Healthy habits are essential for preschoolers to have a healthy lifestyle. The promotion of these healthy habits from a holistic approach by preschool teachers guarantees a better quality of life and a healthier society. Using cocreation, we designed training for healthy habit promotion for preschool teachers . Then, we implemented the training and evaluated its impact on classroom teaching strategies.This study presents the all@once training design and its implementation and evaluation during 2019. The cocreation process involved 8 parents, 9 preschool teachers and 9 health professionals (selected by a nonprobabilistic sampling system according to quotas) to design training from a holistic perspective. To evaluate the all@once impact in classroom practice, a pilot study was undertaken in four public schools in Barcelona (Spain). All@once was implemented with 16 volunteer teachers selected by convenience sampling and 328 children. A mixed methods approach was chosen to collect data based on direct nonparticipating naturalist systematic observations in June and October 2019. After qualitative data categorization, changes in health routines and actions at school were assessed by either contingency table analysis of frequency distributions or nonparametric comparisons of two related samples.The cocreation process provided training organized into online capsules with a holistic view of health in four main dimensions . Of these dimensions, the emotional health dimension comprised half of the training content. Pilot testing of the impact of all@once on classroom health-related activities evidenced an increase in the likelihood of observing fruit consumption by children, healthy habit promotion and hand washing. The most significant all@once-induced changes that we observed were related to teaching strategies concerning the emotional health dimension of the training.This pilot study provides evidence of cocreation being a productive way to design training for preschool teachers regarding inclusive education in integral health. This approach collects the needs of the school community, provides training with a holistic concept of health and effectively impacts classroom routines and family health habits in the short term. The concept of health currently focuses on the ability of people to adapt and self-manage in the face of social, physical, and emotional challenges . This moA growing health problem in Western societies is the increasing prevalence of overweight and obesity, especially in childhood, when these factors are considered predictors of adult obesity and have consequences for both the individual and society as a whole . ChildhoThus, schools emerge, alongside families, as the major field where children learn about health and lifestyle habits because teachers and parents are both central figures for role modeling healthy behavior , 11. It To our knowledge, the existing interventions involving the school community focus on only one or two dimensions of health –25. OtheStudies have suggested that interventions are more meaningful and sustainable if they come from the communities for which they are designed via the involvement of all the stakeholders in a cocreation process . This piIn this study, we analyze the impact of cocreated training for preschool teachers in classroom routines and children’s healthy habits in the short term. To approach this objective, we designed and tested all@once online training for preschool teachers to promote young children’s health from a holistic perspective. The training was developed with stakeholders through cocreation sessions. The all@once training was then implemented, and its impact on short-term outcomes was evaluated in four educational centers in Barcelona, Spain. The cocreation process provided online training with a holistic perspective of health. All@once implementation and assessment in this pilot study resulted in discrete changes in classroom routines and family health habits in the short term.In the current pilot study, we used a mixed methods research design that combined observational and selective methodologies in each phase of the study, following the Guidelines for Reporting Evaluations based on Observational Methodology (GREOM) . Our resWe designed all@once with a cocreation method involving 26 participants. They were recruited by a nonprobabilistic sampling system according to quotas. Our training was implemented in four public schools in Barcelona (Spain) and included 16 teachers selected by convenience sampling and 328 children. To evaluate the impact of all@once in classroom practices, a mixed methods approach was chosen, and before-and-after evaluation was performed. Data collection was based on overt direct nonparticipating naturalist systematic observation (ONPO) that included a data grid and overt indirect ONPO with picture collection of teachers and preschoolers’ behavior. ONPO was performed in June and October 2019. After qualitative data categorization, changes in health routines and actions at school were assessed by either a contingency table analysis of the frequency distributions or nonparametric comparisons of two related samples.A qualitative research method was chosen to design the all@once training program. The training design was participatory and based on a cocreation method defined by Mukhtar et al. . This meCocreation sessions were developed in four stages . First, Consorci d’Educació de Barcelona, which is the main educational authority for the city’s primary and secondary education establishments’ organization. Schools were selected by nonprobabilistic convenience sampling according to their availability and willingness to participate in the study and their allocation in different city neighborhoods, thus guaranteeing the inclusion of participants from different sociocultural strata. In the first stage, a call for interest was launched with positive answers from several schools. Then, personalized assessments through e-mail and life interviews were scheduled to duly explain the study. Therefore, engagement was enhanced by voluntary participation in the project regarding the following aspects: parents of 3- to 6-year-old children attending the schools participating in the project had to commit to attending several meetings; teachers had to be fluent in English (as some of the training contents were developed in this language), specialists in early childhood education (preschool teachers for children aged 3 to 6 years) had to commit to attending several meetings and go throughout a pilot training course; and finally, these individuals had to be able to transfer information to their colleagues and to the director of the center upon request. In addition, health professionals were enrolled, including practitioners, nurses, pediatricians, psychologists and other medical staff of the pediatric Hospital Sant Joan de Deu in Barcelona (Spain). A total of 26 people  participated in the three cocreation sessions in the three different groups mentioned above: 8 parents, 9 preschool teachers, and 9 health professionals. The sampling system was nonprobabilistic according to quotas, where each group  was seen as a sampling unit. Their work ran in parallel, and their outputs and answers were not transferred from one group to another until the very end of the process; even at this point, transference was only done for information purposes by gathering all data and thus following strict anonymization procedures. The criterion of the maximum variability of participants and contexts was sought [Participants in the cocreation sessions came from three different population groups: parents, teachers and health professionals. For the enrollment of parents and teachers, schools in Barcelona (Spain) were approached in collaboration with the s sought . AdditioAn evaluation before and after the training implementation was conducted to assess the influence of the all@once program on teaching strategies in the daily practices of the preschools. The evaluation followed a single session observational method study  and had The evaluation dimensions and categories were constructed from the theoretical content of the all@once training program developed in the cocreation sessions. Once the instruments were constructed, an initial evaluation was carried out in the classrooms. Subsequent validation by consensus  between For implementation of the all@once training, we performed a preliminary pilot study with an intrasessional diachronic analysis  where daFurthermore, the parents of children in a classroom where the teacher joined the study signed an informed consent form. Aligned with previous rationale, children whose guardians refused to join the study and/or would not fulfil the above listed requirements were automatically excluded from the study itself. The researchers duly noted such situations. However, only one class was excluded because the teacher could not ultimately join the study for personal-professional reasons. Because the voluntary approach was taken, researchers ensured the full engagement of the teachers participating in the process. Ultimately, 16 teachers  and 328 children  participated in the assessment and were selected by nonprobabilistic convenience sampling. Some of the teachers also participated in the cocreation sessions.Seven observers collected the direct and indirect ONPO data, including taking pictures of classroom activities. Two of these observers designed the instruments and trained the others in the assessment method and instrument use in two sessions. During the actual data collection, a coordinator provided feedback on data quality and assessment criteria . To analData grid and checklist assessment instruments were raised and constructed from the prioritization and validation phases of the cocreation sessions, which elicited 128 qualitative items categorized in all four health dimensions of the training. For each dimension, the 128 items were regrouped into 8 categories for the dimension of nutrition, 5 categories for the dimension of physical activity, 6 categories for the dimension of hygiene, and 5 categories for the dimension of emotional health. Once the first ad hoc version of the instrument had been constructed by two of the team’s researchers, a consensus meeting  was heldAccording to their relevance for the evaluation, these items were unified into 24 subcategories, following the categorization system that was constructed during the validation phase of the cocreation session. The total number of subcategories was as follows: 8 for nutrition, 5 for physical activity and body awareness, 6 for hygiene, and 5 for emotional health. Data from these subcategories were graded into two values—observed vs. nonobserved—using consensus agreement between two researchers. Differences in the frequency distribution between the first (June) and second (October) assessments were estimated in 2 × 2 contingency tables. For each subcategory, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to quantify the all@once effect in the paired binomial proportions; the McNemar mid-p test was performed to assess the significance of the effect , 61.p values < 0.05. Analyses were performed with the SPSS Statistics v26  statistical package.Data analysis from pictures was conducted following the same procedure as that used for the data grid and checklist. Qualitative data were thus categorized using consensus agreement between the two researchers. Pictures were reviewed one by one and classified into the dimensions named in the all@once training, according to which each training objective was met by the classroom activity shown. As pictures are a multidimensional instrument  and may Cocreation sessions with parents, teachers and health professionals to define, categorize, and prioritize the training needs of teachers to improve children’s health reached similar results. All three groups prioritized those needs that focused on children’s psychological health and development Fig. . The cocDuring the validation process performed by consensus agreement, 12 experts in the field from four countries analyzed the cocreation result diamonds and organized the all@once training. They fit all of the training contents into five final dimensions of the course: a) nutrition, with the 5 subdimensions of healthy lifestyle, water intake, palate education, the social dimension of eating, and healthy habits in the family; b) physical activity and body awareness, with the 5 subdimensions of the psychomotricity class, playtime on the patio, sedentarism reduction, movement in daily routines, and physical activity outside the school; c) hygiene, with the 5 subdimensions of dental hygiene, body hygiene, hand washing, hygiene of spaces, and hygiene of the posture; d) emotional health, with the 5 subdimensions of my own feelings and emotions, the feelings and emotions of the others, adaptation and regulation, emotional development, and challenges and setbacks; and finally, e) sanitary attention and first aid . We found no significant changes in the other parameters assessed, including the likelihood of observed water intake by children and the promotion of healthy eating habits among school staff. In the physical activity and body awareness dimension, we only found an association between the training and an increase in the probability of the promotion of healthy physical activity habits , internal conflicts , external conflicts , and setbacks .Comparisons of data from the emotional health dimension revealed differences in paired binomial proportions between June and October in 4 out of the 5 subcategories analyzed Fig. . We founp = 0.021), while the increase of the frequency of strategies of negative resolution did not reach the level of significance . Conversely, the frequency of strategies of positive resolution increased in the resolution of internal conflicts and in the resolution of external conflicts , whereas the frequency of strategies involving negative resolution showed no changes in either situation . Finally, the frequency of both positive and negative strategies for the resolution of children’s setbacks increased in October compared with June .Teacher interventions for resolving situations related to emotional education observed among children were then classified according to their adjustment to all@once learning outcomes. Interventions were thus classified as positive resolutions (teacher interventions that facilitate understanding of emotions) or negative resolutions (teacher interventions that do not take into account that emotions can be understood). A detailed analysis of these teachers’ strategies showed no clear effects of the training Fig. . Comparip = 0.031). A similar increase in the number of classroom activities in emotional health was found , while no differences were observed in physical activity and hygiene activities , which is in line with previous research . HoweverIn its holistic view of health, our training contemplated emotional health as a transversal dimension, according to the needs expressed by stakeholders in the cocreation sessions. This line of thought was followed in our analysis, paying special attention to teachers’ strategies when addressing this dimension. We found that teachers have an increased tendency to solve problems, such as internal and external conflicts and setbacks, which is in contrast with the statement that positive social relationships are valuable and foundational qualities for well-being beginning at the earliest ages and extending across all ages , althougFinally, the existing evidence suggests that a community-wide capacity-building approach to reducing child obesity is flexible, cost-effective, sustainable, equitable, and safe and has the potential to influence the underlying social and economic determinants of health . These fTaking all of this into account, it is fair to mention the fact that changing behavior is a long-term issue. It is thus necessary to design longer-term interventions at a larger scale. Moreover, researchers’ presence in the classroom during ONPOs may influence the natural behavior of teachers and children. This reactivity bias could have influenced both the pretraining and posttraining ONPOs in the current study. To minimize this bias, we performed the observations at all times children were in school and not just at a specific moment of the day. Nevertheless, we would like to emphasize the utility of the pilot study in obtaining some significant changes in a short time period, with a small population participating in the assessment. This remains, therefore, an interesting line of research to pursue, as it involves more members of the educational community for longer periods.There are some limitations present regarding the design and development of this study. First, the observation sessions were conducted in different moments of the academic year (June and October), which could influence some variables, such as water intake and classroom air circulation. This also applies to the emotional health dimension, which could also be influenced by the different moments of the academic year in the attachment variable. Second, we detected differences in the use of the assessment instruments, despite training sessions to achieve systematic and homogeneous data collection from all observers. These differences influenced our data collection and analysis and should be taken into account in future research in the design and training stages. Third, to detect deeper changes in preschool teachers’ health strategies, an extension of training, implementation, and impact evaluation to the mid and long term is necessary. Moreover, this is a preliminary pilot study with a limited number of teachers and children that needs to be performed at larger performance scale to assess the all@once real impact on schools. Finally, we detected incongruities in some of the results from the cocreation sessions. For example, the idea of a school nurse was not raised in our program, despite all three sessions with teachers, families, and health professionals highlighting the importance of sanitary attention and first aid at schools; however, such a figure does not exist in Spain.In conclusion, using cocreation as a training design for teachers is productive in regard to promoting healthy habits for children, as it addresses the expressed needs of the community . Moreover, we found that the diamond technique for content prioritization is useful for integrating each voice into one. The resulting training, namely, all@once, presents a holistic approach to health , which constitutes a novelty in the field. This approach effectively impacts routines at preschool and promotes healthy habits in the short term. Finally, an observational methodology that allows the inclusion of diverse contextual information that is collected in natural spaces of the schools and that involves qualitative data has been transformed and analyzed with quantitative analysis tools. These mixed method analyses appear to be useful approaches to assessing the impact of educational interventions on preventive health at schools. This may allow the analysis of future interventions involving other health dimensions that include human, material, ergonomic, and economic factors. This transversal integrative strategy outlines a promising path to continue expanding for inclusive education in integral health.


Access to food remains a critical issue in Sub-Saharan Africa. In fact, 24.1% of its population suffers from undernourishment, and malnutrition affects more than a third of children under five years old. This problem will be exacerbated as the Sub-Saharan African population is predicted to double by 2050. To address this problem, it is imperative to meaningfully improve accessibility of fruits and vegetables for the population.They are an excellent source of vitamins and minerals that can fight malnutrition. Fruit and vegetable accessibility can be improved by reducing losses, which are estimated on average to be 50%. A literature review shows that there are many areas where solutions can be implemented to reduce these losses. These areas, in order of decreasing occurrence in the literature are: Cold storage, harvesting methods and pre-storage treatments, packaging, transport to markets and the sale stage. The reduction of food waste in SSA involves the establishment of better practices in all these areas. After analysis, it emerges that packaging should generate more interest due to its comparative ease of implementation to support other technologies like cold storage. Packaging made from agricultural waste or non-consumable materials should be highlighted to prevent pollution issues. This solution, in addition to offering a strong potential to fight against pollution, could also increase farmers’ income. About 21.4% of the population of Sub-Saharan Africa (SSA) suffered from undernourishment in 2020 [Moreover, malnutrition was directly or indirectly responsible for the death of 54% of children under five years old in developing countries in 2001 . The priIn order to achieve the United Nations Sustainable-Development Zero-Hunger Goal (SDG2) and the Good-Health and Wellness Goal (SDG3), increasing fruit and vegetable production is necessary to meet global nutritional needs .Current trends indicate that this situation will be exacerbated in the future. Indeed, according to United Nations projections, the population in SSA will increase by 108% by 2050 . In addiDespite the importance of fruits and vegetables to a healthy diet, most of the food studies and the literature reviews on food in SSA have focused on other crops . IncreasMost fruit and vegetable losses in SSA occur before consumption. These losses are estimated to be 55.9 ± 25.4% and 43.5 ± 16.6% for fruits and vegetables, respectively . AdditioVarious approaches and solutions have been proposed and tested, but some of them are based on inappropriate technologies and do not have the expected impact in real-life applications. From all the solutions analyzed in a large study conducted in Southeast Asian and SSA countries ,13, soluThis paper will investigate in detail whether packaging is the most appropriate solution. The most common solutions in the literature on the reduction of losses will be presented in this article, and their feasibility will be studied. The efficiency of packaging as a solution will also be studied. Next, recommendations for optimal packaging efficiency as well as loss reduction will be presented.It is difficult to estimate precisely the loss quantity for fruits and vegetables in SSA due to the limited data availability and the limited number of resources in the literature . FortunaThe results of a study conducted in Ghana reveal loss statistics for cabbages contained in large bags . These bA study on tomato production and sale in SSA suggests that most of the losses are due to poor road conditions during transport, which generates a lot of physical damage on the freight . The lacIn Ethiopia, the physical losses for plantains along the supply chain were evaluated at 26%. Most of these losses occur during retail due to loss in quantity and quality of plantains, with losses during sales being 16% . AnotherA study on losses in Ethiopia was conducted about papaya.The papaya post-harvest losses were 22%, 12% and 9% during wholesale, transportation and storage, respectively. The main cause of fruit losses was fruit softening, rotting, wounding and compacting due to inappropriate transporting, storage conditions and lack of appropriate marketing place .Tomatoes losses at the wholesale stage in Nigeria were estimated at 23.3% and the amount of mechanical damage  in the evaluated sample was 23% according to a study by .According to another study, the losses of tomatoes in Nigeria at the retail level were 20% with a standard deviation of 10%. Post-harvest losses are between 30 and 50% of the initial mass .The FAO defined the notions of “food loss” and “food waste” in their methodology as follows : “Food lAs noted by the same authors, the methodology of the studies “is challenged by major data gaps for both waste percentages of losses and waste and the causes of losses and waste. The results must therefore be taken with great caution”. Furthermore, this definition has its own limitations because some losses in the early stages of the supply chain such as harvesting can be voluntary . To avoid this ambiguity, the term food losses will be used to refer to both food losses and waste.In order to determine the most proposed stage of interventions for reducing fruit and vegetable losses in SSA, a meta analysis based on 42 articles was conducted. From these, 37 articles are part of the Postharvest loss reduction intervention database (2020). This database is from a study carried out in 57 countries in SSA and South Asia from 1970 to 2019 in which 12,907 studies were filtered to form a base of 334 suitable studies [We used this database of 334 articles to select 37 articles according to two main criteria: The country and the crops.As to the countries, we retained the articles that concern Benin, Burkina Faso, Ghana, Cameroon, Togo, Ivory Coast, Democratic Republic of the Congo, Ethiopia, Guinea, Kenya, Gambia, Niger, Malawi, Mali, Mauritania, Mozambique, Nigeria, Sierra Leone, Somalia, South Africa, Sudan, Tanzania, Uganda, Zambia, Zimbabwe. For crops, we have selected articles concerning fruits and vegetables, namely banana, mango, leafy vegetables, tomatoes, citrus fruits, onion, potato, papaya, sweet potato.We updated this database by incorporating recently published articles on fruits and vegetables in SSA, bringing the total number of articles to 42. The five articles that we added were identified on the basis of keywords. The resulting database covers a period from 1970 to early 2022. Only articles published before February 2022 whose studies targeted one or more well-identified African countries were selected.Harvesting and pre-storage processing: This category includes the picking of fruits and vegetables and all the steps before storage .Fresh storage: This category includes storage of processed food at the farm, during transport and at markets. In some cases, there is no cold storage in the chain.Packing: Process of sorting, grading and putting fruits and vegetables in their packaging before transport.Transport to market: Transport of fruits and vegetables to the various markets .Sale: Phase of sale of fruits and vegetables  after transport from farms to markets and inter-market transport.The database analysed showed that the most mentioned intervention areas in the articles are about fresh storage (40%), harvesting (25%), packing 15%, transport (14%) and sales (6%).Another thing that the analysis of the different databases and literature reviews on the food losses revealed is the lack of data on the status of fruits and vegetables in SSA compared to cereals. Indeed, of the 334 studies on SSA losses presented in the Postharvest loss reduction interventions database, only 7.5% of the interventions focused on fruits and 6.2% on vegetables (non-cumulative) compared to 54.9% on cereals . These rAccording to the data collected by the FAO , there hHowever, while there are several causes of the hunger situation in SSA, the solutions most commonly found in the literature related to food waste may not be the most appropriate. Indeed, their implementation in SSA is fraught with difficulties. It is important to rethink these solutions in order to make their application more effective and efficient in SSA when considering the small number of articles related to fruit and vegetable loss reduction in SSA discussed previously.The area of intervention that stands out the most from the meta analysis conducted on fruit and vegetable losses in SSA is fresh storage (40% of the papers reviewed).Cold storage is the primary method to preserve fruits and vegetables. In fact, without proper cooling, losses can hardly be reduced. While their effectiveness has been demonstrated in other parts of the world, investing in cold-storage solutions that require electricity is therefore inappropriate for SSA countries . HoweverAs far as we can see, this situation will remain a challenge for years to come as SSA has the lowest electrification growth rate in the world. The average growth is 0.8% per year compared to 2.4% per year for other developing countries .Cold storage can extend the conservation of fruits and vegetables during storage but does not prevent against the causes of spoilage such as mechanical damage due to shocks and vibrations. Packaging should be combined with cold storage in order to reduce fruit and vegetable losses in SSA since there are two different aspects of postharvest causes.Another alternative would be to reduce the travel time between farms and markets by improving and building more roads. Indeed, according to several studies, losses during transport to markets are due to mechanical damage to the fruit from the condition of the roads ,15,28. SThe development of adequate transport infrastructures is essential for optimal transport of fruits and vegetables. The use of adequate packaging can help reduce the consequences of the lack of road-network developments with an affordable cost, even if packaging cannot replace the construction of roads. Among the areas of intervention found in the literature such as cold room, adequate harvesting methods, refrigerated vehicle to preserve the cold chain or the implementation of appropriate policy for the agricultural sector, packaging may be the solution with the most potential for reducing fruit and vegetable losses in terms of simplicity of implementation, initial investment and cost efficiency.In this paper, the term packaging designates any material used to contain a product for the purpose of protection, transport and storage. For example, boxed cases carrying bunches of bananas, plastic bags with onions or a basket with oranges are different types of packaging. Packagings can be classified according to their constitutive materials. A distinction is made between plastic, cellulosic , ceramic and metal packaging ,31. PackThere are only a few studies and experiments that can be used to evaluate the potential of packaging for fruit and vegetable loss reduction in SSA. A study conducted in India shows that the use of plastic crates resulted in a 12% decrease in breakage during transport of guava compared to the use of unlined plastic crates . The preAs mentioned in a study, the use of adequate packaging during storage and transport of fresh fruits and vegetables has a positive impact on the quality and shelf life of these products. Between 30% and 50% of fruits and vegetables are lost when transported in traditional packaging in SSA and these losses can be reduced by using more effective packaging .In addition to protecting the fruit and vegetables, packaging could also serve a marketing function that increases vendor revenue and allows for product traceability. Moreover, the use of agricultural waste for the design of bio-sourced packaging using agricultural byproducts such as banana or papaya leaves can also reduce losses and generate income through waste valorization. Another advantage of the use of more effective packaging is they could increase the shelf life of fruits and vegetables in the markets. In fact, by preserving the physical integrity of fruits and vegetable, packaging could contribute to preserving the natural physical barrier against external agents. This makes these commodities more available to the population.Packaging can have other functions that preserve food, such as limiting water nutriment losses. A study analyzed the effect of various plastic film packagings on tomato nutritional values  . The reAnother study on the use of Modified Atmosphere Packaging (MAP) showed that it improved shelf life and preserved the quality of African nightshade. The use of MAP reduced weight loss from 76% to 84% at 20  samples .These results show that packaging allows reduction in waste. It also preserves the nutritional values of fruits and vegetables, which are essential in the fight against invisible hunger. However, the implementation of some nutrient-preserving packaging technologies in SSA requires investment and could not be sustainable due to high cost and unavailable specific-material supply.Our findings show that there is a lack of studies concerning loss reduction for fruits and vegetables in SSA. Moreover, to reduce food waste in SSA, appropriate and low-cost solutions to increase the accessibility of fruits and vegetables for the populations of this region of the world should be investigated.Because of their simplicity and low cost, packaging solutions have a great potential to fight against food loss and waste in SSA. Indeed, they allow facing the challenges related to the lack of good roads and energy infrastructure in SSA, which hinders the implementation of other solutions. While the packaging can be implemented during on-farm storage and the same packaging can be used during transportation and sale stage to reduce losses in different stages.Field trials about postharvest technologies have been conducted by Saran et al.  in SSA aHowever, implementation of packaging solutions in SSA can be limited by their cost, even though it is less expensive than other solutions such as building roads and it could be used to mitigate the lack of infrastructure. Moreover, local food-supply chains in SSA are made such that the packaging cannot be easily returned to the farm holders or carriers making investment on such solutions more complicated. In fact, in the world, 79% of plastic is dumped into the landfills or on the environment, 12% is incinerated and 9% is recycled .Improving bio-based packaging such as those made from agricultural waste and byproducts that are traditionally used in these regions  could beMoreover, the use of agricultural waste for packaging would allow for waste valorization . The dev® made by PaperFoam a Dutch company that produces the Netherlands,United States and Malaysia. This package was made by 70% of potato or tapioca residues and 15% wood-fibres [® produced by YFY Jupiter in China (85% recycled paper and 15% wheat- and rice straw). In China, farmers burn ninety percent of the straw to clear their fields, which leads to soil degradation and air pollution. By using straw for packaging, the costs associated with combustion and pollution can be greatly reduced. These packagings were produced in the context of heavily industrialized countries such as the USA, Germany or China [® made from with palm fibre pulp, waste from fruit and oil production [The production of environmentally friendly packaging made from locally sourced materials can be simpler and less expensive for farmers than from plastic and other synthetic packaging. Indeed, the supply of synthetic materials can be difficult in SSA countries due to their low industrialization and high transport costs when imported . As poind-fibres  NPulp® por China . Smalleroduction . Packagioduction .Thus, the adoption of bio-sourced packaging would seem to be a win–win alternative for farmers, consumers, and the planet. Overall, effective reduction of food access problems in SSA requires the implementation of simple, low-cost solutions. Adopting bio-sourced packaging with better physical properties is one such solution. Other simple, inexpensive and easier to implement solutions such as disinfecting fruits and vegetables on the farm by washing them would eliminate certain germs and preserve the fruits longer. The sanitizing of the packaging used for storage and transport as well as the respect of the maximum capacity of the boxes would make it possible to reduce the losses during transport. These types of solutions, therefore, show great potential to reduce losses and waste without requiring significant investments.In SSA, 24% of the population is undernourished, and an efficient way to solve a part of this issue is to reduce food waste, as around 50% of food is lost before it reaches SSA consumers.The main area of interventions mentioned in the literature is related to cold-storage technologies. While this solution has already been shown to be the most effective solution to reduce fruit and vegetable losses, it is not so efficient for the majority of SSA countries for two main reasons. First, to be highly effective, these solutions need a power source, but SSA has the lowest electrification in the world. Next, cold storage reduces the decay rate of produce but it does not prevent it from happening. On the other hand, protective packaging can be associated with others technologies to prevent damage from occurring during transportation and avoid the subsequent degradation. The use of packaging solutions has real advantages in terms of efficiency, initial investment cost and profitability. In addition, the use of agricultural waste for the design of these packaging solutions would valorize agricultural waste. This valorization in addition to reducing losses would be an additional source of income for farmers and local communities. They also present advantages in terms of preserving nature and the health of consumers.This study adds to the literature on loss reduction for fruits and vegetables in SSA. It shows the importance of the problem of malnutrition in SSA and the need to provide appropriate and low-cost solutions to increase the accessibility of fruits and vegetables for the populations of this region of the world. It also underlines the interest of developing ecological packaging to fight against pollution.


Covid-19 pandemic induced various shocks to households in Malawi, many of which were failing to cope. Household coping mechanisms to shocks have an implication on household poverty status and that of a nation as a whole. In order to assist households to respond to the pandemic-induced shocks positively, the government of Malawi, with support from non-governmental organizations introduced Covid-19 Urban Cash Intervention (CUCI) and other safety nets to complement the existing social protection programs in cushioning the impact of the shocks during the pandemic. With these programmes in place, there is a need for evidence regarding how the safety nets are affecting coping. Therefore, this paper investigated the impact that safety nets during Covid-19 pandemic had on the following household coping mechanisms: engaging in additional income-generating activities, receiving assistance from friends and family; reducing food consumption; relying on savings; and failure to cope.The study used a nationally representative panel data from the Malawi High Frequency Phone Survey on Covid-19 (HFPS Covid-19) and complemented it with the fifth Integrated Household Panel Survey (IHPS), also known as living standards measurement survey. Five Random Effects Probit Models were estimated, one for each coping mechanism.Findings from this study indicated that beneficiaries of safety net programs were more likely to rely on remittances from friends and family than the people who had no safety nets. Furthermore, the safety net recipients were less likely to reduce food consumption or rely on savings than the non-recipients. Despite the interesting findings, we also noticed that safety nets had no significant impact on household engagement in other income-generating activities in response to shocks.The results imply that safety nets in Malawi during the Covid-19 pandemic had a positive impact on consumption and prevented the dissolving of savings. Therefore, these programs have to be scaled up, and the volumes be revised upwards. Countries, including Malawi, responded in various ways to the novel Covid-19 pandemic that disrupted many economies around the world. Malawi introduced various containment measures to reduce the spread of the virus. These measures, included compulsory screening of all travelers coming into the country at the port of entry, a ban on all travelers from highly affected countries, restrictions on public gatherings to a maximum of 100 people and closure of all schools , Malawi Vision 2063, Pan African Vision 2063, and the Malawi Growth and Development Strategy –10. TherLiterature shows that health shocks trigger borrowing or assistance from friends and family rather than the use of any other strategy as these shocks are idiosyncratic –14. HoweIn order to assist households to respond to the economic crisis due to pandemic positively, the government of Malawi, with support from Non-Governmental Organizations introduced Covid-19 Urban Cash Intervention (CUCI) to complement the existing social protection programs. Safety nets play a big role in replacing lost incomes for households affected by various economic shocks and those facing credit constraints to avoid the use of negative coping mechanisms and improve their consumption and increase their asset holdings –20. In tThe study matters and it is of significance to undertake in Malawi at this point and offers lessons beyond Malawi. Firstly, it feeds into the development agenda for Malawi as it potentially shows the aspects that may help put the country on track with the agenda. The Malawi development agenda is guided by the United Nations Sustainable Development Goals (SDGs), whose goal number 1 is to “end poverty in all its forms everywhere.” Under this goal, target 3 stresses the “implementation of nationally appropriate social protection systems and measures for all, including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable.” Target 5 states, “by 2030, build the resilience of the poor and those in vulnerable situations and reduce their exposure and vulnerability to climate related extreme events and other economic, social and environmental shocks and disasters” . TherefoFurthermore, Goal number 2 under the SDGs is to “end hunger, achieve food security and improve nutrition and promote sustainable agriculture.” Target number 1 under this goal states: “by 2030, end hunger and ensure access by all people, in particular, the poor and the people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round.” Target 2 states: “by 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older persons” . Guided All in all, the study contributes to the existing literature on the importance of safety nets during a crisis in achieving the goal of poverty eradication in the medium term through building household resilience to shocks. It also assessed the role of safety nets in enabling household investments to achieve the long-term goal of transforming the Malawi nation into an upper middle-income nation by 2063 as per the aspiration of Malawi vision 2063. This was achieved through an empirical assessment of the impact that safety nets have on the following household coping mechanisms in response to a shock during the pandemic: engaging in additional income-generating activities, receiving assistance from friends and family; reducing food consumption; relying on savings; and failure to cope. In addition, it is the first study within the region and Malawi in particular, which assess the coping aspect in the times of COVID-19.https://microdata.worldbank.org/index.php/catalog/3766.The paper used survey data of Malawi High Frequency Phone Survey on Covid-19 (HFPS-Covid-19) that was conducted by NSO with support from the World Bank. The survey aimed to monitor the socio-economic impacts of Covid-19 pandemic on households in Malawi. This paper used the second and the third waves of the survey. The study also drew some variables from the fifth Integrated Household Panel Survey. The data is readily available for public use and free to download from the World Bank website. In the second and third waves, the households were asked if they experienced any shock(s) due to Covid-19. Each household would list the shock(s) and one coping mechanism they used in response to each. The study mainly focused on five coping mechanisms that were mostly reported by the households. Therefore, the dependent variables were these coping mechanisms: engaging in additional income generating activities, receiving assistance from friends and family, reducing food consumption, relying on savings, as well as doing nothing. These variables took a value of 1 if the household adopted that particular mechanism and a 0 otherwise.As explanatory variables, the models included the variable on whether the household was a beneficiary of any social safety net program. The variable was binary, bearing the value of 1 for a beneficiary and a 0 for a non-beneficiary. The models also included variables on household demographic characteristics of; size, number of dependents, and number of household members above 18 years old. Also included were household head characteristics of: age, sex , their education level, their sector of employment , and marital status . Other household characteristics in the model included the wealth category of the household, its place of residence , as well, as region. On top of that, the shock variables categorized into economic shocks, health shocks and socio-political shocks were also included. Also considered in the study as one of the explanatory variables was the scope of the shocks, i.e., whether the shock was an idiosyncratic or covariate. This variable took the value of 1 if the shock was idiosyncratic and 0 otherwise.3. Then after the descriptive analysis, the econometric analysis was done. Five Random Effects Probit Models were run, because of the binary nature of the outcome variables, one for each coping mechanism. On top of these, gender and regional Random Effects Models were also run to establish if there are heterogeneities in terms of gender and region. Results for the various econometric analysis done, are shown in Tables 4–8.Firstly, descriptive statistics and cross-tabulations were computed to understand the characteristics of the sample for this study. These are presented in As shown in On top of that, the sample largely comprised male headed households, with about 21% of the households being headed by a female. The table also shows that 77% of the household heads in this sample were married while the rest were unmarried. The unmarried category included those who had never been married, those who divorced/separated, and those who were widowed. In terms of household size, the average number of members per household in this sample was five. The smallest household had one member, and the largest had 19 household members.On top of that, the average number of dependents per household, as well as adults above 18 years old, was two. In addition, about half of the households were headed by a member with primary education (51%), almost 37% had secondary education, whereas 9 and 3% of household heads had tertiary and no education, respectively. The sample also comprised households whose majority were employed in a non-agricultural sector, with about 25% being employed in the agricultural sector. In terms of wealth categories, a large proportion of the households in the sample (32%) were in the lowest quintile, whereas the top quintile consisted of about 9% of the households in the sample.Regarding location, the majority of the households in this sample lived in the rural areas, with about 37% living in the urban areas. Furthermore, 15% of the households was in the Northern region, 42% was in the central region and 43% was from the southern region. This means the study was dealing with households mainly from the central and southern regions.In terms of shock distribution, 72% of shocks experienced by the households were economic related shocks which included: job loss, non-farm business closure, increase in price of farming/business inputs, fall in the price of farming/business output, as well increase in the price of major food items consumed. Almost 9% of the household shocks were health shocks which included illness, injury, or death of income-earning member of the household. At the same time, 17% were socio-political shocks which were disruption of farming, livestock and fishing activities as well as theft/looting of cash and other property. On top of that, 51% of all these shocks were idiosyncratic in nature as they only affected one household at a particular time.Out of the households that experienced at least a shock in this sample, about 39% failed to cope with the shocks, 9% relied on their savings, 3% reduced their food consumption, whereas 2% engaged themselves in other income generating activities, and another 2% received assistance from friends and family. This means the rest used other mechanisms not included in this analysis. This implies that a good number of households were indeed failing to cope with various shocks during this Covid-19 pandemic either because of the magnitude of the shocks or they did not have the capacity to respond to the shocks using any other mechanism.The majority of households headed by someone with primary education were using all the mechanisms except reducing food consumption in response to a shock. On top of that, the majority of those relying on savings were employed in the non-agricultural sector.In terms of location, those who relied on savings and those who failed to cope with the shocks were mainly from the central and southern region. In contrast, most of those who engaged in additional income-generating activities and those who received assistance were from the northern region. On top of that, more than half of those who reduced their food consumption were from the country's southern region. In addition to that, all the five mechanisms used in the analysis were mainly used by households that lived in the rural areas.Those who reduced food consumption relied on savings, and failed to cope in response to a shock were mainly the poorest (lowest quintile). At the same time, the majority of those who engaged in other income generating activities and those who received assistance from friends and family were in the second lowest quintile of wealth.In terms of distribution of the three types of shocks, households in the central, southern, and rural areas had been hard hit compared to those in the north and in the urban areas. This is shown in Moving away from the descriptive analysis, we present the regression results in the following sections. The results are presented as marginal effects and shown in As compared to a non-beneficiary household, a beneficiary household of any social safety net program was 5% more likely to rely on assistance from friends and family, 3% less likely to reduce food consumption, and 5% less likely to rely on savings in response to a shock.Other factors that affected the household probability of adopting a specific coping mechanism included; sex of household head, household size, number of dependents in a household, number of household members above 18 years old, education of household head, sector of employment, and region. In addition to these variables, the scope as well as the type of shock experienced by a household also had an impact on the adoption of a specific coping mechanism. When hit by a shock, a female-headed household was about 2% more likely to receive assistance from friends and family as compared to a male-headed household, all things being the same.As the household size increased, the household was more likely to engage in additional income-generating activities, less likely to receive assistance from friends and family, and more likely to reduce food consumption in response to a shock. On top of that, a unit increase in the number of dependents in a household was associated with less likelihood of reducing food consumption as a coping mechanism to shocks, all things being equal. On top of that, an increase in household members above 18 years was associated with less likelihood of engaging in additional income generating activities, and less likelihood of reducing food consumption in response to a shock. In addition, households for non-educated heads were more likely to fail to cope with any shock during the pandemic than those with primary education. Whereas, household heads with secondary and tertiary education were less likely to fail to cope with the shocks than those with primary education, all things being the same.Compared to those employed in the non-agricultural sector, those in the agriculture sector were less likely to reduce food consumption or rely on savings. On the other hand, these households were more likely to fail to cope, unlike those in the non-agricultural sector. Compared to those in the lowest quintile of wealth (the poorest); the affluent households were more likely to engage in other income generating activities in response to a shock. The latter were also less likely to reduce food consumption as a coping mechanism.In terms of regions, households in the central region were more likely to respond to a shock by relying on savings and more likely to fail to cope than those in the northern region. Households in the southern region were also more likely to rely on savings when a shock hits as compared to those in the northern region, all things being the same. On the other hand, those in the central and southern regions were less likely to engage in additional income generating activities and receive assistance from friends and family as compared to those in the northern region. In addition, those in the central region were also less likely to reduce food consumption in response to a shock unlike those in the northern region.Idiosyncratic shocks were more likely to trigger reliance on savings and less likely to reduce food consumption as coping responses to shocks compared with covariate shocks. On top of that, if hit by an idiosyncratic shock during the pandemic, a household was more likely to fail to cope as compared to being hit by a covariate shock. In terms of shock types, economic shocks were more likely to trigger engagement in additional income generating activities as a coping response, whereas socio-political shocks were less likely to trigger this coping mechanism. On top of that, economic shocks were more likely to trigger reliance on savings and a high likelihood of failure to cope. On the other hand, when faced with a health shock, a household was less likely to rely on savings or fail to cope. Besides, households that faced a socio-political shock were more likely to fail to cope with the shock but less likely to receive assistance from friends and family or rely on savings.To assess heterogeneity in the results across regions, regional regressions were run and the results are as presented in We found safety nets to be associated with a high likelihood of receiving assistance from friends and family as a household coping mechanism to shocks across all three regions. However, the results showed a significantly larger difference in the likelihood of seeking assistance between beneficiaries of social protection programs and non-beneficiaries in the southern region than the differences that existed in the other regions. There was also a significantly larger impact in the southern region. The beneficiary's likelihood of relying on savings was much lower than that of the non-beneficiary compared to the other regions.A significantly large difference in the likelihood of reducing food consumption as a shock response also existed in the central region, unlike the other regions. In the area, any social protection program beneficiary was about 3% less likely to reduce food consumption in response to a shock than a non-beneficiary. Whereas, in the other regions, the probabilities' differences were not statistically significant. Full regional regression tables are in the Heterogeneity across genders was also assessed, and the results are as presented in 9Gender regressions showed safety nets having a significant impact on receiving assistance from friends and family, reducing food consumption, and relying on savings for both households headed by males and females. The results showed no differences across the genders. Full gender regression tables are also in the Interesting results emanate from the study. Firstly, we established that households that benefited from various safety nets programs during the pandemic were less likely to reduce food consumption and rely on savings. Thus, the findings support what was also established in Ethiopia and other African countries . This maBased on the above, we may speculate that this was such a case since most of the times, the households that are included in these programs hardly make enough incomes from which they can save , 24. WheApart from the result narrated, education also played an important role. We noted that households headed by an uneducated member were more likely to fail to cope with the shocks during the pandemic. Most of the time, they hardly have reliable incomes or connections to enable them to use other coping mechanisms. On the other hand, those with secondary and tertiary education had enough financial as well as human capital that enabled them to cope with the shocks in one way or the other. These findings were contrary to those by  who founIn this study, those in the third and fourth quintiles of wealth (the rich) were less likely to reduce food consumption in response to a shock than those in the lowest quintile (the poor). This supports the findings by  and can The impact of household demographic characteristics implies that a household would reduce its food consumption in response to a shock if its size increased unless the additional member was a dependent. This is plausible as dependents have a lot of nutritional requirements, unlike others. And also, the household was likely to engage in additional income-generating activities if the additional member was below the age of 18. This is so since such members require a lot of support from the elder members, thereby forcing them to look for other activities where they can generate income from.The finding that idiosyncratic shocks were more likely to trigger failure to cope was in contrast with a risk-sharing theory which stipulates that households have a wide range of coping mechanisms during an idiosyncratic shock unlike a covariate shock . On the The paper has also established that there are regional differences in terms of coping mechanisms adopted by households during the pandemic. Unlike in other regions, there is a significant impact of safety nets on reduction of food consumption as a coping mechanism to shocks by households in the central region. Beneficiaries in this region are less likely to reduce food consumption as a shock response than non-beneficiaries. This may be explained by the fact that the highest proportion (55.8%) of people in the central region are poor unlike the other regions . Malawi We have established through this study a significant impact of safety nets on the increasing probability of household reliance on remittances from friends and family and decreasing the probability of food reduction and reliance on savings as coping mechanisms to shocks. The safety nets programs during Covid-19 pandemic likely improved the beneficiaries' nutrition status. However, these programs had no significant impact on household engagement in other income generating activities, as well as households' failure to cope. This implies they had no impact on household investment. Therefore, these safety net programs during the pandemic have to be scaled up. The amount of funds has to be revised upwards to enable households to have enough incomes to cover both consumption and investment needs. This will in turn, make vulnerable households self-reliant and reduce their dependency on remittances from friends and family during a crisis as this mechanism also has a negative impact on the incomes of the households rendering this assistance, especially during this pandemic as almost every household had been affected in one way or the other.In addition to that, upon investing, vulnerable households may be able to accumulate enough asset holdings and build resilience to future shocks. They may eventually graduate from these social protection programs, and new vulnerable households will be able to be recruited and assisted likewise. In turn, the goal of poverty eradication will be achieved in Malawi.https://microdata.worldbank.org/index.php/catalog/3766.The original contributions presented in the study are included in the article/All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Financial incentives may improve the initiation and engagement of behaviour change that reduce the negative outcomes associated with non-communicable diseases. There is still a paucity in guidelines or recommendations that help define key aspects of incentive-oriented interventions, including the type of incentive , the frequency and magnitude of the incentive, and its mode of delivery.  We aimed to systematically review the literature on financial incentives that promote healthy lifestyle behaviours or improve health profiles, and focused on the methodological approach to define the incentive intervention and its delivery. The protocol was registered at PROSPERO on 26 July 2018 (CRD42018102556).Methods: We sought studies in which a financial incentive was delivered to improve a health-related lifestyle behaviour  or a health profile . The search (which took place on March 3rd 2018) was conducted using OVID (MEDLINE and Embase), CINAHL and Scopus.Results: The search yielded 7,575 results and 37 were included for synthesis. Of the total, 83.8% (31/37) of the studies were conducted in the US, and 40.5% (15/37) were randomised controlled trials. Only one study reported the background and rationale followed to develop the incentive and conducted a focus group to understand what sort of incentives would be acceptable for their study population. There was a degree of consistency across the studies in terms of the direction, form, certainty, and recipient of the financial incentives used, but the magnitude and immediacy of the incentives were heterogeneous.Conclusions: The available literature on financial incentives to improve health-related lifestyles rarely reports on the rationale or background that defines the incentive approach, the magnitude of the incentive and other relevant details of the intervention, and the reporting of this information is essential to foster its use as potential effective interventions. There are major benefits to be achieved by preventive care, including both primary and secondary prevention, for example in the case of diabetes management, yet adherence to healthy behaviors and pharmacological treatment remains a challenge. Financial incentives may improve the initiation and engagement of behaviour change to reduce the negative outcomes associated with non-communicable diseases10. The field of behavioural economics has provided critical insights to influence public policy11, and incentives are one of many tools available. Concepts such as present bias, loss aversion, choice overload, and reference points, among others, have now spread to the field of public health and healthcare delivery. Many non-communicable diseases require effective engagement with lifestyle behaviours such as diet, physical activity and compliance with pharmacological medication, but this is difficult to achieve, with less attention on how the financial incentives and rewards have been developed. Given the growing attention to develop incentive-oriented interventions10, there is still a paucity in guidelines or recommendations that help define key aspects of such interventions, including the type of incentive , the frequency and magnitude of the incentive, and its mode of delivery. To address this gap in the evidence-base, this study aimed to systematically review the literature on financial incentives to promote healthy lifestyle behaviours  or to improve health profiles  with a specific interest in the methodological approach used to identify how the incentive intervention was defined, as well as its mechanisms of delivery.Previous systematic reviews have focused on the effect of financial incentives on lifestyle behaviours21 (seeReporting guidelines22). In addition, the protocol was registered at PROSPERO on 26 July 2018 (CRD42018102556)23. We included studies that: i) had adults subjects (18+ years); ii) included financial incentives as a broad topic, i.e., no specific types of incentives (e.g. cash transfers or vouchers) were sought; and iii) the outcome of interest was a health-related lifestyle behaviour  or a risk factor for a cardiovascular or metabolic disease . To ensure a broad range of included studies, our review focused on the methods of the included study, rather than on the effect of the financial incentive. We also did not require a specific comparator group for the interventions. Therefore, the search approach and the selection and extraction process did not focus on effects estimates, but on the methods, including for example: criteria used to define the incentive, criteria used to define the magnitude of the incentive, and criteria used to define the recipient of the incentive24.A systematic review of the literature was conducted following the PRISMA guidelinesOVID (MEDLINE and Embase),Cumulative Index to Nursing and Allied Health Literature (CINAHL), andScopus from inception to March 3rd 2018. No language or article type restrictions were set. The search terms used in OVID are presented inExtended data22.The search was conducted inEndNote X7 . Duplicates were eliminated from the search results using EndNote duplicate reference identification. Titles and abstracts were independently screened by two reviewers; discrepancies between them were solved by a third party independently. Titles and abstracts selected from this first stage were sought in full-text, and these were studied by two reviewers independently; as before, discrepancies were solved by a third reviewer independently. These selection processes were conducted using theRayyan online software25.Search results were downloaded and saved inet al.24. In particular, the extraction form collated information about the study design, the methodological approach of the intervention, and aspects of the financial reward used, including its direction, form , certainty , frequency, immediacy, schedule, and recipient. The details of the reviewed studies and all data extracted during the review are available at Table 1 and Table 2 (seeUnderlying data22).With the list of selected studies, information was extracted by one reviewer using a pre-specified data extraction form. Data extraction focused on items described in a framework used to document the complexity of financial incentive interventions to change health behaviours created by Adamset al.24. To achieve this aim we undertook a narrative synthesis of the included studies and aimed to summarise the methods followed to decide upon financial incentives, magnitude of the incentives, recipient of the incentives, among other features of the economic incentives intervention. We pre-specified that we would not undertake a comprehensive analysis of the studies’ results , including a meta-analysis, as was not the focus of our study. We also decided not to undertake a risk of bias assessment for the same reasons that this was not considered necessary for our analytical aims.Our review aimed to describe selected characteristics of intervention studies which used economic incentives to promote healthy lifestyle behaviours as per the framework described by AdamsThe search yielded 7,575 results, of which 3,656 were excluded after the initial screening. From 119 texts studied in detail, 37 were included (Underlying data22) summarises the details for each included study. There were a wide range of study populations including employees, families with school aged children, and low-income families. Participants had a range of different health conditions or risk factors, such as diabetes and hypertension. Interventions targeting lifestyle behaviors and health outcomes were also equally diverse ranging from group meetings with rewards, information feedback from clinicians in the form of written letters, and process and outcome-based incentives.Table 1  to be easy to achieve; in addition, they reported that “Incentive payments were moderately sized for two reasons. First, the research team needed to guarantee that total program costs would fall under a budget ceiling. Second, the research team was primarily interested in studying the effects of moderate financial incentives paired with aggressive behavior goals”.Only one study described a detailed rationale for the financial incentive usedUnderlying data22) summarises the financial incentives framework used for each included study. The majority of included studies  used positive gains for the financial rewards, with three studies using the avoidance of a negative loss and three using a mixture of rewards. Cash or vouchers exchangeable for a range of goods or services were used as the financial incentive in 83.8% (31/37) of studies and five used specific goods or services, for example, health insurance discounts or diabetes test strips . The majority of included studies 81.1% (30/37) used financial incentives that participants were certain to receive if they completed the required activity, five studies used a mixed approach , and one study used chance alone . In the majority of studies the recipient of the financial incentive was the individual study participant  with three studies providing a mixture of individual and group rewards, and a further three studies proving household-based incentives .Table 2 . The remaining studies delayed incentives with a maximum lag of one year after the intervention. Just over half  of studies used a fixed schedule for the financial incentives and 17 studies  used a variable schedule, although these were not always provided incrementally., however less attention has been placed on how the financial incentives and rewards were developed. We found that whilst being key to achieve the expected results in any given direction, little attention has been paid to a critical aspect of how to design and define the best possible incentive strategies. The average or range earned per participant was often not described and whilst targets or outcomes were described, the achievement of the tasks depends on its difficulty. If this were to be compared to a pharmacological intervention, the field of financial incentives lacks substantial attention to the design of the pharmacodynamics of the drug —minimum and maximum doses, the most effective delivery modes to guarantee higher adoption, and the frequency and spanning of the doses to be given. Different scheme designs are likely to lead to different outcomes, and hence, it is important to think about the most effective design of incentive schemes12, as subtle design choices in how incentives are situated, framed, or deployed can have substantial effects on their success15. Experimental data indicates that insufficient incentives may paradoxically produce less motivation to engage with a given habit than if there were no incentive at all28. Despite the lack of studies reporting the methodological approaches taken to define the incentive intervention, there was still a degree of consistency across the studies in terms of the direction, form, certainty, and recipient of the financial incentives used, but the magnitude and immediacy of the incentives were more varied.This work aimed to systematically review the literature on financial incentives with a specific focus on the methodological approaches followed to define the incentive intervention, rather than on the effect of the intervention. In so doing, we build upon previous systematic reviews which have focused on the effect of financial incentives on lifestyle behaviours29 or trials (CONSORT)30, observational studies (STROBE)31 or data linkage studies (RECORD)32 should be developed in order to support this process.These findings are relevant to inform checklists and other recommendations to improve the reporting of interventions and other endeavours using financial incentives. Either on the main manuscript, a published protocol, or on an accompanying scientific report, future studies should report on the rationale used to derive key elements of the financial incentives. More detailed information about the interventions that utilize financial incentives, an objective that adds to the broader objectives of improving the quality of the reporting of health research, is needed to critically appraise the interventions, to inform the development and testing of new interventions, and to facilitate the implementation of these interventions at a larger scale, e.g., as a public health policy. We do not have any reasons to think that the available literature did not thoroughly consider the rationale of the intervention while planning the work, yet our findings suggest that this process needs to be better and more frequently reported. The development of standardised reporting guidelines such as those used to report complex interventions (TIDieR)Our study followed standard systematic review methods including a comprehensive search in four international data sources, but there were limitations to our approach. First, because of the aims and scope of our work we did not extract and report on the effect estimates of the economic incentives interventions. Second, we did not conduct a risk of bias assessment because we aimed to summarize the methodology of the financial incentives rather than to evaluate the quality of the whole literature. Third, we did not search libraries specific for economic or behavioral sciences, which could have retrieved additional studies in addition to the health sciences databases that considers the field of health economics. Finally, our search was conducted up to 2018, an inherent limitation given the considerable dynamism in the field. Yet, this does not preclude the recommendation that guidelines for the reporting of incentive-related studies are needed, in particular the need for including information on key design features of the incentive being examined.Our study has systematically reviewed the literature on financial incentives to promote healthy lifestyle behaviours and examined the methodological approach to identify how the incentive intervention was defined and its mechanisms of delivery. We found that studies rarely report on the rationale or background to define the incentive approach, the magnitude of the incentive and other relevant details of the intervention. Future studies to guide interventions and generate evidence about the implementation of financial incentive interventions are required to fill this evidence gap.https://doi.org/10.6084/m9.figshare.14659176.v422.Figshare: Design of financial incentive interventions to improve lifestyle behaviors and health outcomes: A systematic review.This project contains the following underlying data:- 1 Underlying data – Table 1.docx (characteristics of studies included in the review).- 2 Underlying data – Table 2.docx .https://doi.org/10.6084/m9.figshare.14659176.v422.Figshare: Design of financial incentive interventions to improve lifestyle behaviors and health outcomes: A systematic review.This project contains the following extended data:- 3 Extended data – Search strategy.docx (Search terms as used in OVID - MEDLINE and Embase)https://doi.org/10.6084/m9.figshare.14659176.v422.Figshare: PRISMA checklist for ‘Design of financial incentive interventions to improve lifestyle behaviors and health outcomes: A systematic review’.Creative Commons Attribution 4.0 International license (CC-BY 4.0).Data are available under the terms of the The authors responded to my comments to version 1 of the article. I have no additional comments to version 2.Are the rationale for, and objectives of, the Systematic Review clearly stated?YesIs the statistical analysis and its interpretation appropriate?YesAre sufficient details of the methods and analysis provided to allow replication by others?YesAre the conclusions drawn adequately supported by the results presented in the review?YesReviewer Expertise:Economics, Health Economics, Health Econometrics, Economic evaluation, Impact evaluation of health policies.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. No further comments.Are the rationale for, and objectives of, the Systematic Review clearly stated?YesIs the statistical analysis and its interpretation appropriate?YesAre sufficient details of the methods and analysis provided to allow replication by others?YesAre the conclusions drawn adequately supported by the results presented in the review?YesReviewer Expertise:Health program evaluation.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This is a valuable paper. The topic of the systematic review is very relevant as it identifies the magnitude of an important gap in the reporting of studies of financial incentives for modifying health behaviors. In my view, the results of this review ought to be disseminated and standards/guidelines of reporting should indicate the need for including information on key design features of the incentive being examined.  A drawback of this review is that it is not clear why papers from the economic and development literature were omitted. The rationale for that omission is not clear to me. Other than that, this is a valuable review.Are the rationale for, and objectives of, the Systematic Review clearly stated?YesIs the statistical analysis and its interpretation appropriate?YesAre sufficient details of the methods and analysis provided to allow replication by others?YesAre the conclusions drawn adequately supported by the results presented in the review?YesReviewer Expertise:Health program evaluation.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. We are grateful for the feedback provided. The comment that "the results of this review ought to be disseminated and standards/guidelines of reporting should indicate the need for including information on key design features of the incentive being examined" is precisely the key motivation for this work. We agree with the reviewer that an important limitation of our study was that our search strategy did not include databases for the fields of economics and development. This has been highlighted as a limitation in the revised version of our work. Thank you for your time and feedback. The article addresses a topic of great relevance for the design and implementation of financial interventions to improve the population’s behaviours and lifestyles. The study contributes to understanding the key characteristics of these financial interventions and how the applied studies designed (or not) such financial incentives. After reviewing the article, I have three main comments and one minor comment.Major comments:The authors carried out the bibliographic search in March 2018 (over three years ago). In a subject that has had a considerable dynamism, I consider three years is a long time for a systematic review. I suggest the authors update the bibliographic search. If this is not possible because of the workload that it could imply, the authors should establish this point as a study limitation.The authors searched for published articles only in biomedical repositories (such as MEDLINE). From my point of view, this represents the most important limitation of the study, given the economic nature of the subject and considering that in later years the economic literature  has produced several applied studies in the topic. Although the authors mention this as a study limitation, I assume they relativize it, suggesting that economics journals do not focus on this type of applied studies. I consider that this is not correct, and the authors should revalue the relevance of this limitation.The review focus on the empirical aspects of the design of financial incentives, but I consider the authors could enhance the article if they present or reference (in the introduction and/or discussion section) a conceptual framework from Behavioral Economics on individual behaviours in the face of financial incentives. Concepts such as loss aversion, overweighting of small probabilities, hyperbolic discounting, increasing payoffs and reference points have ceased to be characteristic of economics, spreading to the field of public health. Some studies considering this are:et al. “Changing health behaviours using financial incentives: a review from behavioural economics.” BMC public health 19.1 (2019): 1-91. Vlaev, Ivo,et al. “Financial incentives for physical activity in adults: systematic review and meta-analysis.” British Journal of Sports Medicine 54.21 (2020): 1259-12682. Mitchell, Marc S.,Minor comment:The citations/references of the 37 studies included in the qualitative synthesis are not available either in the manuscript or in the tables. The authors should resolve this.Are the rationale for, and objectives of, the Systematic Review clearly stated?YesIs the statistical analysis and its interpretation appropriate?YesAre sufficient details of the methods and analysis provided to allow replication by others?YesAre the conclusions drawn adequately supported by the results presented in the review?YesReviewer Expertise:Economics, Health Economics, Health Econometrics, Economic evaluation, Impact evaluation of health policies.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. We are grateful for the constructive comments provided by the reviewer. We appreciate that our work was deemed “a topic of great relevance for the design and implementation of financial interventions to improve the population’s behaviours and lifestyles.” Here we proceed to respond to his comments.Comment #1: The authors carried out the bibliographic search in March 2018 (over three years ago). In a subject that has had a considerable dynamism, I consider three years is a long time for a systematic review. I suggest the authors update the bibliographic search. If this is not possible because of the workload that it could imply, the authors should establish this point as a study limitation.Response #1: Yes, this is a limitation and we have added it in our revised version. The new text reads:“Finally, our search was conducted up to 2018, an inherent limitation given the considerable dynamism in the field. Yet, this does not preclude the recommendation that guidelines for the reporting of incentive-related studies are needed, in particular the need for including information on key design features of the incentive being examined.”Comment #2: The authors searched for published articles only in biomedical repositories (such as MEDLINE). From my point of view, this represents the most important limitation of the study, given the economic nature of the subject and considering that in later years the economic literature  has produced several applied studies in the topic. Although the authors mention this as a study limitation, I assume they relativize it, suggesting that economics journals do not focus on this type of applied studies. I consider that this is not correct, and the authors should revalue the relevance of this limitation.Response #2: Point taken. We feel partly reassured that the databases used for our review are key ones for the field of health economics, as perhttps://guides.himmelfarb.gwu.edu/HealthEconomics/bibliographic-databases. Another reassurance is that there will be some degree of overlap between economic and health databases as exemplified by this publication that appears on IDEAS database (https://ideas.repec.org/a/eee/ehbiol/v41y2021ics1570677x2100006x.html) and PubMed/MEDLINE (https://pubmed.ncbi.nlm.nih.gov/33611235/). Yet, we concur that not exploring economics and development literature remains a limitation, and we have reworded that limitation in light of the feedback provided.Comment #3: The review focus on the empirical aspects of the design of financial incentives, but I consider the authors could enhance the article if they present or reference (in the introduction and/or discussion section) a conceptual framework from Behavioral Economics on individual behaviours in the face of financial incentives. Concepts such as loss aversion, overweighting of small probabilities, hyperbolic discounting, increasing payoffs and reference points have ceased to be characteristic of economics, spreading to the field of public health. Some studies considering this are:Response #3: Thank you, this is very useful and we have added the two suggested references as well as others. As suggested, we have expanded about this in the introduction and the discussion. The new text reads:“The field of behavioural economics has provided critical insights to influence public policy [REF], and incentives are one of many tools available. Concepts such as present bias, loss aversion, choice overload, and reference points, among others, have now spread to the field of public health and healthcare delivery [REF].”“Different scheme designs are likely to lead to different outcomes, and hence, it is important to think about the most effective design of incentive schemes [REF], as subtle design choices in how incentives are situated, framed, or deployed can have substantial effects on their success [REF].”Comment #4 (minor): The citations/references of the 37 studies included in the qualitative synthesis are not available either in the manuscript or in the tables. The authors should resolve this.Response #4: The tables  provide the first author and the year of publication, together with additional details of the study. We have added the full citation to Table 1 (underlying data).