Increased experiential learning within pharmacy education has highlighted the need for quality preceptors, leading to a recent focus on their development and training. This study describes the design, development and implementation of a pharmacist preceptor training program in a regional Australian University. The design of this program utilized the results of a previously conducted scoping review of preceptor training programs and a comprehensive preceptor training needs analysis. In addition, participation was sought from an expert advisory group, comprising preceptors and pharmacy professional organizations. Program materials were developed and transferred onto a suitable online learning platform for implementation. Post-training program evaluation will follow Kirkpatrick’s model of training evaluation criteria, gaining feedback from both preceptors and students. The four flexible online modules that were designed are aligned with the main preceptor roles: role model, educator, mentor and assessor. The program also included a small-group online interactive networking session and an online discussion forum. Following implementation, 28 pharmacist preceptors completed the training. Preliminary feedback on the training program was extremely positive, particularly to the interactive networking activity. Future programs will continue to be adapted to reflect stakeholder feedback and optimize student placement experiences. Preceptors play a vital role in pharmacy education by teaching and mentoring student and intern pharmacists in practice settings as they develop their professional knowledge and skills. Globally, the focus on experiential learning within pharmacy education has highlighted the increasing role of pharmacist preceptors and the need for preceptor training and development to ensure the provision of quality teaching. Training and support for pharmacist preceptors is thus regarded as essential and considered to be the professional responsibility of the university. The Australian Pharmacy Council (APC) Accreditation Standards for Pharmacy Programs require all professionals who are involved in assessing students or interns to be ‘suitably qualified, experienced and prepared for the role, and ‘provided with appropriate guidance and support’ . In the Two global reviews of preceptor training programs revealed limited documented examples of training programs and a wide variation in the design, delivery and content of these programs ,7. SimilRecent interest has focused on preceptor competencies to provide an underpinning structural framework for preceptor development, promoting consistency of preceptor performance and potentially enhancing the student learning experience. Preceptor competencies are closely associated with a range of ideal preceptor roles, skills and attributes, with their identification being necessary to inform the development of competency standards. Several studies have investigated the ideal skills and attributes of pharmacist preceptors from the perspective of both preceptors and students ,11,12,13In addition to competency standards and adherence to the requirements of professional accreditation bodies, the design of a training program for preceptors needs to consider available resources, the nature of the precepting environment, the background knowledge of the preceptor, their specific roles and responsibilities and their individual training needs ,7,17. WiExperiential learning provides the opportunity for students to link learned theory to the realities of pharmacy practice and is considered by the JCU program as an integral component of their curriculum, with students undertaking 600 h of placement during their degree, under the supervision of a pharmacist preceptor. JCU is a regional university with a focus on rural and remote practice; therefore, preceptors and placement sites are geographically distributed across the state of Queensland, covering an area of approximately 80,000 square kilometres. Placement blocks vary in length, ranging from two to six weeks, with all students required to attend at least one rural placement. This training program was designed to prepare pharmacists for their role as student preceptors, with a particular focus on community pharmacy preceptors, who represent about 70% of JCU’s cohort of volunteer preceptors.The 5-point ADDIE  instructional design model , which hA participatory approach was employed to inform the design of this training program, enabling the program to be tailored to those directly involved in experiential teaching and learning. This approach included a needs analysis of preceptors, academic staff and students, using mixed methods, and collaboration with an expert advisory group. Following a scoping review of preceptor training , both quThe curriculum framework for this program was based on a preceptor training program developed by Condrey , which oAfter the preparation of a draft curriculum for training, the research team established an expert advisory group to provide oversight, especially in relation to the practice, and to contribute to the program design. Group members were chosen by purposive sampling and invited to participate in two online meetings, one prior to program development and one following the completion of the training program by preceptors. The advisory group included the three members of the research team (the authors), two members from key professional pharmacy bodies (PSA and APC) and two preceptor representatives, from both a rural and an urban JCU placement site. The research team are all academic staff members in pharmacy at JCU, with the principal researcher (GK) being an experienced pharmacist and academic, BG being a pharmacist with extensive academic and research experience and MM having a degree in education as well as significant academic experience. To minimize the risk of bias in the program evaluation, the two preceptors involved in the expert advisory group did not participate in the preceptor training program. Advisory group meetings were recorded and minutes were taken, which allowed the researchers to fully examine member comments and suggestions for program improvements.Overall, advisory group members were complimentary of the proposed training program, in terms of both structure and content. Various issues were discussed, including student motivation, the challenges of providing feedback, preceptor competencies and linking preceptor training to career progression. Additional content topics suggested by group members included leadership and teamwork, an expansion of cultural considerations, reflective practice and different student learning styles. Based on feedback from group members, the preliminary draft of the training program was modified and further developed into its final form. A second advisory group meeting was held following completion of the program to report on the program implementation and to discuss any future improvements to the program.The program materials were developed by the principal author and reviewed by the research team. A suitable platform for delivery was selected and prepared and program materials were built as modules within this learning platform. Program implementation was timed to coincide with the schedule of student placements, allowing preceptors to complete the full program prior to hosting their next student. A certificate of completion was provided to all preceptors who completed the program.For quality assurance, the program will be evaluated, guided by Kirkpatrick’s framework model for evaluation of educational effectiveness, which consists of four levels of evaluation criteria: reaction, learning, behaviour and results. The reaction level measures the trainee’s perception of training, i.e., did the learner (the preceptor) enjoy the training. The learning level is a measure of the degree of learning achieved by the trainee, based on the learning outcomes., i.e., was the program informative to preceptors. The behaviour and results section are more difficult to measure and involve ascertaining the effect of the program on work habits and performance outcomes, i.e., did it improve precepting ability and confidence and lead to improved student learning .Student evaluation of the preceptor survey which is routinely conducted by JCU Pharmacy following each student placement. Student post-training surveys for trained preceptors will be compared to untrained preceptors, to identify any changes to precepting behaviour because of training, thus adding to the accuracy of the level 3 evaluation.This evaluation will involve a preceptor self-completion survey immediately following completion of the program, as well as preceptor post-training interviews, conducted shortly after a student has completed a placement in their community pharmacy. The preceptor post-training survey will address the reaction and learning levels of Kirkpatrick’s evaluation of educational effectiveness model. The post-training interviews will seek to identify any self-reported changes to precepting behaviour resulting from the training, thus addressing level 3 of Kirkpatrick’s model. To provide a balanced perspective, the program will also be evaluated from the viewpoint of the student by making use of the standard The scoping review identified a range of preceptor training programs, for both hospital and community preceptors as well as residency preceptors. Modes of delivery of training included face-to-face classes and web-based modules, supplemented by a preceptor manual, assignments and recommended readings. While online training was convenient and often considered a necessity due to the geographic distribution of preceptors, face-to-face training was thought to better facilitate preceptor networking. Program flexibility was important to preceptors due to time and workload constraints. Areas of interest for training content included teaching skills, how to be a good role model, conducting assessment and the provision of student feedback. Various useful support measures were identified, including regular communication with preceptors, recognition of the work of preceptors and the provision of continuing professional development (CPD) credits for participation in training. Training program evaluations were mostly positive and based on post-training qualitative feedback from preceptors, although some programs conducted pre- and post-preceptor surveys or interviews, with only a small number of programs obtaining student feedback .The preceptor training needs analysis reinforced the benefits of preceptor training and made recommendations that all preceptors undertake training. It was agreed that preceptors play many roles, with their key role being to link theory to practice. Important preceptor qualities include good communication and counselling skills, being a good role model, interest and enthusiasm about precepting and providing effective, and timely and constructive feedback. It was felt that training should be predominantly provided online with flexibility of training a key requirement. In addition to the online component, some form of interactive session was desirable, as well as a supplemental preceptor manual .Training program content should include an overview of the university curriculum, preceptor and student expectations, teaching tips and strategies, conflict management and how to provide feedback. As support for preceptors, the university should communicate regularly and involve preceptors in current and future curriculum development. The most significant barrier to preceptor training was time, although lack of training and the voluntary nature of precepting were also considerations when choosing to become a preceptor. The main benefit of training was the delivery of a consistent approach to precepting, which was thought to lead to an improved student placement experience ,10.The decision to conduct an online program was influenced by practicality, with the geographic distribution of preceptors as well as time pressures being a major impediment to simultaneous face-to-face training. While face-to-face programs are relatively common in the United States and are often preferred due to their interactive nature, they can be a challenge in circumstances where there are limited resources and poor preceptor accessibility ,17. ThisThe individual modules contain instructional materials which address the four main preceptor roles outlined in the Condrey program: role model, educator, mentor and assessor . AlthougWhile Condrey’s program included an online component for theory-based information and a four-hour face-to-face training class, the JCU program was conducted fully online and therefore these two components were integrated across the four modules. Whereas in Condrey’s program, face-to-face training concluded with small group and class discussions of case studies based on the four preceptor roles, in the JCU model, this session was conducted as a small group online synchronous case-based interactive session, following the completion of the online modules.To identify and describe the roles of the pharmacist preceptor and their associated skills and attributes.To have a knowledge of the skills required to be a student role model and to promote the profession of pharmacy and the importance of lifelong learning.To recognize the different teaching and learning styles which may impact on the education of pharmacy students during placement and to be able to implement a variety of teaching strategies.To describe the principles of mentoring or coaching to motivate, guide and manage pharmacy students during their placements.To understand the principles of student assessment and strategies for the provision of student feedback in the clinical environment.The module materials incorporate pedagogical approaches, and teaching and learning theories which are relevant to the experiential learning context. Preceptors are clinical educators who teach students in a practice environment. They are also adult learners; therefore, it was considered that andragogical teaching methods featuring a constructivist approach would be most applicable for preceptor training. The preceptors are introduced to a range of educational theories and concepts, such as deep and surface learning, intrinsic motivation, the VARK learning style classification, Miller’s pyramid for clinical teaching and assessment, and the ACPE preceptor teaching methods ,22,23,25A welcome message and introductory materials are also included. Each module contains a set of individual learning outcomes, along with information relevant to the preceptor role, online activities, a range of brief supporting video clips, a list of references and a ten-item multiple choice quiz to provide immediate feedback and allow the preceptor to reflect on what they had learnt. The modules are designed to be flexible and able to be completed in the preceptor’s own time over a five-week period, with the estimated overall completion time for the modules being six hours. It was felt that for an optimal outcome, preceptors should be advised to complete all modules and their associated quiz prior to attending a 1.5 h online synchronous networking session. The networking session was designed to allow preceptors to interact with other preceptors in a small group, thus encouraging the sharing of information and ideas. A series of six case studies were prepared to promote discussion. Cases were linked back to various aspects of precepting which were covered in the four modules. This included pre-placement preparation, setting expectations, teaching styles, one-minute preceptor, student assessment and conflict management. As examples, one case provided a student scenario from which preceptors could use the one-minute preceptor framework to provide student education and feedback and one case presented a situation where a student is lacking motivation and behaving in an unprofessional manner, asking preceptors to discuss their response to the situation.The decision to establish an optional online discussion forum within the organizational site was intended to facilitate further asynchronous communication between preceptors to share ideas and strategies for precepting at their own convenience.JCU Pharmacy Preceptor Training Hub was developed as part of the JCU Blackboard® Learn educational platform, and with the help of a digital support assistant. As the already established educational platform for JCU, this was convenient and was able to be easily accessed at no cost to the preceptors. Program modules were prepared and loaded into this online organization site. An image of the preceptor training organizational site is provided in An organizational site called the Following the preparation of the organizational site, a list of email addresses of current and past preceptors was obtained from the JCU pharmacy placements administrative officer. All 240 current and past preceptors were invited by email to participate in the program, with 62 pharmacist preceptors (25.8%) registering for the program. After completion of the four online modules, seven small-group online networking sessions were conducted with preceptors. A maximum number of nine preceptors per group was set, to ensure that there was ample opportunity for all group members to participate in the discussion. These sessions were facilitated by the main author, with each of the six case studies being presented and discussed among the group members. Opportunities for general discussion were also provided within the session. Preceptors who had registered for the program were also invited to contribute to the online discussion forum. Several comments were added to the forum by the facilitator to promote conversation.Of the 62 registrants, 33 preceptors commenced the modules, and 28 preceptors (46.8% of registrants) completed the entire program and were therefore eligible to receive a certificate of completion.® survey platform .Following participation in the program, and completion of all components, including the module quizzes and the preceptor networking session, preceptors will be invited to complete a 10 min post-training online feedback evaluation survey, developed using the QualtricsStudent Evaluation of the Preceptor post-placement survey, which is routinely conducted online via Qualtrics after each placement experience. All student surveys in the year following the program will be collected, with the surveys of trained preceptors being compared to untrained preceptors, to identify any changes to preceptor evaluations following program participation. The post-training evaluation of this preceptor training program will be the subject of a future article.As a follow-up to the survey, a sample of preceptors will be invited to participate in a post-training interview, to be conducted shortly after hosting their first post-training placement student. The aim of the interviews will be to ascertain the outcomes of the training program in terms of changes in their knowledge and attitude towards precepting and the impact on their behaviour during the placement. Interviews will be conducted by telephone and audiotaped, with an estimated completion time of 15 to 20 min. Program evaluation will also be undertaken from the perspective of the students through the The goal of this training program is to prepare and support JCU pharmacist preceptors in their role as teachers and mentors of JCU students during experiential placements. The program design was informed by JCU preceptors, students, and academic staff, with additional input from key industry stakeholders. In line with stakeholder requirements, the program provided individualized training via a set of flexible online modules, together with a small group interactive online networking session. Curriculum content was tailored to suit the identified needs of JCU preceptors, and the program was evaluated from the perspective of both preceptors and students. This discussion will follow the five stage ADDIE Model of Instructional Design which guided program development.A needs analysis is a commonly used method of identifying trainee requirements to develop an effective and evidence-based training program ,30. A raCommon modes of delivery in recent preceptor development programs have included electronic methods such as on-demand or live webinars, online modules, and face-to-face classes, with many programs choosing a blended delivery approach incorporating online and face-to-face methods ,7,19. ThFrom this study, important preceptor skills and qualities included good communication, being a professional role model, enthusiasm for precepting and being able to provide good feedback. This aligns well with the literature ,13 and rThe second phase of the ADDIE model focused on the design of the training program, which considered both the overall structure and the proposed curriculum. It was decided that for this program, an online format was most appropriate due to the wide geographical distribution of preceptors and placement sites. There has been some debate over the most effective way to teach online, with studies finding that while online learning is a valuable tool for teaching clinical skills, a blended approach to learning was preferred ,5,34. ThThe instructional design of this program considered the nature of the learners (the preceptors) who are clinical teachers facilitating student learning and skill development in the practice setting. Clinical teaching can be complex; while practicing in a dynamic working environment, preceptors must not only create a safe learning space for students, but also ensure that they are managing their workload and providing optimal patient care . PharmacGiven that this program was designed to teach preceptors how to precept students, an understanding of both learning and teaching strategies needed to be included, with a range of educational theories, tools, and frameworks being introduced or integrated into the program. In the Educator module, preceptors were introduced to the VARK learning style classification, which describes four learning modes for students: visual, aural, read/write and kinaesthetic, reflecting the different ways in which students learn. Research has found that by identifying the preferred learning style of the student and adapting their teaching style to suit the student, learning can be improved . It is wThe ACPE identify four main preceptor teaching methods: direct instruction, modelling, coaching and facilitating, which may be used by preceptors at various stages of student development to enhance learning and progress their professional skillset ,38. BecaProfessionalism, Structuring the student’s experience, Motivating the student in the clinical arena, Achieving synergy in clinical teaching and Assessment and evaluation [Principles of learning and teaching, Planning for experiential learning, Teaching and instructional strategies, Student assessment and feedback and Communication skills for effective preceptorship and conflict resolution [A range of pharmacist preceptor training programs have been developed in recent years, including small, site-specific programs, university-wide programs and large consortium-based programs ,6,7. Thealuation ,45. In taluation . An intesolution . On closOne of the most desired requirements for a pharmacist preceptor training program is the provision of continuing professional development (CPD) credits for training. Since preceptors are time poor and frequently contribute in a voluntary capacity, they will often prioritise their time based on potential rewards. CPD credits for training are a feature of many current training programs and the integration of preceptor development tools into professional CPD portfolios may also encourage preceptor participation in training in the future ,47.Following the development of the course materials and review, the JCU online program was made accessible to participants, with 28 preceptors completing all components of the program. It was thought that this relatively low participation rate was due to the current high workload of community pharmacists in Australia, considering also the impact of the COVID-19 pandemic on workload and staff absences . Of noteLearning settings can be enriched through collaboration and interaction, with preceptors valuing opportunities to network and interact. ,5,39. WhPreliminary results from the post training evaluation survey indicate that preceptors were overall very positive about the program, particularly appreciating the online networking session. The full results of the post training evaluation will be the subject of a future article.Limitations of this study include the low number of preceptor training program completions, which was thought to be due to the already high workload of pharmacist preceptors, as well as the fact that only 39.6% of preceptors invited to participate had indicated a willingness to host a student within the past 12 months. There was potential for a positive response bias with the researchers being known to most preceptor participants.While the overall response rate for the needs analysis was low, the mixed methods study design with a participatory approach provided breadth and depth to the analysis, thus increasing the validity of the findings. This approach was also instrumental in ensuring that the program was able to be tailored to the needs of JCU preceptors. The broad experience of the research team in both teaching and pharmacy practice was advantageous in providing the most appropriate educational design for the program.It is anticipated that this program will continue to be offered on an annual basis, with refinements being continually undertaken in response to stakeholder feedback. Considering preceptor feedback from previous studies, the wide variation in preceptor experience in both practice and precepting may warrant the streaming of preceptor development programs to cater for both the novice and the more experienced preceptors ,17.It is expected that the existing professional requirements for preceptor development will necessitate mandatory training in the future, which will further promote the development of training programs across Australia. While this program is currently focused on training community pharmacy preceptors, there is potential for it to eventually be expanded to include all preceptors across the broad range of experiential placement sites. The general principles of precepting are similar across a range of health professionals and with the increased emphasis on interprofessional practice in healthcare systems, interprofessional training for preceptors may be a practical and cost-effective approach to facilitate preceptor development, with potential for collaboration with other health professional programs such as medicine and nursing ,51.Although preference for preceptor development tailored to institutions and the individual preceptor has been identified ,5, thereThe training and development of pharmacist preceptors is considered crucial to the success of experiential placements. This study provides an example of a tailored training program which has been informed by the previous literature, as well as through a comprehensive needs analysis and direct consultation with the profession. The development and implementation of this program has been strategically planned and structured to provide preceptor flexibility, with evidence-based and educationally focused content, and linked to a national pharmacist competency framework. Ongoing modifications and extensions to this program in response to program feedback should ensure that it continues to meet the individualized needs of all preceptors. The further development of specific preceptor competencies for pharmacists is recommended to provide and maintain quality and consistency for future preceptor training programs. An increased focus on preceptor development in pharmacy programs will ensure that student placement experiences are of high quality and provide maximum benefit for both the preceptor and the student, promoting the achievement of optimal graduate outcomes.


Despite many initiatives over more than 4 decades, the diversity of United States physicians still does not reflect the diversity of the United States population. The present study undertakes a literature review of the last 30 years to investigate barriers and protective factors underrepresented college students encounter as applicants for medical school. Known barriers that influence matriculation into medical school were analyzed such as academic metrics and test scores. Additionally, elements that are less well studied were investigated such as factors perceived as barriers by underrepresented applicants in addition to protective factors that allow them to persist in their journey in the face of difficulties and adversity. It has been known for many years that the United States is facing a significant physician shortage in particular in the primary care field  and thisThere are many reasons that it is important to increase diversity in health professions. For example, studies have shown that URiM graduates are more likely to become primary care providers and serve the underrepresented and underserved communities, often coming from these communities themselves . AdditioNevertheless, despite a nearly 60% increase in enrollment in US medical schools in the last two decades , and a cThere has been considerable discussion of the factors that contribute to the underrepresentation of minorities and marginalized individuals in all of the health fields, which has led to the concept of a “leaky pipeline” from college to medical school with some inclusion of K–12 . Many coU.S. News & World Report continue to base rankings of medical schools on research funding, school reputation, and student selectivity factors not the number of diverse graduates , Grutter vs. Bollinger (2003), and Fisher vs. University of Texas (2013)], the fate of existing admissions policies which support student diversity is currently (2023) again under consideration by the US Supreme Court  of an application to ensure that candidates from diverse backgrounds and experiences are reviewed . Howeverraduates . Anotherraduates  and thisraduates . Holistiraduates . Althougme Court . The effme Court .A further issue that contributes to continuing inequities in the matriculation of URiM students is the lack of diversity in academic medicine. Data from the AAMC shows that in allopathic medical schools over 83% of the medical school faculty is white or Asian and almost 90% of this same group hold the rank of Professor . This laLooking at the financial cost of medical school, in 2019 the average 4-year cost of medical school was $250,222 at a state institution and $330,180 at a private medical school . Costs lthis is not a pathological condition, imposterism does correlate with burnout, psychological stress, depression, and adverse mental health  courses can lead to higher stress levels, anxiety, depression, poor attendance, lower course grades, and less persistence in STEM and beyond  checklist , a combi2.3.Both researchers screened the literature with specific inclusion and exclusion criteria, which were modified throughout the study selection process to narrow the focus of the selected articles.To be included in the review, papers needed to specifically discuss or focus on factors that either supported or reduced the pool of underrepresented applicants to US medical schools. The target participants were URiM high school and college students. Articles discussing strategies for retention of matriculants in medical school or strategies for increasing enrollment in other health professions were not included. Additionally, papers were excluded if they discussed factors that did not match one of the theme areas we had identified, were not published in English, or pertained to schools other than those in the United States.Screening took place in two phases. Phase 1 consisted of screening title and abstract of articles retrieved during the search of keywords. The screening was for specific terminology related to URiM admissibility and/or matriculation into medical school in the United States. In Phase II, full-text articles were assessed for eligibility and relevance to the goals of the study and research question.3.3.1.Initial search results were exported to EndNote and duplicates removed for a total of 196 citations. Upon further exploration and browsing of appropriate foundation websites, citation alerts, and review of cited references, 30 additional publications were added for a total of 226 citations. Phase I screening excluded 78 articles and 148 were deemed appropriate for full review by both authors. After Phase II, full text review confirmed that 66 articles met all criteria. A flow diagram was adapted from the PRISMA guidelines  and used3.1.1.A significant and much studied barrier for increasing diversity is academic metrics since medical schools rely heavily on MCAT scores and undergraduate GPA to determine admission, but data continue to show a persistent score gap for URiM and low SES applicants . There i3.1.2.One issue, stemming from the previously mentioned lack of faculty diversity in academic medicine, is that admissions committees may have different perspectives of the barriers that URiM students will face in acceptance to, and success in, medical school . To demo3.1.3.Many URiM applicants come from lower socioeconomic backgrounds and attend underfunded and disinvested schools and institutions, significantly limiting the number of resources available to these students which can result in lower rates of college attendance, undergraduate degree completion, and lower MCAT scores ; Table 3Underrepresented in medicine applicants are also less likely to have access to positive educational opportunities such as research experience, exposure to healthcare career opportunities or have a family member who is a healthcare provider . An earl3.1.4.In addition to the obvious concerns of the cost of medical school , financi3.1.5.In this category, which covers the highest percentage of the citations, we looked at psychosocial factors which are less studied but are clearly significant for historically minoritized and marginalized students . We haveUnderrepresented and first-generation students often experience feeling like impostors in college and this can negatively influence their academic performance, their confidence in their abilities, and ultimately their success. The feeling of additional pressure to prove others wrong and the experience of microaggressions and perceived racism is particularly prevalent in minoritized and marginalized communities . An inteSelf-efficacy as defined by To provide continued motivation to carry on with their pursuit of medical school, URiM and marginalized applicants rely on social support systems and mentoring . For som4.The lack of physician diversity in the US has been investigated extensively and the vast majority of literature is aimed at investigating barriers that negatively affect URiM students matriculating to and graduating from medical school. This review, which focused on the application and matriculation of URiM applicants to medical school, reinforced the known barriers of academic criteria, educational disadvantages, lack of faculty diversity, and financial considerations. For a low SES applicant, which encompasses many URiM applicants, healthcare experience opportunities, involvement in research, summer enrichment programs, and even co-curricular activities are often out of reach due to the need to work to support themselves and their families . Lack ofIn addition to the obvious barriers, there are also a number of psychological, cultural, and social factors that contribute to the premedicine journey of URiM students. Impostor phenomenon is increasingly reported in historically minoritized and marginalized communities and is considered by some as a consequence of structural racism  and lackOther facilitators of URiM students to continue their journey to medical school include self-efficacy and/or self-belief, which is developed in many pipeline programs and research experiences. Clearly to support the cultural wealth of historically minoritized and marginalized students, the involvement of strong role models through high-school and college and social support networks which can foster this development must be nurtured and encouraged. In addition, spirituality and high levels of racial or ethnic centrality have been seen to be important in giving historically marginalized students the tools to deal with perceived and real racism. Finally, any attempts to increase the matriculation of URiM students into medical school must be coupled with a commitment from the institutions that they will provide the climate that will support the persistence and success of those students.This review was not meant to be exhaustive but instead focused on several factors that we identified that effect underrepresented students on the premedicine pathway. Limitations of this review were that much of the literature discussed came from qualitative reports and from self-reported data and surveys, information which is subjective. In many cases, the cohorts under study were small and were from a single institution or single program. The primary focus was on the racial and ethnic minorities of Black/African American and Hispanic/Latinx, since although Native Americans and Alaskan Natives are also underrepresented in medicine, we were unable to find sufficient literature to speak on additional factors related to this population. The expectation is that the same factors will apply to these groups. In addition, in some regions, Southeast Asians are considered URiM but data reports and most literature aggregate Asian populations. We also did not include other historically minoritized and marginalized groups such as sex assigned at birth/gender/gender identity (LGBTQ+) or disabled. Although diversity initiatives extend back over four decades, this review focused on the last 30 years to cover only two iterations of the MCAT. Finally, our grouping of articles was largely subjective and based on the broad categories, and the articles themselves may not have used the same terms and/or language when discussing the various barriers or protective factors.To conclude, if the diversity of US physicians is ever to approach the diversity of the US population, all factors should be investigated to increase the academic success and eventual matriculation of historically minoritized and marginalized students to medical school. The emphasis on barriers to success should be balanced with promoting protective factors, in particular, those that diverse students rely on for persistence in their education.CT and CG contributed to conception and design of the study. CT proposed the factors and barriers based largely on her experiences as a first-generation Latina and wrote the first draft of the manuscript. CG organized the database. All authors contributed to the article and approved the submitted version.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.


Transient ischaemic attack (TIA) and minor stroke are frequently assumed as temporary or non-disabling events. However, evidence suggests that these patients can experience relevant impairment and functional disability. Therefore, the present study aims to evaluate the feasibility and effectiveness of a 3-month multidomain intervention programme, composed of five non-pharmacological strategies, aimed at accelerating return to pre-event level of functionality in patients with TIA or minor stroke.Patients diagnosed with a TIA or a minor stroke are being recruited at the emergency or neurology departments of the Hospital Pedro Hispano, located in Matosinhos, Portugal (n=70). Those who accept to participate will be randomly allocated to two groups (1:1): (a) Intervention—receives a 3 months combined approach, initiating early post-event, composed of cognitive training, physical exercise, nutrition, psychoeducation and assessment/correction of hearing loss; (b) Control—participants will not be subject to any intervention. Both groups will receive the usual standard of care provided to these diseases. Recruitment began in May 2022 and is expected to continue until March 2023. Socio-demographic characteristics, lifestyles, health status, cognitive function, symptoms of anxiety and depression and quality of life will be assessed; as well as anthropometry, blood pressure and physical condition. Time to complete or partial recovery of instrumental activities of daily living will be assessed using an adapted version of the Frenchay Activities Index. All participants will be evaluated before the intervention and after 3 months.This study was approved by the Ethics Committee of the Local Health Unit of Matosinhos (Ref. 75/CES/JAS). Written informed consent will be required from all the participants; data protection and confidentiality will be also ensured. The findings of this project are expected to be submitted for publication in scientific articles, and the main results will be presented at relevant scientific meetings.NCT05369637. This protocol describes a pilot randomised controlled trial addressing the effect of an innovative multidomain non-pharmacological intervention programme on post-transient ischaemic attack and minor stroke functionality.The intervention programme will start early after the diagnosis of the vascular event, maximising health gain and targeting brain plasticity.The main outcome is based on the time to recover instrumental activities of daily living after the event, which is more suitable due to the characteristics of residual impairment.This study will explore a wide range of different outcomes, including study feasibility, cognitive function, lifestyle behaviours, physical and emotional status.Given the characteristics of the intervention, blinding of the participants is not possible. In addition, the main outcome is evaluated by self-report and is based on a predefined list of activities of daily living. Therefore, we cannot exclude the existence of recall bias regarding our main outcome.A transient ischaemic attack (TIA) is defined as a ‘transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction’ by the American Heart Association,6The study of the overall morbidity associated with a TIA or a minor stroke is often neglected, since most of the time they are assumed as being transient or non-disabling events. However, evidence suggests that these patients can experience relevant disability even with a NIHSS of 0 or 1.6Taken together, these findings highlight the importance of multidomain interventions aiming to promote functioning levels among patients with TIA or minor stroke, and to develop preventive actions and health promotion plans specifically designed for this group. As such, this pilot study primarily aims to explore the feasibility and the effectiveness of an innovative multidomain intervention programme, composed of five strategies: cognitive training, physical exercise, nutrition education, psychoeducation and assessment/correction of hearing problems. These are aimed at accelerating the return to pre-event functionality in patients with a TIA or a minor stroke diagnosis. The primary objectives are as follows:To assess the feasibility of methodology for early recruitment, collecting information and delivering the interventions.To estimate the effectiveness of this programme on the time to recovery in each instrumental ADLs.As secondary objectives, the effect of this intervention on cognitive function, adherence to the Mediterranean diet, physical function, basic ADLs, symptoms of anxiety and depression, quality of life, anthropometric measures and blood pressure, will be also assessed.The present study is a two-arm parallel, superiority, pilot randomised controlled trial (RCT), which will be nested in the ongoing project ‘Multiple Interventions to Prevent Cognitive Decline’ (MIND-Matosinhos).The primary endpoints will be the feasibility of this multidomain programme, as well as the time to recovery to pre-event functionality after the occurrence of a TIA or a minor stroke. A block randomisation with a 1:1 allocation will be performed.This pilot RCT will be conducted at the department of neurology of the Hospital Pedro Hispano E.P.E (HPH), as part of the Local Health Unit of Matosinhos (ULSM), which is integrated in the Portuguese National Health Service. The HPH is located at the Matosinhos municipality, Northern Portugal, and is responsible for providing care to 318 000 inhabitants from the municipalities of Matosinhos, Vila do Conde and Póvoa de Varzim.Patients aged 18–85 years old and with a clinical diagnosis of TIA or minor stroke as defined by an NIHSS score ≤3 are eligible for this study. Additional inclusion criteria include: the onset of symptoms within the last 7 days; first-time stroke or TIA; at least 4 or more years of education; discharged home without the need for inpatient rehabilitation; modified Rankin Scale (mRS) 0–2. Patients will be excluded if they are unable to attend the face-to-face intervention sessions, or if they have: previous diagnosis of dementia or severe disability; contraindication for physical exercise, severe loss of hearing, vision or communication skills; frailty, reduced life expectancy due to severe disease or need for regular treatments that compete with availability for intervention .Participants will be enrolled through consecutive sampling from the Neurology Department (stroke or emergency care units) of HPH. Healthcare professionals from the recruitment site will be informed about the protocol and their potential role, and an experienced researcher will be on-site to provide coordination. The neurology medical team will be responsible for screening eligibility and obtaining written informed consent for all the participants. Recruitment started on 11 May 2022.The participants will be randomly assigned (1:1) to the intervention or control group after the baseline assessment. Randomisation will be done using a computer-generated programme, using random blocks of four sizes. A researcher who is not immediately engaged in the project will implement the randomisation process.Participants will be evaluated at baseline (before the beginning of the intervention programme) and at 3 months, as depicted in Data regarding clinical diagnosis, onset of symptoms, hospital admission and discharge date, mRS score, NIHSS score, medical history of cerebrovascular events, age and need for inpatient/outpatient rehabilitation will be retrieved from the patient′s medical record. Clinical characteristics of the cerebrovascular event will also be collected.The intervention will be implemented over 3 months and will comprise five different components, including cognitive training, physical exercise, nutritional education, psychoeducation and assessment and correction of hearing problems. Only the intervention group will be exposed to all or any of the components of this comprehensive intervention programme. Both groups will continue to receive the usual standard of care provided to this type of clinical disease in the hospital setting. The usual standard of care consists of the initiation of the appropriate secondary prevention and referral to the outpatient cerebrovascular diseases clinic . Depending on the clinical presentation and neurological deficits, patients can also be referred to an outpatient physical medicine and rehabilitation appointment.Since early intervention post-vascular event is decisive, given the time interval between neurological injury and the onset of nervous function recovery activities, intervention sessions are aimed to begin within no later than 15 days after the cerebrovascular event. Considering this timeline, once the participants are recruited and randomised, the intervention will start immediately, especially cognitive training.To minimise refusals and losses to follow-up, all evaluations and sessions will be scheduled by the participant’s preference. A written plan with the intervention schedules will be given and sessions reminded through email or phone messages in the day before . If one intervention session is missed, efforts will be placed to arrange another suitable time in another group and individualised meetings will be rescheduled. If not possible, the missed appointment will be documented, and the dropout or non-compliance reasons will be registered for further analysis.Monthly in-person sessions in groups of a minimum of five participants (60 min) will be conducted by a psychologist. Additionally, during the 3 months a daily home-based cognitive training individual (30 min) sessions using the COGWEBPhysical exercise sessions in-person or remotely twice a week with a duration of up to 60 min, guided and supervised by a graduated physical exercise technician, will be conducted. Activities will be tailored to each participant tolerance, medical history and comorbidities, focusing on impaired balance and weakness. During exercise sessions, the exercise technician will track symptoms of chest pain, shortness of breath, wheezing, dyspnoea, lightheadedness, nausea, among others. Small groups allow to set short and attainable goals with the participants and have a graded exercise programme, starting with reduced intensity and gradually increasing.In-person sessions will be preferred, however if online sessions are needed, the participants without a computer will receive booklets with physical exercise instructions twice a week and the researcher will contact the participants to assess adherence to the exercises.Intervention arm will include individual appointments  and in-person group cooking sessions (once a month with a duration of 90 min). During individual sessions, the nutritionist will emphasise the benefits of adhering to the Mediterranean diet and salt reduction, particularly for overall cardiovascular health advantages. Group sessions start with the nutritionist’s presentation of healthy recipes and further analysis of nutritional values, then the participants will undergo its preparation. In these sessions, participants can bring their partners or one family member.Monthly in-person psychoeducation sessions (60 min) in groups of a minimum of five participants will be conducted by a psychologist. These sessions will support people in understanding, exploring, and self-managing their emotions and impairments, through peer support and promotion of lifestyle changes.At the beginning of the intervention programme, a hearing assessment and correction will be performed. This evaluation will be conducted by otolaryngologists and audiologists, who will evaluate previous hearing problems and use of hearing aids, and includes otoscopy and audiogram. Those detected with any hearing problem will be referred for a medical appointment with an otolaryngologist.The primary outcomes for the study are related with its feasibility and time to partial or complete recovery of each instrumental ADLs.To evaluate the feasibility of this study, the following primary outcomes will be assessed:Recruitment time frame: proportion of participants recruited within 7 days after onset of symptoms. It will be assessed by dividing the number of participants recruited within the time frame divided by the total number of participants.Beginning of the intervention: proportion of participants that started any of the interventions no later than 15 days after onset of symptoms.Adherence to each component of the intervention: proportion of adherence to each component of the intervention and different intervention modalities (remote/in person), calculated as the number of sessions attended divided by the total number of sessions provided. For the COGWEB training, the outcome will be the absolute number of sessions.Dropout: proportion of participants who dropped out of the study, calculated as the number of participants who dropped out after attending at least one session divided by the total number of participants who attended at least one session.Time to recovery in each instrumental activity of daily living will be measured by an adapted version of the Frenchay Activities Index (FAI). The translated and validated version of the FAI—adapted version for the Portuguese populationFor the present study, only activities that are part of participants’ daily lives will be considered, namely those that were performed at least once in the last 12 months. Time to recovery will be defined as the time from the start of the intervention programme to the time of complete or partial recovery. Each participant will report their level of performance in each activity at the baseline and follow-up at 3 months. In the baseline, if a participant scores a specific activity as altered (score 1–3), their level of performance before the TIA or minor stroke will be confirmed to understand if the change in the activity performance is related with the cerebrovascular event. It will be also inquired and recorded the date when a difficulty in a certain activity ceased. The average of activities altered post-event  at baseline and the average of activities that improved in both groups on completing the intervention programme will be measured.Secondary outcomes and the instruments that will be used for their assessments are described in Due to the nature of the present intervention, it will not be possible to guarantee a proper blinding to the intervention arm among participants; nevertheless, allocation group will not be actively reported. Regarding the outcomes assessment, interviewers will be independent and blinded to each participants’ allocation group.The associations between the social and clinical characteristics and feasibility  and lifestyle outcomes will be quantified through linear or logistic regression models, as applicable. Time in days from the onset of symptoms to complete or partial recovery in each instrumental ADLs will be estimated and illustrated by Kaplan-Meier survival curves. The time comparison between intervention and control groups will be made through the log-rank test. To estimate the association between the intervention and the recovery time, HRs will be estimated, through the computation of univariate and multivariate Cox regression models.Training of the interviewers and use of standardised procedures for data collection is expected to contribute to a low proportion of missing data, and no imputation is being planned.To the best of our knowledge, there is no previous information regarding effect sizes and SDs regarding the primary outcome related with the recovery of functionality after a TIA or a minor stroke. Nevertheless, a sample size of at least 70 participants (35 per arm) is commonly recommended for a pilot study when estimating the pooled SD.To achieve the sample size needed to accomplish the proposed objectives, we expect to invite approximately 100 individuals, since a participation of 70% was previously observed in the EPIPorto cohort.This study intents to recruit participants within 7 days after the onset of symptoms and start intervention no later than 15 days, which is a considerably short period. This recruitment time frame may be difficult to attain, so additional measures may have to be adopted, namely receive referrals from other hospitals in neighbouring counties .Due to the COVID-19, the number of in-person sessions and participants per group may be reduced. However, if necessary, all activities will be home-based. To minimise the potential impact of the pandemic on participation and retention rates, additional mitigation measures may be adopted, including enlarging the recruitment period or an increase in the sample size.Patients and public were not involved in the conception, design and dissemination of this study.Ethics approval was obtained by the Ethics Committee of the ULSM (Ref. N° 75/CES/JAS) and the Data Protection Officer of the ULSM (Ref. 14/CLPSI/2021) and Institute of Public Health of the University of Porto. Any substantive protocol amendment will be reported to the respective Ethics Committee for approval.Written informed consent will be obtained from all the participants once the study’s objectives and procedures are fully explained. The voluntary nature of participation will be emphasised, clearly stating that they can refuse to participate or leave the study with no penalty associated, namely their right to medical care. There are no expected risks or discomfort other than those arising from the sessions, interviews, anthropometric measures and the collection of venous blood and 24-hour urinary samples. The intervention group will be covered by personal accident insurance to indemnify any unlikely accident related to the sessions. Due to the expected low risks and the study small sample size, a data monitoring committee was not established.To guarantee safety and security of physical exercise, participants with contraindications for exercise practice would not be included in the study. In-person sessions will be preferred, but if sessions are online, some of the exercises will be in a sitting position and participants are encouraged to have someone near them throughout the sessions at home.This study involves collecting, analysing and processing sensitive personal data, including contact information, health and clinical data from questionnaires and participants’ clinical records. Therefore, measures are in place to guarantee the confidentiality and anonymity of the participants. All data from clinical records will be collected by clinical members of the research team and privacy will be assured. Health and clinical data will be pseudonymised, with each participant being assigned and identified with a unique numerical code in the study. The principal investigator will be the only person with access to the file containing the correspondence between this unique numerical code and the personally identifiable information. Only specific members of the research team have access to the names and contact information of the participants, which will be only used to book evaluations and intervention sessions and resolve any logistical problem throughout the implementation of the intervention programme.Documents with personal identification data and informed consents will be securely stored, separated from other documents and with access limited to the research team and no personal identifiers will be used in data analyses. Only the research team will have access to the study data set, saved on a password-protected secure computer. The study is in accordance with the Helsinki Declaration of 1964, further amendmentsThe implementation of the present study will elucidate the feasibility and impact of a multidomain non-pharmacological programme in recovering functionality after a TIA or a minor stroke, which may contribute to delineate further larger RCT and adequate preventive actions. This study will also provide important data to the refinement and validation of the BoT, which will allow a more practical, intensive and economic monitoring of cognitive performance in this specific population. The expected results will be relevant for public health policies, by providing a characterisation of residual sequelae of a TIA or a minor stroke, to improve patients’ functionality and promote a faster recovery. It may, ultimately, contribute to a better allocation of resources and the creation of synergies between different stakeholders, as well as to improve the management of care.The findings of this study will be disseminated at several levels, including the publication of scientific papers in international peer-reviewed journals and presentation in relevant national and international conferences. A short training course on secondary prevention post-stroke for public health researchers and students will be also conducted and the project will contribute to the training of researchers through the production of a master dissertation. The main conclusions of the project will be disseminated through press releases and conferences to the media , fostering a connection between science and society.


Syria has been in continuous conflict since 2011, resulting in more than 874,000 deaths and 13.7 million internally displaced people (IDPs) and refugees. The health and humanitarian sectors have been severely affected by the protracted, complex conflict and have relied heavily on donor aid in the last decade. This study examines the extent and implications of health aid displacement in Syria during acute humanitarian health crises from 2011 to 2019.We conducted a trend analysis on data related to humanitarian and health aid for Syria between 2011 and 2019 from the OECD’s Creditor Reporting System. We linked the data obtained for health aid displacement to four key dimensions of the Syrian conflict. The data were compared with other fragile states. We conducted a workshop in Turkey and key informants with experts, policy makers and aid practitioners involved in the humanitarian and health response in Syria between August and October 2021 to corroborate the quantitative data obtained by analysing aid repository data.The findings suggest that there was health aid displacement in Syria during key periods of crisis by a few key donors, such as the EU, Germany, Norway and Canada supporting responses to certain humanitarian crises. However, considering that the value of humanitarian aid is 50 times that of health aid, this displacement cannot be considered as critical. Also, there was insufficient evidence of health displacement across all donors.The results also showed that the value of health aid as a proportion of aggregate health and humanitarian aid is only 2% in Syria, compared to 22% for the combined average of fragile states, which further indicates the predominance of humanitarian aid over health aid in the Syrian crisis context.This study highlights that in very complex conflict-affected contexts such as Syria, it is difficult to suggest the use of health aid displacement as an effective tool for aid-effectiveness for donors as it does not reflect domestic needs and priorities. Yet there seems to be evidence of slight displacement for individual donors. However, we can suggest that donors vastly prefer to focus their investment in the humanitarian sector rather than the health sector in conflict-affected areas. There is an urgent need to increase donors’ focus on Syria’s health development aid and adopt the humanitarian-development-peace nexus to improve aid effectiveness that aligns with the increasing health needs of local communities, including IDPs, in this protracted conflict. • Health aid displacement is not an effective tool for aid-effectiveness used by donors in Syria.• Some health aid displacement is evident for some leading donors such as the EU, Germany, Norway and Canada.• Donors prefer to fund humanitarian activities with humanitarian aid being 50 fold more than development health aid; this is largely because humanitarian projects are easier to implement with sanctions and highly dynamic borders.• There is an urgent need to adopt the humanitarian-development-peace nexus, considering the localization agenda. This approach can bridge the gap between the humanitarian and development phases, thereby increasing aid effectiveness. The unprecedented number of protracted humanitarian emergencies in the last decade, including armed conflicts, natural disasters, political violence, human rights violations, climate change and COVID-19, have contributed to the greatest humanitarian challenges since World War II, leading to more than 100 million forcibly displaced persons, including refugees and internally displaced persons (IDPs) in May 2022 [Many conflict and crisis-affected countries depend on donor aid (both humanitarian and development), particularly during times of crisis. However, it is unclear where humanitarian aid is additional or displaces other aid and whether crises affect the quality of aid. Also, it is unclear how donors used needs’ assessment data for decisions to allocate funds . ReallocIn comparison, very few studies have considered health aid displacement at the donor level, which refers to shifting funding from the health sector to other sectors, such as the humanitarian sector during crises to reflect the humanitarian needs and/or shifting priorities of donors; this displacement does not always consider domestic health needs during decision-making . The limHowever, there are no studies on health aid displacement in conflict settings in the MENA region. Syria offers a unique example of a protracted conflict for more than a decade, which has left a humanitarian crisis described as the worst of the twenty-first century . With arThe main objectives of this paper are to analyse trends in humanitarian and health aid in Syria between 2011 and 2019 and their alignment with needs in terms of key dimensions of the Syrian conflict. We also examine whether there is evidence of health aid displacement across all donors, assess whether and how this differs between donors, and compare the volume of health and humanitarian aid in Syria to other fragile states.Syria has been in a state of continuous conflict since 2011, resulting in more than 874,000 – directly and indirectly deaths , 14, TheIn 2014, UN Security Council Resolution 2165 was issued to allow donors to provide humanitarian aid through four border crossings: Bab al-Salam and Bab al-Hawa on the Syrian-Turkish border, Al-Yarubiyah on the Syrian-Iraqi border and Al-Ramtha on the Syrian-Jordanian border, which were all not under the control of the Syrian government. This Resolution is to support areas outside the control of the Syrian government and does therefore not require its approval . At the The ten most significant humanitarian donors according to OCHA in 2019 (the last year of our study) were: the USA, Germany, UK, EU, Canada, Norway, Denmark, Japan, France, and Sweden, respectively . The secThe humanitarian clustering model was established in Turkey for the humanitarian response in Syria across border in 2014 . It is lMoreover, another humanitarian hub emerged inside Syria in Al Hasaka governorate in 2017, coordinated by the North East Syria (NES) NGOs Forum. It manages several technical working groups and has loose links with the WoS approach in Amman, Jordan.This is a mixed methods country case study that tracks aid trends and allocation from donor countries and organisations in response to the humanitarian crises in Syria. It is then combined with follow-up qualitative interviews with an expert panel of key informants and stakeholders in the humanitarian and health sectors in Syria to complete and corroborate results obtained by analysing aid repository data.The research team charted the crisis timeline based on four quantitative indicators after excluding many others due to their limitations in the Syrian context. These indicators were then tested in the expert panel to see if they were suitable or if they required adaptation. The relevant humanitarian indicators to explain key dimensions of the Syrian conflict include: 1) the number of IDPs; 2) the number of people in need of humanitarian assistance; 3) the number or frequency of internal movements (displacements) due to the conflict and violence only. As Syria did not witness significant natural disasters during this period, the number of internal movements due to natural disasters was at the most 2,300 until the beginning of 2017. It then increased to 27,000 in 2018 and dropped to 17,000 in 2019 . 4) the For this study, we could not include casualty figures as an important indicator because when compared to refugee data, casualty data is of a lesser standard of validity for the period. The United Nations stopped counting fatalities in the conflict by January 2014, citing the difficulty in accurately recording the constantly increasing toll .After expanded discussion with the experts in the panel, we concluded that, although there were limitations associated with each indicator individually, quantitatively, reading these four indicators together would best express the crisis timeline in Syria.Data on internal movements and IDPs were collected from the Internal Displacement Monitoring Centre (IDMC), which is a comprehensive source of data and analysis of internal displacement worldwide. The Centre was established as part of the Norwegian Refugee Council (NRC) in 1998 . And datData on humanitarian and health aid for Syria were collected from the OECD's Creditor Reporting System (CRS) . DespiteThe data, in the CRS, are reported by 42 multilateral donors ; 49 bilateral donors , and 36 private donors .The CRS provides financial data for 2002 -2021 with almost 200,000 – 300,000 data entries per year. Furthermore, it covers the specific economic or social programs that the aid seeks to support in a recipient country and classifies them into sectors. In addition, some contributions are not subject to sector-specific allocations and are reported as non-sector allocable aid . Donors The CRS data used in this study are based on the 31 April 2021 update .The scope of the study is the whole of Syria whether the government- controlled area or the non-government-controlled territories.Based on the databases mentioned earlier, we identified several variables representing crisis timelines, health aid and humanitarian aid. Table We collected information about the Syrian conflict's key dimensions from various sources annually between 2011 and 2019. Then we applied trend analysis techniques to trace their trajectories, which allowed us to comprehend the interrelations among them. Simultaneously, we explored the connections between the crisis timeline and the fluctuations in health and humanitarian aid trends.We gathered financial data from the CRS and performed a trend analysis using Excel from 2011, the year the protests began in Syria, until 2019, the last year with available data at the CRS database at the moment of downloading the data. In this analysis, our definition of aid includes “Official Development Assistance”: “ODA grants” and “ODA loans” and “Private Development Finance” from the Bill & Melinda Gates Foundation (BMGF). In addition, aid excludes “Equity Investment” and “Other Official Flows” , 31, 40.We extracted data on gross disbursements rather than commitments because we were looking for “the actual international transfer of financial resources, or goods or services valued at the cost to the donor” . To analWe considered that a decrease in health aid while an increase in humanitarian aid in a given year as a sign of health aid displacement.We also conducted semi-structured interviews by constituting a panel of humanitarian sector experts, humanitarian practitioners, and public sector officials; this was a crucial step, especially in this setting where quantitative data alone is often not an entirely accurate reflection of what is happening on the ground.We used purposive sampling followed by snowballing sampling approaches to identify the participants. The research team invited 31 humanitarian workers in senior positions from health NGOs and INGOs, local authorities, technical entities, and the Turkey Cross-border health cluster for Syria’s response to an Expert Panel in Turkey – Mersin in August 2021. Twenty-five out of 31 accepted and attended the panel, 88% of the participants were from a health and medical background with vast experience in humanitarian and health programs. The discussions were conducted in Arabic with 3 research assistants writing notes as the participants did not agree on recording the session.We also followed up findings from the Expert Panel with four key informants interviews (KIIs) with representatives of the four leading donors in September–October 2021 to understand the key stakeholders’ perspectives. The feedback from these key informants aligned strongly with the areas discussed in the Expert Panel. The KIIs were conducted in English and recorded. They were later transcribed and anonymized using a unique identifier for each participant. Following a thematic analysis approach, data from the Expert Panel and interviews were extracted and categorised into different themes.For qualitative data we used a thematic analysis approach, data from the Expert Panel and interviews were extracted and categorised into different themes. The qualitative approach was aimed at completing, interpreting, and understanding the quantitative data-related results, comprehensiveness of the aid databases, and scope of the humanitarian and health interventions (emergency and/or development).It can be seen from Fig. The volume of internal movements peaked in 2013 and in 2017. Finally, the number of people in need peaked in 2016 and 2017 with 13.5 million people in both years.The four indicators reflect the severity of the humanitarian crises which showed an increase in the years 2013, 2014, 2016, 2017, and 2019. However, it seems that the year 2017 was worse due to the length of the crisis and the large number of violent incidents that occurred in 2016. A total of 338 attacks on health facilities were recorded across Syria, 38 attacks on education facilities and a quarter of the Syrian population lived in besieged or hard-to-reach areas . Health When considering aid trends against the crisis timeline, we notice a significant rise in health aid in 2017, which corresponds to the four indicators: the number of IDPs in Syria (6.78 m), number of internal movements (2.91 m), people in need 13.5 m), and the total population (17 m)  indicates the latter to be about 50 times higher than health aid Fig. . We exclIt can be seen that health aid and humanitarian aid trends are, in fact, inversely correlated as health aid decreased by 7 $million, whereas humanitarian aid increased by 1.5 $billion between 2011 and 2013, and health aid increased when humanitarian aid decreased after 2016. However, the magnitude of financial flows is very different. The increase in humanitarian aid from 2011 to 2013 was far more significant in scale than the corresponding decrease in health aid, so this aid displacement is negligeable. Moreover, between 2013 and 2019, there was no health aid displacement at this aggregate level.The Expert Panel and KIIs all stated that although CRS database is a great resource, they questioned the reliability of data presented in this work given funds from Gulf countries at the beginning of the crisis were not recorded, as well as other sources of private funding such as individual donations, therefore CRS misses an important source of funding. This finding is in accordance with the literature which also states that a major limitation in CRS is the omission of data from countries which do not report their aid disbursements to the CRS which includes China, Qatar, and Saudi Arabia , 54.The participants also stressed the importance of excluding Turkey as a donor and that the amounts registered as humanitarian aid within Syria are, in fact, aid that was disbursed to Syrian refugees within Turkey, also emphasizing that there are not many precise details on how these amounts were spent.The following six charts show the health aid displacement at the level of the six largest donors in the health and humanitarian sectors in Syria between 2011 and 2019: the USA, Germany, the UK, EU, Norway, and Canada Fig. .Fig. 5AiThe United States did not spend on health during the study period. Instead, it focused on humanitarian aid, so there is no displacement of health aid for this donor. For Germany, there was an apparent decrease in spending on health with $2.3 million per year between 2015 and 2017 and spending reached zero in 2018 and 2019; this was accompanied by an increase in spending on humanitarian aid with $545 million per year between 2015 and 2017, which, theoretically, could be considered a displacement of health aid.The UK did not spend on health in the first six years, while its spending has increased steadily in the last three years; no evidence of health aid displacement from the UK.In the first six years, European Union spending on health was close to zero, then increased in the following three years. In 2017 and 2019 there was a shift in EU investment in favour of health aid, while, in 2018, spending on health decreased by $4 million, and there was an increase in spending on humanitarian funding by approximately $2.3 million in the same year; this could be considered health aid displacement.For Norway, in 2019, the decrease in health funding from $3.4 million to zero was accompanied by an increase in humanitarian funding by nearly $27 million, and this can be considered a health aid displacement.Finally, for Canada, there was an apparent decrease in health funding after 2016 from almost $1.6 million per year until it reached 0 in 2019, and this was accompanied by an increase in humanitarian funding by almost $37.5 million per year during the same period, which can be considered health aid displacement.A key takeaway is that although there is slight health aid displacement at the level of some donors in specific years especially after 2015 there is no consistent evidence of displacement over the study period. Also, by comparing the individual donors’ result with aggregate data in Fig. Figure The reason for humanitarian aid favouritism between 2011 and 2019 mentioned by participants in the Expert Panel and KIIs is the weakness of a governance structure in opposition-led areas such as north west Syria and north east Syria. This might discourage funding health programs as a development investment. So, donors prefer funding emergency health programs defined as humanitarian through UN agencies because it is less risky in terms of aid diversion and tends to be less politicised.Also, the participants in the Expert Panel and KIIs pointed out that the multiplicity of governments, the different areas of military control, and the governance complexity make donors more inclined towards humanitarian aid rather than health aid of a developmental nature. The dramatic change in military influence over the last decade was accompanied by significant changes at the level of governance and the management of humanitarian and health aid.In addition, the participants in the Expert Panel and KIIs mentioned the “blurred lines” between humanitarian and development health aid. Most of the participants confirmed that many humanitarian actors provide health services in a development sense, and that could be because many local NGOs are led and managed by individuals from a health and medical background. The definition of health programs in humanitarian emergency and development settings is confusing, and the boundaries between the two scopes are unclear. In the same course, the participants questioned the standardised methodology and definitions used to classify health programs implemented inside Syria by donors in CRS database, and whether the mix between humanitarian and developmental activities on the ground also affects the reporting and thus the reliability of the distinction between humanitarian and health aid in CRS database.To the best of our knowledge, this is the first study that provides an analysis of health and humanitarian aid trends and explores health aid displacement in a conflict-affected setting in the MENA region. It covers the Syrian crisis from its start in 2011 until the year 2019, the latest available information on the CRS database at the downloading data moment; we wanted to look at all the available conflict years to study the trends.We present a crisis timeline while considering different criteria -number of IDPs, total population, number of internal movements, and number of people in need. However, it seems that none of these indicators strongly influenced donor aid allocation in Syria. This is consistent with other literature which identifies alternative criteria that donor countries take in their decision- making process such as perceived risk of investment, colonial/post-colonial links, nationalist policies, domestic concerns, dynamics of a conflict , 56.Although we observed reductions in health aid disbursements alongside increases in humanitarian aid among donors such as the EU, Germany, Norway and Canada, the scale of the increased humanitarian funding in all cases except the EU far exceeded that of reductions in health aid. This suggests that while health aid displacement may have occurred, most of the increase in humanitarian aid was additional, increasing the overall health and humanitarian aid envelope. In comparison, we observed in the literature a different pattern in other conflict settings such as South Sudan, Sierra Leone, and Lebanon where humanitarian aid was added to the health aid and did not replace it –9.However, when comparing the ratio of humanitarian aid to health aid given to Syria to that of all other fragile states, there is a strong indication that donors prefer to fund humanitarian activities in Syria as the ratio is 2 to 98 in favor of humanitarian aid compared to 22 to 78 in the other fragile countries.Humanitarian aid can include funding to the health sector, and sometimes donors label health aid as humanitarian aid in humanitarian crisis settings. According to OCHA, in 2019, 8,6% of Syria’s humanitarian aid was health-related . This paOne would also argue that given the protracted nature of the Syrian conflict, humanitarian aid would somehow cross with development health aid given that most humanitarian agencies, donors and INGOs try to adopt the humanitarian-development-peace nexus  which caPreference for humanitarian aid was confirmed by the participants in the Expert Panel and KIIs due to the governance challenges and donors’ desire to avoid dealing with the Syrian Regime largely due to its involvement in war crimes and crimes against humanity. This is consistent with the literature on health governance in opposition-held areas that shows that although there is a form of quasi-governance in both NWS and NES, donors are hesitant to support health directorates as they believe they lack capacity. Donors also prefer to work through NGOs partially due to concerns about treating opposition-controlled health authorities as political substitutes for the Syrian regime , 65. AlsThe reason why the United States did not invest in health aid of a developmental nature is mostly its stance against the violations of the Syrian regime since the protests began. First, the US government imposed economic sanctions on officials in the Syrian regime less than a month after the protests began , then, fDespite its limited amounts, health aid by most donors seems to be decreasing annually, except for UK and EU donors, at a faster pace than that of humanitarian aid. However, this is not the case with the overall trends where health aid is slightly increasing annually, contrary to humanitarian aid which is decreasing.This slight increase in “interest” in health aid by UK and EU may be primarily due to a major change in the political climate in Syria: the international community has partially resigned to the fact that the Assad regime is going to stay in power, so a political transition is unlikely. A few of the European embassies and Arab countries have reopened in Damascus with Assad’s diplomatic visits on the rise , 75.Western countries are gradually easing restrictions on supporting and dealing with Syrian state institutions, so it is expected that development aid will increase in the coming years. Based on the Expert Panel and KIIs, this shift in the political environment would pose critical ethical challenges for the donors and the international community: How can donors support developmental health aid in light of a complex governmental reality in Syria? This is astounding given that the Syrian government has almost completely controlled state institutions for more than five decades.The health cluster mechanism in Syria, operating under the WoS approach, primarily focused on providing life-saving services during the first decade of the Syrian crisis . As a reEstimates in this study may be incomplete as some donors, such as China, Qatar, and Saudi Arabia, also, other sources of private funding, do not report their aid disbursements to the CRS , 78, 79.The population indicator may not be an ideal indicator of the crisis timeline, but it has been used due to the lack of regular updates on the number of refugees, deaths, and new births.Although the number of IDPs and internal movements are suitable indicators for expressing the fundamental crises, they cannot represent the entirety of all the crises in the Syrian context, as many areas have witnessed significant humanitarian crises due to the military siege. For example, a high-level UN investigation reported in 2018 that the more than five-year siege of Eastern Ghouta in a war-torn country is “barbaric and medieval” . HoweverWe highlighted above several challenges of aid that are faced in Syria, a highly complex conflict setting with multiple local, regional, and international players along with state and non-state actors and combatants. A few recommendations can be made which would help in improving aid at different levels: the OECD should do more to ensure having more inclusive databases that go beyond the current donors reported to CRS, such as including China and other so-called “emerging” donors that do not share comprehensive information about their aid funds. And there should be a clear distinction between humanitarian and health aid categories at the levels of the UN, OECD, donors, and recipient governments. Also, the OECD Secretariat should ensure quality and comparability by regularly reviewing donor input.UN-OCHA should encourage donors to invest more in the health sector in Syria. It can prepare an annual response/development plan independent of the humanitarian response plan with more involvement for the local governance bodies in different areas.In the humanitarian phase of the conflict in Syria, there was understandably limited engagement from humanitarian donors and organisations with local governments, considering the involvement of these governments in conflict atrocities. However, as we transition into the early recovery phase it becomes crucial to employ the humanitarian-development-peace nexus. This approach encourages simultaneous and synergistic efforts on humanitarian aid, sustainable development, and peacebuilding. The nexus becomes especially significant with the increased need to implement the localization agenda for sustainable humanitarian interventions and to pave the way for development, demanding more engagement with local actors.It is essential to recognise that Syria now has new “de-facto borders” with different areas of control, a reality that has already been established by the 12 years of conflict. Therefore, a single approach to early recovery for the whole country is neither feasible nor best practice. The UN agencies and donors should prioritise efforts in enhancing health governance and development activities within each of the three main areas of control, including NWS and NES, to bridge the gap between the humanitarian and development phases.To initiate development activities, it is important to assess the capability of each area and foster positive competition among them. At the central levels  donors should exert diplomatic pressure and engage in technical negotiations with the various central and local governments. This engagement facilitates meaningful involvement at the community and district levels, while harmonizing activities at the national level.The lack of political engagement with governments involved in the conflict has provided them with opportunities to exploit humanitarian responses, evade public accountability, divert funds towards perpetuating violence and conflict, and exert control over aid distribution. The case of South Sudan serves as an example of these challenges .Addressing these issues necessitates providing robust support to technical health bodies that play quasi-governmental or governmental roles at local and community levels based on human rights principles becomes imperative. This support can contribute to the formulation of comprehensive national needs strategies and plans, ultimately enhancing the effectiveness of health aid in Syria during the early recovery phase.In this study, we realized that in contexts as complicated as that of Syria, there was insufficient evidence of health displacement across donors. Yet there seems to be evidence of slight displacement for individual donors.There is a strong indication that donors prefer to fund humanitarian activities, including health, in favor of humanitarian aid in Syria compared to other fragile countries. Especially that humanitarian aid was 50 folds more than development health aid, as humanitarian projects are easier to implement with sanctions and highly dynamic borders. UN agencies and INGOs should work more on providing more inclusive and better-defined aid reporting systems to ensure that all the received aid to a given country is recorded and that there is a clear distinction between humanitarian and development aid. This will provide more reliable evidence for policymakers to advocate for more development projects, especially in protracted conflicts such as Syria, where humanitarian projects cannot meet local needs.The humanitarian-development-peace nexus should also be implemented to bridge the gap between the humanitarian and development phases. This can be achieved through leading technical negotiations by UN agencies and donors with the various central and local governments to facilitate meaningful engagement at the community and district levels. This approach helps to reduce the politicization of aid, empowers local communities, and enhances their ownership of development plans until a political solution matures in Syria.The data used for quantitative analysis herein are based on donor reporting and donors' inputs without results and achievement-based reflection. And therefore, future work should focus on aid effectiveness in reference to the five goals of the 2005 Paris Declaration: Alignment, Harmony, Ownership, Results and Mutual Accountability.