The dawn of the digital age, aptly characterized by “computers everywhere”  machine learning. While this editorial focuses on the big picture, highlighting some key aspects in both areas without purporting to represent a comprehensive review, the research papers published in this Research Topic provide detailed insights into the unfolded content area. We organize the remaining part of the editorial according to the three perspectives typically addressed in the discussion of the impact of digitalization on social science research: the epistemological perspective (Section 2), the data perspective (Section 3), and the data analytical perspective (Section 4).Against this backdrop, the Research Topic covers two core elements of CSS, (i) There are multiple competing epistemological concepts in the discussions about CSS . While trying to trace the complex networks and data flows that shape modern societies and economies in much greater detail and to establish causal inferences beyond traditional methods, they tend to be less preoccupied with the data generating process, including aspects of research design or protocol  and Seewann et al. (in this volume) examined how new methods and techniques could support social scientific work but also expressed their concerns about ethics and limits attached to such methods.Nevertheless, scholars pursuing these ideas certainly see much benefit in the increased amount of available data, the rich granularity, and new types of measures. Likewise, they are eager to integrate new data sources and methods into their theoretical work, but they will interpret their results more carefully and reflected and deal critically with the limitations of their data. Developing and expanding a social scientific perspective , social network and interaction data, data from webpages , online consumer behavior data, geocoding  and time references, physical condition and mobility data, internet search engines results, to information extracted from images and videos. Accordingly, DBD fall under the minimal definition of “big data,” typically characterized by the three Vs: (i) huge in volume, (ii) high in velocity, and (iii) diverse in variety . Their diversity ranges from social media text and respective metadata  for scientific purposes marks the beginning of a big data era . For a comprehensive overview of the various ML algorithms, see the textbooks of Bishop (Machine learning (ML) lacks a precise definition, being “as much a culture defined by a distinct set of values and tools as it is a set of algorithms”  in input data X without labeled output data Y. However, this binary classification of ML approaches is neither disjoint nor exhaustive . It is also worth noting that many algorithms subsumed under the ML paradigm already have a long social science research tradition but are not explicitly designated as an ML application. Prominent examples are linear modeling, hierarchical agglomerative and k-means clustering, k-nearest neighbor algorithms, principal component analysis, and neural network analysis.The field is broadly classified into two domains: supervised and unsupervised learning. Although both share the automated extraction of information from data, they differ in their learning objectives. Supervised ML utilizes labeled output data X. In contrast, the traditional stochastic statistical modeling approach, referred to as “generative modeling”  For explanatory purposes, ML modeling strategies require conceptual and technical optimization to generate valid interpretable results that illuminate the generative social mechanisms based on massive amounts of DBD  theory. The positions range from “the end of theory” and “correlation supersedes causation” proclamations  The data deluge and the availability of data-driven ML algorithms for analytical processing evoked a (iii) ML algorithms optimized for prediction offer an opportunity to extend the key epistemological goals in sociology. While the prediction task has so far only played a minor role alongside the explanation task , advocating a conceptual differentiation between algorithmic fairness and distributive justice.(iv) Assessing the quality of (out-of-sample) predictions requires respective performance metrics. Alongside the traditional technical measures . Building on Lazer et al.  and LeitUniversities need to adopt their institutional structures and facilities to meet the demands. This includes an organizational restructuring to facilitate interdisciplinary collaboration and the financing of the computational infrastructure mandatory for the storing, linking, and high-speed processing of massive amounts of data under the highest security standards.(i) Social science education needs to be reformed. In particular, the traditional training in methods and methodology, focusing on survey data and classical frequentist statistics must be supplemented by CSS elements based on mathematics, computational statistics, informatics, and data science to maximize the students'  data literacy. Besides training in gathering, processing, analyzing, and visualizing big digital data with software packages such as R or Python, this also includes conducting simulation studies  Big centralized data infrastructure needs to be established. This infrastructure is intended to serve the systematic comprehensive collection, processing, and secure storage of any social science data in accordance with legal data protection standards. The main objective is to provide this data to the scientific community for secondary data analysis. In addition to the financial resources, technical innovations, and know-how, this requires a new culture of willing data and code sharing from the stakeholders such as researchers, universities, public authorities, and social media companies  Detailed data protection regulations and ethical guidelines are necessary to establish handling security for researchers. The progressive digital technologies enable researchers to explore, in principle, entirely new methodological pathways in studying social phenomena and generating empirical evidence for decision-making. However, relevant legal and ethical questions still need to be resolved to legitimize the use of these methodological innovations, especially because many data are sensitive or difficult to anonymize  The application of AI innovations in teaching and throughout the research process needs to be regulated. Current developments, particularly the distribution of the chatbot software ChatGPT (Generative Pre-trained Transformer),(v) The above aspects outline the key efforts required to provide the CSS agenda with a solid foundation for long-term success. The Research Topic aims to serve as a platform for different contributions to the core elements of CSS: big data and machine learning. Ideally, the Research Topic and its articles encourage further research and contribute to the progress that the digital revolution has brought to social science research methodology.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


The article by Cabral et al. ,,,Alcohol consumption during pregnancy is associated with many gestational outcomes,including stillbirth, miscarriage, preterm delivery, intrauterine growth retardation andlow birth weight ,To mitigate the problem, for more than a decade, guidelines from internationalorganizations/institutions have recommended that women who are pregnant or planning tobecome pregnant abstain from any alcohol consumption during this period Despite this, the prevalence of this consumption during pregnancy remains high worldwide.However, Brazil has a gap on this topic, with few studies and most of them conducted inspecific populations. The article by Cabral et al. Thus, understanding the role of early alcohol consumption in this scenario will allow thedevelopment of public policies aimed at greater surveillance of alcohol consumption inthis age group and the screening of groups at higher risk for alcohol consumption duringpregnancy. To what extent does the high prevalence of alcohol consumption among women inadolescence and early adulthood affect its persistence during pregnancy?To answer this question, we need to take a step back and consider trends in alcoholconsumption among adolescents and young adults in recent decades.,,Studies have shown that, despite a downward trend in the prevalence of alcoholconsumption among women , binge drinking has grownamong young women of reproductive age worldwide Global Status Report on Alcohol and Health,Data from two editions of the In Brazil, population studies have pointed to high alcohol consumption among women, withan increase also among adolescents.Brazilian National Survey of Alcohol andDrugs showed an increase among both men and women in consumption per week and in the proportion of excessive alcohol consumption , although thisdid not occur in all genders and age groups.The study by Caetano et al. Study of Cardiovascular Risk Factors in Adolescents (ERICA), aBrazilian school-based study that evaluated 74,589 adolescents, observed a similarprevalence of alcohol consumption in the last 30 days for boys (21%) and girls (21.5%),with higher among adolescents aged 15 to 17 years (29.3%) The BrazilianNational Survey of School Health (PeNSE) observed that girls were morelikely to try alcohol  and to have consumed it in the last30 days  compared with boys. PeNSE 2015 also showed thatregular alcohol consumption, despite its very high prevalence, especially among girls,decreased from 27.3% (2009) to 23.2% (2015) A study based on data from 100,914 ninth-grade students from the 2015 In a recent study conducted in the 2004 Pelotas (Brazil) birth cohort, the prevalence ofalcohol and cigarette experimentation increased at age 15 among girls ,,,Studies conducted in different regions of the world show that high alcohol consumptionbefore pregnancy is one of the most important risk factors for persistent consumptionduring pregnancy ,Other important studies sought to assess risk behaviors among adolescents and youngpeople, the concomitance of these behaviors, the most vulnerable groups, and the effectof such behaviors on adulthood, including the persistence of heavy alcohol consumptionGlobal Status Report on Alcohol and Health,,,Brazilian National HealthSurvey (PNS) showed that heavy alcohol consumption among women aged 18 to24 who were single/not cohabiting was associated with inconsistent condom use According to the 2018 Studies also pointed that early age of onset of alcohol consumption is associated withincreased early initiation of sexual intercourse and early pregnancy Therefore, knowing the scale of the problem and better understanding the groups most atrisk will allow the establishment of public policies aimed at surveillance duringprenatal care and developing screening strategies to increase access to health servicesfor pregnant women.Promoting studies that seek to understand the factors involved in alcohol consumption byadolescents and young people - especially early age and heavy drinking among girls -should be the initial step for the implementation of public policies aimed at preventingthis consumption and counseling on alcohol consumption by women of reproductive age.This consumption, as aforementioned, affects not only the health of adolescents andyoung people in the short term, but when it coexists with conditions of socioeconomicvulnerability, it often persists, increasing the risk of alcohol consumption duringpregnancy. Thus, studies aimed at assessing the prevalence of alcohol during pregnancyand seeking to identify the most vulnerable groups, such as the study by Cabral et al.


Photonic nano/microstructures  with tunable properties provide new possibilities for the manipulation of light–matter interactions at the nanoscale, enabling many emerging technologies for novel applications, such as advanced imaging, large-bandwidth and high-speed communications, flexible and high-contrast displays, high-capacity data storage, optical computing, and biomedical technologies. Tunable nanophotonics and reconfigurable metadevices are becoming hotspots in optics as the precise control of optical properties becomes more possible and future applications are discovered. The implantation of various tunable materials or reconfigurable structures is a straightforward method for the realization of tunable nanophotonics. Recently, an increasing number of studies have paid attention to active tuning and driving methods in metamaterials/metasurfaces to increase their flexibility and applicability in nanophotonics. This Special Issue aims to collate contributions in the fields of tunable nanophotonics and reconfigurable metadevices.This Special Issue, entitled “Tunable Nanophotonics and Reconfigurable Metadevices”, includes some remarkable studies: four research articles and one review article. The issue covers a wide range of topics: tunable localized surface plasmon resonance (LSPR) in Ag nanobars , electriOverall, this Special Issue provides an interesting flavor of the diversity of tunable nanophotonics and metadevices incorporated with tunable or reconfigurable mechanisms. These new results demonstrate the most recent advances in tunable metamaterials and their potential usefulness in various aspects, both experimentally and theoretically. We expect that more and more tunable and reconfigurable metasurfaces/optical nanostructures with smart properties will emerge in the future for functional metadevices.


Rickettsia in humans and dogs and typhus group Rickettsia in dogs in Reynosa, Mexico. Our investigation revealed serologic samples reactive to spotted fever group Rickettsia in 5 community members, which highlights a potential rickettsial transmission scenario in this region.We found serologic evidence of spotted fever group  Rickettsia rickettsii, the bacterium responsible for Rocky Mountain spotted fever (RMSF), a major pathogen of public health concern linked to severe hemorrhagic illness in humans. SFG rickettsiae are maintained through a tick–vertebrate host cycle; humans are incidental hosts  and opossums (Didelphis spp.), and by ectoparasites such as the rat flea (Xenopsylla cheopis) and cat flea  (Rickettsia contained in the feces of either fleas (R. typhi) or human body lice (R. prowazekii) or simply by inhalation of contaminated dust (R. prowazekii in the United States has been associated with ectoparasites of flying squirrels (Glaucomys volans) (The spotted fever group (SFG) rickettsiae, which are transmitted primarily by tick bite to rodents, dogs, wild animals, and persons, comprise a phylogenetically discrete clade of the family Rickettsiacae, encompassing ≈30 species. SFG rickettsioses represent a major cause of febrile illness worldwide. This group includes During 2013–2022, a total of 2,232 RMSF cases were reported in 5 of 6 northern states of Mexico contiguous to the United States  were positive for TG Rickettsia IgG antibodies  were positive for SFG tibodies  Table 1.tibodies  Table 2 nditions  Table 1.Rickettsia in Reynosa, Mexico, in 2022. Seroevidence of domestic dog exposure to R. typhi in Reynosa warrants further investigation, especially given the endemicity of murine typhus in the contiguous Hidalgo County, Texas, USA, that involved >1,000 human cases reported during 2008–2019. Our results validate the theory that dogs can be sentinels for human diseases and demonstrated their assistance in inferring the temporal and spatial dynamics of some diseases in regions associated with their vectors  are warranted. This transborder transmission scenario appears to repeat along Mexico towns contiguous to the US border, where brown dog tick  infestations are known to be rampant. Most dogs roam freely in relatively squalid conditions throughout our studied areas. In this context, evidence of TG Our findings suggest that the epidemiologic fabric of the region is strongly affected by the high incidence of SFG and TG rickettsioses. We hypothesize that improvement of the urban environment, using a One Health approach, along with integrated vector control management of ectoparasites  would be of utmost importance in reducing the spread of rickettsial diseases in regions such as our study area. Evidence of TG rickettsia exposure of domestic dogs in this study highlights the need for further surveillance to determine the vector phenology and transmission cycle in the region. In conclusion, SFG and TG rickettsiae surveillance and control, by both standard and novel approaches, are urgently needed for areas along the northeastern Mexico–United States border.More information for study of spotted fever and typhus group rickettsiae in dogs and humans, Mexico, 2022.


Background: Approximately 40 million people in need of palliative care worldwide, while 80% of them live in low- and middle-income countries. Kazakhstan, a low-to middle-income country with a reforming healthcare system, is committed to improving quality and accessibility of care for its 100,000 terminal patients in need of palliative care.Policy Options and Recommendations: To join the group of countries where palliative care is available, accessible, and affordable, Kazakhstan must integrate palliative services into the mainstream healthcare system at all levels, from primary healthcare to hospices, and from major cities to remote villages. Based on the evidence thoroughly collected directly from the Ministry of Health, authors propose a feasible set of recommendations regarding palliative policy, pain relief, infrastructure, workforce, and education, which could be implemented in LMICs beyond Kazakhstan.Conclusion: This study presents an analysis of challenges, recent developments, and needs of palliative care in Kazakhstan, including funding, policy, workforce, education, and infrastructure, providing an evidence base and recommendations for future development of palliative care in Kazakhstan and in other LMICs. According to WHO, of the 40 million people who require palliative care worldwide, only 12% receive it, most of whom live in high-income countries [er km2 . In 2021er km2 . This pler km2 . The diser km2 . Despiteer km2 , 8. As ter km2 . The purer km2 , 10.Target 3.8 of the Sustainable Development Goals adopted by the United Nations in 2015 indicates the necessity to achieve universal health coverage (UHC), including access to essential healthcare services and medicines, and financial risk protection for all by the year 2030 . AccordiIn 2020, the Kazakh government introduced a new National Palliative Care Standard, which now assists the integration of palliative care into the primary healthcare system, ensuring continuity of care. According to the Standard, multidisciplinary palliative teams should be created in all major medical centers, general hospitals, and specialized clinics of the republican level. As part of the National Cancer Control Plan, terminal cancer patients across the country have access to mobile teams that provide in-home palliative care . MoreoveCurrently, in-patient palliative care in Kazakhstan is provided mainly in stand-alone hospices and palliative care units of specialized cancer centers or general hospitals see . There aCurrently there are 101 nurses and 45 physicians providing in-patient palliative care in hospices across Kazakhstan. The ratio of palliative physicians to palliative patients is 1:2,000, while the WHO recommends a ratio of 1 physician per 1,000 people in the general population . In totaHealthcare in Kazakhstan is funded by the Mandatory Social Health Insurance and by the government guaranteed Statutory Free Medical Assistance. The total palliative care budget amounted to approximately $6 million in 2020, $10 million in 2021, $15 million in 2022, and is projected to reach $22 million in 2023. Despite the substantial increase in the annual funding, it is important to ensure that the allocated budget is used efficiently and effectively to meet patients’ needs. Funding for palliative care is based on bed-day reimbursement, i.e., the length of stay of each patient, without considering actual costs of inpatient care. The need and access to opioids is a tracer of overall availability of palliative care and pain relief . Pain reCurrently, there is no recognized specialty in “palliative care” for physicians and nurses in Kazakhstan. The only existing advanced training course , termed “hospice and palliative care,” is available solely for physicians, although nurses represent the main workforce in palliative care. In 2020, elective palliative care courses were introduced into educational programs for physicians, nurses, and paramedics for both undergraduate and postgraduate studies. However, the content, scope, and structure of such courses are non-standardized and often they are inconsistent with international requirements. While high-quality education requires trained faculty, there are no palliative care specialists who can provide such training.• Establish continuous and transparent mechanisms of quantitative monitoring of quality of palliative care services and its outcomes.• Establish registry of patients in need of palliative care, which is necessary for effective healthcare systems .• Reorganize the distribution of palliative beds across regions in favor of established hospices and palliative care units.• Remove system barriers to availability of opioids and close the gap between needs and actual consumption of opioids by expanding the list of available pain medication beyond injectable morphine and fentanyl patches.• Establish regular courses for physicians on pain and symptom management and safe use of opioids.• Provide educational opportunities for all healthcare providers and establishing palliative care specialization for nurses. The training required for healthcare providers to implement palliative care at each level of healthcare has been recommended by WHO and described in the literature .• Establish mobile palliative care teams to improve access to palliative care in remote areas, where half of the population lives without access to palliative care .• Examine perspectives and challenges of key stakeholders in palliative care  to identify and address gaps.• Encourage awareness-building campaigns and public education regarding palliative care and pain relief, which is key to expanding access .• Establish mobile teams for home-based care for patients whose palliative care needs could be met in their place of residence even after discharge. Should these patients require specialized inpatient care, they can be referred to a local hospice or palliative care unit.• Prioritize oral forms of morphine over injections. Immediate-release oral morphine represents an effective, essential, and inexpensive intervention which is unjustifiably denied to most patients in need in LMICs.• Integrate family caregivers into palliative care as they represent a major workforce and are crucially needed in LMICs settings. Empowering and utilizing them could improve the quality of care and reduce the burden on the resource-limited system.• Participate in international agenda and collaborate with international stakeholders, such as the World Hospice Palliative Care Alliance and the International Palliative Care Association, which frequently offer programs and grants designed for LMICs facing similar challenges.• Establish a cohort of palliative care specialists with advanced knowledge and skills to deliver high-quality palliative care services and provide training to others .• Develop free online and onsite educational resources on palliative care for family caregivers can be an additional effective measure to improve the quality of life of patients and their families in resource-limited settings, whereas a wide range of medical staff should also have access to basic palliative training to make palliative literacy ubiquitous in all settings .Recent developments have undoubtedly improved the image of Kazakhstan’s healthcare, however, to join the group of countries where palliative care is available, accessible, and affordable, Kazakhstan must integrate palliative services into the mainstream healthcare system at all levels throughout the country, from primary healthcare to hospices, and from major cities to remote villages . Based oWhile goals of extending life are well-prioritized and well-funded, they need to be followed by goals to reduce suffering by offering adequate pain relief and symptom management at the end-of-life. Therefore, developing high-quality palliative care services must be prioritized by the Ministry of Health to ensure higher quality-of-life and end-of-life care among people with terminal diseases.In conclusion, the development of palliative care, in addition to the “ethical imperative” of eliminating the suffering of people with life-threatening illnesses, has several benefits for the state: it saves healthcare budgets by freeing up hospital beds, it reduces the number of hospitalizations and medical interventions, it reduces social tension and frees economically active family members, and improves society as a whole . Being a


The current Special Issue entitled “Sustainable Cementitious Materials for Civil and Transportation Engineering” aims to discuss current research on the preparation, characterization, and application of sustainable cementitious materials for civil and transportation engineering, with a special focus on the development of low-carbon construction materials.2 emissions. To address issues pertaining to sustainability and reduce the carbon footprint, it has become a new trend to research and develop novel sustainable cementitious materials, especially materials with low carbon emissions. In this context, on the one hand, construction and demolition waste (CDW) obtained from civil and transportation engineering, recycled concrete aggregates (RCAs) and recycled asphalt pavements (RAPs), for instance, could be treated and reused in the manufacturing of cementitious materials without compromising their properties, which would promote the sustainability of raw materials. Concrete is the most widely used material for construction and building globally. The traditional cement and concrete industry is a main consumer of natural resources and contributes approximately 5~8% to total COThe recycling of CDW ,2 is a cAfter further processing, the construction waste could be converted into recycled aggregates, recycled sand and recycled powder. In the recycling process, it is necessary to control the particle size distribution, particle shape, impurity content and other indicators of recycled aggregates, recycled sand and recycled powder to ensure that their quality and performance meet the requirements of concrete manufacturing.3), calcium aluminate cement, and calcium sulfoaluminate cement) and alkali (acid)-activated binders  [3 of comparable strength, but it can reduce CO2 emissions 20–40%, costs by 15–25%, and thermal energy requirements by 20%. Moreover, geopolymer is an alkali-activated binder with excellent properties and is a promising alternative to Portland cement. During the preparation of geopolymer concrete, solid waste and an alkali activator that is derived from the waste are frequently used, and therefore the carbon footprint can be further reduced. Successful applications of these sustainable cementitious materials in civil and transportation engineering are also significant.Portland cement is a main source of carbon emissions; on the other hand, Portland cement could be partially or completely replaced with recycled cement ,4, induspolymer) ,6. For eThe research interests of this Special Issue include, but are not limited to, the following: low-carbon cementitious binders; carbonation-enhanced concrete; low-carbon cement and concrete technology based on non-Portland cement systems, such as alkali-activated materials or geopolymeric materials; recycled aggregate concrete; green admixtures for cement and concrete; the durability of low-carbon concrete; case studies on applications of sustainable cementitious materials in specific regions for civil and transportation engineering.


Migration and health are increasingly recognised as a global public health priority, but concerns have been raised on the skewed nature of current research and the potential disconnect between health needs and policy and governance responses. The Migration Health South Asia (MiHSA) network led the first systematic research priority-setting exercise for India, aligned with the global call to develop a clearly defined migration health research agenda that will inform research investments and guide migrant-responsive policies by the year 2030.We adapted the Child Health and Nutrition Research Initiative (CHNRI) method for this priority setting exercise for migration health. Guided by advisory groups established at international and country levels, we sought research topics from 51 experts from diverse disciplines and sectors across India. We consolidated 223 responses into 59 research topics across five themes and scored them against five predefined criteria: answerability, effectiveness, feasibility, impact, and effect on equity. We then calculated research priority scores (RPS) and average expert agreement (AEA) each research topic and theme.A third of the 59 research topics were on migrants’ health and health care access, 12 on social determinants of migrants’ health, 10 on policies, law and migration health governance, eight on health systems’ responsiveness, and five on migration health discourse. Three of the top five priority topics pertained to migrants’ health care access. The policies, law, and governance theme had the highest overall RPS score.There is a noticeable gap between research priorities identified by experts at the country-level and the current research focus and priorities set globally. This disconnect between the global and local perspectives in migration health scholarship hinders the development of context-specific and suitable policy agendas for improving migrants' health. Our co-developed agenda emphasises the need to prioritise research on the capacity of existing systems and policies so as to make them more migration-aware and responsive to migrants’ health needs. Migration and health has emerged as an important global research and policy priority in recent years and is now framed as pivotal to achieving the Sustainable Development Goals (SDGs) 8.8 and 10. Researchers and sectoral experts have called for the inclusion of migrants in global health policies, especially in relation to Universal Health Coverage (UHC) and the broader health and development agenda ,3, the WThe policy appeals have highlighted the need for a more robust and relevant evidence base and the development of related research capacities ,9. TheseIn South Asia, migrants are a highly transient and heterogenous population group, with complex mobility patterns and unique precarious contexts arising from structural inequalities and shared colonial history. These contexts affect migration pathways and health care access and health outcomes in multiple ways ,12, yet Critical gaps in data and health information systems hinder the development and implementation of migration-aware policies and limit any opportunities to drive evidence-informed policymaking. The COVID-19 pandemic highlighted this disconnect, where universal precautionary and relief measures adopted by national governments failed to account for the health and social care needs of mobile populations in resource-poor contexts. Recognising this disconnect in global discourse from regional/local migration specificities and mobility trends, experts have called for the development of and investment into a clearly defined migration and health research agenda to inform migrant-aware policies ,19-22.Acknowledgment of these gaps establish the imperative for a local research priority-setting to address the critical policy vacuum at regional and national levels. Against this backdrop, the Migration Health South Asia (MiHSA) network initiated a process to develop regional migration health research agenda through country specific processes, starting with India. It was established in 2019 with the core mandate and vision of building communities of knowledge and practice and capacitating them to address evidence and policy deficits in migration and health at the regional level. Besides building capacities of early and mid-career scholars through workshops, summer schools, and seminars, MiHSA is spearheading initiatives to bring forth evidence on complex patterns of migration in South Asia and its intersection with health, while recognising migrants’ precarity and agency. These include systematic evidence mapping, policy responsiveness assessment and research priority-setting.We used the Child Health and Nutrition Research Initiative’s (CHNRI) research priority-setting method, a leading systematic and democratic approach in setting health research priorities ,24, to cAdopting this method provides an opportunity to identify critical, yet neglected areas in migration and health scholarship in India, to embed migrant health more firmly in the national agenda, and strategically align the research agenda with the core preamble of Agenda 2030, of “leaving no one behind”. Here we describe the research priorities in migration and health in India solicited through the CHNRI method to address the regional evidence gap and accelerate translation of this evidence into migrant-aware policies and practices for India by 2030.We adapted this research prioritisation exercise from the CHNRI method as per Rudan et al. ,26, usinWe set up two advisory groups at the outset to guide the CHNRI adaptation process and assist delivery of the exercise; a five-member International Advisory Group made up of senior experts in migration and health, identified through MiHSA’s existing networks and collaborations, and a six-member National Steering Group composed of leading academic and policy experts in the field of migration health in India  from various institutions in India, academia, civil society representatives working in migration, labor and health spaces, and the government. We used a mix of systematic database searches and snowball methods to identify experts, involving a search of Google Scholar and PubMed using keywords  . Two res− Migrants’ health and healthcare access− Health systems’ responsiveness to migrants’ health needs− Social determinants of migrants’ health (SDMH)− Policies, laws & governance of migration health− Migration health discourse in research and policyWe invited experts who provided research topics to independently score the 59 consolidated research topics against the set of five pre-agreed criteria  by dividing the sum of the scores  by the number of scorers (excluding those who left their answers blank). We also calculated an overall research priority score (RPS) calculated as the average of the five intermediate scores, converted into percentages (i.e. a range of 0-100), which we then used to rank the research topics.We calculated an average expert agreement (AEA) score as a measure of cohesiveness or dispersion in the scorers’ opinion around the most common score (mode):T is the research topic that experts are being asked to evaluate competing research topics. For each evaluated research topic, AEA is informing us what proportion of scorers gave the same most frequent answer for an average . The participants had wide-ranging geographic and disciplinary expertise, representing at least 15 disciplines, mainly community and public health and preventive medicine, developmental studies, epidemiology, demography, social work, and anthropology/medical anthropology.Of the 34 experts who scored the consolidated research topics in Stage 2 of the exercise, 26 were researchers and eight were representatives of civil society organisations working in the migration, labor, and health space, and the government. As in Stage 1, most of the participants’ had a background in community and public health and preventive medicine, followed by developmental studies, demography, social work, and anthropology/medical anthropology.As elaborated earlier, we assigned the research topics to one of the five research themes. One-third of the topics  related to migrants’ health and health care access, followed by SDMH , policieRPSs for the 59 research topics ranged from 0.945 (highest) to 0.35 (lowest), with a median score of 0.783. Four of the top ten research topics that received the highest overall scores  ranging between 0.729 and 0.915, indicating overall general agreement of experts with the suggested research topics , migrant workers in Gulf , refugees or displaced communities , seasonal migrants (#34), urban migrants , migrants living in slums (#57), and others. These appeared to reflect a focus on groups that may be experiencing heightened precarity attributed to their minority and social status, unfavorable policy/ political environment, poor development infrastructure, and transience. Two of the topics focussed on families of migrants instead of migrants themselves (#32 and #56). Three research topics focussed on adolescents and children, while two outlined different age groups  and 54 did not specify any specific age group.Gender emerged as a cross-cutting priority across all the themes. Twelve topics drew attention to study of the gendered implication of migration, in alignment with SDG 5.1 and 5.6. In terms of health focus, mental health also emerged as a high priority amidst the experts within 10 research topics. Three research topics addressed both gender and mental health . Four research topics dealt with infectious diseases (not including COVID-19) , with two falling in the health systems’ responsiveness theme and two in migrants’ health theme, highlighting the need to study prevalence and pathways of risks/exposure to infection  in migrants, rate of infection, and barriers to surveillance for achieving continuum of care. Despite the prevalent discussions of migrants and climate crisis, only one research topic identified mapping of climate-related migration in India and impact on migrants’ health (#39), under SDMH. Three topics pertained to COVID-19 pandemic , with interest in health systems’ and governments’ responsiveness to migrant crisis and studying mental health challenges in migrants during COVID-19. Only one study specifically focussed on pandemic preparedness (#8), focusing on governments’ strategies to respond to internal migrants during COVID-19, but not highlighting preparedness for future pandemics per se. Eleven of the research topics were addressing UHC, i.e. of ensuring the physical and mental well-being of migrants as their right to health, availability, affordability, and utilisation of health services, the responsiveness of health systems, access and utilisation by migrant populations, health insurance, and others. Seventeen research topics focus on promoting healthier populations, i.e. studying how different determinants affect migrants’ health and their inclusion/exclusion from services and policies (SDMH), and how optimal evidence-informed policy design and implementation can correct this course , migration health research agenda, and research translation and policy implications of findings.While CHNRI has been previously used for national-level research priority-setting exercises in India -31, thesThe method helped develop a research priority database that reflects collective optimism on topics of researchers from academic institution, civil societies, and other stakeholders, a failure of current mainstream scholarship and agenda setting . This coThe research prioritisation exercise involved experts representing several disciplines and regions in India, especially the states with the highest recorded migration rates. However, we observed a clustering of research and policy institutions working on migrants’ issues in big cities in the country’s southern and western regions. Even though snowballing enabled accessing researchers from states not represented in the first round, and we noted that the participants’ research expertise had a wider geographic scope than the city they were located in, leading to the northern-most and northeastern states being under-represented in this exercise. This suggests the need for appropriate research structures at sub-national levels and targeting initiatives to build research capacity in neglected regions. Incentivising participation from under-represented states can help correct the representational balance in migration health research.Similar to other democratic prioritisation methods, a limitation of CHNRI is its time-consuming nature. Although a systematic crowd-sourced process, ranking 59 topics against five criteria is a time-consuming process and may have impacted the experts’ interest or intent of continuing with the exercise, because of which only 34 out of 51 experts who submitted topics ranked the final topics. Recognising this drawback, we have modified the process to create a digitised form of a Microsoft Excel sheet  with a drop-down menu for easier ranking for roll out of CHNRI in other countries in the South Asia region.The exercise raises important questions on the value placed on research topics that are more complex, difficult to answer in the political climate, and consequently less feasible. The top ten research topics indeed sought to answer fundamental questions around availability, accessibility, and utilisation of health services by different migrant populations, factors enabling or hindering their access, and their inclusion in government policies or COVID-19 response schemes. However, questions related to migrants’ participation in social and political processes, macro-environment and processes such as labor regulations and supply chains, funding landscape, or aspects of migration health governance received lower scores. Lower prioritisation of topics that are critical to advancing migration health governance can be attributed to the challenges of doing research in the precarious and transient contexts that migrants inhabit and the impenetrability of the related policy and governance landscape.The research priorities identified by regional experts emphasise areas that are often missed in global initiatives for setting research agendas and priorities. For example, the Lancet Migration European Regional Hub’s migration health research priorities for 2020-2021 were UHC and climate change. In contrast, our exercise in India, home to 600 million internal migrants and displaced populations , identifWe further observed a disconnect between current focus of global and national research and the actual need/priorities for improving migrants’ health. Bibliometric analysis on global evidence on migration and health showed an overwhelming focus on mental health (47% of the 21 457 archived studies) and infectious diseases (13.7%), with issues such as mental health, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), disparities/inequalities, or discrimination dominating in author keywords . A similMigration awareness and migrant-responsiveness of existing policies and health systems found renewed traction during COVID-19, where relief measures introduced tended to ignore migrants in precarious situations . While tThe responses also confront the general tendency in migration health literature to dichotomise migrants vs locals, presenting both groups as homogenous. In the process, policies and research tend to erase migrants’ unique contexts of precarity, structural vulnerabilities and agencies. Explicit references to specific migrant population groups like Bengali migrants in Assam, nomadic ethnic communities like Nats and Gujjars, Gulf-return labor migrants draw attention to various social divisions and structural inequalities defining migrants’ precarity, mobility patterns, and their health in India. Experts recognised the heterogeneity among migrants in India, where they represent diverse caste, ethnicity/indigeneity, and religion. These divisions operate as fault lines in migration governance and disease management and become critical considerations for designing and implementing research. Even across the 12 research topics mainstreaming gender, experts incorporated intersectional perspectives like increased vulnerabilities due to informality of work, socio-economic status, caste, religion, adolescence, and of families left behind. The identification of gender as a key access of studying vulnerability among migrants is in line with the growing attention to gender in labor migration scholarship in India . This exOur findings also established the merit in branching out from broad and generic regional priorities  to focus on specific and unique country contexts to drive local funding into relevant research addressing structural challenges leading to migrants’ poor health and health care access. MiHSA is undertaking similar country-level CHNRI exercises in the wider South Asia region facing similar challenges across distinct population groups and political contexts – for example, in Pakistan, with the access problems faced by the Afghan refugee crisis and Bengali settlers in the country within the wider political context, or in Nepal, with health care access challenges of seasonal labor migrants traveling to and from India.As with all research agenda setting tools and processes, defining research priorities/ agenda in itself cannot advance migration health. Advancing an evidence-based agenda for health of migrants needs concerted advocacy with and buy-in of policy makers, funders, and international agencies, and the political will to allocate resources to empirical research on identified priorities and uptake of research evidence for migration aware and migrant-responsive policies and systems.Such research-evidence-policy translation cycle requires a research governance ecosystem that is embedded in migration health governance and policy domains. Countries in the South and Southeast Asian region  offer promising roadmaps for such translation. For instance, the National Migration Health Secretariat and Taskforce (NMHT) in Sri Lanka  and the These processes are critical for integrating research ecosystem within the policy domain, ensuring the translational value of research and providing technical policy direction for advancing migration health.In federal systems such as India, such platforms must be established at both national and sub-national levels as the migration dynamics differ greatly across states and regions. It is also important to ensure that these mechanisms are not re-imagined as vectors of top-down agenda setting where policy makers dictate the research agenda. Appropriate structures to facilitate meaningful engagement of migrant populations is necessary in driving this agenda. The formation of meaningful “bottom up and inside out” networks described above requires both political and academic will, and willingness of policy makers and researchers to collaborate on driving evidence-based migration health research agenda . Such neThe production and use of evidence on migration is steeped in global inequities . Researc


Social media holds promise as an intervention platform to engage youths in healthy weight management and target racial inequities in obesity.This mixed methods study aimed to examine social media habits, preferences, and obesity-related behaviors  among adolescents of color and understand preferences for healthy weight management interventions delivered via social media.This mixed methods study is comprised of a cross-sectional web-based survey and a series of digital focus groups. Study participants (English-speaking youths of color ages 14-18 years) were recruited from high schools and youth-based community settings in Massachusetts and California. For surveys, participants were invited to complete an anonymous web-based survey assessing self-reported sociodemographics, social media habits and preferences, health behaviors , and height and weight. For focus groups, participants were invited to participate in 45- to 60-minute web-based group discussions assessing social media habits, preferred social media platforms, and preferences for physical activity and nutrition intervention content and delivery. Survey data were analyzed descriptively; focus group transcripts were analyzed using a directed content analysis approach.A total of 101 adolescents completed the survey and 20 adolescents participated in a total of 3 focus groups. Participants reported most frequently using TikTok, followed by Instagram, Snapchat, and Twitter; preference for platform varied by purpose of use . TikTok emerged as the platform of choice as an engaging way to learn about various topics, including desired health information on physical fitness and diet.Findings from this study suggest that social media platforms can be an engaging way to reach adolescents of color. Data will inform future social media–based interventions to engage adolescents of color in healthy weight management content. The high rates of adolescent obesity in the United States remain a significant public health concern. Nearly 1 in 4 22.2%) adolescents aged 12-19 years in the United States had obesity from 2017 to 2020 [2.2% adolDigital or mobile health interventions, defined as health services delivered electronically through formal or informal care, hold promise as a modality to engage adolescents in improving obesity-related health behaviors, such as diet and physical activity -8. StudiGiven the high prevalence of smartphone and social media use among adolescents, social media–delivered health interventions are a promising approach to engage adolescents in healthy weight management . In 2021The limited literature on adolescents’ exposure to and consumption of health information, particularly related to healthy weight management, through social media platforms has produced mixed findings. A small pilot study evaluating the consumption of health- and fitness-related social media content among adolescent females found that participants did not follow health-related pages or accounts and did not actively search for health content on social media . A systeThis mixed methods study aims to (1) examine social media habits, preferences, and obesity-related behaviors  among adolescents of color and (2) understand intervention preferences to inform the development of future healthy weight management behavioral intervention delivered via social media through cross-sectional surveys and focus groups among a sample of adolescents of color.This study collected quantitative and qualitative data from high school students aged 14-18 years who identified as people of color in order to assess adolescents’ weight management behaviors, attitudes, practices, and social media preferences. Participants were asked to answer questions related to their social media habits, preferences for physical activity and nutrition intervention content and delivery, preferred social media platform, self-reported measures of obesity-related behaviors , and height and weight via an anonymous cross-sectional web-based survey and web-based focus groups.Study procedures were approved by the Institutional Review Board of Boston University Medical Campus (IRB # H-40968).The investigative team contacted youth-based or youth-affiliated organizations in their network, including the Massachusetts Alliance of Boys & Girls Clubs (BGC), high schools in California, and community partners in Massachusetts and California to recruit participants. BGC staff, high school administrators, and community partners in Massachusetts and California were informed of the purpose and methods of the study. In total, 3 BGCs in Massachusetts and 2 high schools in southern California indicated interest in participating and were asked to share physical recruitment flyers with adolescents of color ages 14-18 years. Adolescent participants were also invited to share the survey with their social networks. Survey recruitment and administration took place from March 2021 to April 2022 with interested and eligible participants provided with a web-based QR code to access and complete the 1-time web-based survey. Focus group recruitment and facilitation took place from April 2021 to September 2021. Study staff contacted interested and eligible focus group participants to identify a date and time for a web-based 1-hour meeting (6-8 participants per group). Focus groups were conducted by a trained facilitator using Zoom, lasted 45-60 minutes in duration, and were recorded and transcribed.Inclusion criteria for survey and focus group participants included 14-18 years of age; self-identification as a person of color ; and able to read and communicate verbally in English. Survey participants were asked to provide electronic consent. Focus group participants were recruited from the sample of survey participants. Focus group members provided verbal consent. Participants were offered a US $25 gift card for participating in the study survey and US $50 for participating in the study focus group.Web-based survey questions measured self-reported sociodemographics, health behaviors, height and weight, and social media habits and preferences. Sociodemographics included gender ; age (years); grade level; Hispanic or Latine ethnicity; race  with more than one response permitted; and state or territory of residence in the United States. Items from the 2019 Youth Risk Behavior Surveillance Survey were used to assess health behaviors, including number of servings of fruit, vegetables, and sugar-sweetened beverages (SSBs) on a typical day in the past week ; number Survey items on social media habits and preferences assessed current use of major platforms  as well as asked participant to identify their single most-used platform. Participants reported usage frequency  for each platform of interest and were asked to identify their preferred platform to receive health information and connect with other adolescents of color on health behaviors.A trained facilitator asked a series of open-ended questions assessing social media usage and preferences, health-related concerns, and design and content preferences for a social media intervention to address obesity risk behaviors , healthy weight (5th-84th percentile), overweight (85th-94th percentile), and obese (>95th percentile), with missing or implausible responses excluded. Average daily screen time combined the number of hours watching television and using video games and computers.For participants who did not respond to the question on single most-used social media platform (n=23), a most-used platform was imputed based on their reported usage frequency of each platform, resulting in 93 responses for this measure. Overall social media usage frequency  combined the reported frequency of use for each individual platform and was defined as frequent usage if the frequency exceeded once per day.Differences in health behaviors, social media habits, and covariates of interest by gender  and weight status  were explored using chi-square tests. Data presented in the tables were not stratified by gender or weight status as the study was not powered to detect differences by these characteristics, and data were not compared by race or ethnicity, state of residence, or social media usage frequency because the sample lacked sufficient distribution across subgroups. All analyses were conducted using SAS .Focus group audio was transcribed verbatim and thematically analyzed by study staff. The analysis used a directed content analysis approach, where common themes were identified by a study staff member and used to formulate an initial codebook . Two indA total of 101 adolescents of color  completed the survey. An equal proportion (48.5%) identified as male and female, and 3.0% identified as nonbinary. The majority of respondents indicated Hispanic or Latine ethnicity (79.0%) and California residence (63.4%). Over half of the participants (53.6%) had BMI in the healthy weight category, followed by overweight (25.8%) and obese (17.5%). Social media usage frequency exceeded once per day for 88.1% of survey participants see . The majP=.01) and consumed more daily servings of SSBs . No other significant differences were found between male and female participants in terms of age, social media usage frequency, screen time, BMI, fruit and vegetable intake, or sleep measures. Participants with overweight or obesity were significantly more likely than those with healthy weight or underweight to report consuming more than one daily serving of SSBs . No other significant differences in health behaviors by weight status were observed. We were unable to assess whether weight status or health behaviors varied by frequent social media usage due to an insufficient number of respondents (n=12) reporting usage frequency of once per day or less . Among males, TikTok was the most-used platform for 40.0% of respondents, followed by Instagram (22.2%) and Twitter (15.6%). Only 4.4% of males reported Snapchat as their most-used platform. Female respondents also reported TikTok as their most-used platform (41.3%), followed by Snapchat (19.6%) and Instagram (13.0%), with only 2.2% of females reporting Twitter as their most-used platform. The distributions of the most-used social media platform, preferred platform to receive health advice, and preferred platform to connect with others did not vary significantly by weight status (data not shown in tables).Among the 93 participants with data on a single most-used platform , a significant difference was found in the distribution of most-used social media platform by gender  from 8 youth-based settings participated in 1 of 3 web-based focus groups for the qualitative portion of this study. Using a directed content analysis approach, 4 themes were identified and coded based on the focus group guide: preferred social media platform, purpose of platform use, satisfaction and engagement with platform, and preferences for healthy weight management content and delivery. These themes are summarized in TikTok emerged among focus group participants as the overall preferred platform of choice generally and with respect to health content. Most participants preferred TikTok due to its versatility, tailored content for the individual user, and options for multiuse engagement . The majority of participants also described initiating use or engaging in more frequent use of TikTok as a result of being isolated from their peers during the first year of the COVID-19 pandemic. Instagram emerged as the second most preferred platform with ease of being able to visually share information and updates, follow and engage with people outside of one’s personal network , and connect with real-life network members .Participants discussed using multiple social media platforms for different purposes. With respect to obtaining new content or information and entertainment, TikTok emerged as the preferred platform. With respect to frequent  messaging and engaging in conversation with others, including interfacing with new individuals or accounts, Snapchat and Instagram were identified as the preferred platforms. In terms of maintaining real-life connections  with family members and friends, participants identified using Snapchat, Instagram, and Facebook.The majority of focus group participants discussed TikTok as yielding the highest amount of satisfaction and engagement. Participants reported that often learning or being exposed to something uplifting, positive, or humorous (resulting in improved mood) on TikTok and that this platform offered a variety of content that was constantly tailored to user preferences. Participants also valued TikTok as a platform for its novelty  and relatability . The second most preferred platform was Instagram, where participants enjoyed viewing updates, viewing inspirational content, and seeing representation of other peers.Key suggestions and preferences for healthy weight management content and delivery via social media that participants voiced included content that addressed the intersection of mental and physical health ; peer messengers and information from trusted sources ; posts or content that were relatable ; and consistency and frequency in posting content on small, attainable behavioral goals . Participants’ views on the ideal source for health-related content were mixed; some participants wanted to see content from health professionals only, whereas other participants preferred to view content from peers with the same everyday, lived experiences.This mixed methods study is the first to our knowledge to examine social media platform use, design, and content preferences for social media–delivered weight management interventions among adolescents of color. Participants in our study reported most frequently using TikTok, followed by Instagram, Snapchat, and Twitter, and preference for platform varied by purpose of use. Participants reporting using TikTok primarily for entertainment, consumption, and creation of content, Snapchat and Instagram for frequent communication or messaging, and a variety of platforms  to stay connected with family, friends, and peers. These findings are similar to a small pilot study conducted among adolescent girls aged 12-18 years who reported using Snapchat and Instagram as ways to communicate and stay connected with friends .In concordance with recent trends on social media use among US teens ages 13-17 years from a 2022 Pew Research Center report, TikTok was the most popular social media platform reported by our sample of adolescents of color aged 14-18 years, followed closely by Instagram and Snapchat -21.Importantly, our study added to the literature by examining adolescents’ preferred platform by function (information vs connection) in the context of a healthy weight management intervention and solicited open-ended input from adolescents of color on their preferences for health intervention content, design, and delivery. Quantitative and qualitative data from this study highlighted TikTok as one of the top preferred platforms of choice for learning new information on healthy weight management, and TikTok and Instagram as preferred platforms for connecting with others  on healthy weight management behavioral changes. This study additionally identified adolescents’ specific healthy weight intervention design preferences, such as trusted sources for health information , consistency and high frequency of content exposure, importance of being able to relate to others through content (creator or story is one that they can identify with) or connection (engaging with other viewers going through similar experiences), and priority topics they would find engaging and relevant .Compared to national estimates, the prevalence of certain health behaviors among our target sample of adolescents of color (majority Latine) differed; 44% of our study sample reported consuming 5 or more servings of fruits and vegetables daily and 39% reported sleeping 8 or more hours per night compared to 15% and 26% of adolescents from the 2017 Youth Risk Behavior Surveillance Survey, respectively . With reTo date, there is a lack of research on healthy weight management or obesity interventions delivered via social media among adolescents in the United States. A few studies have examined the efficacy of mobile health interventions targeting diet, physical activity, and BMI among adolescents with promising improvements in certain health behaviors, though the vast majority of these interventions are app or text-based, are not delivered via social media, and lack adequate representation of participants of color -26. One Given the high rates of social media use among adolescents and the prevalence and fast spread of inaccurate health information on social media, the following design considerations, based on our results, may be helpful to guide the development of social media–delivered interventions targeting healthy weight management behaviors among adolescents of color . These iStudy strengths include the recruitment of adolescents of color who experience disproportionately higher rates of obesity and are underrepresented in health research and the use of quantitative survey and qualitative focus group methodology to understand patterns and preferences for a social media–based intervention targeting healthy weight management behaviors. Qualitative data provided additional context of the reasons behind participants’ preferences of certain social media platforms over others, why certain platforms were preferred for a social media–based intervention targeting healthy weight management, and what respondents felt should be included in such an intervention. Study limitations include a relatively small sample size of 101 survey respondents and 20 focus group respondents (compared to larger polls or cohort studies), where most focus group respondents were female ; cross-sectional assessments, which limit our ability to examine changes over time; the use of self-reported measures, which may be subject to recall and social desirability bias; selection bias ; and convenience sampling, which resulted in a majority Latine sample recruited from Massachusetts and California, thus limiting generalizability of study findings.Given the near ubiquity and high prevalence of social media use among adolescents and adolescents of color, a social media–delivered intervention has a high potential to reach and engage adolescents of color in healthy weight management behaviors. Findings from this study, along with further partnership with adolescent peer leaders, can be used to begin to inform the choice of platform and development of content and strategies for future social media–delivered interventions for youths of color and subsequent efficacy trials of intervention approaches tailored for this population.


Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (The program’s audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.The online version contains supplementary material available at 10.1186/s13012-023-01324-w. Contributions to the literatureThe effectiveness of audit and feedback on unwarranted clinical variation is influenced by the individual strategy components used and how they interact with local contextual circumstances.This uncertainty around what works, for whom, and why, limits the ability to design audit and feedback strategies that lead to the greatest impact when implemented at scale.We demonstrated that audit and feedback may impact unwarranted clinical variation through eight potential mechanisms, which are only triggered under certain contextual circumstances.We developed a Model for Audit and Feedback Implementation at Scale, which advances our understanding of how audit and feedback can be implemented across entire health systems at scale.Addressing unwarranted clinical variation in hospital care remains a key challenge to health system improvement. Despite all the improvements to health outcomes from modern medicine, care is not always provided in line with clinical practice guidelines , 2. The Clinical variation may occur due to a multitude of complex and interacting reasons. Warranted variation refers to situations where multiple effective options exist, and choice depends on patient preference. Sometimes there is genuine uncertainty among clinicians –16 in diAudit and feedback is a common strategy used to reduce unwarranted clinical variation . ProvidiIn Australia, the New South Wales (NSW) Health system has invested in several programs to operationalise the concept of “value-based healthcare”. Value in health is defined as the net improvement of welfare across individuals within a society . A valueIdentify and articulate the audit and feedback implementation strategies used to reduce unwarranted variation in care for patients with CHF, COPD, and diabetes.Determine the mechanisms  by Investigate the impact of different contextual circumstances on the relationship between these implementation mechanisms and outcomes of interest.The aim of this study was to identify how, why, and in what contexts the audit and feedback strategy contributed to the implementation of a state-wide value-based healthcare program to reduce unwarranted variation in care at scale. The main objectives were to:A realist study was conducted to investigate how the LBVC audit and feedback strategy contributed to the implementation of a state-wide value-based healthcare program to reduce unwarranted variation in care. Realist study designs are theory-driven evaluations, based on a realist philosophy of science , 42. TheThe study was conducted and reported according to our published protocol  and the 2 [This realist study took place in NSW, Australia, examining the implementation of the LBVC program at scale between 2017 and 2021. In Australia, state and territory governments are responsible for healthcare planning and delivery by public hospitals. NSW Health provides universal access to health care services for Australia’s most populous state (~ 8.15 million people in 2022), which is operated by more than 130,000 staff spread across 234 public hospitals and multi-purpose facilities, over a geographical area of more than 800,000 km2 . In rela2 .A maximum diversity, purposive sampling approach was taken to obtain a variety of organisational and individual perspectives considered best placed to provide information on the implementation of the initiatives. NSW Ministry of Health, Agency for Clinical Innovation, and local hospital staff eligible for participation were identified initially by the project partners and invited by the partners via email. Further respondents well placed to discuss the proposed program theories were identified through snowballing and were approached by the investigators directly via email. Informed consent was recorded verbally at the commencement of each interview.n = 51 articles) [We developed and undertook a Realist Dialogic Approach to identify the initial program theory for the audit and feedback strategy to reduce unwarranted variation in care . A progrrticles)  to identInternal documents pertaining to the LBVC program (126 documents) were reviewed to further situate the initial program theories within the program of interest. Semi-structured realist interviews , 58 to rRetroductive analysis was undertaken by five investigators  concurrently with data collection using NVivo 20. This analysis used both inductive and deductive logic to identify causal mechanisms behind patterns of change. Investigators cycled between inductive and deductive logic across the program documents and interview transcripts, incorporating their own insights . Transcrn = 21) and Agency for Clinical Innovation staff (n = 11) to translate into generalisable theoretical models for implementation. These validation groups included some of the original interview participants from stages 1 and 2, providing the opportunity for re-engagement and further feedback from key stakeholders with deep insights into the program of interest, which is an important aspect of realist methods.The program theories were presented to three healthcare quality expert panels for validation. A group of 19 Australian healthcare quality experts was assembled in a breakout meeting during the International Society for Quality in Health Care (ISQua) International Conference in Brisbane, Australia in 2022. A recommended model for the implementation of audit and feedback to reduce unwarranted clinical variation was proposed to the group, and questions were asked to seek confirmation, disconfirmation, and other interpretations  and two people nominated from the local hospital. Retrospective auditing of 40 case medical records took place without necessarily standardising the timeframe of case hospital admissions or whether cases were randomly or purposively sampled. Audit data were returned to the Agency for Clinical Innovation for data cleaning and visualisation prior to a feedback session at the hospital, typically within four to six weeks. Feedback was not always delivered by someone with a clinical background. Hospital staff at the feedback meeting were asked to identify three components of care that were being performed well and three components that could be improved. Unspecified ongoing support was offered by the Agency for Clinical Innovation for local hospital improvement efforts and follow-up audits were organised for hospitals on a voluntary basis. The audit and feedback strategy was refined over time to reduce the number of indicators and data points, increase the involvement of clinical staff or people with a clinical background, and prepare hospitals for the feedback sessions, and provide opportunities for reflection post-feedback.The audit and feedback implementation strategy is hypothesised to operate through eight mechanisms under different contextual circumstances, underpinned by regular measurement and feedback of both clinical processes and outcomes. The strategy worked well when clinicians (1) felt ownership and buy-in to the process, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for the proposed changes. The success of the strategy was constrained by 5) rationalisation of the status quo, 6) perceptions of unfairness and concerns about data integrity, (7) development of tokenistic improvements plans, and (8) perceived threats to professional autonomy. We report the manifestation of each audit and feedback mechanism to pinpoint key factors that determine success or where the strategy might falter  . HoweverOur realist study integrated context within hypothesised causal models. In developing theory for implementation strategies in healthcare, it is not uncommon to divide contextual factors, theoretical mechanisms, and implementation outcomes, and study these factors in isolation , 80. ThiThe three LBVC initiatives targeting inpatient variation in care were complex interventions that included more than just audit and feedback. It is possible that our focus on the audit and feedback strategy within these initiatives did not sufficiently capture complex interactions between the audit and feedback strategy and other approaches, such as defining best practice management, capability building to support best practice management, and systematising local processes to detect and address unwarranted clinical variation. The research team was not involved in developing or delivering the audit and feedback strategy, limiting our ability to report the strategy according to the AACTT framework . The strOur realist study identified eight mechanisms by which audit and feedback implementation strategies may impact unwarranted clinical variation in hospital care. Ownership and buy-in were more likely to be achieved when audits were conducted in collaboration with respected local hospital clinicians to better capture local workflows. Furthermore, where these local leaders facilitated engagement between the external auditors and local clinicians, performance on audit indicators was better able to be integrated with localised knowledge to make sense of the practice change implications. Comparisons with peer equivalent hospitals motivated a sense of positive social influence if clinicians considered the audit indicators and processes of care to be within their responsibility and locus of control. Where there was no meaningful partnership between auditors and local clinicians, too many audit indicators were assessed that lacked the necessary meaning and accuracy to be actionable, leading to clinicians rationalising existing care processes rather than focussing on potential areas for quality improvement. This lack of partnership can create a perception of unfairness when local workflows are not adequately accounted for in the audits. Improvement plans were underdeveloped or not implemented when sufficient time to interpret audit results and a clear indication of the level of ongoing implementation support was not provided. Finally, where clinical expertise was not respected because of rigid audit indicator criteria, the process was considered a threat by some to professional autonomy.Recommendations for future audit and feedback strategies include limiting the number of audit indicators and data points, ensuring the involvement of clinical staff and local leaders in delivering feedback, preparing hospital staff for the feedback sessions, and providing opportunities for reflection post-feedback. Future research could determine how to optimise benefits and avoid unintended outcomes by focussing on head-to-head comparisons of audit and feedback strategies, incorporating these elements with embedded process evaluations to determine the interaction effect of the hypothesised contextual factors in our program theories.Additional file 1. Audit and feedback program logic for CHF and COPD initiatives.Additional file 2. Audit and feedback program logic for Inpatient Management of Diabetes Mellitus Leading Better Value Care initiative.Additional file 3. RAMESES II reporting standards for realist evaluations.Additional file 4. Study protocol adaptations.Additional file 5. Initial audit and feedback program theory for CHF, COPD, and diabetes initiatives.


Obesity is a rampant global epidemic that is associated with excessive accumulation of body fat, with psychological, social and somatic consequences affecting the quality of life –4. The WAn unhealthy lifestyle, including low levels of physical activity and increased intake of calorie-rich foods, is a key factor accelerating obesity . ImplemeNew insights on the management of obesity with nutrition and physical activity”. Accordingly, the goal of this Research Topic was to provide findings from original research and or review articles on the effects of physical activity and/or nutrition on the treatment of obesity.To clarify the effects of various aspects and interventions  in managing overweight and obesity in children, adolescents and adults, we launched a Frontiers Research Topic entitled “Twenty-three manuscripts were received for this Frontiers Research Topic. After rigorous review, nine articles were finally accepted for publication. The contributing 58 authors were from five countries, including Canada, China, Portugal, Spain and Saudi Arabia. This Research Topic received more than 11,000 views and downloads as of September 2023. The key contents and findings of each paper are as follows:Alsulami et al., evaluated obesity prevalence, physical activity, and dietary practices among Saudi adults in the Makkah region of the Kingdom of Saudi Arabia (KSA).In this study, The authors used a validated questionnaire, Arab Teens Lifestyle Study (ATLS), to evaluate the physical activities, sedentary behaviors, and nutritional habits in addition to demographic data. Their results show that overweight and obesity was prevalent in 32.8 and 23% of the population, respectively, and that sociodemographic factors were associated with obesity. However, focused intervention strategies are needed to overcome the prevalence of obesity in KSA.Chen et al. explored the associations of different types of unsaturated fatty acids (FAs) with overweight/obesity risk among the Chinese population. The study enrolled 8,742 subjects free of overweight/obesity at entry in the China Health and Nutrition Survey (CHNS) that were followed until 2015. Dietary unsaturated FAs were assessed by 3-day 24-h recalls with a weighing method in each wave. Cox regression models were used to obtain the hazard ratios (HRs) and 95% confidence intervals (CIs) for overweight/obesity risk associated with unsaturated FAs. The results demonstrated that higher dietary intake of monounsaturated FAs was associated with a lower overweight/obesity risk, which was mainly driven by dietary oleic acid from either plant or animal sources. Intakes of α-linolenic acid, n-6 polyunsaturated FAs and linoleic acid were related to a higher risk of overweight/obesity. The authors concluded that their results support consuming more monounsaturated FAs for maintaining a healthy body weight among the Chinese population.The study by Lages et al. from Center for Innovative Care and Health Technology based in Polytechnic of Leira  characterized the chronotype and determine its relation to the phenotype and dietary patterns of healthy patients and those with obesity.The study of The characterization of the chronotype and the circadian system as a phenotype is innovative and should be taken into consideration in patient-specific forms of obesity in order to develop targeted nutritional interventions. Dietary intake and sleep quality was assessed using validated questionnaires. Body composition was also assessed and blood samples taken to quantify circadian and metabolic biomarkers. This study has helped improve our understanding of the complex mechanisms underlying obesity.Ma et al. investigated how Chinese adolescents' lifestyles clustered into different lifestyle patterns, and analyzed the correlation between these patterns and adolescent overweight and obesity. The investigated respondents included 13,670 adolescents aged 13–18 from various administrative regions in China. The studied demonstrated that there was a coexistence of healthy behaviors and health-risk behaviors in the lifestyle clustering of Chinese adolescents. Low physical exercise and high intake of snacks and carbonated beverages were the most common. Physical exercise and health consciousness were the protective factors of overweight and obesity in adolescents.The study by n = 839 from 22 schools, aged 8–13 years, 51.1% girls) examined the relationship between 24 h movement guidelines (jointly self-reported by parents and children) and insulin resistance . Plasma glucose and insulin levels were also measured. Those children (particularly girls) with insulin resistance had more sedentary lifestyles, while those who were more active had improved metabolic parameters—about half of the study group did not meet recommended movement guidelines, with better adherence to recommended total sleep times for this age group. A strength of the report by Salas-González et al. is studying a multitude of lifestyle factors , showing the importance of understanding the role of a combination of these coexisting choices.The health risks of sedentary lifestyles are of increasing global concern, particularly in growing children. Many children and young adults seem addicted to electronic devices, are less likely to actively participate in sports and end up with less quality sleep, and it is likely that these traits will persist in adulthood. A study of Spanish primary school children from five geographic regions  identified some risk factors affecting exercise behavior among overweight and obese people in China. This large-scale study of over 3,300 individuals considered the lifestyles of obese people. The study showed that the proportion of active physical activity among obese people was 25%. Groups with better sexual and reproductive health, higher levels of education and income were more likely to take part in sport. Obese people who lived in rural areas, were single or divorced, or in the 35–40 age bracket, had a significantly lower percentages of engagement in active physical activity. Health promotion programs for those who are obese need to be further strengthened and targeted to get closer to WHO recommendations.The report by Tu et al., explored changes in physical characteristics in preschool children from 2000 to 2020, and forecast development trends over the next 10 years. The results show that the growth and nutritional status of Chinese preschoolers improved dramatically over the past 20 years, but that overweight and obesity remains. Overweight and obesity rates are expected to continue to increase rapidly over the next 10 years, particularly among boys, and effective measures should be taken to control the obesity epidemic.The study by Wang et al. reports on the cardiac structural and functional benefits of treating a rat model of type 2 diabetes with MOTS-c. Levels of endogenous MOTS-c are reduced in diabetes, and the results this study indicates that restoring MOTS-c levels with exogenously administered MOTS-c (i) repaired mitochondrial damage, (ii) restored cardiac systolic and diastolic function, (iii) improved gene regulation of fatty acid metabolism, immunoregulation, angiogenesis and apoptosis. These data provide the first molecular evidence that MOTS-c improves cardiovascular function in diabetes.The report by Manda Wang from Shunchang Li's group based in Chengdu Sport University adds to their other studies on the metabolic effects of MOTS-c, an endogenously produced regulator of metabolic homeostasis that stimulates glucose uptake and increases insulin sensitivity. The cardiovascular effects of MOTS-c include improved endothelial function, a hallmark of diabetes in humans and animal models. The study by Yu et al. conducted a systematic review and network meta- analysis (NMA) by comparing adjuvant therapy with different nutritional supplements for overweight and obese adults, so as to provide a reference for clinical practice. The study show that nutritional supplementation lowered cardiovascular disease risk factors in overweight and obese patients. Probiotic supplementation might be the best intervention for blood glucose control; Vitamin D, probiotic + omega-3 have a better impact on improving lipid metabolism.The editors of this volume are extremely grateful to the authors for their contributions and hard work sharing their research insights. We hope the readers of these papers will benefit from this Frontiers Research Topic and utilize the information herein to advance their scientific pursuits.HZ: Conceptualization, Writing—original draft, Writing—review and editing. CT: Conceptualization, Writing—original draft, Writing—review and editing. KJ: Conceptualization, Writing—original draft, Writing—review and editing. IL: Conceptualization, Writing—original draft, Writing—review and editing.