The efficiency of the patient care process of short-term medical service trips is often not assessed. The Gregory School of Pharmacy has organized annual medical camps in rural Uganda, however, the paper health records used for documentation and communication between stations have shown several limitations that hinder an optimal patient care process. Therefore, our objective was to implement an electronic health record system in these medical camps to improve the workflow and optimize the patient care process.An electronic health record system that functioned over a battery-operated local area network was developed and implemented. Patient health information was entered and reviewed at the different stations using mobile devices. The impact of electronic health records (used in 2019) on the patient care process was assessed using the number of patients served per physician per hour and the number of prescriptions filled per hour and comparing these to paper records (used in 2017).Electronic health records were successfully implemented and communication across stations was fluid, thus improving transitions. Importantly, 45% more patients were served per physician per hour and 38% more prescriptions were dispensed per hour when using electronic (2019) compared to paper records (2017), despite having a smaller team in 2019.Implementation of electronic health records in rural Uganda improved the patient care process and the efficiency of the medical camp. Providing health care and health services to vulnerable populations around the world through short-term medical missions (STMM) is increasingly popular . AnnuallSTMMs have become part of educational programs in medicine , nursingSTMMs are an important experiential component of the Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, serving people in Central and South America, Africa, Asia and domestically in South Florida, Georgia and Alaska , 15. SinWe anticipated that using electronic health records (EHRs) would resolve these challenges encountered with use of paper health records, thereby improving the flow and communication between the stations and optimizing the patient care process. The use of EHRs and hand-held devices on STMMs has previously been described with most systems being web-based requiring internet access . HoweverThe aim of this study was to investigate the impact of implementing an EHR system that could operate independently without requiring access to electricity or internet on the workflow and the patient care process at medical camps in rural Uganda.This study was conducted at a series of 1-day medical camps in five rural villages within the Mukono district of Uganda, which the Gregory School of Pharmacy has organized annually since 2013 in collaboration with Ugandan health care workers, the non-profit organization Word In Deed Ministries–that has a continuous local presence promoting education, health, empowerment and entrepreneurship–and local Churches. Most of these rural villages do not have electricity. For the planning and executing of the medical camps, Ugandan physicians and School of Pharmacy faculty communicated regarding the therapeutic drug formulary and the Ugandan guidelines and protocols for common encountered disease states. This approach is in line with the recommendation that STMM teams work together with partners in the host country  and thatFaculty , PharmD students and alumni (PharmD) from the School of Pharmacy formed an interprofessional healthcare team with Ugandan physicians, nurses, community health workers and interpreters. As part of their training, PharmD students were involved in all steps of the patient care process while being supervised by Faculty and licensed  health care workers. Thus, students participated in patient intake, assisted physicians during anamnesis and diagnosing, offered therapeutic recommendations, performed and interpreted point-of-care tests, and filled prescriptions along with counseling on proper medication use. Non-PharmD faculty members were not involved in clinical decision making and were mainly responsible for the logistics, planning, and budget of the STMM as well as overseeing non-clinical activities, such as community events. Dental services and public health services related to HIV, women's health, and family planning were provided by Ugandan agencies and community partners.Each day, all necessary equipment, devices and medications for the medical camp were set up by the team upon arrival in each village and packed up at the end of the day. The different stations see  were typWhen using paper records, name(s) and patient number were recorded on the form at patient intake. The form was in letter size format and the front was reserved for the primary family member with room for 3 additional patients on the back . If additional forms were needed to document information, these would be stapled together. Patients brought their forms to each station where pertinent information was added and evaluated. This paper form also served as the prescription in the pharmacy where they were collected at the end of the patient care process. At the conclusion of the STMM, these forms were transported back to the US for data analysis.The EHRs and a wireless communication network that can be utilized in places that have no electricity or internet access were developed by Infotech Solutions in 2018 using an open-source web platform (TikiWiki), an open-source database platform (MySQL), and an open-source web server (Apache). The EHR structure was designed by members of the mission team using the paper records as a blueprint. When using electronic records, name(s) and patient number were entered at the triage station and the form was sent from station to station digitally over a local area network (LAN) connection. At each station, pertinent patient information was entered and evaluated by accessing the electronic queue where the patient record was residing. After processing the patient information, the record was put in a queue for the next station with a priority queue for urgent cases. In the pharmacy, there were separate queues for filling, verification, and medication counseling. This workflow enabled the team to check patient transitions between stations in real time. Information from up to 10 family members could be documented per record and digital files, such as pictures, could be attached.The EHR program was installed on a laptop computer . A battery-operated LAN was created with portable routers, signal extenders  and the laptop as the LAN server. The system allowed multiple devices to use the system simultaneously (we connected up to 12 devices). Tablet computers  with bluetooth keyboards and laptop computers connected to the LAN were used for data entry and evaluation. To ensure patient confidentiality, data were encrypted and the server and electronic devices were password protected. Upon arrival in each village, one person would set up the EHR system and connect all devices to the LAN. A battery-operated printer  was available to print documents as needed.Other than using paper health records in 2017 and EHR in 2019, there were no differences in the allocation of numbers, the information that was gathered on the health records, the workflow or the patient care process.t-test  and considered statistically significant when p < 0.05. Graphs were created using SigmaPlot 12.3 .Data obtained in 2017, the last year we used paper forms throughout the whole medical service trip, were compared to the data obtained in 2019, the first year the EHR system was exclusively utilized. The efficiency of the patient care process was defined as the number of patients served per physician per hour, which is an important determinant of the total number of patients that can be served. Each day had 2 or 3 physicians in the physician's station. The impact of EHRs on pharmacy operations was defined as the number of prescriptions that were dispensed per operational hour of the pharmacy. Data filled was either collected by hand from the paper records or exported to a Microsoft Excel file for the EHR  pharmacists in these processes. p < 0.05). As a result, 38% more prescriptions were filled per hour in the pharmacy when using electronic records compared to paper ones: 64.0 ± 3.8 and 46.6 ± 1.8, respectively  pharmacist who would do the data entry into the health records, which occurred while the physician was talking to and assessing the patient. Indeed, use of medical scribes, unlicensed persons who enter information in the EHR at the direction of a health care practitioner, has been shown to improve the time efficiency and productivity of physicians . This beHaving detailed overview of the demographics, encountered disease states, and the types and number of medications dispensed in each village will optimize planning of future trips to the same or similar locations as it relates to the type and quantity of medications needed. However, post trip gathering of this data from paper forms is labor intensive as each form needs to be transcribed by hand into a spreadsheet separately and the challenges of messiness and poor handwriting remain. The ability to export data sets from the EHR system to Microsoft Excel makes data analysis easier and more time efficient. The system also has a search function to find and access the records of individual patients, which could help to follow patients longitudinally when returning to the same sites. The use of EHRs could also facilitate research studies by collecting and analyzing data, such as those related to the benefit of pharmacist interventions studies  and coulThere are some limitations to the study. Firstly, the teams were not identical in each year, although three of the four physicians involved participated in both years. However, the observed increased efficiency appears to be caused by the EHR rather than team composition as a similar increase in the number of patients served per physician per hour was observed in 2018, the year the EHR was used on some days and paper records on other days. Secondly, differences in clinical complexity regarding the patients could also account for differences in efficiency. However, the average number of prescriptions per patient was actually higher when the EHR was used, which may indicate a higher level of clinical complexity. Thirdly, the study is a retrospective analysis and was therefore not designed to have similar conditions between both years, although the only change that was made to the process was changing paper records to electronic ones.Although the intent of participants of medical service trips is to do good and bring health to vulnerable populations, some have voiced concerns regarding the lack of official oversight by governmental agencies or accrediting bodies of the care provided , 5. ThisSince familiarity with the system improves the workflow , we recoAn EHR system that does not require access to an electrical grid or the internet was successfully implemented in medical camps in rural Uganda in an interprofessional health care setting. Compared to using paper records, use of EHR leads to a more efficient workflow and patient care process where per hour more patients can be served per physician and more prescriptions can be filled in the Pharmacy. Therefore, implementation of EHRs on medical service trips is recommended to improve the efficiency of health services provided to vulnerable populations and could be a helpful tool to study the impact and quality of the health services provided.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.HM: conceptualization, methodology, visualization, and writing–original draft. HM and KO: funding acquisition, investigation, and data collection. HM, KO, WM, GT, MS, AN, and LR: implementation and writing–review and editing. HM, MS, AN, and LR: resources. KO: software. All authors have read and agreed to the published version of the manuscript.This research was funded by a Quality Initiative grant from Palm Beach Atlantic University.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.


The dopaminergic and serotonergic systems are two of the most important neuronal pathways in the human brain. Almost all psychotropic medications impact at least one neurotransmitter system. As a result, investigating how they affect memory could yield valuable insights into potential therapeutic applications or unanticipated side effects. The aim of this literature review was to collect literature data from animal studies regarding the effects on memory of four drugs known to act on the serotonergic and dopaminergic systems. The studies included in this review were identified in the PubMed database using selection criteria from the PRISMA protocol. We analyzed 29 articles investigating one of four different dopaminergic or serotonergic compounds. Studies conducted on bromocriptine have shown that stimulating D2 receptors may enhance working memory in rodents, whereas inhibiting these receptors could have the opposite effect, reducing working memory performance. The effects of serotonin on working memory are not clearly established as studies on fluoxetine and ketanserin have yielded conflicting results. Further studies with better-designed methodologies are necessary to explore the impact of compounds that affect both the dopaminergic and serotonergic systems on working memory. Memory is defined as the ability to retain and recollect information regarding previous experiences . FollowiWorking memory is a function that focuses on information which can be stored and used for performing cognitive tasks. The concept is usually presented in opposition with long-term memory, and thus, generally refers to short-term maintenance of information, with the possibility of it being updated flexibly . Puig etThe dopaminergic and serotonergic systems are two of the most important neuronal pathways in the human brain and they influence a wide variety of cerebral functions, including the modulation of memory and learning. Most psychotropic drugs affect at least one of the neurotransmitters from these systems, therefore studying their influence on memory could provide useful information regarding additional therapeutic benefits, or, on the contrary, raise awareness for potentially undocumented side effects.Dopamine is a catecholaminergic neurotransmitter synthesized in three specific brain regions: the ventral tegmental area, the substantia nigra in the midbrain, and the arcuate nucleus in the hypothalamus. The main dopaminergic pathways of the brain are: the nigrostriatal pathway, part of the extrapyramidal system and involved in the motor function; the mesolimbic pathway, forming the reward system of the brain; the mesocortical system, hypothesized to be the origin of both cognitive and affective symptoms of schizophrenia; and the tuberoinfundibular pathway, involved in prolactin secretion . Multiple studies have investigated the role of dopaminergic neurotransmission in memory processing, especially in patients with Parkinson’s Disease, most of them concluding that dopamine depletion impairs such functions ,6. In taDopamine is involved in the processes of motivation, attention, and the positive reaction to reward. The former process has its neural correlation in the prefrontal cortex, while attention and positive reinforcement can be correlated with the nucleus accumbens. This fact can explain why motivation and reward make the learning process more effective . Functional magnetic resonance imaging (fMRI) studies have correlated tasks involving working memory with the activation of the dorsolateral prefrontal cortex (DLPFC), although multiple brain areas need to be activated or inhibited to different degrees when the subject is performing such tasks . DopaminIn human subjects, multiple studies have associated working memory deficits with psychiatric disorders such as schizophrenia, attention deficit hyperactivity disorder (ADHD) , bipolarSerotonin is a monoamine neurotransmitter synthesized in the raphe nuclei, located in the midbrain and pons. While there are only five types of dopamine receptors, serotonin receptors are much more diverse, seven classes of 5-HT receptors being known to date. The seven classes of serotonergic receptors can be divided into multiple subtypes. The most relevant in the process of memory formation is the 5-HT1A receptor, which acts as a modulator of other neurotransmitters, such as acetylcholine, gamma-aminobutyric acid (GABA), or glutamate. Such connections take place in the raphe nuclei, amygdala, septum, hippocampus, and cerebral cortex. Experiments on such receptors have demonstrated a pro-cognitive effect of their blockage, specifically using inverse agonists, thus facilitating glutamatergic neurotransmission, and on the other hand, their stimulation in human subjects has negative effects on explicit verbal memory . Other sWhile serotonin has been less investigated than dopamine in the context of executive function regulation, multiple studies have investigated its role in modulating dopaminergic neurotransmission, specifically in the prefrontal cortex. This interaction involves the D2 and 5-HT2A receptors, and one review by Fink and Gothert 2007) indicated that blocking the 5-HT2A receptors increases dopamine release in the prefrontal cortex, indirectly [07 indicaApart from modulation via certain neurotransmitters, there are other processes which can affect memory, such as neural degeneration. Aluminum, a neurotoxic substance, known to cause memory impairment, can cause both inhibition of various neurotransmitters  and neural degeneration  . The purpose of this review was to collect and evaluate literature data from studies done on animals regarding the effects of drugs known to act on the serotonergic and dopaminergic systems on memory.The aim of this literature review is to investigate the effects on memory of 4 pharmaceutical compounds known to act on the serotonergic or dopaminergic systems: one agonist and one antagonist for each system considered.The selection of the 4 pharmaceutical compounds to be included in this literature review was made considering the availability and amount of published data regarding their effects on working memory in animals. To identify which compounds were studied in this respect, a database search was conducted using the keywords: “dopamine agonists memory”; “dopamine antagonists memory”; “serotonin agonists memory”; “serotonin antagonists memory”. The literature search protocol was adapted from the PRISMA protocol recommendations. The eligibility criteria of the articles for this systematic review were selected based on the PRISMA protocol . The stuEach study was manually evaluated by one reviewer. The data from each study that was analyzed in this review were the following: authors, year of publication, study design, animal model and species used, details about the pharmacological intervention: compound administered, dose and mode of administration, assessments used for evaluating working memory, and the results of the intervention on the animals’ performance in the working memory tests used.The compounds that had the most studies investigating their effects on working memory were bromocriptine and haloperidol, fluoxetine, and ketanserin.Bromocriptine is a dopamine receptor agonist that has been studied extensively for its effects on working memory in animal models. Haloperidol is a dopamine receptor antagonist. Fluoxetine is a selective serotonin reuptake inhibitor. Ketanserin is a serotonin receptor antagonist.The literature search conducted according to the predefined protocol identified 1078 articles in the PubMed database. One record was excluded because it was a duplicate. 970 records were excluded for not respecting eligibility criteria (any other study design such as review articles or studies without open access). Another 78 articles were excluded for the following reasons: irrelevant once full text was obtained (37), no existing English translation (2), human subjects (32), and studies investigating other types of memory, such as fear memory (7). After checking for duplicates and evaluating the studies according to the inclusion criteria, a total of 29 articles were selected and included in the final analysis. The Flow diagram is presented in Out of the 29 articles included in this review, there were 4 articles related to bromocriptine, 10 articles related to haloperidol, 12 articles related to fluoxetine and 3 articles related to ketanserin. A summary tabulation of the articles selected and included in the analysis is presented in Most of the studies relied on various types of mazes for the assessment of working memory. These tests are based on the animal’s capacity to retain spatial information based on specific cues. While they are easy to implement and measure, maze tests have the disadvantage that they require the animals to be stressed, which could affect the results of any kind of cognitive tasks .The Morris water maze is based on the rodents’ aversion to water. It consists of a container filled with water, with an escape platform that is not directly visible. In order for the animal to escape, it must use certain visual cues, which are accessed using working memory. The parameter that the Morris water maze measures is the escape latency, which is the time necessary for the rodents to find the escape platform .The Y and T mazes are based on the animals’ innate curiosity and interest in novelty. A spontaneous alternation is defined by the subject’s choice to explore novel areas, rather than those which the rodent had walked through before. Alternations can be encouraged by rewards, which are only accessed if the animal browses a new arm of the maze .The radial arm maze consists of either 8 or 12 arms, which emerge radially from a central area, where the subject is initially placed. A reward is placed at the end of each of the arms, and the number of errors is counted, which are calculated as the number of times that the animal enters the same arm twice. Better working memory performance implies fewer errors . The elevated plus maze is a cross-shaped maze, placed at a certain height above the ground. Two of its arms are open, and the other two are closed. This assessment is used to measure anxiety-like behavior, and therefore it is useful in testing the effects of anxiolitic compounds. Anxious subjects tend to prefer to stay in the closed arms, and have a lower tendency of walking through the open ones . The Barnes maze is a round surface, with a number of holes close to its circumference. Under one of them there is an escape tunnel. The rodent needs several training sessions in the acquisition phase. When the subject is tested, the escape tunnel is removed, and multiple parameters are measured, such as the distance traveled by the animal before reaching the previous escape tunnel location .The Wisconsin General Test Apparatus is a device used to study learning in primates. It consists of a tray, on which various objects are placed. Underneath one of the objects there is food reward. Between the subject and the investigator, there is a one way screen, allowing the researcher to observe the animal’s behavior .Three out of the four articles identified for bromocriptine concluded that bromocriptine led to improved working memory in different types of maze tests ,24,25. TFive of the ten eligible studies included in this review used mice as test subjects, four studies used rats, and one article investigated the effects of haloperidol on working memory in monkeys. Two of the studies on rats, including a total of 204 subjects, revealed detrimental effects of haloperidol on working memory, in contrast to risperidone which was evaluated using different maze tests ,33. AnotTen of the twelve studies included in this review investigated the effects of fluoxetine on previously induced memory loss through multiple interventions, such as: radiotherapy and temozolomide, a type of chemotherapy, ; intrahiOf the three articles on ketanserin included in this study, Levin et al. (2007) showed that doses of 0.5 mg/kg, 1 mg/kg, or 2 mg/kg caused a negative effect of the compound on working memory improvements produced by a 0.2 mg/kg dose of nicotine in a total number of 11 rats. However, the same doses of ketanserin did not affect memory performance when the animals received 0.4 mg/kg of nicotine . A studyBromocriptine is a dopamine receptor antagonist that has been studied extensively for its effects on working memory in animal models. Bromocriptine has the highest affinity for D2 receptors and acts primarily on the tuberoinfundibular pathway. Antagonists work by binding to receptors and inhibiting the effects of the same receptors’ agonists. Generally, their intracellular effect is to block messenger pathways . BromocrHaloperidol is a dopamine receptor antagonist, acting particularly on the D2 receptors in the mesolimbic pathway; however, its effects on the tuberoinfundibular, mesocortical, and nigrostriatal pathways are responsible for its prevalent side effects . It is mFluoxetine is the first selective serotonin reuptake inhibitor (SSRI) that was discovered, and is used as an antidepressant . FluoxetKetanserin is a serotonin antagonist, acting selectively on the 5-HT2 receptor. It is prescribed sparsely today, however, it is still used as an antiplatelet drug in patients over 55 , and as The results of this review are in line with the previous literature published, showing that both the dopaminergic and serotonergic systems play a role in learning and memory ,70. DopaAlthough one might hypothesize that a higher concentration of a neurotransmitter in the synaptic cleft would result in better working memory performance, the results of studies reviewed here do not consistently support this hypothesis, especially in the case of serotonin, where excess levels can impair cognitive function and memory. Further studies are needed to investigate the effects of different doses of serotonergic and dopaminergic compounds on working memory performance.Both neurotransmitters appear to have an optimal concentration in the synaptic cleft for maximal working memory task performance. Therefore, the results of this study regarding dopamine are consistent with the study conducted by Seamans and Yang , where wTherefore, the results of this review suggest that an optimal concentration of either neurotransmitter is needed for maximal working memory task performance in animal studies. Moreover, the most significant instance when drugs could improve working memory is if associated organic disruptions in the subject’s brain are already present. Such disruptions could potentially benefit from pharmacologic intervention, targeting pathways such as the dopaminergic or serotonergic systems.A practical example of drugs that act on both serotonergic and dopaminergic receptors and have effects on the functions correlated with the prefrontal cortex are atypical antipsychotics. These compounds bind to multiple serotonergic and dopaminergic receptors, thus controlling psychotic symptoms in patients suffering from disorders such as schizophrenia. Other than the known positive symptoms of psychotic disorders, cognitive disruptions, including working memory deficits, can also be identified in such patients .Having a variable affinity for 5-HT2A receptors, but with a homogenous antagonistic effect, atypical antipsychotics may have an additional benefit of improving cognitive symptoms, including working memory impairment, by specifically increasing dopamine secretion in the area of the brain that is predominantly correlated with cognition, namely the prefrontal cortex .Taking into consideration the different paradigms of working memory, depending on the species investigated, as mentioned in the introduction, it is important to note that studies of working memory should be compared only within the same class of species, and a common, clearly defined terminology should be adopted to avoid cross-species confusion.It is also important to note that the effects of a drug on working memory may vary depending on the specific task and the dosage used.Animal research plays an important role in investigating the effects of drugs on cognitive processes such as working memory. It can provide a framework to gain valuable insights into the underlying mechanisms of these processes and how they may be affected by various drugs. It can also help identify potential safety concerns or adverse effects of drugs on cognitive processes and determine the therapeutic benefits of drugs for cognitive impairment.Therefore, animal studies can be used for the identification of certain brain circuits involved in processes such as working memory, as well as the influence of different drugs, both on the respective circuits and on the subject’s behavior. Such studies are easier to conduct than those involving human subjects, and having the possibility of obtaining animal models for specific psychiatric disorders, animal studies are crucial in the first steps of developing new drugs. Apart from identifying underlying mechanisms or physiological and pathological processes, animal subjects also offer insight into potential adverse effects and safety profiles of newly developing compounds.However, animal research also has limitations. For instance, findings from animal studies may not always translate directly to humans due to differences in physiology and biology. Therefore, animal research should be used in combination with other approaches, such as human clinical trials and in vitro studies, to gain a comprehensive understanding of the effects of drugs on cognitive processes. Additionally, ethical considerations should be considered to ensure the humane treatment of animals used in research.The use of animal models in behavioral research has been criticized, and even though such models usually have good face validity, it is difficult to assess them in terms of predictive or construct validity ,75. FutuAn important limitation of this study is that only one type of memory could be investigated, due to a lack of standardization for the evaluation of other types in non-human species. Therefore, multiple meta-analyses and systematic reviews should be performed, investigating studies including exclusively human subjects, and evaluating multiple types of memory.Identifying a specific psychological pattern induced by pharmacologic manipulation of neurotransmitters could offer additional aid in alleviating symptoms associated with psychiatric disorders such as depression or schizophrenia. These types of studies could help in understanding the pathophysiology of such disorders, with the hope that one day enough information will be collected to facilitate an etiological treatment in favor of a symptomatic one.No study risk of bias assessment or certainty assessment was conducted. This review included a small number of studies, which were heterogenous regarding both the species included and the assessments used to evaluate working memory. In addition, this review presented an interpretation of the outcome of each study included based on the reported statistically significant results. However, the statistical significance has the great limitation that it depends on sample sizes. Therefore, the conclusions for each compound studied may not be accurate, and a different study design, such as a systematic review or meta-analysis should be applied, highlighting the need for statistical analysis and further interpretation of the results.This literature review provides an overview of studies examining the impact of four compounds that affect the dopaminergic and serotonergic systems on working memory in animals. The findings suggest that stimulating the D2 receptors with bromocriptine may enhance working memory in rodents, whereas blocking these receptors can reduce working memory performance. However, the effects of serotonin on working memory are inconclusive due to conflicting results from studies on fluoxetine and ketanserin. More research with improved methodologies is necessary to better understand the impact of compounds that affect both the dopaminergic and serotonergic systems on working memory.


The development of competency frameworks serves as the foundation for the development of competency-based education. It is vital to develop a country-specific framework to address the specific needs of the local population for pharmacy services. This study aimed to describe the development process of a competency framework for undergraduate pharmacy education in Kuwait with a unique matrix structure. The process started with the development of guiding principles for curriculum revision and implementation, as well as the identification of global educational outcomes. This process was followed by: (A) a needs assessment with key stakeholders; (B) development of the initial competency framework; and (C) refinement of the framework. Qualitative data were thematically analyzed to identify the main competency domains that students need to perform the identified entrustable professional activities (EPAs). Five population needs were identified by the needs assessment, with 17 EPAs suggested to fulfill those needs. In addition, 11 competency domains were identified. The initial competency framework was created as a 3 × 8 matrix, with 3 professional and 8 transversal competency domains. Refinement of the framework resulted in the removal of redundancies and the development of a global behavior competency profile. The development of a matrix competency framework and associated EPAs for Kuwait serves as a foundation for preparing pharmacists to fulfill local population needs and expanding the scope of practice in the country. To support the provision of competent pharmacists, the International Pharmaceutical Federation (FIP) proposed a needs-based education model to guide colleges of pharmacy in developing a competency framework that would be aligned with local needs ,2. The mThe only college of pharmacy in Kuwait is part of Kuwait University, a comprehensive public university. The college was established in 1996 with four academic departments: pharmaceutical chemistry, pharmaceutics, pharmacology and therapeutics and pharmacy practice. The college admitted its first cohort of students in 1997 to a five-year BPharm program. In 2014, the college embarked on a plan to transform its pharmacy education, to better serve the community and to introduce more advanced  professional activities, in addition to the more traditional pharmacy roles and responsibilities. Considering the scarcity of advanced clinical pharmacy expertise and the unavailability of consistent advanced pharmaceutical services in the country .The construction of a custom-made competency framework is the foundation for the development of competency-based learning since it includes what is expected to be undertaken by pharmacists locally ,10. AlthThis manuscript describes how a competency framework and associated EPAs were developed for undergraduate pharmacy education in Kuwait and the results obtained, as they could help others to follow the same process in their own context. In addition, we compare our framework’s structure with existing frameworks, as it is presented in a unique compact matrix format. The full process of competency-based curriculum development is beyond the scope of this manuscript and is presented elsewhere .A team, with two representatives from each academic department, chaired by the dean of the college at the time (author PM)—who has vast experience in curricular reform—was assembled to revise a draft add-on PharmD program that was already developed in the years prior to 2014. The team initially prepared guiding principles for the curriculum revision and implementation. It was important to define these guiding principles early in the process to steer the development of the curriculum towards a unified vision . It was (A)Needs assessmentn = 39) were grouped according to their sector and interviewed for approximately 90–120 min to collect data that would provide a deeper understanding from the population of interest. The questions presented in The objective of the needs assessment was to determine the global population needs with regard to the pharmacists’ contributions, the type of professional services that should be offered to meet the needs  and the competencies needed to provide professional services. A qualitative study design, using focus group interviews, was used to conduct the needs assessment. Eight focus group interviews were conducted with different groups of stakeholders: pharmacy students, hospital pharmacists, ambulatory clinic pharmacists, industrial and regulatory pharmacists, community pharmacists, pharmacy service managers, physicians and patients. Participants were invited to the interview and only attended if they agreed to be there, and they had the freedom to answer or reject any question. The participants ((B)Initial competency frameworkThe team convened to discuss the results of the needs assessment and start constructing the competency framework. The occurrence of competency domains was calculated by adding them from each set of focus group notes. A competency could be mentioned within several professional activities, explaining why the occurrences could surpass the number of focus groups. For example, the “communication” competency domain could have been brought up for five different professional activities during one focus group. These five occurrences were added to the occurrences in the other focus groups to obtain a total number. Starting from the list of competence domains obtained, a series of competency frameworks and national pharmacy standards of practice were reviewed to identify the enabling competencies  that would define the expected outcomes. The frameworks included the AACP’s Center for the Advancement of Pharmacy Education (CAPE) , the PhaThe competency framework was then used to develop competency profiles (subsets of enabling competencies) for each of the professional activities initially identified during the needs assessment. These professional activities, with their unique competency profiles, became the EPAs that were integrated as the backbone of the add-on PharmD curriculum. For each EPA, the competency profile was used to determine the learning activities to be performed, the assessment criteria and the rotations’ learning objectives. The level of entrustment was used to assess the students, as previously published . When co(C)Refinement of the competency frameworkIn 2019, after three years of using the initial framework and EPAs in the add-on PharmD program and in preparation for the launch of the ep-PharmD, the EPAs were critically revised and further simplified. This goal was accomplished by a task force comprised of educators who were involved in the add-on PharmD and, more specifically, in competence assessments using the initial EPA profiles. The first task was to reduce redundant EPAs and combine those that had similar competency profiles. Then, rather than starting from the competency framework itself, the task force worked from the competency profiles and identified enabling competencies that were either redundant, needed reformulation or were difficult to assess during EPA performance. Changes in the profiles were reflected in the global competency framework, and this revised framework is presented (see results).(A)Needs assessmentDuring the needs assessment, five population needs were identified as met, unmet or future needs . AccordiThe focus group structured questionnaire allowed for the identification of major competency domains that needed to be acquired by students to perform the expected professional services (EPAs). (B)Initial competency frameworkWhile regrouping the competencies that were highlighted by the groups consulted , the tea(C)Refinement of the competency frameworkAfter three years of using the initial framework, it was thoroughly revised (see Methods). First, the number of EPAs was reduced to remove redundancies for those sharing nearly identical competency profiles. For example, medication therapy management, specialized pharmacotherapy and intoxication management were all merged to be under medication therapy management. Similarly, distribution and quality control were grouped under the dispensing EPA. An EPA called practice management was added to better assess this important aspect of practice, which was not captured initially as a professional activity. The number of EPA was reduced from 17  to 12 F, within Additionally, based on experience with the initial framework and as described in the Methods section, the enabling competencies were refined. This additional streamlining step reduced the number of enabling competencies in our competency profile from 77 to 66 . Our curDuring the competency framework revision, it was noted that some enabling competencies were not assessed as frequently as others. These competencies included the lifelong learning, teamwork , professionalism and proactivity (leadership) competency domains. To remedy the situation, a global behavior competency profile was added to the EPAs to capture enabling competencies that are better assessed longitudinally, rather than during the assessed performance of a professional activity occurrence.Our initial decision to improve pharmaceutical education, first with a two-year add-on PharmD, followed four years later by an ep-PharmD, greatly helped to develop the country’s scope and capacity of advanced pharmaceutical practice. The add-on PharmD graduates are now part of clinical pharmacy units in major hospitals and have introduced a series of professional services supporting pharmaceutical care at multiple practice sites, which have expanded the scope of practice for pharmacists whether at hospitals or in ambulatory care settings. They are also improving the experiential learning capacity for clinical activity supervision. The initial competency framework, with the creation of 17 EPAs and their own competency profiles, allowed us to prepare the add-on PharmD graduates to be work-ready in providing most of these professional activities. Within this two-year add-on program, the same EPAs (and competency profiles) were used when students practiced in our laboratories and during their rotations within the healthcare system. This process allowed for seamless continuity between the first-year (on campus) and the second-year (rotations) of the curriculum. The same model was adopted for the ep-PharmD but with a longer timeframe.To support competency-based learning, one needs a complete competency framework that includes what is expected to be mastered by pharmacists locally ,10. AlthThe needs assessment also caused us to realize that transversal competencies are generally intertwined with professional activities. The total score for the competency domains presented in As analyzed and reported before, most of the published pharmacy competency frameworks have been shown to be quite similar . HoweverThe three professional and eight transversal domains of our competency framework are reminiscent of the FIP global competency framework, with our transversal domains being part of the personal/professional cluster and the three other clusters being similar ,27. ThisHaving hands-on experience with the first competency framework and measuring student performance though EPAs and their associated competency profiles exposed issues with the wording or the redundancy of several enabling competencies. Indeed, when juxtaposed within a competency profile for an EPA, it is easier to see what represents a unique enabling competency and what is already measured, at least partially, by another competency. Because several competency frameworks are produced by regulatory authorities or associations that do not have hands-on experience with their implementation and measurement, simplification and streamlining may not occur as readily. Such frameworks are often intellectual activities involving several stakeholders, but they are not necessarily revised after testing in the field. We had the advantage of doing so, and it had a significant impact on simplifying, thus improving the use of our learning and assessment tools. It is our contention that, if an enabling competency is not used within a professional activity (as defined in the EPA profiles in our model), then it is theoretical (often centered around knowledge), cannot be effectively measured and should be removed from a competency framework. Indeed, it is most likely implicit within another enabling competency, like knowledge is always .Using EPAs as a means to measure competence makes the process much easier, as the practice and assessment of EPAs can be distributed throughout the curriculum and rotations . HoweverThe creation of a specific competency framework also bears some limitations. Its applicability to other colleges or countries is limited, especially considering that the societal needs and professional activities (EPAs) identified are likely to differ. However, the objective of this work was to provide a structured process to build a personalized framework and to create a format for a competency framework that limits redundancies. There is no intention to suggest that the competency framework presented here could be considered as a universal framework or that the EPAs that were identified apply globally. In addition, the construction of the framework depends on the knowledge and experience of the people involved, as several decisions to include or exclude enabling competencies can be subjective. The revision of our framework after years of usage clearly illustrates that it is a living document that requires regular revision to stay current and useful to support the advancement of the profession.The College of Pharmacy at Kuwait University has successfully developed and implemented a competency framework to support its competency-based learning efforts after assessing the need of the country. Hands-on experience with the initial framework and EPAs allowed for a thorough and practical revision of the framework to improve it further. Efforts were undertaken to remove redundancies, avoid explicit knowledge and skills (they are implicit to competence) and focus on measurable enabling competencies. Thus, the compact matrix-shaped framework has a limited number of enabling competencies that are suitable, with the use of a competency profile for each EPA, for frequent practice and assessment. The needs assessment provided the relevant professional activities (EPAs) and the competency framework , which are the foundations of our educational efforts to prepare pharmacists to fulfill the population’s needs in Kuwait. It was also instrumental in engaging external stakeholders in expanding the scope of practice in the country, based on locally obtained evidence.


The Coronavirus Disease-2019 (COVID-19) pandemic is not just a health crisis but also a social crisis. Confronted with the resurgence of variants with massive infections, the triggered activities from personal needs may promote the spread, which should be considered in risk management. Meanwhile, it is important to ensure that the policy responses on citizen life to a lower level. In the face of Omicron mutations, we need to sum up the control experience accumulated, adapting strategies in the dynamic coevolution process while balancing life resumption and pandemic control, to meet challenges of future crises. We collected 46 cases occurring between 2021 and 2022, mainly from China, but also including five relevant cases from other countries around the world. Based on case studies, we combine micro-view individual needs/behaviors with macro-view management measures linking Maslow’s hierarchy of needs with the transmission chain of Omicron clusters. The proposed loophole chain could help identify both individual and management loopholes in the spread of the virus. The systematic actions that were taken have effectively combated these ubiquitous vulnerabilities at lower costs and lesser time. In the dynamic coevolution process, the Chinese government has made effective and more socially acceptable prevention policies while meeting the divergent needs of the entire society at the minimum costs. Systematic actions do help maintain the balance between individuals’ satisfaction and pandemic containment. This implies that risk management policies should reasonably consider individual needs and improve the cooperation of various stakeholders with targeted flexible measures, securing both public health and life resumption. According to the WHO’s weekly epidemiological update on COVID-19, as of 13 November 2022, 632 million confirmed cases and 6.5 million deaths have been reported globally . FurtherThe aim of this article is to illustrate densely-populated countries, taking China as an example, can make effective and more socially acceptable prevention policies while meeting the divergent needs of the society at the minimum costs, even for the pervasive Omicron, that is, the system actions approach, before transiting to the new stage of post pandemic. The approach is by identifying individual and management loopholes in the spread of Omicron more precisely and quickly by the proposed loophole chain of our analysis, which can help fight against pervasive Omicron at lower cost and lesser time while also meeting the divergent needs of people. For densely-populated countries with scarce medical resources, systematic actions to fight against pervasive Omicron could be a cautious transition into next stage.In addition to the combination of micro-personal needs and macro-governmental management, this paper has four major contributions to the analysis of pervasive Omicron cluster prevention. First, this article describes the complete process of cluster outbreaks in key groups and places, providing a direction toward future epidemic prevention. Second, it identifies tipping points, that is, personal and management loopholes, to help fight against pervasive Omicron with more precise systematic actions at lower cost and lesser time. Third, this article presents a detailed analysis of the high level of needs of individuals , which are being underestimated by the current research. The needs can ensure normal functioning of life and economy during the Omicron outbreaks in a positive way. This provides an important strategy for dealing with the Omicron crisis. Fourth, systematic actions provide a way to maintain the balance between individuals’ satisfaction and pandemic containment. This also implies that risk management policies should reasonably consider individual needs and improve the cooperation of various stakeholders with targeted flexible measures, securing both public health and life resumption.2.The epidemic has significantly affected people’s everyday lives. The virus also exhibited potential for mutation, which greatly threatens community health, social stability, and economic development. Countries have adopted different prevention and control measures to maintain people’s normal lives as much as possible. Aside from common viral testing, many other measures to prevent COVID-19 are also being applied, such as maintaining social distance , temporaAlthough surveys in South Africa and other countries show that the mortality and severity of the fourth wave of infection have decreased , as the Some countries have also tried to make adjustments to maintain people’s daily needs. Since late December 2021, the number of countries affected by the epidemic has continued to increase , and theAside from problems in medical treatment, other fields are also facing problems caused by the high prevention and control costs. To revive daily life and production needs, countries are looking for effective defensive measures with lower cost. Every country has its own regulations on the prevention and control standards as well as quarantine times and dynamically adjusts the degree of strictness. The strictness of the prevention and control policy is related to the country’s original institutional framework and governance philosophy. Countries in East Asia, such as South Korea and Japan, invested more resources in isolation and tracing and achieved remarkable results . In ChinHowever, the effectiveness of the previous policy has been weakened by Omicron. A bar in China still experienced cluster infections even after implementing temperature checks, disinfection, and crowd limits . ThailanUnder the pressure of reality, many countries had to adopt the strategy of dynamic adjustment. To balance economic development and medical health, some countries have made dynamic adjustments to the prevention and control measures. South Korea has eased restrictions. If the situation becomes stable, most social distance restrictions will likely be lifted . When OmThe large scale of the infected population as well as the fast infection transmission has caused greater social pressure than ever. Employees, especially in the service industry, are at a higher risk of exposure and are prone to burnout and nervousness. In December 2021, early in the Omicron outbreak, many retailers and restaurants in the United States were forced to close or shorten the drinking hours as there were not enough employees . The panCampuses are also key places that are prone to large-scale infections. American researchers have demonstrated that frequent testing coupled with strict attention to behavioral interventions  is effective in preventing further COVID-19 transmission and outbreak in campuses . Groups Some of the previous measures are still effective but are not enough to deal with Omicron and other possible variants that may occur later. Besides, long-term personal protection can cause behavioral fatigue . These sThe loopholes are not only occurring in countries that lack infrastructure but also in countries with relatively complete protective chains. Despite Israel’s high level of development, children are also at risk of food shortages due to segregation. Furthermore, the low vaccination rates and a sudden increase in gatherings during the winter holidays have contributed to the effectiveness of the prevention and control policies . This ty3.Human needs are the basis of individual actions. Although the activities motivated by human needs may cause further spread of Omicron, satisfying human needs is the basic function of society. Some human needs are also helpful in containing the spread of Omicron and ensuring the normal functioning of society when the cluster epidemic spreads.According to Maslow , human bTo present the context of human needs and activities that promote further transmission, we collected data and case details of Omicron cluster infection from official reports and authoritative media news. To provide a clearer picture of how personal and management loopholes evolve to an eventual cluster outbreak, we employed the case study approach  to proviConsidering the information abundance for the chain analysis, the cases reported in the article are carefully selected to represent the correspondent Maslow’s scales. Among the five types of needs in Maslow’s hierarchy of needs, each has multiple forms, for example, physical needs include food, clothing, shopping, and transportation. With this circumstance and the fact that the characteristics of Omicron were not fully understood in the early stage, China withstood the pressure from different groups of people and different levels of needs during the Omicron outbreak in early 2022, reducing the impact of the virus on society and people.When community cluster infection of Omicron has occurred, the virus has spread in multiple rounds in various ways, making it extremely difficult to find the clear transmission chain. However, the transmission chain was relatively clear before the community transmission, resulting in the clear discovery of the tipping point of cluster infection so as to intercept and contain the continued spread of the virus at the minimum cost. Therefore, community management and the cooperation of residents are both feasible and necessary for the prevention of the epidemic. This article uses figures and tables to clearly show the complete transmission chain of Omicron community infection in the case analysis. The figures present the possible loopholes causing the chain of Omicron cluster infections due to human needs, including loopholes in personal and management measures. Loopholes start from human needs, which cause people to be exposed to the virus and leading to its spread in public places with the appearance of crowds. The tables in the case study summarize the possible loopholes causing other cases of cluster infection due to related needs.3.1.Food, clothing, and transportation are basic needs for human survival. During the recovery period, both personal and management loopholes while meeting physiological needs led to the occurrence of Omicron infection cluster outbreaks. After the emergence of Omicron, cluster outbreaks frequently occurred in markets, buses or cars, clothing stores, etc. Based on the analysis of the collected clusters of infections see , the traIn March 2022, a cluster infection occurred, which started in a restaurant in Beijing. As of March 22, the cluster has infected 17 people, including diners and their family members, as well as restaurant staff . Figure Various management loopholes induced by restaurant owners are also key factors in this cluster infection. Although Beijing required all units to strictly implement customer health code scanning, many stores did not practice it. During the outbreak tracing, the disease control department found that the restaurant had not implemented health code scanning, temperature detection, health monitoring of employees, and other epidemic prevention measures. Furthermore, the restaurant operators did not report the condition of the temporary waiter, Zhang, which resulted in the exclusion of Zhang from the epidemiological investigation. This resulted in the spread of the epidemic, and 92 people in nine units, including hotels, restaurants, supermarkets, and wet markets, were monitored. To learn from this in combating Omicron, Beijing strengthened the implementation of health code scanning and posting of the warning sign “responsibility for epidemic prevention has not been implemented and there are high risks” outside the stores to warn customers.Restaurants, supermarkets, and trains have relatively closed spaces and poor air flow. In these environments, personal and management loopholes could easily cause cluster infections. In November 2021, a cluster infection of Omicron occurred in Norway because of diners who spent too long in a relatively closed space and neglected self-protection . CustomeTo balance the needs of traditional Chinese catering culture and epidemic prevention and control, the government hardly adopted large-scale policy measures to stop dine-in and to close shopping malls during the period of epidemic prevention and control. The checking of health code was only required upon entering closed, semi-closed, and crowded places. To facilitate nucleic acid testing for citizens, the government has improved the layout of standardized nucleic acid testing sites so that all residents can walk 15 min from their homes or offices to a free testing point. This would help improve their cooperation. Furthermore, some areas have explored the implementation of the meal-sharing method, strictly controlled the number of people gathering for meals, moved the dining venue to sparsely populated suburbs, and opened special takeaway windows. Henan, Gansu, and other places have combined dining restrictions with prohibitions on alcohol, which is stricter. At the same time, the society also calls on individuals to play a good supervisory role and cooperate with law enforcement to reduce the risk in dining areas.3.2.After meeting the basic physiological needs, people will next seek security, hoping that the environment they live in is safe. The continuing epidemic and the emergence of Omicron variants have compromised people’s safe living space, from hospitals to other spaces, such as schools and nursing homes.In March 2022, an intra-school cluster infection occurred in Jiutai District, Changchun City. Safe space encroachment has also occurred in older adult nursing homes in Hong Kong, China. A total of 360 nursing homes in Hong Kong have been attacked by Omicron, with more than 420 employees and 1,100 older adult infected . Figure In terms of management loopholes, the Hong Kong government does not require staff below the level of nursing staff to undergo hygiene and infection control training, nor does it supervise the hygiene of nursing homes. Besides, due to the lax management, temporary workers in nursing homes often fail to perform disinfection in a standardized manner. In addition, nursing-home staff have a heavy workload and do not have sufficient time to care about the physical condition of the older adult. These have become potential dangers during the epidemic, and once Omicron occurs in nursing homes, it would be very difficult for them to quickly detect and effectively prevent the spread of the virus. Moreover, some nursing homes have stopped health screening on visitors, which enabled the infected people to enter the nursing homes. Also, the untimely transfer of groups with a high risk of infections also aggravated the spread of the epidemic.The following are examples of the impact of Omicron on safety needs. Two schools in Howell, United States, had a cluster of Omicron infection in January 2022 . During There were also some positive cases that demonstrated that the elimination of personal and management loopholes in the virus transmission can contain the spread of Omicron. Compared with Jiutai teachers who lack occupational consciousness, the freight driver from Shanghai fulfilled his responsibilities very well. He underwent self-quarantine in the truck for 27 days to prevent risks to others . Jilin UIn January 2022, the fifth wave of the outbreak in January this year was the most severe one ever seen in Hong Kong. This surge in the number of cases has resulted in a serious shortage of medical resources. Many patients needed to wait for treatment in tents or open spaces outside the hospital . Further3.3.Belonging needs indicate that individuals desire to establish an emotional connection with others, the need for friends, and to seek solace in the group and family. Due to these needs, in the case of safety needs, we described the process of an intra-school cluster infection in Jiutai District, Jilin Province, but the cluster infection was not contained within the school. The school mistakenly sent 5,000 students’ home. These students, who experienced an infection at school, were in desperate need of emotional comfort from their families but then infected them when they went home. In terms of personal loopholes, the students lacked self-protection awareness and did not undergo health monitoring at home after coming into contact with the infected classmates and teachers. Their family members also did not protect themselves, thus resulting in their infection. There were also management loopholes in this case. The first one was sending home students who were possibly infected instead of subjecting them to quarantine. Furthermore, due to the failure to identify which department was responsible for the students and their parents, the nucleic acid testing was not immediately carried out. Meanwhile, for students who had undergone nucleic acid testing at school, their results were delayed, which led to cross-infection among the families of those who were positive. In addition, loopholes such as the lack of clarity in the respective responsibilities of the epidemic management and shifting of responsibilities have expanded the scope of Omicron spread. Moreover, Jiutai is far away from the urban area, and there are insufficient medical resources to deal with large-scale cluster infections, resulting in the untimely transmission of infections and lack of good treatment.From groups with high risk of infections (students) receiving the school’s notification to return home, and to the large-scale spread in the community, multiple transmissions have been experienced during this period see . If the The community transmission in this case can be regarded as the secondary spread of intra-school infection based on personal emotional needs. The following case of Hong Kong is a daily life scene with a complete and independent transmission chain. A flight attendant returned to Hong Kong from Los Angeles on December 27, 2021, and tested positive for Omicron on December 31. During this time, the flight attendant stayed in the house, but her mother, who lived with her, was free to move. She danced at Victoria Park on December 31, with a scale of 20 people, causing the initial spread of the virus. Since then, some of the infected people have boarded the cruise ship, and some have participated in a concert on January 3, causing a wider spread. As of January 13, 2022, this cluster infection has spread for five generations, resulting in the infection of 24 people . Figure The Hong Kong government stipulated that passenger crews must undergo centralized quarantine after returning, whereas cargo crews can be exempted from this quarantine, that is, they only need health monitoring at home for 3 days. To avoid concentrated crew quarantine, Cathay Pacific took the liberty of converting all passenger aircraft operating on international routes to freighter status upon their return to Hong Kong . This acThere are also many positive examples of preventing the spread of the epidemic. For example, Mr. Lin, a 60-year-old man who was doing renovation work in Shanghai, was about to leave after finishing his work. However, he took the initiative to quarantine himself to help reduce the spread of the virus when the community implemented static management . By inte3.4.The epidemic has inspired the sense of responsibility and prompted people to cherish life by respecting each other and doing their best to contribute to society. Compared with the previous epidemic prevention and control, the current one includes not only ordinary citizens who make selfless dedication but also staff who stick to their posts. During the Omicron epidemic, more people participated in the prevention and control see . These pvia self-drive or company-chartered vehicles, achieving a closed-loop return. Among the 20 recent enhancements enacted in China, the level and number of quarantine days have been reduced, as well as the barriers to pursuing esteemed needs, and activities have been facilitated by the abolition of entry circuit breakers ,” which has been updated with the latest regulations on key populations, such as teachers and students, to adapt to the new epidemiological situation . Second,The systematic actions against Omicron also need to strengthen the cooperation between various departments, including operators and managers of key places, government management departments, and medical treatment systems. First and foremost, operators and managers of key places, such as restaurants and shopping malls, should comply with the relevant requirements issued by the epidemic prevention and control department and cooperate with their work. Although the situation is better now, there is no room for laxity, as many outbreaks have rebounded due to the negligence of managers. In the case of physiological needs, the CDC department of China found that the restaurant operators failed to implement epidemic prevention measures, such as health code scanning; temperature detection, which brought various problems and troubles to the subsequent epidemic source tracing; quarantine; and transfer of groups at a high risk of infectious. Second, the relevant government departments need to elucidate their respective responsibilities and strictly perform them. The negative cases of the paper all showed loopholes, such as untimely nucleic acid testing, unclear responsibility for joint prevention, and untimely transfer of groups at a high risk of infections by the government department. The government’s epidemic prevention department is the most important part in the entire anti-epidemic process. Only by ensuring its rapid and effective operation can it exert the cohesion and coordination of systematic measures to quickly stop the epidemic. Also, the medical system should fully cooperate with the overall epidemic prevention work. In view of the relatively weak medical capacity in some areas, medical treatment requires hierarchical diagnosis and treatment. In addition, the capacity of medical institutions needs to be strengthened by planning ahead to prepare designated and subdesignated hospitals, mobile cabin hospital, and central quarantine sites to ensure rapid activation in the outbreak . Hong KoThe systematic actions summarized in this article to fight against cluster infections are being flexibly adjusted according to the latest epidemic situation. After the success of the maskless World Cup with loosened policy responses against COVID-19, there have been 20 new measures by China’s in the fight transiting to the next stage, e.g., lowering the level of control, emphasizing precise prevention, and controlling and standardizing regional management policies. That is also the limitation of our study as polices are being dynamically adjusted considering the experience of other countries and the expectations of citizens. For example, various cities in China have hundreds of positive cases; however, mass testing for earlier identification have stopped. Residents who are homebound for a long time and do not need to go out may not take the nucleic acid test, thus avoiding the risk of infection due to aggregation. Nevertheless, systematic actions do prevent the spread of the virus on time and ensure the stability and order of people’s lives and economic resumption for quite a long period. For densely-populated countries with scarce medical resources, systematic actions as a cautious way contribute lower level of infections before transiting to next stage. This also implies that risk management policies should reasonably consider individual needs and enhance the cooperation of various stakeholders with targeted flexible measures, securing both public health and life resumption. Furthermore, the weapon of systematic actions can also help us maximize the effectiveness of epidemic prevention at minimal cost in future crises.5.In view of the new challenges brought by Omicron’s characteristics, this paper summarizes some experiences of systematic actions to reduce the cost of epidemic prevention and the impact of various measures on people’s basic needs. Through cases study of different needs, we combine micro-action at the individual level with macro-management at the social level, using Maslow’s hierarchy of needs theory to analyze the epidemic spread chain. The personal and management loopholes identified can help prevent and control potential waves in the future. With the personal and management loopholes, the biggest challenge in preventing the spread of Omicron is speed and precision; otherwise, it may lead to the continued development of the virus transmission chain, triggering further community infection. The large-scale cluster epidemics in cases 1–3 were caused by the failure of the participants to carry out multiple links in the epidemic prevention system to actively perform their responsibilities, resulting in delays in prevention and control; thus, the epidemic had to be fought at the cost of wider control and more resource consumption. The latter two cases suggest that even in crowded situations, it is possible to keep people safe and meet their needs through dynamic management and efficient cooperation. This article offers policy recommendations based on five cases, not only for the management departments but also for communities and individuals who have an important role to play, to achieve a more dynamic and effective prevention and control at the minimum cost. Based on the China’s cases, we illustrated densely-populated countries made effective and more socially acceptable prevention policies while meeting the divergent needs of the society at the minimum costs with system actions. The mutual support and cooperation between various actors in the system, through which the entire social system could return to normal at lower costs and lesser time. Systematic actions have explained China’s effectiveness in the fight before COVID-19 variants turn into more transmissible.The systematic actions summarized in this article to fight against cluster infections are being flexibly adjusted according to the newest epidemic situation. With the mutation of the virus, infection situations in the epidemic, the popularization of vaccination and the accumulation of domestic and foreign fighting experience, the prevention and control of the COVID-19 epidemic in China has entered a new phase. Under the premise of efficiently integrating the epidemic prevention and economic development, the management of COVID-19 in China was downgraded to a less stringent level. That is also the limitation of our study, because the polices are being dynamically adjusted considering the experience of other countries and expectations of citizens. For example, the targeting strategy for nucleic acid testing has been adjusted. Community residents will be tested when they want or need to be, and citywide nucleic acid screening is no longer conducted. The focus on personal protection is more advocated. Nevertheless, before this phase, systematic actions do prevent the virus spread on time and ensure the stability of people’s lives and economic resumption for quite a long period. For densely-populated countries with scarce medical resources, systematic actions may be difficult but a cautious approach with a lower level of infections fighting against pervasive Omicron before transiting to the next stage. This also implies that risk management policies should reasonably consider individual needs and enhance the cooperation of various stakeholders with targeted flexible measures, securing both public health and life resumption. Furthermore, the weapon of systematic actions can also help us maximize the effectiveness of epidemic prevention at minimal cost in future crises.The original contributions presented in the study are included in the article/JX and NW: conceptualization, supervision, and project administration. JX, NW, and HL: methodology and formal analysis. JX, NW, and BL: resources. BL: data curation. JX, NW, HL, and TX: writing—original draft preparation. TX: writing—review and editing. NW: visualization. JX, NW, and HL: funding acquisition. All authors contributed to the article and approved the submitted version.This research was funded by the National Social Science Fund for Young Scholars, grant number 18CZZ010; the Integrity government construction research project of Jilin University, grant number 2018LZY003; the Social Science Fund for Young Scholars of Jilin Province, grant number 2021C18; the Fundamental Research Fund for Universities of Central Authorities, grant number 2572020BN01; the Fundamental Research Fund of Jilin University for Philosophy and Social Science Research Project, grant number 2017QY010; CPPCC theoretical research project of Jilin University, grant number 2021zx03002; and the Scientific Research Project of Jilin Provincial Education Department, grant numbers JJKH20220940SK and JJKH20231254SK.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.


There is growing interest from health researchers in the governance of Health in All Policies (HiAP). Furthermore, the COVID-19 pandemic has re-ignited managers’ interest in HiAP governance and in health prevention activities that involve actors from outside health ministries. Since the dynamics of these multi-actor, multi-sectoral policies are complex, the use of systems theory is a promising avenue toward understanding and improving HiAP governance. We focus on the concept of equilibrium within systems theory, especially as it points to the need to strike a balance between actors that goes beyond synergies or mimicry—a balance that is essential to HiAP governance.We mobilized two sources of data to understand how the concept of equilibrium applies to HiAP governance. First, we reviewed the literature on existing frameworks for collaborative governance, both in general and for HiAP specifically, in order to extract equilibrium-related elements. Second, we conducted an in-depth case study over three years of an HiAP implemented in Quebec, Canada.In total, we identified 12 equilibrium-related elements relevant to HiAP governance and related to knowledge, actors, learning, mindsets, sustainability, principles, coordination, funding and roles. The equilibria were both operational and conceptual in nature.We conclude that policy makers and policy implementers could benefit from mobilizing these 12 equilibrium-related elements to enhance HiAP governance. Evaluators of HiAP may also want to consider and integrate them into their governance assessments. Health in All Policies (HiAP) refers to health policies that target a range of health determinants and involve multiple actors  and so aThere is a dearth of knowledge about HiAP governance, and what does exist revolves around the use of a step-by-step process to launch the implementation of the policy and oversee the intricate interlinking of actors to be mobilized. Shankardass et al. point out the importance of acknowledging the interconnections between the different subsystems at stake during HiAP implementation, namely, the executive, intra-sectoral and intersectoral subsystems . BilodeaCollaborative  governance fits with the dynamics of HiAP. Indeed, it is understood as a network perspective whereby “…the multi-actor nature of interaction settings and the presence of diverging and sometimes conflicting perceptions, objectives, and institutions are the starting point for analysis and management” ( p14). AtWe were interested in the concept of equilibrium in HiAP governance for several reasons. First, HiAP involves multiple actors, individuals and organizations, and calls for solutions to be found that benefit this collective work. It requires strengthening and taking into consideration the logic of each actor’s actions. We argue, as do others , 11, thaBaumgartner and Jones’ punctuated equilibrium theory  discusseScholars in implementation science have studied equilibrium from the perspective of the policy/implementation nexus . They arIn healthcare, the complexity of the sector makes it relevant to apply complexity theory because of its emphasis on agent interactions and emergent system outcomes . PreviouWe mobilized two sources of data to understand how the concept of equilibrium applies to HiAP governance. First, we reviewed the literature on existing frameworks for collaborative governance, both in general and for HiAP specifically, in order to extract equilibrium-related elements. Second, we conducted an in-depth case study over three years of an HiAP implemented in in Quebec (Canada). The data that we collected during the implementation of this HiAP by policy makers highlighted the existence of contradictory dynamics that co-exist and co-evolve. We compared the elements revealed by the two separate analyses and then reconciled them with the five dimensions identified to come up with a final list of equilibrium-related elements applicable to HiAP governance.We carried out a literature (scoping) review for frameworks that could be informative about equilibrium in the governance of multi-stakeholder and cross-sectoral policies like HiAP.Scientific articles and grey literature from 2000 to 2019 were included. The search was carried out in Google Scholar, Google and the university database for topics related to aspects of equilibrium like trade-offs and related concepts . A combination of the following keywords was employed: collaborative/intersectoral/interministerial/joint/distributed/interstitial/boundary with governance/management/collective leadership, and policy/capacity/design/coherence/trade-off/input/output/synergy/adjustment/equilibrium/boundary/interstitial. Any document related to local initiatives and street-level managers was excluded. After a review of each title and summary, 66 documents were analyzed.Equilibrium was broadly defined for this study as dynamics that could be in opposition and could potentially co-evolve, in other words as a state of oscillation between two extremes. This conceptualization is in line with how complexity theory conceptualizes complex adaptive systems that possess organizational capacities and move between order and transformational change . IndividIn general, we found that existing frameworks for HiAP governance and collaborative governance do not directly consider equilibrium. Rather, they simply mention a concern for the management of balances either explicitly or indirectly. One framework mentioned how collaborative governance is affected by (im)balancing in representativeness among the participants, and how relationship building depends on formal and informal work . Few stuThe frameworks dedicated to HiAP are silent on the topic of equilibrium Table . There iWe identified six elements that pertain to equilibrium during governance in the literature.While at times information can be provided in a one-way information provision, collaborative development requires that attention be paid to the partners’ preferences about how they want to act strategically within the policy . The comFor actors in governance, working together encompasses knowing where one stands in terms of individual and organizational knowledge on health and its determinants, knowing where partners stand in terms of this knowledge, and knowing how to bridge any gaps between the two. This requires that each participant is able to grasp the extent of the others’ knowledge and to either fill in the gaps or ensure brokering activities. Two attributes were emphasized in the literature: political knowledge, which is “information that an actor possesses about the policy preferences and strategies of other policy actors” and scientific knowledge, which refers to “actors’ perceptions of the adequacy of scientific understanding about the causes and consequences of the problems they face, and their possible solutions” , 32. We Overall, a knowledge of bonding zones, i.e., the potential for closeness, complementarities or similarities, comes from the knowledge of what the others know, do and are competent at doing. Such knowledge helps actors strike the right balance in collaborative HiAP governance and reach a modus vivendi between partners.tribal governments and external organizations such as businesses, nongovernmental organizations (NGOs) and universities [While HiAP implementation often mobilizes multiple government levels at the national, provincial/state, regional and/or local levels, and even extra-governmental systems  or interersities . While tA policy requiring multiple interventions from a wide range of organizational partners is subject to changes in partners’ priorities, which has ripple effects on the collective policy.In such a situation, adaptive co-management is a form of governance that leaves room for the resilience and adaptability of systems to uncertainty and change , 40, 41.Organizations are committed to not just a single policy but to multiple collaborative activities . Hence, Partners all come with their own unique strengths, be it their knowledge of the problem, their partners onsite or their unique capacity to mobilize nongovernmental actors. Integrating the uniquely different resources of partners can facilitate the achievement of collaborative goals , 11, 49.Mindset: Sectoral actions informed by a flow of multidisciplinary inputs.Knowledge: Knowledge of bonding zones.Actors: Government accountability to implement a mandate with unbound extra-governmental actors.Mindset: Sectoral actions informed by a flow of multidisciplinary inputs.Learning: Seeking collective problem solving in the pursuit of a set agenda.Principles: Propagation of policy principles beyond the inner circle of partners.Sustainability of the policy topic: Taking advantage of controlled entities for autonomous co-management.To summarize, our literature review of governance frameworks identified six equilibrium-related elements . It involved actors located outside the health sector, and its goal was to promote/improve health and quality of life by acting on various elements, while also focusing on equity. The efforts targeted the reinforcement of support given to partners and the establishment of collaborations between partner organizations. The policy was led by the public health department of Quebec’s Ministry of Health and Social Services and relied on a cross-sectoral approach. The rationale was that it was important to involve a variety of stakeholders and actors in order to deal with societal changes that have, or will have, either direct or indirect repercussions on the population’s health and quality of life. A significant number of ministries and/or national organisms were involved throughout the process: a total of 15 partners  in addition to various other ministry of health (MoH) departments. For this policy, and in collaboration with its partners, the MoH elaborated an action plan with targets. As part of the governance process during the plan’s implementation, relevant bodies had to be put in place to anchor intersectoral governance at the decision-making and operational levels Table .Table 2We believe this case study is relevant for capturing the notion of multiple and intricated equilibria as it has a fair chance of being visible here for few reasons. Key activities that took place required some type of negotiations. This naturally created dynamics that could be in opposition and could potentially co-evolve, such as during the launch of the policy when each partner wanted some level of visibility, or during discussions about the allocation of additional funds to proposals by different partners, or when it came time to navigate the competing demands of daily administrative tasks and advocacy work aimed at newly elected officials.Our data come from 58 secondary sources , 16 semi-structured interviews with members of working groups and the coordination bureau, and 11 observations of meetings. The data were collected over a span of three years, namely from 2019 to 2021. A first analysis was carried out as part of a mandate to prepare a report for the lead ministry on governance and its success as a collective endeavor. A second analysis was intended to detect dynamics that could be in opposition and yet co-exist. Using a grounded theory methodology, two individuals reviewed the data and extracted all information related to the concept of equilibrium. They did not use any set categories for analysis initially so as to remain as open as possible in the search for equilibrium-related elements.We identified two broad types of equilibria: conceptual equilibria, which are about ideas, and operational equilibria, which relate to tasks and daily work.The HiAP initiative highlighted social inequalities in health. This involved launching awareness-raising activities for organizational partners on the policy from the point of view of social inequalities in health using a dedicated resource. However, the tangible application of social inequalities to the specifics of each sector was not achieved. At the same time, several of the organizational partners felt they were already working with vulnerable groups as part of their mission, thereby addressing social inequity even if the term “social inequity” was not being used. Thus, there was a gap between the tangible actions and intangible targets being pursued.None of the partners mentioned any change in their way of approaching the plan’s implementation as compared to how they were used to implementing any other plan. This was despite brainstorming sessions being organized on the advantages and expectations of intersectoral management, and discussions being held on what aspects of intersectoral governance needed to be measured. While the lead ministry aimed to trigger new ways of working, this goal was not reflected in concrete terms. This points to tangible work being carried out without repercussions in the intangible realm.In general, the HiAP governance observed in this case study alternated between ideas and their operationalization within the realities of the partner organizations, highlighting that an equilibrium has to struck between tangibles and intangibles. One is being accompanied by the other.The policy plan contained several measures, some of which were not new and were redundant with other sectoral policies. On the one hand, this created confusion among partners who were receiving instructions from different agencies responsible for multiple policy plans and generated a densification of accountability for wording changes that could be slight or marginal. On the other hand, this redundancy highlighted a certain level of consistency and linkages between interministerial plans within an ecosystem of plans. It allowed for continuity from one interministerial plan to the next, allowing for measures that had been planned but were not yet implemented to be kept in sight. Here, the policy and its instruments are seen to be positioned within an ecosystem of policies, both existing ones and those in the process of being made public. So the equilibrium is about fitting the policy within an ecosystem of already existing policies.We observed the health policy’s governance during the funding phase, when interactions between administrators and policy makers were inevitable and were intended to feed policy makers. A concern for transmitting information in a concise and attractive format for policy makers marked this period. On the one hand, many notes to advise the minister of health were prepared and served to document the request for funding with explicit, easily interpretable figures. On the other hand, administrators demonstrated an ability to reach actors within the political sphere, including the health minister’s cabinet, and receive suggestions and advice from partners on the information expected by political actors. In this sense, we can see a mix of formal actions and informal networking at work.As the many partners implemented the policy, the voices of all partners were heard at the discussion table. However, some partners lacked the necessary human resources or time to participate fully in the plan’s implementation. Since the implementation could not depend on each partner organization having the same capacities, and since the partner organizations did not have the same interests, issues and priorities as the MoH with respect to the HiAP, there had to be a balancing of capacities and organizational structures between the MoH and each partner organization.Consistent with the dissymmetry in resources and ways of handling organizational processes, including in the context of accountability, it was agreed to let each partner organization decide on what internal validation process to use for the accountability form.As a result, collective reporting was done in coordination with a variety of ministerial management frameworks. One organization, for example, required that the reporting form be signed by several managers concerned by the various measures, while another organization only required a supervisor’s signature. Leeway was given for each organization to coordinate its own reporting internally using its usual processes. This points to a balance between the needs of the collective and the internal processes of partner organizations.The implementation of the plan was subject to seven evaluations. The usefulness of these for organizational learning and improving the subsequent plan was not discussed by the governance structures nor foreseen in any discussions underway as of March 2021. Subsequent to reporting, feeding back to partners on where they stood based on the data collected was to be the next step. However, the reporting tools were designed only for the lead ministry report; they did not take into account their usefulness or added value for the management of partner organizations. While reporting data were available, there was no plan to present the results in such a way that they could be useful to the partners, for example through specific support, data parties or infoletters. Overall, coordination was thin when it came to the development of innovations and new practices.Mixing tangible and intangible aspects.Fitting into an ecosystem of related plans.Mix of formal and informal roles with decision makers.Working with an acknowledged dissymmetry in the format of collective leadership.Coordination of individual organizational capacities.Sustainability of lessons learned.To summarize, our case study of HiAP governance identified six equilibrium-related elements  objectives’ . It should also bring an added-value for future studies and frameworks on joined-up health policy governance and HiAP governance.