Global plant breeding activities are reliant on the available genetic variation held in extant varieties and germplasm collections. Throughout the mid- to late 1900s, germplasm collecting efforts were prioritized for breeding programs to archive precious material before it disappeared and led to the development of the numerous large germplasm resources now available in different countries. In recent decades, however, the maintenance and particularly the expansion of these germplasm resources have come under threat, and there has been a significant decline in investment in further collecting expeditions, an increase in global biosecurity restrictions, and restrictions placed on the open exchange of some commercial germplasm between breeders. The large size of most genebank collections, as well as constraints surrounding the availability and reliability of accurate germplasm passport data and physical or genetic characterization of the accessions in collections, limits germplasm utilization by plant breeders. To overcome these constraints, core collections, defined as a representative subset of the total germplasm collection, have gained popularity. Core collections aim to increase germplasm utilization by containing highly characterized germplasm that attempts to capture the majority of the variation in a whole collection. With the recent availability of many new genetic tools, the potential to unlock the value of these resources can now be realized. The Commonwealth Scientific and Industrial Research Organisation (CSIRO) cotton breeding program supplies 100% of the cotton cultivars grown in Australia. The program is reliant on the use of plant genetic resources for the development of improved cotton varieties to address emerging challenges in pest and disease resistance as well as the global changes occurring in the climate. Currently, the CSIRO germplasm collection is actively maintained but underutilized by plant breeders. This review presents an overview of the Australian cotton germplasm resources and discusses the appropriateness of a core collection for cotton breeding programs. By 2050, the world population is estimated to reach 9.1 billion people, and an increase of 70% in agricultural production is needed to feed and clothe the world . Land anPlant genetic resources (PGR) constitute the foundation of sustainable agriculture and global food security and stability . While tSince the 1970s, the conservation of PGRs has become a large-scale independent activity detached from crop improvement efforts. The germplasm held in genebanks is utilized by plant breeding organizations, often globally, and breeding programs are reliant on the genetic diversity that is available . Elite cGlobally, approximately 7.4 million accessions are preserved in over 1750 genebanks , with fiGossypium; G. arboreum L. (Desi cotton), G. herbaceum L. (Levant or Arabian cotton), G. barbadense L. , and G. hirsutum L. . The continued development of productive cultivars will rely heavily on exploiting the available variation present in conserved This paper aims to build on previous reviews on the purpose and relative benefits and challenges of germplasm collections . The outA plant germplasm collection is defined as a collection of seeds or breeding material, typically to conserve genetic diversity, but to also act as a source of material to address future challenges in agriculture . GermplaAlthough genebanks around the world have had great successes in collecting germplasm to conserve crop genetic diversity, the scale of success is often limited by inefficient data and germplasm management. The germplasm collections often become so large that maintenance of the conserved germplasm becomes difficult both from lack of resources and accumulated human errors in processing and handling, and potential contamination during seed regeneration cycles . In addiOne method to tackle the management of large germplasm collections was suggested by From the definition by The development of “subset collections” and mini-core collections has also increased in recent years in response to germplasm management resource limitations , 2012a,bIn cultivated cotton, there are currently few core collections that exist globally . HoweverHistorically, Australian plant breeders across a range of crops acquired and maintained their own germplasm collections. However, in the early 1980s, the Commonwealth and State governments established a series of genetic resource centers to conserve national germplasm collections. The Australian Tropical Crops and Forages Genetic Resource Centre (ATCF) based in Queensland was the center that included cotton, although that collection has now been transferred to the Australian Grains Genebank in Horsham, Victoria, as part of a national consolidation effort. Currently, the only other two cotton-focused collections in Australia reside at the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Agriculture and Food in Narrabri, New South Wales and Canberra, Australian Capital Territory.G. hirsutum and some G. barbadense, with a small number of undomesticated or landrace stocks. The next largest group of accessions belong to the cultivated diploid cottons, with the majority being G. arboreum and a smaller number of G. herbaceum. A significant number of accessions of the Australian species are also held, particularly G. australe L., G. sturtianum L., G. nelsonii L., and G. bickii L. However, these are the result of individual germplasm explorations, so it is unknown what genetic variability exists between the accessions. Small numbers of accessions of most of the other Gossypium species are also held . Over the previous few decades, there have been numerous reports of attempts to transfer useful traits from these species , but docstrength . In morestrength . This isGossypium species, has also held great interest. The characterization of these diploid species has been reasonably well documented . The Protocol is a multilateral international treaty with the purpose of ensuring “fair and equitable sharing of benefits arising out of the utilization of genetic resources,” which covers all organisms, including wild accessions of cotton and its relatives, wherever they are found. Researchers collecting new germplasm from the wild will have to enter into “access and benefit sharing” arrangements with the host country prior to their collection expeditions. These arrangements set out who might profit, and how, from the organisms being used, and stipulate how to distribute the benefits fairly, for example, through co-authorship of publications, or more importantly sharing of profits from products such as newly bred crops or new medicines. Although Australia signed and ratified the CBD in 1993, it is not a signatory to the Nagoya Protocol which was added in 2010 as it already had existing National and State and Territory laws consistent with the Protocol that regulate benefit sharing from any new collections of Australian indigenous biota, including  the CBD , so goinSince the proposal of a core collection, there have been many techniques and sampling methodologies developed. Creating a core collection can be simple or complex and is heavily influenced by resource allocation and information available. Therefore, often a preliminary core collection is developed, that is larger than intended, and then characterized at a deeper level and subset. In general, five generic steps are followed .Step 1: Definition of the material that should be represented; this is termed the domain of the core collection and can range from related species, wild-types, ecotypes, landraces, previous breeding lines or a specific focus area of the diversity of a species. The definition is subjective to the available material, what constitutes a suitable set of material for core development, and the objectives behind the establishment of a core collection.Step 2:Decide on the size of the core collection. Generally, most core collections are 5–20% of the size of the collection from which they were derived, although can be much smaller if the main collection is very large. A sampling strategy should define both a sampling method and an allocation method, and various sampling strategies and methods have been utilized to develop core collections  allocate entries in some proportion according to the relative numbers of accessions that occur within each group; (2) if enough material has been characterized with genetic markers, comparisons of marker diversity within the groups and basing the allocation of numbers based on maximizing allelic diversity or richness within each group; (3) subjectively consider the breeders needs and other informal knowledge about the accessions within the groups, i.e., passport data, availability to the collection curator.Step 5:Choose the specific entries that will be maintained in the core. The final process of choosing which actual accessions should be included in the groups, maximize diversity, and serve the purpose of the core collection. However, breeders also need to consider the quality of the documentation of the entries, seed availability, and the role of the accessions in their breeding programs  provide a good basis for the initial development of a drought-tolerant cotton mini-core collection. In addition, landrace accessions and cotton wild relatives are essential for the inclusion as they may have drought traits that have been lost from cultivated varieties due to selection pressure for yield potential under optimal conditions . The yieSeveral institutions have developed core collections in other crop species with increased tolerance to abiotic stresses: chickpea , sorghumG. hirsutum cultivars TM-1 (the genetic standard for G. hirsutum) and zhongmiansuo24, a commercial cultivar  identifying a source of resistance to the stress and (2) developing an effective screening method to characterize the level of resistance. The development of a core collection for resistance to an abiotic or biotic stress is limited by the variation available in germplasm. In some circumstances, particularly for biotic stresses, there may not be any resistant germplasm in either the main or core collection and the pest or pathogen will be better controlled by management strategies. Therefore, a wide screen of the germplasm available using an appropriate phenotyping method is critical before deciding if a core collection is an effective solution. Once a source of resistance is identified, a high-throughput screening assay that is reflective of field resistance needs to be developed. However, this is often a lengthy process and is complicated by several factors. First, the susceptibility of plants to the stress varies with respect to timing, duration, and intensity and often under field conditions, plants encounter specific abiotic and biotic stresses in combination with other stressors. Second, controlled environment and pot-based experiments are generally not well correlated with field performance. Finally, resistance to abiotic and biotic stressors is often polygenic, including a complex of gene networks involved in stress sensing, signal transduction, and expression of stress-responsive genes. Therefore, the development of core collections to assess a wide range of germplasm rapidly and effectively for abiotic and biotic stress resistance can be an ambitious goal.While core collections for drought tolerance have been assembled, gains in limited water and rainfed cotton productivity have largely been incremental and reflective of improvements in yield potential under non-stressed conditions. Thus, future genetic gain in abiotic stress resistance will require a combination of traditional plant breeding and new breeding methods such as genomic selection, as well as the integration of panomics , novel fThe major bottleneck for the development of core collections remains the required level of investment. Developing and maintaining a germplasm collection is time-consuming and expensive, and there is a clear reluctance to investment due to the large cost of germplasm maintenance and the continual characterization of germplasm for numerous traits. Adding to the expense is the high likelihood that novel resistance traits will often lie in related cotton species, rather than older varieties or landraces, and characterizing and introgressing resistance from those more distant sources is a lengthy and costly process. To encourage funds to be allocated to germplasm centers, the development of a core collection must show a clear return on investment and have an applied and impactful outcome to commercial breeding programs.The challenges facing the Australian cotton industry include increasing production costs, pests, and diseases, and new environmental conditions due to climate change. While these challenges are both numerous and diverse, a core collection would only be useful to the CSIRO breeding program if it was a single collection that contained deeply characterized accessions for multiple traits. This is because the fundamental focus of the breeding program is the production of commercial cotton varieties, not germplasm banking. Thus, the investment required for the core collection must match the desired outcome and provide impact in terms of cultivar development. However, it should be acknowledged that the approach used for trait screening and ultimately cultivar development over the last few decades by CSIRO has utilized the central principles involved in developing a core collection. The screening and characterization of approximately 200 diverse accessions for Fusarium wilt resistance  are a good example of how the principles of developing a core collection can be employed in breeding.Although yield will always be the main priority for the CSIRO cotton breeding program, the core collection would not directly target high-yielding accessions. Rather, the traits targeted would include those with less complex genetic backgrounds, such as biotic stress resistance and the fiber quality parameters of length, strength, and elongation. It is an ambitious goal that abiotic stress tolerance would be included as a characterization parameter due to the complexities in phenotyping for that type of tolerance. It is probable that the categories across the core collection would contain an unbalanced number of accessions as target traits may only be present in low frequencies throughout our entire germplasm collection. Conversely, for traits that are common, the highest performing accessions would be selected for inclusion in the core collection. Importantly, adequate representation from related cotton species must be included, historically sources of host plant resistance to biotic stressors have been identified in landrace and crop wild relatives in the CSIRO cotton breeding program . We concConserving germplasm is, in the long term, the most efficient and inexpensive method of genetic conservation for agriculturally important plants. However, the conservation of germplasm quickly becomes unmanageable, and accessions will be underutilized if a cost-effective management system is not implemented. Core collections are one strategy to increase the utilization of germplasm and have moved from a period of experimentation to one of increasing popularity and endorsement.The development of core collections presents great opportunities for cotton and provides a resource use-efficient strategy enabling the identification of the most accessible source for a given trait . Core coNevertheless, the significant challenges of developing a core collection must be clearly acknowledged. To be of real value, the core collection should target traits specific to that required by the industry that a breeding program is supporting. This will be different for different countries, regions, and production systems. Significant investment from the program would need to be allocated to develop and maintain the core collection. Therefore, the target traits must be a continuing important breeding goal to the relevant industry. Due to the vastly different cotton production systems across the globe, it is unlikely that a single global cotton core collection would provide merit to all breeding programs; rather, a country- and trait-specific core collection model would be more appropriate.Finally, to fully exploit the potential that core collections can bring to a breeding program, coordinated efforts between the private and public sectors are required. The goal of these efforts is to ensure that meaningful germplasm access and exchange can occur, resulting in core collections that better represent the diversity of the focus traits of that specific core collection. However, it must be acknowledged that germplasm protection is fundamental for all commercial breeding programs. Therefore, access to the full range of germplasm is unlikely. This can in part be mitigated through commercial agreements providing access to recently released cultivars, and private sector breeding programs releasing commercially obsolete germplasm to publicly available germplasm libraries.LE conceived and drafted the review. LE, WC, and WS designed and wrote the review. All authors contributed to the article and approved the submitted version.This work was supported by Cotton Breeding Australia, a joint venture between Cotton Seed Distributors Ltd. Australia and CSIRO Agriculture and Food.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.


This article explores the effect of preoperative health education, in the form of animation videos, on postoperative self-reported pain levels and anxiety in femoral fractures.Ninety cases of femoral fracture were divided at random into the oral instruction group, the recorded video group, and the animation video group, with 30 cases in each group. Sociodemographic data were collected the day before surgery. Health education was then offered in one of three ways: orally, using a recorded video, or using an animation video. On days 2, 4, and 7 after surgery, the state-trait anxiety inventory (STAI) and the visual analog scale (VAS) were used to assess postoperative anxiety and pain levels, respectively, in the participants.P < 0.01), and the pairwise comparisons indicated statistically significant differences . However, the levels of postoperative pain in the animation and recorded video groups were not significantly different (P > 0.05). STAI scores in the three groups were found to have significant interactions with the measurement time . However, there were no apparent interactions between the VAS score and the measurement time  in the three groups.At different time points during the evaluation, total anxiety scores in the animation and recorded video groups were significantly lower than in the oral instruction group (Preoperative health education with the aid of multimedia is more effective than oral instruction in lowering patients’ postoperative anxiety and pain levels. In addition, animation videos are superior to recorded videos in mitigating postoperative anxiety. Whether the two approaches differ in reducing postoperative pain in bone fractures remains to be further tested. Patients scheduled to undergo surgery for a femoral fracture might experience preoperative anxiety due to a sense of uncertainty about the prognosis . In the Evidence suggested that preoperative health education might be effective in reducing the incidence . EffectiNinety patients, hospitalized between October 2012 and June 2013 in the Department of Orthopedics of a hospital, were included in our analysis, in accordance with the following criteria: (a) having undergone surgery for femoral fracture at the Department of Orthopedics, (b) aged over 18 years, (c) no auditory and visual disabilities, (d) awake consciousness and no psychological impairments, (e) able to speak and understand Mandarin, (f) agreed not to use analgesics after surgery, and (g) willing to participate in this experiment give their informed consent. Patient exclusion criteria for the study were as follows: cases not hospitalized in the Department of Orthopedics, or not receiving surgery for the first time, or for reasons other than femoral fracture.A quasi-experimental design and three-group pre–post tests were adopted, with 30 cases in each group. Data from cases that met the exclusion criteria or who asked to leave the study were eliminated. To compensate for excluded participants, another case that met the inclusion criteria was selected. The study was approved by the Medical Ethics Committee of our hospital. In this experiment, the cases were equally divided into the animation group (who were instructed by watching an animated video), the recorded video group, and the control group . The case information was collected by the most convenient method possible. In order to avoid interference between patients, data from the control group were collected first, followed by data from the recorded video group and, finally, from the animation group. The preoperative data collection was performed 1 day before surgery, and consent was obtained from the patients. The informed consent for the three groups is listed in The pre-intervention data were collected from all three groups. The measurement time points, the form of preoperative health education, and the specific content of preoperative health education are shown in The Chinese version of the state-trait anxiety inventory (STAI) was administered to the patients in the three groups. This scale can distinguish between state (temporary) and trait (stable) anxiety and applies extensively to adults with anxiety disorders .Questions 1–20, corresponding to state anxiety, determined how the patients felt during the recent or perioperative period and assessed such feelings as fear, tension, worry, and nervousness. Questions 21–40, corresponding to trait anxiety, measured the frequency of anxiety. The cumulative scores of the state and trait anxiety scales were calculated, and the allowable range was 20–80 points. The higher the score, the higher the level of the specified type of anxiety.Postoperative pain was measured using visual analog scale (VAS) on a horizontal 10 cm-long straight line. A score of 0 indicated no pain, while a score of 10 indicated severe pain. The higher the score, the greater the degree of postoperative pain.The author of this scale declared that the scale might be used for free without authorization. In addition, the scales used in this paper had good validity .To create content for the preoperative health education methods, patients, operating room medical staff, and ward employees were interviewed before surgery and asked what subject matter should be included. These interview results were integrated with the experience of the researchers and their knowledge of evidence-based medicine. A pilot experiment was carried out using the produced video program, 10 patients with femoral fracture were selected to watch the video, and the length of the video was adjusted according to the experimental results of the patients to make it more concise and suitable for repeated viewing. Patient sampling was carried out using conventional methods, and patient groups were restricted from conferring with each other. Patients within groups were encouraged to learn from each other, and patients were rewarded with a small gift to increase their level of attention and participation in the study.P < 0.05 was considered statistically significant.Data were statistically analyzed using SPSS 20.0 software. The measurement data were expressed as P > 0.05). All the STAI scores in the animation video group were much lower than those of the recorded video group on days 2, 4, and 7 after surgery. The STAI scores of the latter were markedly lower than those of the oral instruction group (P < 0.01). The STAI scores of the three groups varied in different ways throughout the duration of the study, which suggested an interaction with the factor of time . On days 2, 4, and 7 after surgery, the VAS scores in the animation video group showed no distinct differences from those in the recorded video group (P > 0.05). In these two groups, the VAS scores were considerably lower than those in the oral instruction group (P < 0.01). The trend variations in the VAS scores in the three groups were consistent over time, indicating no apparent interaction with the factor of time , as seen in As shown in Health knowledge and information are the basis for establishing positive health beliefs and attitudes and subsequent health behaviors. Health education is of great significance to patients since it not only helps them to understand their condition and take appropriate health behaviors to promote treatment and rehabilitation but also reduces fear and anxiety caused by the unknown.Anxiety is the experience of an adverse emotional reaction to a potential threat, whereas fear leads to avoidance behavior, whereas anxiety is associated with uncontrollable or inevitable events . SurgerySurgery can cause damage to the body and can cause a sympathetic nervous system response. Tissue damage triggers the production of histamine and other inflammatory cytokines, and nociceptors are stimulated and produce pain signals that are transmitted to the brain, producing postoperative pain . About 8Preoperative health education is highly important for all surgical patients. As a measure to boost postoperative recovery, preoperative health education may be traditionally performed by oral instruction or group teaching, and it can rely on two-dimensional printed materials or multimedia. The traditional form of preoperative education, due to its common form and small impact, cannot achieve the effect expected by doctors. Recorded videos are often overloaded with educational content, and scenes depicting surgical bleeding and tissue incision may aggravate anxiety. Animation videos allow a lively representation of the contents of health education, which systematically instructs patients and their relatives on the surgery that they are going to undergo and the matters that require attention. If necessary, patients can watch the video repeatedly before surgery, and the risk of cross-infection caused by distributing and reading pamphlets does not exist. The use of videos for preoperative health education also reduces the workload of healthcare workers and its associated costs, as they otherwise would have to go from bed to bed to instruct patients orally.With advances in multimedia technology, modes of health education in hospitals are constantly changing, and many medical organizations in China have carried out multimedia video-based health education activities . AnimateIn recent years, medical disputes caused by insufficient health education have occurred frequently, and, therefore, the provision of adequate health education plays an important role in medicine today. Animation videos can be applied as a useful tool, not only to promote a better and transparent doctors-patients relationship but also to reduce preoperative anxiety among children and adults .P < 0.01). The STAI score was significantly lower in the early period after surgery (day 2) in the animation video group than in the other two groups (P < 0.01). At each time point after surgery, the STAI scores of all three groups significantly decreased compared with those before surgery (P < 0.01). This suggests that the anxiety levels of patients declined rapidly with time following sufficient health education. The pain levels of the three groups varied consistently over time. The animation video group and recorded video group showed significant differences in the effectiveness of alleviating pain compared with the oral instruction group as the control (P < 0.01), the difference between the animation group and the oral information group is that the difference before and after watching the animation video group is greater than the difference before and after oral instruction group, but the two experimental groups did not differ significantly (P > 0.05). Although all three approaches toward preoperative health education were effective to some extent, the animation video provided the greatest benefit in alleviating either postoperative anxiety or postoperative pain. However, the use of an animation video did not achieve a significantly prominent effect in pain relief compared with the recorded video. The reason may be the similarity between the content taught by the two types of media and the fact that the recorded video contains few elements that may affect patient pain levels. The patients in our group generally agreed on the importance of animation videos as a preoperative health education tool, and therefore this method deserves further investigation.In this study, it was found that postoperative anxiety levels in patients with femoral fractures were lowered considerably after watching an animation video. The smallest reduction in anxiety was found with oral instruction (In addition to enhancing patient understanding, animation videos convey additional benefits over other forms of preoperative health education, such as oral instruction and printed materials. For example, the method of playing the video can be adapted according to the specific conditions, such as the hardware facilities available at the hospital. The contents of the video to be played can be determined by the patients themselves or by their relatives, depending on their learning ability and individual needs. Thus, multimedia health education using animation videos meets the demands of a more diverse group of patients and achieves higher learning effectiveness. In addition, the patients and their relatives are offered a complete set of health education programs suitable for repeated viewing.To sum up, preoperative health education in the form of animation videos can reduce the levels of postoperative anxiety and pain in patients with femoral fractures. Compared with the recorded video and oral instruction groups, the use of animation videos facilitated knowledge assimilation related to surgery and recovery, strengthened patients’ coping abilities, and lowered postoperative anxiety and pain levels. Therefore, it is worth popularizing this approach to preoperative health education in medical practices. However, since this study is affected by limitations, such as a small sample size and a lack of randomization, further investigations are required to confirm the conclusions reached in this paper.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the First Affiliated Hospital of Shantou University Medical College. The patients/participants provided their written informed consent to participate in this study.YW conceived of the study. XH participated in its design and coordination. ZL helped to draft the manuscript. All authors read and approved the final manuscript.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.


Population ageing is one of the most significant demographic changes underway in many countries. Far from being a homogenous group, older people and their experiences of ageing are diverse. A better understanding of the characteristics and geography of the older population, including the older workforce, is important. It allows policymakers and stakeholders to better adapt to the opportunities and challenges that the ageing population brings. This paper describes the implementation of the Ageing in Place Classification (AiPC) in England. AiPC is a multidimensional geodemographic classification, and it employs a wide range of spatially representative attributes of older people’s sociodemographic characteristics and their living environment at the small area level. The openly available product provides valuable insights that can be implemented in both local and national contexts, in particular to improve service delivery and inform targeted policy interventions. AiPC is readily updateable with the arrival of new Census data; the concept and framework are also transferable to other countries. The population of England is ageing. By 2041, approximately 26% of the UK’s population will be aged 65 and over, with ages 50 and over likely comprising around half the adult population ONS, . ConcurrTo better understand the social and spatial heterogeneity within the older population and thereby support effective policy development and targeted service provision, this project develops an open access, multidimensional classification of the older population in England at a small area level. Geodemographics, built with cross-sectional data, are widely used to support service planning and policy development . Though a cross-sectional snapshot, such classifications can provide valuable insights into the nature of need, vulnerability and opportunity in a population which will continue to age. This understanding provides a robust basis for effective planning and policy intervention.The paper proceeds in the following way. First, it provides an overview of literature related to various geodemographic classifications and the rationale for creating a bespoke geodemographic classification of ageing population. Second, it outlines the data, computation of variables and methods employed to create the Ageing in Place Classification. Then it presents the results including the characteristics of the derived clusters and finally, it discusses the findings and their implications within the context of how such national classification can enhance our understanding of the needs and support local service provision for older generations.ageing-in-place  will be incumbent upon a fine-grained understanding of the dynamics of place-based ageing, yet such understanding is currently lacking. Singleton and Spielman  demonstrGeodemographic classification organises areas into categories sharing similar attributes across multidimensional variable space . An initial set of variables and metrics were then generated from various sources to reflect different characteristics of the domains identified. Variables include direct measures that are obtained from the UK Census and other measures derived from secondary data such as NHS English prescribing data and the British Population Survey.Statistical analysis of the initial set of variables and metrics including examination of their distribution, spatial coverage and patterning, as well as correlation between variables. Sensitivity analysis was also performed to measure the impact of variables on the cluster forming process  in England at the small area level with a general aim to enable a better understanding of the geography of this demographic. Such a classification would allow for more effective service planning and policy development in the face of an aged and ageing population.To inform the selection of appropriate variables to include, we considered two established frameworks relating to the experiences of aged and ageing people, and the places in which they live and work: (1) World Health Organization (WHO) Age-Friendly Cities Framework (AFCF), and (2) WHO Active Ageing Policy Framework (AAPF). Review of these frameworks signalled key aspects to be represented in the domains of our AiPC, respectively spanning areas such as social infrastructure, physical infrastructure, social capital, the physical environment and aspects related to the socio-economic and demographic charactristics of older people themselves.Review of these established frameworks, relevant literature and consultation with our expert advisory group allowed us to identify nine inter-connected AiPC domains, reflecting the characteristics of older people and the places in which they live Fig. . These aFollowing decisions as to the domains of the AiPC, an initial set of variables and metrics were identified, gathered, generated and reviewed as potential inputs, with the majority of the variables sourced from the 2011 Census.An advantage of the UK Census dataset is the availability of the Local Characteristics (LC) tables. LC provides detailed results that cross-tabulate two or more topics/dimensions, showing the greatest level of detail. The age dimension is available in many LC tables; therefore, it is possible to derive information focusing on only older people using a threshold of 50 years old or other age-adjust methods. This differentiates our classification from other extant geodemographic classifications  for each LSOA was calculated using the LOSA older population from the Census 2011.This work used an aggregation unit transformation approach suggested by Comber et al. . The steIt should be noted that dementia is highly associated with age, but this work does not produce age-standardised dementia medication prescribing rates due to data limitations. Therefore, the result can only indicate places with higher levels of prescribing for dementia medications. These are not adjusted by age. A higher prescribing rate should not be interpreted as a higher prevalence of dementia in a particular area. Rather, it is indicative of the treatment environment in which older people, themselves at higher risk of being diagnosed with dementia, live in. When combined with local understanding and knowledge of other dementia-risk factors in an area and the health service infrastructure, this can help end-users of this classification better understand the possibility of need and importantly, unmet need, in their local population.Digital is one of the key domains in the AiPC. In an increasingly digitised world, where the internet not only provides quick access to information but increasingly access to a range of services, access to the web in older age may be an important component to well-being in later life. Indeed, it is a potential tool to reduce social exclusion  with the constraint variables that are listed in Table The estimated percentage values from SMS are then used to train a series of XGBoost models, which is a tree-based supervised machine learning model. To build a robust model, only LSOAs with 11 or more observations were used for training purposes, which accounted for 3198 LSOAs . These were further sample weighted by the number of observations.In addition to Census, NHS data and BPS, a number of other secondary datasets are also used in this study to provide further direct measures related to older people and their living environment. They are distributed across different domains, and the key ones are introduced here. Full details about these data and the derived measures are provided in the acknowledgement and Appendix The Access to Health Assets and Hazards (AHAH) dataset and the Journey Time Statistics (JTS) were used to describe  access to different services and locations, air quality and green space. Index of Multiple Deprivation (IMD) scores were used to obtain information on older people’s income deprivation, housing quality and the context of local crime rates. Furthermore, a median house price indicator derived from ONS HPSSA (Mean house prices by middle layer super output area) dataset was also used to build the AiPC. Finally, we used the Ordnance Survey POI (points of interests) data to estimate the capacity for civic activity as a proxy for civic participation. This was calculated as a number of civic assets in a buffer zone (1 km) of each LSOA, divided by the number of residents in each LSOA.Variable selection is a crucial phase of developing a geodemographic classification, ensuring the development of meaningful and application-relevant clusters.  were tested, followed by consultations with expert stakeholders. For AiPC, the end users (stakeholder community) expressed their preference for keeping the model relatively consistent with established open geodemographics classification products in the UK. As a data product, this helps to ensure the AiPC results are more intuitive for users and can be comparable to other products, such as the OAC  clustering , the clusters are well separated in the input variable space (the y axis), so the suitable number of clusters can be identified  and groups (second-tier) were given a name and descriptions for each cluster, referred to as “Pen Portraits” based on their principal and distinctive variables . Residents are highly educated and likely to be either in full-time employment or self-employed Fig. . They doA final stage of creating the bespoke geodemographics involved a ground-truthing validation exercise to understand better whether the clusters and the corresponding descriptions (names and pen portraits) were appropriately representing the real world. The framework was similar to the approach used in the work of Vickers and Rees . A panelParticipants were asked to provide up to 3 postcode districts, and maps were then created to show the postcode districts and the surrounding cities, towns or countryside  were provided by a panel of 25 peer reviewers, consisting of 9 PhD students and 16 external participants. The students were familiar with geography and urban planning, while the external participants were scholars and expert users of geodemographic classification. The responses were distributed across England, covering all regions in England Fig. , with slThe quantitative results Table  and the For instance, the initial name of supergroup 4: “Retired Rural and Coastal Stability” had the lowest accuracy rate with only 56.5% of participants providing accurate response. Using geography in the cluster name was confusing to some respondents. Despite many LSOAs in this cluster located in coastal areas, a non-coastal and suburban distribution was also substantial. As such, the cluster name was altered to ‘Retired Fringe and Residential Stability’ to better reflect its data driven characteristics. Changes were also made to the initial names of clusters (supergroups) 3 and 5 and their descriptions, addressing issues raised by the respondents.COVID19 illuminated an openly ageist narrative in public policy and the media, indicative of the long-standing marginalisation and homogenisation of older people. Old age is equated with dependency and frailty, with the ageing population framed as a burden on the national coffers. However, our experience of old age and of ageing is highly individualistic, itself determined by our wider socioeconomic characteristics, the places in which we live, and the places we have lived. Policy and service planning needs to better capture the social and spatial heterogeneity of the aged and ageing population if it is better meet the variable needs and potential opportunities an older and ageing population presents. To support that, a better more detailed understanding of the geography of older people is needed, moving beyond simplistic evaluations of ‘percentage aged 65 + ’ and ‘level of deprivation’. Building on existing advances in the creation of geodemographics, we present a bespoke geodemographic classification of older people in England. Developed in consultation with an expert advisory panel drawn from gerontologists, geriatricians, local authority policy makers, community workers, lay people and beyond, the domains have been critically interrogated to maximise the utility of this product for end users.k-means inputs are readily available. Different models  and novel secondary datasets (listed in Appendix Our results show five distinctive clusters (Supergroups) and 13 nested subclusters (Groups) depicting distinctive features of the older population and their local environments. The AiPC is a multidimensional classification portraying differences and similarities between clusters and subclusters across nine key domains, distinguished by difference from the national average. The research output is, to the best of our knowledge, the first bespoke geodemographic classification of the older population for England, which utilises novel data sources including a consumer behaviour survey and NHS prescribing data, alongside more conventional sources (e.g. the Census). It should be noted that not all measures and data used as The process of building AiPC was grounded within a stakeholder community to maximise the utility of the research outputs and embed their design within a process of co-production. It provides new and valuable insights that can be implemented at both local and national contexts, in particular to improve service delivery and inform targeted policy interventions.Though the methodology was rigorously designed, with all methodological decisions open to scrutiny and critique from our expert and stakeholder advisory board, the adopted approach is not without limitation. First, we make use of Census data from 2011 as the basis of the classification. As a cross-sectional snapshot of the population, these data are Census data are already outdated. However, at time of creation this was still the gold-standard available data and the insights gleaned remain of value. Second, surveys used to measure the digital engagement of the older population (e.g. British Population Survey) were not representative at small area level, therefore synthetic values had to be computed. Though this may introduce some discrepancies, the methods employed to compute the estimates are rigorous, tested methods used for such purposes. Third, NHS and Census data were used for estimating prescribing rates, while the two datasets are reported and updated in different time scales and frequency. The gaps between Census (2011) and prescribing (2015–2019) lead to higher uncertainty in the result, the migration of older people and changed age structure could all impact the accuracy of the estimated prescribing rates. This might be improved with the arrival of new Census. Finally, we were unable to capture some key attributes identified by our expert panel due to a lack of reliable data. One particular example related to the (perceived) safety of older people in their local environments. This was raised frequently as an important element, and is something to consider for future iterations.Nevertheless, the combined critique and support of our advisory board, and the absence of such a classification to date, ensures the AiPC will have policy relevance and value. The AiPC is pertinent to the experiences of the current ageing population, offering clues to target routine policy development and service planning. Incorporating with small area estimation models, AiPC has the potential to be used to better understand older people’s loneliness, housing need, digital engagement gaps and more (Birkin & Clarke, With the arrival of new Census data, it will be readily updateable as an open source product, further maximising its continued use in the face of a rapidly ageing population. The AiPC presented in this work could also be used for comparison as a snapshot of the past, providing a reference for identifying the changes in the geography and characteristics of older people in England. Future iterations must exploit the ever-growing availability of geo-referenced data to enhance the value of this classification, while end users should endeavour to illustrate where more age-disaggregated spatially referenced data is needed to further improve its performance.


The assessment highlighted a centralized approach to implementation, which can set aside the crucial collaborations and partnerships demonstrated and developed during the pandemic. The financing for local governments was strengthened with a new ruling that could alter UHC integration tendencies. A smarter allocation of tax-based financing sources, along with strengthened information and communications systems, can confront issues of trust and accountability, amidst the varying capacities of agents and systems.The 2019 Philippine Universal Health Care Act (Republic Act 11223) was set for implementation in January 2020 when disruptions brought on by the pandemic occurred. Will the provisions of the new UHC Act for an improved health system enable agile responses to forthcoming shocks, such as this COVID-19 pandemic? A content analysis of the 2019 Philippine UHC Act can identify neglected and leverage areas for systems’ improvement in a post-pandemic world. While content or document analysis is commonly undertaken as part of scoping or systematic reviews of a qualitative nature, quantitative analyses using a two-way mixed effects, consistency, multiple raters type of intraclass correlation coefficient (ICC) were applied to check for reliability and consistency of agreement among the study participants in the manual tagging of UHC components in the legislation. The intraclass correlation reflected the individuals’ consistency of agreement with significant reliability (0.939,  The Philippines has taken great strides in moving towards universal health coverage. In 2019, the Philippine Universal Health Care Act (UHC), or Republic Act 11223, was signed and the planned implementation in January 2020 was disrupted by the COVID-19 pandemic [The content analysis approach is one widely used in political science to detect the policy positions of parties  and is oThis section includes an overview of the Philippine health system and the country’s pandemic performance, followed by the guiding framework.The Philippines is a middle-income economy in the southeast Asia region, with per capita gross domestic product (GDP) of 3550 USD in 2021 . It has Since the enactment, 60 operational guidelines and policies have been drawn up to implement UHC, and in accord with its Implementing Rules and Regulations (IRR). Fifty-five (55) are considered as finalized and issued. Thirty-three (33) implementation sites are considered to be advanced implementation sites (AIS) . The UHCStructural integration—toward the creation of the city-wide and province-wide health systems; this means bringing together the inter-local health zones (ILHZ) which group municipalities into districts. This structural integration means having various service delivery structures at province, municipal, and district levels work together more closely. Primary health care, the lowest level of operations, will operate as the system gatekeeper, channeling patients through diagnostic systems at secondary levels and specialist and inpatient care through to tertiary and the apex, as needed;Managerial integration—towards the strengthening of the Provincial Health Board and the City Health Board; these boards are the policymaking instruments for UHC, as well as the units that approve resource allocation and execute oversight of the implementation; this will entail the bringing together of representatives from the various offices of the Province, Municipalities, DOH, and the private sector, both for-profit and non-profit. This integration will involve the strengthening of the Provincial Health Office as the technical arm of the province in overseeing the hospitals , as well as the public health facilities . It is conceivable that the private sector facilities will become part of the scope of the Provincial Health Office;Financial integration—this means bringing together the resources from national government , resources from the province, and resources from the municipality into one or two Special Health Funds (SHF) which will be managed by the province and highly urbanized cities, respectively. From this Special Health Fund, allocations and disbursements will be made.This strategy for UHC implementation demonstrates a centralizing approach, as presently the provinces and highly urbanized cities are the owners and the locus of the health services delivery of the health system, responsible for planning, payroll, and budget allocations to government health services and activities in their jurisdiction.When the 2019 UHC Act joint legislative deliberations began in 2017, relatively strong economic growth had been registered in prior years. Election promises and some reduction in the poverty levels have created a wider receptivity to health sector advocacies. The Act was discussed and drawn amidst much fiscal space, benefitting from payroll contributions and new revenue sources in the form of sin taxes  and reforms that earmarked and increased the financial resources for health. The allocation of roles and responsibilities, where the Philippine Health Insurance Corporation  is responsible for personal health services, while the Department of Health (DOH) covers for the population health services, is a convenient way to divide fiscal resources. The role of local government units (LGUs), who are the de jure owner of the facilities below regional levels, such as provincial hospitals, city and rural health centers, and barangay health stations, was not clearly specified. Many of the LGUs were not aware of their roles, as voiced in the deliberations about its implementation rules. A separate law, the Local Government Code (LGC) or Republic Act 7160 in 1991, governs LGUs. The integrated local health systems (ILHS), established within the provincial and highly urbanized cities, are tasked under the UHC Act to be responsible for both the planning and managerial supervision of population-based and individual-based health services within respective local jurisdictions (Sec. 19.8).One area affecting national–local relationships is the health workforce. When local governments took over the health functions in the 1991 decentralization, they had to contend with paying health personnel with a higher pay structure, different from regular government personnel, and mandated in another law, the Magna Carta for Public Health Workers Act . The difIn a recent policy development, known as the Mandanas Ruling by the Supreme Court in 2018 (and confirmed in 2019), the LGUs’ share of national funds or the Internal Revenue Allocation (IRA) will increase by an estimated 30.7% under the new funding formula, without earmarks. The increase was made possible as the allocations were expanded from a broader set of taxes, including customs and excise taxes. The intention is to support full devolution, assisting the LGUs with their service delivery functions, including health services . This puBy mid-February 2022, the 24th month since the pandemic was officially declared, the Philippines had registered 3.6 million cases and 55 thousand people had died from COVID-19. The active cases, tested via RT-PCR, at that point in time were 72.3 thousand. An estimated 62% of the population were officially reported by then to have received at least one dose of the vaccine . There wThe fiscal space for UHC implementation has since shrunk with the pandemic; the structure of service delivery and financing are challenged with the physical and human resource requirements and coordination needs. In exploring complex systems, such as health care, the country’s initial response during this pandemic can be characterized by dysfunctional coordination platforms, inadequate and mismanagement of resources, as well as limited information systems and capacities, as similarly indicated in systems thinking analysis ,21. ThatThe pandemic also highlighted the crucial and effective role performance of the LGUs, given weaknesses at the central level. Emergency funding was speedily approved nationally, but distribution to lower levels were not as quick. International partners (such as the Asian Development Bank) were also forthcoming with speedy support for infrastructure, such as laboratories and expensive GenXpert machines. The LGUs looked to the central authorities for guidance and support with materials. When these were unclear, not forthcoming, or delayed, they proceeded within their own mandates through their local legislative systems. Public–private partnerships were launched . It is nThe WHO provides a framework where health systems’ performance is viewed in terms of three goals, four functions, and six building blocks . AdaptinTo assess the UHC Act from the lens of the experience under the pandemic, studies have identified interconnected areas that can be built on and are likely to endure for the long term: the strength of engaging with local communities; protection of health workers and other essential workers; effective national coordination; and transparent and consistent information or messaging ,25. HaviA team composed of seven individuals/raters conducted content analysis of the UHC Act (RA 11223). These raters had legal, economics, physics, medical, public health, and computer science backgrounds. They were chosen for their varying knowledge of the UHC Act and general legislative processes to balance familiarity bias. One once served as PhilHealth Vice President, three read the Act in full for the first time, and two were fully acquainted with the Act but new to the given format. All of the team had graduate degrees. The instruction was to ‘tag’ clauses to the actors, blocks, and functions as read and not to go too deeply into ultimate ends or causes. The chapters and clauses of the law were put as rows in an Excel spreadsheet. The first step in the manual tagging of each chapter and clauses in the Act was made based on its directionality, or who it was being directed to. The next step was to examine these clauses into the functions and building blocks, using pre-determined components supporting the study’s framework . The tagThis ‘tagging’ of the Act’s clauses and provisions to the framework components were further examined to check for reliability or consistency of the responses. The reliability or homogeneity of the measurement of the tagging process on different components performed by seven different raters was assessed through the intraclass correlation coefficient (ICC). The ICC on individual and average ratings was estimated. The average ICC can be used when the teams of raters are used to rate a target . When the unit of analysis is an average rating, the interpretation of the ICC pertains to average ratings and not individual ratings.Koo and Li  recommenThe ICC estimates and their 95% confidence intervals (CI) were calculated using STATA/SE version 15.1, based on a mean-rating (k = 7), consistency of agreement, and two-way mixed-effects model.Following a rule of thumb for the researchers to obtain at least 30 heterogeneous samples and to involve at least three raters when conducting a reliability study, it was suggested that ICC values less than 0.5 are indicative of poor reliability; values between 0.5 and 0.75 indicate moderate reliability; values between 0.75 and 0.9 indicate good reliability; and values greater than 0.90 indicate excellent reliability .Each rater tagged the different statements per chapter in the UHC Act according to the 14 components identified in the framework . Each stp < 0.001), indicating that both the individual and average tags were randomly dependent on the type of component and fixed on the corresponding rater making the measurements.Under a mixed-effects model, the individual ICC estimated was 0.69 (95% CI: 0.50–0.86), showing a correlation between the individual tags, while the average ICC was 0.94 (95% CI: 0.87–0.98), showing a correlation between the average tags made on the same component. The consistency of agreement of the seven raters for the individual tags on each component implied a moderate reliability, while there was excellent reliability for the average tags made per component. The estimated coefficients were statistically significant  = 16.41, The dominance of the DOH and PhilHealth is as expected, as the law can be viewed as their mandate to access increased revenue resources and implement wide-ranging health sector reforms to achieve or progress towards universal health coverage. Contracting, which surfaced as the third most tagged, refers to an instrumentality or mechanism that will be exercised by the primary agents to reach other agents. The least tagged, or what was viewed as less attended to in the law, included health human resources, LGUs, and the demand side of health services that involves health benefits. Three themes emerged as crucial in the UHC implementation, particularly from the post-COVID-19 lens. These are the national–local interactions, stakeholder engagement and contracting, and the capabilities and tools for coordination. This section discusses the challenges and directions in these areas.The UHC implementation appears to have been envisioned as a strategy of re-centralization, given the context of integration. At present, the provinces and highly urbanized cities are the owners and locus of health services delivery of the health system; responsible for planning, payroll, and budget allocations to government health services and activities in their jurisdiction. The content assessment, that showed LGUs as having the least attribution or responsibility, points to a critical neglect.Under the implementing rules and regulations , the locDOH and PhilHealth, outside of headquarters, conduct their primary responsibilities in a ‘cooperative’ arrangement. This arrangement has made for a mixed implementation of the devolution enshrined in the local government code . The newIt has been indicated in the first part of this paper that one contentious area in national and local relationships has to with the responsibilities and payment for the health workforce. For the implementation of the UHC Act, more work needs to be completed in the harmonization of various laws and policies, as they affect both the government workforces and the private provision of care. The health workers paid from the local government funds are not receiving the same amount as the national government-funded health workers, creating a contentious area within the same workspace. The private providers may not be able to pay its workers all of the benefit payments given to public health care workers, and using this as a precondition for accreditation may put off private providers from UHC implementation. In the midst of the pandemic, there were mounting complaints from the private providers about unpaid accounts, an issue that has always been lodged against the institution , and forOur content analysis has shown that engagements with the private sector and community groups were weakly ascribed in the Act, and contracting figured prominently as the main instrument to relate with stakeholders. In the Act’s provisions on the private sector, its participation in the integrated local health system, through a contractual arrangement with the province-wide or city-wide health systems, is encouraged.Since public (tax) and member funds are involved, services are not just purchased by central authorities but will be underpinned by contracts, or formal agreements among government agencies and affected stakeholders, including public and private facility operators, and the health workforce. Schuhmann and Bautista  observedThe new UHC Act and its IRR view contracting as a “meeting of the minds”; however, among a very diverse group of parties with equally varying interests and considerations, this is not sufficient. It will be a challenge for the DOH, DILG, PhilHealth, and the LGUs to develop a contract that will satisfy the varying interests of the diverse group of entities sought to be brought together. The conceptual nuances of managing through contracts has been discussed in more depth . Much ofThe DOH and PhilHealth have been given the task of providing general guidelines for these contractual arrangements, hence the impression and concern that these contracts will be very “top down” in nature is warranted. It is recommended that, to counteract this possibility, the task ahead is to empower and strengthen the Provincial and City Health Boards in order to provide nuanced, localized, and, consequently, responsive oversight and management over the contracts that establish the ILHS and other networks.The role of non-government organizations, patient, and community groups was highlighted during the pandemic. They were involved in community mobilization, contact tracing, and coordinating the treatment of individuals in the community, even the provision of social assistance and support. They may continue to be partners post-pandemic. Access to UHC funds is likely also to be through the contracting mechanism. Government procurement systems are not user friendly to community groups and non-government organizations. Membership in the health boards is one venue for participation.The top-down approach has created various anomalies in the light of limited tools utilized to implement the new Act. Moving contracts from being mere transactions to moving monies and paying vendors will require better provider payment systems, which rests on improved information technology systems; with both, steering the system towards health care quality. Financing and information systems form the backbone on which the structure of the health system stands. The new UHC Act’s central feature divided responsibilities by type of intervention; between DOH for population health activities and PhilHealth for personal health care. Linkages on financing, particularly on payments to providers, did not prominently figure in the content assessment.Fair provider payment processes are critical to push for quality services from accredited hospitals, using analytic and evidence-based approaches, rather than relying on its quasi-judicial mandate and flexing its muscle on fraud detection and conflicting policies. The funds from these two agencies will be pooled in provincial and highly urbanized cities to form the special health fund that is managed by reconstituted local health boards. Considering the slight majority of the private sector over government health in the facilities count, there is no indication as to how the private sector will accept not being directly in receipt of funds from the main insurer, PhilHealth. Instead, they will have to collect against the Special Health Fund (SHF), which is managed by the local political bureaus. Furthermore, the payment delays to hospitals, scandals over inappropriate payments, and manipulation of the system through case creep (how one simple case diagnosis will be upgraded to a more complicated case) have percolated into trust issues between PhilHealth and the private providers .While the UHC law improves on the governance of PhilHealth by tightening the qualifications of PhilHealth board members, the financing reforms needed would require more transformative leadership. The pandemic experience has shown how easy it is to wipe out the financial reserves saved over the surplus years, erode agency credibility with the scandals and untimely premium increases. Cost efficiency is gained by altering the way payment is made to the providers, by moving from case payments to more cost control systems, such as global budgeting . The ActThe information requirements and systems needed for efficiency and equity are vast. While new regulatory agencies have been identified in the new UHC Act, such as the Health Promotion Bureau and Health Technology Assessment, the availability and quality of the data and information they will be working with for improved decision-making still need to be constructed. As they generate the data, frequent analysis and updates on diagnostic codes, weights, and costs will form part of the information technology systems that will yield more transparent and robust internal evaluation, utilization processes, knowledge exchange, and management for a nimbler health system.As decentralized local delivery systems and a strong private health sector are the contexts under which the centralizing approach of the new UHC will be undertaken, incentives will be the main mechanism by which purchasing agencies, the DOH, and PhilHealth, are going to relate with stakeholders. Under a strengthened central authority, incentives need to evolve from simple ‘carrots’ or bargaining sticks to being part of a global budget scheme, similar to how international agencies, such as the Global Fund, allocate funds to countries. It is based on robust modeling and evaluation protocols. Only through an interface with technology and evidence-based management can the financial flows in the system be used to drive the strategic choices of users, be it as a provider, health center staff, patients, managers, or decision makers. Only then will the system be efficiently and equitably managed to ensure affordability and universal coverage. Without innovations, adoption will be slow, if not resisted.A key challenge for the information system sector is the provision in the UHC Act’s implementing rules and regulations, stating that the Department of Health and the Philippine Health Insurance Corporation will be funding the development and upgrading of the information system software to be utilized by health care providers and insurers, at no cost (Section 36.3) to them. Several initiatives have been undertaken through the Philippines’ eHealth Agenda framework of 2010. Some of the key players in the pandemic case reporting systems were from the group. Central systems must be designed with local capacities and interoperability in mind. Knowledge partnerships have been shown to be critical during the pandemic, and can only be strengthened with less hierarchical systems.This content assessment study set out to examine the provisions of the new UHC Act for its intentions and directionality. While the ICC estimates obtained in this study implied generally good reliability, these results may not be generalized to other populations of raters, as the raters were not independently sampled but rather fixed in this mixed-effects model. The educational and professional backgrounds of the raters may have influenced the consistency of their ratings. While representativeness to the general population may be unwieldy with the method chosen, the analyses are meant to draw insights into law making in the health sector and for reflection on implementation design.Drawing from various viewpoints and levels of technical expertise, a robust content analysis uncovered tendencies towards centralization. Weak system links were identified with respect to the health human workforce, financing and information systems, pointing largely to basic governance issues. The key players in the system, such as local governments and the private health providers and community groups, which played critical roles during the pandemic, are cursorily treated. The harmonization of the critical laws affecting the health workforce and the local government code is in order. The enhancement of devolution through additional non-earmarked funding for local governments is expected to create further tensions at implementation, in light of the centralizing tendencies of the new UHC Act. Weak relationships with local government units, the private sector, and community group engagements will need reexamination, given their importance in pandemic resilience and in the networked systems envisioned for UHC. In particular, a re-examination of the integration approach, in terms of the technical capacities for planning and evidence-based management in the light of fresh resources, may be in order. Viewing the UHC Act from the perspective of the pandemic also highlighted leverage areas to include innovations in governance areas, such as public–private partnerships, improved financing through provider payments’ reforms, and the smarter allocation of tax-based sources. Contracting and allocation arrangements can improve the quality and efficiency of decision-making in the UHC system. An alternative view of contracts and incentives beyond a mere transaction exchange towards system steering can be examined more empirically and contribute to a more equitable system.


Supported Employment (SE) has shown better results in the employment rate for persons with disabilities than other methods within vocational rehabilitation, but how SE affects the employment rate for subgroups in the interventions needs further attention.To examine previous research regarding the influence of intersecting statuses on the employment rate in SE for people with psychiatric, neuropsychiatric, or intellectual disabilities according to type of diagnosis, sex, race/ethnicity, age, level of education and previous work history.A systematic literature search was conducted in nine databases including peer-reviewed articles from 2000 to April 2021. Articles presenting the employment rate in SE interventions according to the intersecting statuses listed in the objective were included.The searches identified 3777 unique records, of which 53 articles were included in data extraction. In most of the included articles, intersecting statuses did not affect the employment rate for people in the SE interventions with psychiatric disabilities. Few studies have examined neuropsychiatric and intellectual disabilities. A majority of the studies subjected to full-text analysis were excluded due to a lack of reporting of the effects of intersecting statuses on the employment rate. The studies that reported on the effects of intersecting statuses on the employment rate often had small samples and lacked statistical power.Intersecting statuses do not appear to affect the employment rate for people receiving SE interventions, but systematic reviews with pooled samples need to be undertaken because of the low reporting rate and underpowered sample sizes in existing studies. InitialThe manual-based approach to SE, Individual Placement and Support (IPS), for people with SMI emphasizes client choice, rapid job finding, competitive jobs, integrated work settings and follow-along support services and de-emphasizes excluding clients, extensive initial assessments, and prevocational training . IPS has1.2The concept of intersectionality was launched by Crenshaw in 1989 and is based on the idea that people have several individual statuses at the same time and that these statuses intersect in different ways . InterseAs for intersecting statuses and employment rates for people with disabilities, sex is a significant predictor of employment. Women with disabilities are less likely to be employed than men with disabilities and persons without disabilities in all regions in the world . EthniciThe type of diagnosis is not an intersecting status for disability per se, but different types of diagnoses seem to have a hierarchical structure depending on the perceived severity and affect the employment rate for people with different types of disabilities . Consequ1.3Although SE, and especially IPS, have achieved better results regarding employment rates for people with disabilities than other vocational rehabilitation methods, few reviews have examined how intersecting statuses in relation to disability impact the results. Hence, systematic reviews on SE and IPS have requested more subgroup analyses . In a liThus, there are few previous reviews of the influence of intersecting statuses on the employment rate in SE, and they are often out of date. Only one identified review, which only studied diagnoses and no other intersecting statuses, used a systematic approach. Moreover, the results from previous reviews are ambiguous and inconclusive. Consequently, there is a need to systematically review how intersecting statuses influence the employment rate in SE.1.4The objective was to examine what has been reported regarding the influence of intersecting statuses on the employment rate in SE for people with psychiatric, neuropsychiatric, or intellectual disabilities according to the following: (i) type of diagnosis, (ii) sex, (iii) race/ethnicity, (iv) age, (v) level of education and (vi) previous work history.2Before choosing what type of review to conduct, a systematic reading of the articles included in the current systematic review by Nøkleby et al.  was perf2.1–Population: People of working age with a psychiatric, neuropsychiatric, or intellectual disability in need of support to obtain work in the open labor market. Populations that consisted of already employed study participants were excluded, and populations with mixed target groups were excluded if the participants were mixed in the results section. The term mixed target groups was used strictly.–Concept: Employment rate achieved as a result of the SE/IPS interventions in the included studies, related to any of the following: (i) type of diagnosis, (ii) sex, (iii) race/ethnicity, (iv) age, (v) level of education and (vi) previous work history. If the statuses were reported only at baseline demographics or in the intention to treat group and not at outcome level according to the intervention group , the study was excluded.–Context: SE/IPS interventions labeled as SE/IPS interventions by the authors of the different articles. Studies not labeled SE/IPS or only examining augmented SE/IPS were excluded.Based on the population, context, and concept as outlined by Peters et al. , the criIn addition, only peer-reviewed, original articles with quantitative study designs written in English, Danish, Norwegian or Swedish were included. Any other publication type and gray literature were excluded, and articles older than the publication year 2000 were excluded to ensure that only articles reflecting the current SE/IPS practice were included.2.2With support from a university librarian, the first author performed electronic literature searches in December 2019 and additional updated searches in April 2021. Searches were performed in the PubMed, PsycInfo, Cinahl, Social Services Abstracts, Sociological Abstracts, Business Source Premier, Eric, Scopus, and Web of Science databases. Due to the interdisciplinary nature of SE, the databases were chosen because of their different scopes and subject areas. Two search blocks were constructed: search terms related to Supported Employment and search terms related to mental/intellectual disability. Adding another search block with terms related to the employment rate reduced the results considerably, and this search block was abandoned to avoid excluding important results where the employment rate was not mentioned in the title/abstract. Both thesauruses, where it was applicable, and free text searches were used. For the free text search of the search block mental/intellectual disability, the categorization of disorders in the DSM-V was used to organize the search terms. Older terms and synonyms were also added to the block. For the Social Services Abstracts, Sociological Abstracts and Business Source Premier databases, only the search block of Supported Employment was used due to the few results. The limits of the search were publication language according to the inclusion criteria. The search strategy for the search in PubMed is presented in After the initial database searches, duplicate articles were removed, and the first, second and fourth authors independently screened the titles and abstracts of the remaining articles according to the inclusion criteria. The articles were marked with yes, no or maybe for inclusion using the Rayyan software . To ensuData from eligible studies were charted using a data extraction form developed by the authors for this study. The form contained background information of all eligible studies  and study information on the overall employment rate in the SE intervention and the employment rate according to type of diagnosis, sex, race/ethnicity, age, level of education and previous work history. All authors extracted data independently and ensured that the data from each article were extracted by two reviewers. After the data extraction, the first, second and fourth authors jointly checked the results of the data extraction for errors.Data synthesis was conducted by using descriptive statistics (frequency counts) of the variables in the data extraction chart. The average (unweighted arithmetic mean) employment rate for all the included articles which reported the employment rate at outcome was calculated and the differences in proportions of men and women in the SE/IPS-interventions were tested for statistical significance using 1-sample proportions tests with continuity correction with R .33.1Out of 244 articles that had their full text analyzed, 116 were excluded because they did not report any intersecting statuses for employment rate at the outcome level according to the intervention group. Fifty-three articles met the inclusion criteria and were included in the data charting . The bacOf the 46 populations studied, 34 originated from the Anglo-Saxon world. The objectives of the articles were related to examining the influence of one or several individual factors of the outcomes in the SE interventions in 34 cases . In 19 cAs demonstrated in 3.2The measurement of the employment rate varied across the studies. Most studies measured the employment rate as obtaining a (competitive) job at any time during a follow-up period. These follow-up periods varied from 26 weeks up to more than 4 years, and 26 of 46 studies chose a follow-up period of 12 to 24 months. Three of the studies did not define the length of the follow-up period. Additionally, the length of time for employment to count as an employment outcome varied between the studies. Thirty-five of 46 studies did not define the length of employment at all .The variations in the definition of the employment rate make it difficult to compare the studies. However, the mean employment rate in the 44 of 46 studies that did report this number was 50.8% with a standard deviation of 16.9. The variation in the employment rate among the included studies was thus large.The included studies reported on the influence of the intersecting statuses to varying degrees, and ethnicity/race and work history were the least reported. Of the studies that examined whether the intersecting statuses had a significant influence on the employment rate, 24 of 30 reported no significance for diagnosis, 26 of 32 reported no significance for sex, 17 of 23 reported no significance for race/ethnicity, 26 of 33 reported no significance for age, 26 of 31 reported no significance for level of education and 13 of 20 reported no significance for work history .Of the studies reporting significant differences in the employment rate due to sex, 5 of the 6 studies reported that men were more likely to obtain employment than women. The sixth study by Taylor and Bond  studied Of the studies reporting significant differences in the employment rate due to previous work history, the results supported the notion that having previous work history positively affected obtaining employment. Campbell et al. , Fortin The studies that reported significant differences in the employment rate because of different diagnoses showed no clear tendencies. Campbell et al.  reportedThe results were inconclusive for the studies reporting significant differences in the employment rate due to race/ethnicity. Beimers et al.  found thSimilarly, the results were inconclusive for the studies reporting significant differences in the employment rate due to age. Burke-Miller et al. , Henry eThe results of the studies that reported significant differences in the employment rate due to level of education were also mixed. Taylor and Bond  and WaynA few of the included studies also reported on how the statuses that intersected with disability also intersected with each other. Barreira et al.  found th44.1do examine intersecting statuses, and at first glance, the overall results of this scoping review suggest that the intersecting statuses in most cases do not significantly impact the employment rate of SE/IPS interventions. This finding is positive for the SE/IPS methodology as the intersecting statuses examined, such as sex, race/ethnicity, and age, are shown to impact the employment rate for persons with different types of disabilities in settings other than SE [The objective of this study was to examine what has been reported regarding the influence of intersecting statuses on the employment rate in SE for people with psychiatric, neuropsychiatric, or intellectual disabilities. Although the studies in this review do not describe intersectionality or intersecting statuses, they  than SE , and edu than SE .4.2There are, however, several concerns that require attention when interpreting the results. As shown in the results, approximately half of the studies that were analyzed in full text were excluded because they did not report the effects of intersecting statuses on the employment rate at the outcome level according to intervention group. According to Macias et al. , this ma4.3Even if a majority of the studies in this review did not find the intersecting statuses to significantly affect the employment rate, it could be of interest to further investigate the studies that did report significant differences in the employment rate. Campbell et al.  note thaSome articles that used the same study sample acquired different results in different articles. In the case of the two articles using a Norwegian study sample , the dif4.4Another topic that needs some attention is which persons participate in SE/IPS interventions. Scientific studies might not be representative of the typical participants of an SE/IPS intervention in all “real-world” settings, but they might give an indication. The absolute majority of the studies in this review exclusively had participants with psychiatric disabilities. Concerning IPS-studies, this is not surprising because IPS is developed for persons with SMI . HoweverA majority of the studies in this review that reported on sex had significantly more men than women as participants. This finding is in line with the results of the systematic review by Nøkleby et al. . One pos4.5Because many studies do not report the effects of intersecting statuses on the employment rate at the outcome level according to intervention group and those that do are often underpowered, it is difficult to conduct a robust intersectional analysis of the results as the analysis will be uncertain. The intersecting statuses chosen in this study are all statuses that usually affect employment outcomes . However4.6This scoping review was comprehensive with an extensive database search complemented by a manual search. The reporting of the review has also been transparent. However, there are some limitations to the methodology. The search strategy in the databases with two search blocks, of which one was related to the diagnoses specified in the methods section, might have resulted in the exclusion of studies with the same categories of diagnoses if the types of diagnoses were not specified in the title, abstract or keywords that were screened. However, because the manual search of the included articles did not detect any further articles, this risk seems to be low. Gray literature was not searched for further references, which might be a limitation because valuable studies that could only be found in gray literature were not included. Another limitation is the language skills of the authors. A majority of the included studies were of Anglo-Saxon origin, which might have skewed the results since other major languages were lacking.5Intersecting statuses do not appear to affect the employment rate for people in SE interventions in a majority of cases, at least not for people with psychiatric disabilities. However, many studies do not report the influence of intersecting statuses, and those who do are often underpowered. There is therefore a need for more systematic reviews with pooled samples to properly assess the influence of intersecting statuses on the employment rate. There might also be a need for constructing studies that focus on intersectionality and intersecting statuses to be able to determine the effects of intersecting statuses for people with disabilities. If the positive outcomes for SE/IPS that were found in this scoping review remain after further studies, there will be a great need to examine why SE/IPS does not reproduce the patterns from the overall society.