedom, SEMARNAT (State agency) accredited forest technicians being entitled to draw up the FMP, while in Nepal and Canada communities and, respectively, owners can do it by themselves. The approval of the document (I20) must be granted by the national forestry authority in Brazil, Nepal, and Argentina. Interestingly, Quebec producers have less freedom to maximise NWFP production (I21) when compared to the other countries.Brazilian owners have more rights than Argentinian ones regarding operational management rights: their possibilities are even greater than those of Quebec producers . Nevertheless, Quebec non-producers are free to choose operational goals (I22), such as rotation length (I24), selection of trees to harvest (I23) and forest species to replant (I25).Still, Nepal is more permissive than Brazil-Amazonas and Argentina-Misiones when it comes to operational management. Thus, Nepalese owners can decide rotation lengths (I24) based merely on technical provisions, as well as manage the forest by themselves without the help of professional consulting. Users are not allowed to sell the timber for commercial purposes outside the group before fulfilling the demand within the group, as will be seen further along in alienation rights. In Nepal, in general, market demand for timber does not influence forest management.This is also true for operational management: Quebec producers need a forest management plan to determine the amount of wood to cut if they want to receive government subsidies. Non-producers, on the other hand, are completely exempt from having such a document. This contrasts with the situation of Brazil-Amazonas, Argentina-Misiones, and Nepal in which a forest management plan is mandatory, regardless of the forestry work, and the cost of drawing up the FMP is to be paid by the owner.ejidos and producers in Quebec. Then comes Brazil-Amazonas (moderate restrictions) and Nepal (a little more permissive). Non-producers in Quebec have almost complete freedom. For example, both categories in Quebec were the only ones in our study that have no reforestation obligation, neither after final cutting nor after natural catastrophes  and Mexico have the highest score when it comes to the restriction of access to the property for recreational purpose (I26) . No regulations were found for Nepal and Argentina on this topic, therefore both got only 30 degrees of freedom as in the original setting of the PRIF. Legislation on the restriction of access to forest roads crossing the property (I27) was only found in Brazil-Amazonas and México . Camping (I28) can be fully restricted by forest owners in Brazil and both Quebec categories (100), while this indicator is not regulated in Argentina (50) and only partial restrictions can be applied in Nepal and Mexico community forests.Ejidos can define an area where hunting is allowed with some restrictions (80 degrees of freedom), while in Nepal hunting is forbidden in national forests, therefore 0 degrees of freedom was attributed to this indicator. Lastly, fencing of the forest (I32) is allowed by law in every country (100 degrees of freedom), except in Nepal, where no legislation was found on the matter.The second subcategory of exclusion rights concerns the exclusion of public use of NWFPs. Brazil-Amazonas and Canada-Quebec offer full rights to owners, averaging 100 in this subcategory with four indicators. Recreational mushroom picking (I29) in Argentina is considered “everyman’s right”, therefore, forest owners cannot prevent members of the public from doing it. Meanwhile, in Nepal and Mexico, the communities have the possibility of putting up signs letting outsiders know that there are some restrictions, corresponding to 80 degrees of freedom. All countries but Mexico have full freedom to restrict commercial picking (I30). Mexico scores the same (80 degrees of freedom) for commercial and recreational picking. Hunting (I31) can be fully restricted by forest owners in Brazil-Amazonas, Argentina-Misiones and both instances in Canada-Quebec. In Mexico the Thus, Brazil-Amazonas (95.7 degrees of freedom), followed by Canada-Quebec, producers and non-producers (90.7 degrees of freedom), have the highest exclusion rights, having almost complete freedom to exclude. On the other hand, in Nepal (55.7 degrees of freedom) and Argentina-Misiones (55.7 degrees of freedom) owners have relatively low rights to exclude Fig. . In the In Nepal and Mexico, alienation rights (I33) belong to the state as a specific legal setting regulating community forests. On the other hand, full alienation rights are permissible in Brazil-Amazonas. It is the only jurisdiction, among those studied, where owners can sell forest land without any restrictions. In Canada-Quebec, it is required that the state be informed before selling one's forest and permission for the sale can be denied. As for Argentina-Misiones, there is no need to inform the state but there are also some restrictions to selling. There is a minimum and maximum price for forest land (I34) in Argentina-Misiones depending on specific conditions, at the discretion of the provincial court.Only owners from the case studies from Brazil and Mexico have total freedom to decide to whom to sell timber (I35), while the remaining owners have restrictions. All the jurisdictions studied, except for Nepal, allow owners to choose the form of selling timber (I36), but the price (I37) is imposed for some markets in the case studies from Mexico and Canada-Quebec, and always imposed in Argentina-Misiones.The average degree of freedom for alienation rights for the six analysed jurisdictions is 69 Fig. .The PRIF and the five categories of property rights allow the comparison of the distribution of property rights across the different jurisdictions. This study shows clear variations in decision-making for forest owners across the analysed jurisdictions. The PRIF ranges from 48.6 degrees of freedom in Argentina-Misiones to 85.8 degrees of freedom in Canada-Quebec non-producers case study Fig. . The comThe overall assessment of the PRIF points to the differences in the assumed selection of the case studies. The lowest overall score in the Argentina-Misiones case study is linked to the reduced scores for withdrawal and management rights considering the greater emphasis on forest protection corresponding to the intermediate level yellow forest protection category selected for the analysis. On the other hand, the non-producer owners from Canada-Quebec have the highest scores for withdrawal and management thus showing the amount of freedom given in this jurisdiction to those owners that do not want to apply for state subsidies.It can be observed that owners from Canada-Quebec and Brazil-Amazonas have more freedom to exclude people and change the land use than the owners from other jurisdictions. Forest owners have, for example, almost full exclusion rights in Canada-Quebec and Brazil-Amazonas while these same rights are very restricted in Nepal and Argentina-Misiones.When looking at the case studies selected from Canada-Quebec, the PRIF explains well the differences between the non-producer owners, that have greater management and withdrawal rights compared to the producers.To identify the role of each subcategory of rights in differentiating the selected case studies, a Principal component analysis (PCA) was performed on the ten variables describing PRIF Fig. .Figure 2The analysis was carried out regarding the 37 indicators grouped into 10 sub-categories of rights. The six case-studies from the five jurisdictions were projected on the first two principal components that, together, explain 66.64% of the variance Fig. a.The first principal component  is explained by indicators on exclusion for the use of NWFP 20.0%), exclusion of public access (17.1%) and alienation rights for forest land (14.9%)  is highly determined by management rights  but also by withdrawal rights for timber (16.8%). The second factor depicts the owners’ freedom to formulate management goals and to make operational management decisions. These categories differentiate between the jurisdictions in the upper half, that have fewer alienation but more management rights, and those in the lower half.The analysis of each quadrant and their diagonals, in this case, permits a better understanding of the PCA characteristics and components. The first quadrant (upper-right) is characterized by a high degree of management and withdrawal freedom, exemplified by Quebec non-producers, who are not obliged to follow a FMP. Argentina-Misiones is on the opposite side of this diagonal (quadrant 3). In this jurisdiction, the forests analysed are partially protected (yellow category) and have high conservation values, the legal regime therefore being the most restrictive when it comes to management and withdrawal rights. This diagonal explains the different legal approaches impacting on owners’ rights when the forestry goals are production-oriented versus conservation-oriented.Meanwhile, the jurisdiction distribution along the second diagonal is explained by alienation, exclusion, and access rights. Jurisdictions from the second quadrant (lower right) are those with higher scores in these rights, while at the opposite end we can find jurisdictions with lower scores . This diagonal can be framed as community versus individual rights in forest utilisation.ejidos to hunt animals for subsistence or rituals, an alternative which is not found in the original design of the PRIF, but which was covered in a satisfactory manner by the existing alternative “the owner can decide the amount of game to be hunted in the framework of an imposed maximum/minimum limit or state approval”.While the PRIF has been methodologically designed for the specific legal situation of European private owners, this study shows that the PRIF can be applied to countries outside Europe, despite their different legal and governance arrangements. The study confirms that the PRIF methodology can be used outside Europe to perform worldwide comparative analyses. First, it was confirmed that the questionnaire was applicable for each indicator composing PRIF in all the jurisdictions. This points to the fact that the list of indicators selected to differentiate between the five rights categories is universal enough to be implemented across different property regimes in different regulatory contexts. Secondly, the list of alternatives provided for each indicator was found to be sufficiently detailed to cover the variations between countries and to score each indicator. Nevertheless, the terminology of the alternatives may need to be adapted to the local property rights regime. One example was the right of Mexican 43 is provided for the PRIF values (Appendix 58. Only 2 out of the 28 (7%) analysed legal texts were modified after 2015.In order to contextualise the results of the analysis, a comparison with the results published by Nichiforel et. al.Appendix  and for .43 points to three arguments validating the PRIF methodology: (i) The six PRIF scores of the added jurisdictions are well spread among the values of the European countries  Thsis Fig. , albeit 43) while the owners from the Argentinian case study still enjoy a slightly higher level of freedom that the private owners from some Eastern-European countries . Having a closer look at the land use management category, it appears that, within the added jurisdictions, unlike many European countries, there is no timeframe set for the owner’s reforestation obligation after final cutting , or even no reforestation obligation at all (Canada-Quebec producers and non-producers). This is still true in the case of reforestation after natural catastrophes (I15), except in Brazil-Amazonas, where the owner is exempted from the reforestation obligation. As a result, all these added jurisdictions  have a higher score in land use management, which reflects the high degree of liberty of the forest owners concerned. It seems that this variable differentiates to the highest degree the non-European jurisdictions from the European ones.Comparing the PRIF scores, the Quebec-non producers’ case study is rated at 98.8 degrees of freedom, this PRIF value being the highest when putting together all jurisdictions , the ‘alteration’ can depict more nuanced situations in which the nature of the good remains the same, e.g., forests, but the landowner can decide on the amount and type of services his/her forest provides. This is a critical distinction at the heart of the European debate on nature restoration law60, e.g., to what extent the forest owner has the right to change essential characteristics of the forests such naturality, diversity or connectivity without these changes being considered forest deterioration. In this respect, PRIF-based analyses could bring relevant qualitative information about the existing set of rights in forest management that will influence the implementation of any new international or national policy.Land use management is quite distinct from the other kinds of management. Galik and Jagger61. According to62, de jure rights are among the five most frequent variables explaining social and environmental outcomes. Therefore, it is important to take them into account, whether it is about understanding and assessing community forests’ management benefits or their disadvantages. To compute the PRIF indicator of these forests in Nepal and Mexico, the users were considered as proprietors, as per63. In many situations, not all the users contribute equally to decision-making64. This phenomenon has already been observed in community forest literature66. For example, while Nepal and Mexican Ejidos have similar PRIF values , the composition of the 5 categories was quite different. As expected, alienation rights were low due to the nature of community ownership. For access rights, Nepal has more instances where the state can restrict the community members’ access to their forest land. In the meantime, management rights are greater in Nepal, especially in the subcategory of management operations, where Nepal scores 64.2 and Mexico 44.2. Thus, the PRIF allows a fine qualitative analysis of legal decision-making power for similar forms of governance.Up to now, the PRIF had been applied only to individual forest ownership. The studied framework has now been successfully applied also to community forests within Nepal and Mexico. This paves the way for a comparison between different community forest jurisdictions but also between other types of forest management jurisdictions, such as Joint Forest Management67. In Nepal, Argentina-Misiones and Brazil-Amazonas, FMPs mainly operate as a “stick”, since they are mandatory to exploit goods from the property, in certain agreed modalities, and sanctions may apply if not observed. In this sense, they fulfil a regulatory function, within a paternalistic state paradigm68 and rationalist planning approach69. In this situation, state regulation curbs the owners’ ability to use their knowledge to manage the forest2, which is reflected in lower values of the PRIF, but make room for other stakeholders’ claims upon forest goods and services70.As shown in Fig. de jure to the forest agency, which may influence forest owners’ motivation to apply. Consequentially these subsidies can have limited success if informational and educational actions are neglected by government agencies71. Thus, PRIF may contribute to a deeper understanding of private forest owners' motivation to adhere to different payment schemes, while they affect their overall bundle of rights in forest management.In Quebec, forest owners that chose to be “producers” are required to have FMPs to benefit from economic incentives, and thus the FMP plays the role of a “carrot”. However, as soon as an owner decides to adhere to an FMP, some management rights are transferred Through the division of property rights into five property right categories, the PRIF can enable researchers to better understand how the rule-of-law interferes with the substantive content of the ownership. Secondly, PRIF indicators allow a comprehensive analysis at different levels of decision-making, from a constitutional level (which is often the case of access and exclusion rights), thus deeply rooted in public policies to an operational level (which is the case of harvesting quantity and mushroom picking rules). Additionally, the PRIF provides a structured overview of property rights differences between countries. It can transform various legal norms and rules into one integrative index and open the way to a deeper institutional analysis. Besides, the temporal dynamic of the index is easy to access as long as the traceability of legal changes subsists. Therefore, the establishment of a common PRIF index for other countries, as seen above, should be possible and advisable. The PRIF can mark a big step forward, as the index is able to depict a particular regime in forested area with a homogenous institutional environment, e.g., form of ownership, timber production goal, conservation regime, etc., as opposed to the current practice of focusing solely on one jurisdiction-related legislation. For example, countries such Brazil, Argentina, Mexico, and Canada have different rights in each federal state/province. Moreover, for the same state/province, as is the situation in Canada – Quebec, the regime applying to a certain forest area may be completely different as shown in the case of producer/non-producer forest owners. Thus, a very accurate analysis of each state/province and of each forest regime in place for different forms of private ownership can be done.de jure governance and can conflict with actual practices, especially in countries affected by corruption or where informal governance mechanisms  are predominant72. Many private areas in Brazil, for example, but also in Europe, witness failures to comply with the law, and alternative approaches to regulation are under discussion, such as the pay-for performance approach74 or result-based payments75. Indeed, huge discrepancies may exist somewhere between the rule of law and the actual implementation of the law, an issue highlighted in literature as law or policy enforcement failure76, policy implementation gap79de jure and de facto rights83 or as institutional voids84.However, our objective was to understand if the PRIF can be used to disentangle the legal regimes applying to private forests outside Europe and to community forests. At this stage, the PRIF is scoring the ‘de jure’ situation and shows that the content of the property rights as “legal entitlement by law” or “right to act” may vary from one country to another or even within a country. The next step will be to distinguish85 between the economic property rights and legal property rights, e.g., what an owner can effectively do versus what an owner is entitled to do. In fact, analysing the tension between ‘de jure’ and ‘de facto’ property rights is a promising way of researching institutional entrepreneurship, or for improving policy implementation88. Therefore, the PRIF could be adapted to assess the gap between legal property rights and economic property rights, if it is thought to effectively score the level of operational freedom that owners have.A few constraints can be pointed out concerning the PRIF. Firstly, the PRIF only works on 89. This is the case when FMPs are not compulsory, but the owner decides to adhere to forest certification schemes, leading him to follow market-driven forest standards. However, the impact of the market-driven governance mechanisms on the property rights can be assessed, as in the case of the voluntary FMPs (Canada-Quebec producers’ category). Furthermore, unclear laws can pave the way for different interpretations, and some indicators might be less relevant depending on their context such as grazing and tree. For example, in Quebec, “tree silviculture” is only applied for experimental purposes and grazing under tree cover is less common than in Europe, thus not regulated.Secondly, the PRIF does not consider market-driven governance mechanismsFinally, a constraint to be acknowledged is that the PRIF has high reliability and provides good explanatory values when it is calculated for forest areas with similar management goals, e.g., primary economic functions or nature conservation functions allowing a certain level of management actions that can be decided by the owner. This precaution will reduce the potential bias that contrasting management goals may generate and will provide more reliability to data comparison.This paper proves the possibility of extending the applicability of the PRIF outside Europe and to distinct types of ownership, particularly to community forests. The latter represent 14% of the total forest area in the world and are the object of a constantly renewed interest for researchers. Whether it is about assessing the best system for forest conservation or exploring the benefits and drawbacks of community forest management on the living conditions of the community members, community forests are a growing field of interest. The fact that the PRIF was successfully applied to Nepal and Mexico community forests paves the way for future research to apply this tool to other community forest jurisdictions, but, even though the list of indicators used was applicable to the cases analysed in this paper, the global diversity of the internal rules for community forest management might require modifications and the addition of more specific indicators to the current PRIF methodology.90. This broadens the applicability of the PRIF to research conducted in different directions. One way is to compare the level of restrictions on property rights in the same jurisdictions considering different conservation requirements such as, for example, for the three zones existing in Argentina. This can provide stronger arguments to obtain for financial support for forests with conservation goals to compensate the owners for the level of restrictions imposed, in contrast with the absence of restrictions imposed on owners of forests with economic goals. Another applicability is to use cross-country comparisons between legal requirements imposed for areas with the same conservation status . The results show that PRIF is a powerful analytical tool that enables the cross-country comparison between different forest legal regimes. As a way of further exploring the PRIF potential, future research could also look at how the index would fare being used as an environmental/management governance indicator and how it compares to other well-established governance indicators.The preliminary studies done to test the PRIF adaptation to the context of protected area management in Europe show the potential of the PRIF to identify the level of restriction on property rights between different types of conservation zones, also applied toSupplementary Information 1.Supplementary Information 2.


Over the last decade there has been considerable research into the treatment, management, and quality of life of people living with multiple myeloma. However, there has been limited investigation into topics deemed important to patients and caregivers within this community. We conducted a James Lind Alliance Priority Setting Partnership to establish the ‘Top 10 Priorities for Myeloma Research’, informed by patient and public partners.A research team and steering group were established in 2019 to conduct the myeloma priority setting partnership. Steering group members included patients, caregivers, and healthcare providers who advised the research team and oversaw the scope of the project, grounded on their lived experience. Following the James Lind Alliance guidelines for identification and ranking of research questions, we used surveys and a virtual workshop to collect and prioritize questions posed by myeloma patients, caregivers, and healthcare providers across Canada.The Top 10 list of priorities for myeloma research was finalized at the consensus-building workshop and encompassed questions related to diagnosis, treatment, management, and living well with myeloma. A final participant evaluation survey elicited a positive response.The myeloma priority setting partnership identified the research priorities of people living with myeloma, caregivers, and healthcare providers to inform clinical research on this disease going forward. This project underscores the importance of patient and public engagement in the identification of research questions, highlighting the concerns of people affected by myeloma to ultimately improve the lives of people living with this disease.The online version contains supplementary material available at 10.1186/s40900-023-00476-9. Research on multiple myeloma, a rare blood cancer, rarely focuses on topics that are personally important to people living with myeloma, their caregivers, and their healthcare providers. The purpose of this study was to complete a priority setting partnership, following guidelines from the James Lind Alliance, to identify unanswered research questions from people directly affected by myeloma. The project was guided by a steering group of people living with myeloma, their caregivers, and healthcare providers who informed all stages of this process including two questionnaires to collect and rank questions and a priority setting workshop. The workshop brought together representatives from each group to form the final ‘Top 10 Priorities for Myeloma Research’, which included questions related to diagnosis, treatment, management, and living well with myeloma. This process allowed us to identify the research priorities of the myeloma community and highlighted the importance of including patients and the public as team members in the research process. We encourage other myeloma researchers to do the same to ensure research is meaningful and relevant to the communities who rely on it.The online version contains supplementary material available at 10.1186/s40900-023-00476-9. Over 160,000 people worldwide are currently living with multiple myeloma (commonly referred to as myeloma) . Even thThe James Lind Alliance is an organization focused on aligning research with the needs of patients, caregivers, and healthcare providers by developing a process for priority setting partnerships . The aimRecently, a pan-Canadian priority setting partnership was conducted to determine the research priorities of patients living with colorectal cancer . The queIn the United Kingdom, a priority setting partnership was conducted to determine the priorities of young people diagnosed with cancer to inform research funding decisions and encourage further research with this community . This poFurthermore, previous research has highlighted that, without the involvement of patient and public partners throughout the research process, results focus primarily on drug-centered treatments . A surveThe success of the priority setting partnership model can be attributed in large part to the involvement of patients, caregivers, and healthcare providers as equal partners in the decision-making process throughout the duration of the project. In doing so, this approach shifts the traditional research paradigm, thus allowing those who are directly affected by a health condition to take on an active role in seeking answers to their health-related questions .The purpose of this research was to conduct a pan-Canadian James Lind Alliance priority setting partnership to inform future research about multiple myeloma by identifying the long-term research priorities in this field.The priority setting partnership focused on adult patients living with multiple myeloma, their caregivers, and healthcare professionals. A steering group of patients, their caregivers, and relevant healthcare providers was formed to oversee every decision made for this project. From the outset, the steering group determined the scope of the project would encompass questions related to myeloma diagnosis, treatment, management, and living well with the disease. As a result, the project set out to identify the Top 10 unanswered questions related to these areas of myeloma research in Canada.Given the varying outcomes of this disease based on location alone , 12, theAfter learning of the James Lind Alliance and the process of priority setting partnerships, a medical oncologist (priority setting partnership lead) initiated the myeloma priority setting partnership with the help of the Maritime Strategy for Patient-Oriented Research (SPOR) Support for People and Patient Oriented Research and Trials (SUPPORT) Unit (MSSU), one of 11 units funded by the Canadian Institutes of Health Research established to support and promote Canada’s national Strategy for Patient-Oriented Research. This group will be hereafter referred to as the research team. The research team was responsible for the day-to-day operations of the myeloma priority setting partnership, including research activities  and administrative tasks.Shortly thereafter, a James Lind Alliance advisor was assigned to the newly established priority setting partnership to oversee the project and ensure that it was conducted based on the organization’s principals and procedures. Furthermore, the advisor served as an impartial facilitator who participated in all discussions and meetings for the duration of the project.Finally, Myeloma Canada was secured as the project funder. Myeloma Canada is a non-profit, patient-led organization focused on funding research, advocating for patients, and educating newly diagnosed patients and caregivers on myeloma. In addition to funding the project, Myeloma Canada partnered with the research team and used their national network to identify potential steering group members. They also supported the implementation of the project by aiding in the dissemination of surveys, facilitating outreach, connecting with appropriate stakeholders, and advising on the research landscape.Per the James Lind Alliance recommendations, neither the priority setting partnership lead, nor the research team had any voting rights or decision-making power throughout the course of the project. Likewise, while Myeloma Canada was a key partner in the priority setting partnership, its staff did not have voting or decision-making capacity.A significant component of this project was the establishment of a pan-Canadian steering group made up of patients, caregivers, and healthcare providers. While the priority setting partnership lead initiated the project, the steering group guided and oversaw all project planning and decision-making going forward. Patient and public partners were fully engaged in all aspects of the project as described below in accordance with the GRIPP2 form checklist , stage of disease (or of family member’s disease), stage of career, and location within Canada. These parameters were identified as having a potential impact on the experiences of people living with myeloma and were utilized to ensure as many voices as possible were amplified throughout the project.n = 3), caregivers (n = 4), and healthcare providers (n = 3), to support inclusivity, diffuse power imbalances amongst members, and ensure that patients and caregivers were meaningfully involved. Of the ten members, three were from Atlantic Canada, four from Central Canada, one from the Prairie region, and two from the Pacific Region. To encourage and maintain an inclusive working environment, the preferred communication methods  of each steering group member were noted and utilized.The steering group consisted of nearly equal membership between patients  were thoroughly documented and sent to the steering group for feedback and approval.The myeloma priority setting partnership followed the iterative process developed by the James Lind Alliance  and one question devoted to “other” queries. The survey ended with several demographic questions  to ensure that all relevant voices were heard.The first survey was open from October 2019 to January 2020, during which time it was distributed through Myeloma Canada’s email lists and social media accounts and through the networks of individual steering group members. The survey was conducted in English and French, both official languages of Canada, and was available in online and paper formats. The research team computed descriptive statistics for demographic variables and examined them regularly throughout the data collection phase to direct recruitment towards underrepresented groups . Per the recommendation of our James Lind Alliance advisor, these variables were used solely to guide recruitment efforts; we did not examine the relations between participants’ demographic characteristics and research questions. Unfortunately, since the demographic questions were placed at the end of the survey, incomplete surveys led to considerable missing data on these questions.The survey generated 3042 questions from 594 participants (see Table https://www.jla.nihr.ac.uk/priority-setting-partnerships/myeloma/top-10-priorities.htm).Questions that did not fall into the scope of the project were identified and removed by the research team with approval from the steering group. The research team then reviewed and assigned codes to the remaining questions and grouped similar questions together into broad categories . The questions and corresponding codes were reviewed by the steering group. Once all of the questions were categorized, a summary question (known as an ‘indicative’ question) was developed by the steering group and research team to encompass all questions related to that code. This process produced a list of 66 indicative questions which were reviewed and approved by the steering group. More information about the indicative questions, including exemplary raw questions and related codes, can be found on the James Lind Alliance website  to 10 (least important).The survey platform offered a unique and interactive way to sort the questions and allowed us to present the 45 questions in random order to avoid bias towards questions as the top of the list. While participants could have ranked the Top 10 on paper, the experience and responses would not have been comparable to those who participated online. Therefore, the research team decided, with support from the steering group, to only offer the survey online. For this survey, the steering group and research team opted to collect only two pieces of demographic information: participants’ role  and province of residence. These demographic questions were featured at the beginning of the questionnaire in order to minimize the risk of missing data. Participants were asked to respond to these questions and then choose their Top 10 questions and rank them from most to least important. At the end of the survey, participants were asked if they were interested in being considered for future phases of the study.Any participant that had at least 10 cards sorted was included in the analysis for a total of 651 participants  to ensure that all groups had their voices heard. This list of questions was then brought to the final workshop.The final priority setting workshop was held in April 2021 and was designed to hold small group discussions to determine the Top 10 questions for future multiple myeloma research. Participants were contacted by the research team from the pool of interested survey participants and targeted recruitment through the steering group’s networks and asked to complete an expression of interest form. Expression of interest forms asked participants to identify their role , province of residence, gender identity, and racial and ethnic background. This information was used by the steering group and research team to select a diverse group of workshop participants .On the second day of the workshop, new breakout groups were formed with the goal of determining a final list of questions ranked according to priority. Small groups decided on the Top 10, the next 11–14, and the final 15–18 questions. At the end of day two, the Top 10 lists from each group were combined again prior to a final discussion to ensure that this list was unanimously agreed upon.Following the priority setting workshop, a final survey was administered to all participants to elicit final thoughts and input on the ranking of the questions, as well as feedback on the overall process.This study was reviewed and approved by the Horizon Health Network Human Research Protection Program including the Research Ethics Board (RS#: 2019–2788). Informed consent was obtained from participants at each stage of the research process.The project culminated in a ranked Top 10 list of research priorities for the future of myeloma research that is shared among people living with myeloma, caregivers, and healthcare providers Table . This lihttps://www.jla.nihr.ac.uk/priority-setting-partnerships/myeloma/top-10-priorities.htm).The remaining questions were also ranked from 11 to 18 and are available on the James Lind Alliance website In all, we received feedback from 17 of the 23 participants . Participants were first asked to comment on the Top 10 and the Top 11–18 questions. Overall, participants were pleased with the order of the questions, regardless of whether their “personal” Top 10 questions were included in the final list:According to participants, small groups allowed for more in-depth discussions and were thus seen as an important component of the workshop. However, regarding the end of the second day, attendees would have preferred having more time during full-group discussions to understand more fully the final Top 10 list.There were a few disagreements over the final ranking order as some participants felt that some questions should have been placed higher or lower on the list. At the same time, participants recognized that all 18 questions would be presented to myeloma researchers, and that some of the Top 10 questions, if answered, would help to answer the Top 11–18 ranked questions.The questions I was less attached to were easy to let go of when I heard the perspectives of others and felt their emotions. Members on Day 1 and Day 2 greatly influenced how I prioritized most of the questions. I gained knowledge and perspectives that made it very easy for me to reprioritize the questions. (ID#4)Despite these criticisms, participants valued their discussions with fellow workshop attendees, and felt hearing their stories allowed them to accept changing their personal Top 10 questions:I would ask people if they need a paper version sent in the future as most people can print off a final version to work from. Saves time, money and the environment. (ID#10)In general, participants felt that pre-workshop materials were helpful, as shown in Table ’ that these sessions were used effectively and that all attendees had the opportunity to openly share their thoughts and voice their opinions Participants were then asked about the flow of the workshop and how they felt about the large and small group sessions. Overall, everyone ‘Agreed’ or ‘Strongly Agreedns Table . Most pans Table . In the The people in the groups I was in were all very supportive and encouraging. Everyone was respectful of others and listened to and asked questions relating to their experience or expertise. All participants were super engaged and eager to share their thoughts. It was such a great experience for me personally, even outside of the top 10 priority setting. (ID#1)Finally, participants were asked if the workshop increased their knowledge of myeloma and priority setting in research. Many felt it did ‘a great deal’ or ‘a fair amount,’ while approximately one third of respondents did not feel the workshop increased their knowledge of myeloma Table . The majThe only thing I would say that if participants were open to being contacted by another participant, that there should be [a way] to do that. With an in-person meeting, that is easily done with the exchange of personal info, should anyone feel like they might want to connect at some point to share experiences etc. (ID#1)Throughout the open-ended survey responses, participants offered suggestions to improve future consensus-building workshops. Among these were recommendations to facilitate a process for relationship building amongst participants, increasing the length of the two-day workshop by thirty minutes, and circulating the preliminary rankings between Day 1 and Day 2 so that participants could review and reflect on them on their own time.Recommendations from survey participants were shared with the James Lind Alliance to improve future priority setting workshops.The Canadian Myeloma Priority Setting Partnership was the first of its kind to bring together people living with myeloma, their caregivers, and healthcare providers involved in their care to identify the top priorities for future myeloma research. Our results demonstrate that among those involved, the priority is that current and future research aims to improve the treatment of this disease, including finding a cure.Previous research conducted on the James Lind Alliance process demonstrated a discrepancy between the subject of disease-based research and the questions patients, caregivers, and healthcare providers want answered , 11. In Workshop participants were satisfied with the Top 10 research questions and found the experience to be robust and enriching. Furthermore, a medical group from Oxford, United Kingdom, recently replicated our findings in their own local priority setting project, where seven of their Top 10 questions were related to drugs, treatments, and their side effects .Questions related to living well , lifestyle factors , and caregiver burden were identified as questions in the first survey, but following the interim prioritization surveys and final workshop, they were not ranked as highly. Thus, while these topics are perceived as worthwhile to the myeloma community; they pale in comparison to the research needed to improve myeloma treatment.These results align with the current state of myeloma research. Over the past 30 years, the incidence of multiple myeloma has been rising steadily . Given tAfter the consensus-building workshop and creation of the Top 10 list, the project entered its next phase, which involved disseminating the list as widely as possible to inform both the funding and the conduct of myeloma research. At this stage of the process, the steering group was dissolved, but members were still given the option to assist with knowledge translation activities. All patients and caregivers accepted to oversee the knowledge translation phase, while the healthcare providers regretfully withdrew their participation due to competing priorities and obligations.The sub-group of interested steering group members (knowledge translation steering group) developed a knowledge translation plan based on target audiences, their preferred mode of research consumption, and associated costs. Knowledge translation steering group members were actively involved with knowledge translation, including informally sharing the results with peers  and presenting to potential research funders while the research team developed traditional knowledge translation products (which were reviewed and approved by knowledge translation steering group members) tailored to the needs of the clinical and research members of the myeloma community. These knowledge translation products included a correspondence article in a peer-reviewed journal and presentations at national and international conferences .Finally, the results were shared with Myeloma Canada who created a research grant to fund projects related to the identified priorities. In its inaugural year, Myeloma Canada committed $150,000 to two projects aligned with the results of the priority setting partnership .While the present study highlights the current knowledge gaps in myeloma research that are pertinent to patients, caregivers, and healthcare providers, questions remain regarding the outcomes of the priority setting partnership approach. Currently, there is a lack of evidence that supports the identification of meaningful and practical outcomes of the priority setting partnership method beyond passive dissemination, such as the publication of findings in scientific journals , 18. ForMany priority setting partnerships have found that patients ask for more research into holistic treatments and living well , but theSuccess of this priority setting partnership will be defined by research funding directed to the priorities identified through this initiative and the amount of original research, systematic reviews, and clinical practice guidelines aimed at addressing these questions. Ultimately, when these questions have been answered by a rigorous evidence check, such as the one performed during this project, the myeloma priority setting partnership will have achieved its goal.Furthermore, given that one aim of the myeloma priority setting partnership is to inform the funding of research related to the identified priorities, grant mapping would be an appropriate tool to measure the long-term impact of the priority setting partnership , 19. ThiThese priorities can also be used to apply to other research fundings organizations such as the Canadian Cancer Society and Canadian Institutes of Health Research. These organizations emphasize a person-centred approach to cancer prevention, detection, and care, and recognize the value of engaging patients at all stages of the research process. Moreover, the priorities identified through this project align with their strategic goals. For example, the Canadian Cancer Society strategic plan includes the need to develop new and more precise therapies to extend cancer survival and improve quality of life during and after treatment , 21.Patient and public engagement was an integral part of this project, and without it, our results would likely not meet the needs of knowledge users in the myeloma and research communities. This engagement allowed for the formation of precise, indicative questions that ultimately led to a rich discussion at the final workshop, and results that are meaningful to the community at the focal point of the research. As with any research project involving patient engagement, there were some lessons that are important to highlight for future research.First, it is imperative to ensure patients and caregivers understand the process of a priority setting partnership in its entirety before agreeing to join a steering group. To avoid potential barriers to participant involvement, transparency around the expected timeline and level of commitment required for involvement is paramount, with the understanding that completion could take longer than initially expected .Second, initial informal meetings held for steering group members were beneficial for relationship development at the onset of the project and allowed members to gauge compatibility with other group members. Although the subsequent meetings were held virtually due to the COVID-19 pandemic, we feel that, when possible, future priority setting partnerships should aim to hold some steering group meetings in-person to fully engage patient partners and build cohesiveness between the research team and patient and public partners.Third, frequent contact with patient and public partners in between meetings was valued and improved communication throughout the duration of the project. This ensured that patients were aware of project details, were involved in the legwork of the project, had ample opportunities to voice their concerns, and felt like valued members of the research team.The present study used a robust, transparent, and multi-stakeholder approach to identify the priorities of myeloma research stakeholders; however, some limitations to this process exist. Our primary method of survey distribution was via channels of communication that are frequently utilized by Myeloma Canada and affiliate organizations. While there was a great uptake of survey completion, our sample was mostly comprised of active members within the myeloma community. As a result, the views expressed by the study participants may not be representative of the myeloma community in its entirety, and research priorities for individuals who do not receive frequent communications about myeloma may differ from those who do.Furthermore, steering group members were comparable demographically; most resided in large metropolitan centres and identified similarly across racial and ethnic groups. Future research should aim to prioritize diversity across the steering group and study participants to ensure that myeloma research priorities are consistent across demographic groups and a variety of voices are amplified during the research process.We experienced challenges recruiting healthcare providers as study participants. We conducted targeted outreach to professional organizations including: Canadian Clinical Trials Group, Canadian Medical Association, Canadian Association of Pharmacy in Oncology, Myeloma Canada Research Network, Canadian Association of Nurses in Oncology, Cell Therapy Transplant Canada, Canadian Hematology Society, Canadian Society of Hospital Pharmacists, Canadian Association of Pharmacy Technicians, Neighbourhood Pharmacy Association of Canada, Canadian Association for Population Therapeutics, Canadian Association of Medical Oncologists, Canadian Hematology Society, all Provincial and Territorial Medical Associations, all Provincial and Territorial Pharmacy Associations, and all Provincial and Territorial Health Authorities. Despite our best efforts, the proportion of healthcare provider respondents relative to patients and caregivers remained low, which could be due to the generally low response rates of healthcare providers and the length of our survey . HoweverThe onset of the COVID-19 pandemic during the project precluded in-person meetings of the steering group  and the consensus-building workshop. Most priority setting workshops are held in person and allow for a greater degree of collaboration and networking than virtual workshops, while encouraging participants to be fully immersed in the priority setting experience . NeverthThe pandemic also contributed to lost momentum when it came to support from regional health authorities and organizations as their focus was understandably diverted to COVID-19. The pace of the project was subsequently reduced out of respect for the team’s mental health during lockdown. This ensured they had ample time for self-care and avoided becoming overwhelmed from project-related tasks. Taken together, these factors led to the project taking two years as opposed to the 12–18 months recommended by the James Lind Alliance .This project highlights important future directions for research on multiple myeloma and garners insight into the priorities of people living with this disease, such as the improvement of symptoms, its impact on daily life, and how medical research can work to improve the lifespan of myeloma patients. To further disseminate the Top 10 Priorities for Multiple Myeloma Research, we intend to follow the direction of previous James Lind Alliance priority setting partnerships –28 by usAdditional file 1. GRIPP-2 Check List.Additional file 2. Interim Prioritization Survey Results.


In the context of the digital transformation of all areas of society, health care providers are also under pressure to change. New technologies and a change in patients’ self-perception and health awareness require rethinking the provision of health care services. New technologies and the extensive use of data can change provision processes, optimize them, or replace them with new services. The inpatient sector, which accounts for a particularly large share of health care spending, plays a major role in this regard.This study examined the influences of current trends in digitization on inpatient service delivery.We conducted a scoping review. This was applied to identify the international trends in digital transformation as they relate to hospitals. Future trends were considered from different perspectives. Using the defined inclusion criteria, international peer-reviewed articles published between 2016 and 2021 were selected. The extracted core trends were then contextualized for the German hospital sector with 12 experts.We included 44 articles in the literature analysis. From these, 8 core trends could be deduced. A heuristic impact model of the trends was derived from the data obtained and the experts’ assessments. This model provides a development corridor for the interaction of the trends with regard to technological intensity and supply quality. Trend accelerators and barriers were identified.The impact analysis showed the dependencies of a successful digital transformation in the hospital sector. Although data interoperability is of particular importance for technological intensity, the changed self-image of patients was shown to be decisive with regard to the quality of care. We show that hospitals must find their role in new digitally driven ecosystems, adapt their business models to customer expectations, and use up-to-date information and communications technologies. Digital transformation is permeating all areas of society ,2. ScienOn the one hand, there are numerous current trends resulting from digital transformation . ArtificIn contrast, general trends related to population health are leading to changing framework conditions ,13. LeapOur central research question addressed how current trends in digitization influence inpatient service delivery. We approached this question in 3 steps. First, we identified the international trends in digitization that have an impact on the hospital sector. Second, we addressed the adaptation of these trends with regard to the German hospital sector. Finally, we derived drivers and barriers and concluded which developments result from these trends.We conducted a sequential study. Our mixed methods approach consisted of a scoping review and a qualitative survey. Our research design was based on 5 steps, as shown in The scoping review is reported according to the PRISMA  guidelines . AccordiOur scoping review referred to current and future trends related to digital transformation on the one hand and service delivery in hospitals on the other. The words “forecast” and “foresight” were searched in combination with other terms . The search terms used in the various databases are shown in Articles were included if the following 3 factors applied: a reference was made to the future or trends, a reference was made to the terms “digital” or “technology,” and a reference was made to inpatient service provision or hospitals. The documentation is shown in The identified articles from all databases were uploaded to the EndNote software , and duplicates were removed. In total, 2 researchers independently performed the first step of the screening process based on titles and abstracts, as reported in Any discrepancies that arose during the data extraction process were clarified through discussion among the authors. Subsequently, the extracted contextual factors were labeled according to their topic, and the studies were summed up so as to show the respective factors. In addition, the studies were classified using 2D scales. The first dimension described the inclusion of the user within the trend. The second dimension related to the intersectoral component. Furthermore, the trend factors were grouped into the 3 application fields: planning and steering, core clinical processes, and communication and data connection. For each of these areas, individual trend factors were described as having an impact on inpatient care. Each factor was double-checked by the 2 researchers, and incongruities were resolved through discussion. We used a narrative approach to synthesize the data . FinallyThe identified trends were further processed for in-depth analysis and verification. The transfer of the trends that were extracted based on international scientific literature resulted in a qualitative survey of experts . In thisExperts from 4 specific groups were interviewed in equal numbers: first, the group of inpatient care suppliers; second, the group of digital service providers in the health care industry; third, overarching institutions in the health care sector; and fourth, the group of relevant scientists. The number of interviews that needed to be conducted was not determined in advance. After 12 interviews, information saturation was reached . The guiThe extracted data from the literature and the obtained research data from the interviews were synthesized into a heuristic logic model ,88. HeurBundesdatenschutzgesetz (German implementation of European Union regulations). Email invitations were sent to prospective candidates. The invitation included an overview of the project and the research scope. The voluntary nature and anonymity of participation were pointed out, together with complete information on the European Union General Data Protection Regulation. We requested written informed consent from all participants to record the interviews and use the information provided in our research.The study did not meet the need for ethical review as it did not involve special categories of personal data. All procedures performed in this study were in accordance with the ethical conducts of the General Data Protection Regulation and The search strategy identified 1344 articles from the 5 databases, as shown in detail in The main characteristics of the included studies are listed in From the included studies, 8 trends were identified that affect hospitals as a result of digital transformations. For this purpose, 44 studies ,38-80 weThe core trends are presented in To illustrate the interrelationships between the individual trends, we presented the connecting factors in a matrix according to the number of times they were mentioned in the studies. Trend 1—changing the patient rolePatients are taking on a new role in the entire care process from prevention to diagnosis and therapy. They participate in decision-making, generate and use data, and have transparent information on diseases and available health care services. The most important technologies are the internet, smart devices, and mobile health apps.Trend 2—connected, integrated delivery of careConnected technologies and cross-provider data exchanges promote intersectoral collaboration. Providers exchange and share data across the care process. Important technologies include electronic health records, the Internet of Things (IoT), and e-prescriptions.Trend 3—data-driven resource allocationA data-based allocation of resources by means of predictive models enables the precise planning and control of care capacities. As a result, available resources are better allocated and used across an organization. Consequently, waiting times can be reduced, and patient throughput can be optimized. The most important technologies are data mining, machine learning, and predictive analytics.Trend 4—performance optimization in primary processesThe performance of core clinical processes in diagnostics and therapy is optimized. This involves using available data in real time to deploy equipment, rooms, or personnel efficiently. Relieving systems are used for the staff. In addition, services are patient-centric to meet the individual needs of patients within an institution. The most important technologies are electronic health records, machine learning, and assistive robots.Trend 5—new information and communications mediaEmerging information and communications technologies are transforming the interactions between all stakeholders in the care process. They promote information transfer and facilitate the understanding of complex interventions through visual media. The most important technologies are avatars, mobile health, and IoT.Trend 6—increased technological intensityThe intensity of technology is increasing rapidly at all levels. The hospital is becoming a high-technology digital institution. Intensive data use leads to intensified collaboration with digital service providers and the extensive use of software or algorithms. The most important technologies are smart devices, robots, and cloud services.Trend 7—outcome improvement and personalized treatmentsThe quality of outcomes is rising in the context of increasing data use and the associated optimization of treatment procedures focusing on predictive forecasting models for the early detection of diseases. The perspective of personalized diagnostics and therapy is at the heart of the treatment process. The most important technologies are data analytics, machine learning, and predictive medicine.Trend 8—emergence of new ecosystemsDigital networking is leading to new providers and new business areas so that health care is evolving into an ecosystem in which established service providers have to maintain their competitive position and find their role in providing care. Platforms for exchanging data and mediating health care services play an important role in these ecosystems. The most important technologies are mobile health, machine learning, and predictive analytics.The qualitative approach to analyzing the impacts of trends brought to light additional aspects aside from the findings from the literature. On the basis of the core trends shown, The changed patient role leads to an increase in transparency, more patient autonomy, better opportunities for participation in the treatment process, and an expansion of self-competence. However, in the case of an overload of information, this can also lead to excessive demands or the communication of incorrect information. Therefore, the decisive conditions are to strengthen trust in acting institutions and make information available through public authorities. The driving factors are good health literacy and a high level of digital competence. Connected and integrated cooperation between providers leads to better access to health care services and faster data exchange between them. However, this may lead to increased competitive pressure, resulting in the exit of market players. The key conditions for this trend are incentives to cooperate so that individual providers are not disadvantaged. To achieve this, compensation systems must be adapted so that network-integrated collaboration is worthwhile and the necessary interfaces for data exchange are available. Driving factors include easy market access and existing supply gaps. Data-driven resource allocation leads to increased efficiency, a better use of capacity, and offsetting of skill shortages. However, there are strong dependencies among service providers regarding the extent to which they are willing to collaborate and share information. The intensive exchange of data at various levels between institutions can lead to data protection and data security risks. The governing conditions include the availability of data, interfaces, and technical expertise. The driving factors include scarce capacities, high data density, and public data platforms.The performance optimization of core clinical processes leads to higher productivity, increases in quality, and higher patient and employee satisfaction. In contrast, there is a high internal dependency on a wide range of factors and the need for a continuous process of adaptation and optimization. The decisive conditions are investments in new systems and the associated qualifications of the workforce. Acceptance and openness are essential for success. The driving factors are medical progress, falling costs of innovations, and new job profiles. New information and communications technologies are accompanied by a change in patients’ need to interact with providers. They lower communication barriers and lead to better information delivery. For clinics, the wide range of media may result in higher costs for their operation, and additional qualifications may be necessary. The key conditions are an understanding of communication needs and an acceptance of media use by all stakeholders. The driving factors are the digital competencies of all stakeholders and the current general societal trends in media preferences. Increasing technology intensity ensures higher productivity and compensates for a lack of skilled workers. This is accompanied by greater complexity and the associated requirements for cybersecurity and employee qualifications. Comprehensive long-term investments and the acquisition of new knowledge are required as decisive conditions. The driving factors are technological progress and rising patient expectations. The application of personalized medicine leads to an improvement in outcomes as well as the possibility of specialization and the opening up of new fields of treatment. In contrast, there is an adjustment of care-oriented business models, which, among other things, also include prevention to a greater extent. The key conditions are high data quality and availability, the market maturity of innovative technologies, and confidence in new treatment procedures. The driving factors are medical and technical progress as well as the service offerings of competitors.The emergence of new ecosystems has led to new customer-centric health care services, an exploitation of the potential of the platform economy, and the associated opportunities to increase customer value. This creates new competitive situations that can put pressure on providers and lead to inappropriate power relationships among individual market participants. The decisive conditions are an understanding of digital ecosystems also on the part of the legislator, transparency, and fair conditions on platforms for all service providers. The driving factors are low barriers to market entry, little regulation, and a strong focus on customer needs. The interrelationships between the trends are very complex and require an adequate form of representation to be able to understand the trend effects. We show these relationships in a heuristic impact model in For a more intuitive illustration of the trend development perspective, we placed the value of care as a result of digital transformation in a temporal context. The convergence of personalized medicine as a result of better diagnostics and individualized therapy decisions, incorporating the spectrum of technological innovations of today and the future, results in an adapted range of care offered by hospitals ,58,61. TThe analyses described numerous blockades and barriers that slow down the trends. Internal hurdles are factors that occur within the hospital setting and can largely be solved there. The most frequently cited obstacle is a lack of knowledge of the use of digital applications ,50,68,74External hurdlesRegulation of service delivery ,74Data protection regulations ,46Uniformity of data structures ,49,55,75Lack of interfaces for data exchange ,71,76Insufficient investment in technical infrastructure ,70,74Lack of political understanding of appropriate frameworks ,74Internal hurdlesInadequately qualified personnel ,50,68Low acceptance of substantially changing processes ,63,67,75Unwillingness to make large investments ,55,63,68Failure to ensure cybersecurity ,42Continuous training needs ,55,59,71Availability of suitable business models ,65,79We included 44 studies in our analysis, drawing a picture of hospital trends. Subsequently, the trends in the German hospital care setting were discussed, validated, and refined through expert interviews. A wide range of aspects were considered, covering the use of new technologies, the implementation of process innovations, and behavior changes or role shifts among patients and hospital staff. The trends shown provide a framework for better assessing current and future developments from the perspective of clinics and other health care stakeholders. This allows for a snapshot of one’s own point of view or an assessment by higher-level authorities as to which changes in the framework conditions can accelerate or slow down the trends. For this purpose, trend barriers and developmental hurdles were also extracted from the studies. These can be used to derive policy options.The trends described were not examined in terms of their positive or negative impact. Nevertheless, a positive trend is discernible in the development horizon, which is improving inpatient care and steering it in a patient-centered direction. Therefore, it is conceivable that not all trends will lead to a positive development for all stakeholders involved. The increased use of technology, automation, and AI systems will in some cases entail job losses or a restructuring of work . TherefoOur study shows that there is enormous potential for public health to make care in hospitals more patient-centric as a result of digital transformation. This means that diseases can be detected and treated earlier. At the end of a successful transformation, there is a healthier population that takes advantage of the opportunities offered by preventative and precautionary health care. Clinics contribute to realizing this goal and must be prepared by decision makers for their changed role. As a result, comprehensive savings are possible, which can relieve the pressure on the health care system . StraineThe included studies already cover a comprehensive range of current and future trends. Nevertheless, the individual aspects may not have been considered. The analysis was primarily conducted from the perspective of inpatient service provision. The patient, as an important participant in the care process, was not explicitly examined. For example, sociological trends with regard to the use of digital applications could lead to findings that were not reflected . These iIn our study, we showed the influence of digital transformation on inpatient care. In the process, the high complexity of the interacting players became clear. We extracted 8 core trends from the international literature and validated them with experts in relation to the change in hospital care provision in Germany. We presented the interrelationships in a heuristic impact model. Our study highlights the barriers to successful transformation based on internal and external factors. We provide recommendations for action for decision makers on how public health can be improved by a digitally transformed hospital landscape and which hurdles need to be overcome.