This paper systematically reviews existing United States-based water insecurity literature with the goal of understanding the evidence base for developing public health water insecurity intervention strategies in Oregon. The authors conducted the systematic literature review using an adjusted PRISMA reporting checklist to document the review process. Results find 11 public health-related water insecurity interventions including surveillance practices and indicator and policy development. Research on water insecurity health impacts and solutions is still an emerging field. Nevertheless, state agencies perceive a risk to communities from inadequate safe water and are taking steps to assess and reduce these risks. From the review, strategies include improving water affordability, carrying out community education events, documenting drought risk and water loss, and tracking improvements in safe drinking water compliance. The review finds opportunities to take varied approaches that are community-specific, partnership-based and culturally relevant. Recommendations for Oregon include characterizing communities experiencing water insecurity, assessing community needs, tracking regional water scarcity and recognizing the human right to water in Oregon. Despite the common belief that Oregon is water-rich, population- and climate-driven pressures on water insecurity are a real concern for all people in Oregon. In this paper, we define “water insecurity” as inadequate or inequitable access to clean, safe and affordable water for drinking, cooking and sanitation and hygiene. As an ideal and opposite state, “water security” describes the conditions where water quality, quantity and access are enough to protect public health.Climate changes that are increasing the frequency and severity of droughts, floods, wildfires and other natural disasters. These strain our aging infrastructure and expand water insecurity threats to vulnerable communities .Social determinants that affect access to clean and safe water such as socioeconomic conditions , population distribution and community engagement.Physical determinants of water security such as drinking water and wastewater storage, treatment and delivery systems, housing status and geographic location.Three key factors affecting water security include:An alternative definition of “water security” refers to a water system’s ability to prevent and recover from physical security threats such as water contamination from chemical, biological and radiological agents.Because of varied definitions of “water security,” and to highlight the relationship to public health, we use “water insecurity” as our reference term. Preventable direct health outcomes of water insecurity include water-borne illnesses, exposure to contaminants and toxins, dehydration and malnutrition. Indirect outcomes include emotional distress, depression and anxiety. Understanding water quality and quantity needs and inequities in access to safe water in Oregon is a prerequisite to developing community-specific and culturally-relevant water security policy solutions to help communities build adaptive capacity, strengthen resiliency and protect the health of all people in Oregon.The Millennium Development Goal Report (MDG) of 2015 estimated that “663 million people worldwide use unimproved drinking water sources, including unprotected wells, springs and surface water, while 2.4 billion use unimproved sanitation [United Nations Water, the Global Water Partnership, and the World Economic Forum are a few of the international organizations focused on global water security efforts. In 2010, the United Nations General Assembly and the Human Rights Council recognized the human right to water as part of international law and the human right to sanitation followed as a distinct right in 2015 . Under tLegionella in the last decade.In the United States (U.S.), water security is critical to protect public health. Drinking water contamination disrupts water access leading to poor health outcomes from exposure and a sense of concern among communities at risk . Figure Legionella accounted for all acute respiratory illness and the causes of acute gastrointestinal illness outbreaks included exposures to Cryptosporidium, Giardia, Clostridium, E. coli, Campylobacter, norovirus, cyanotoxins, nitrite and 4-methylcyclohexanemethanol (MCHM) [In more recent data, l (MCHM) .Cryptosporidium from a lake or reservoir resulting in two hospitalizations. In the following year, four cases of Legionella associated with well water resulted in four hospitalizations and one death [Two of the 42 waterborne disease outbreaks occurred in Oregon, affecting individuals served by community water systems. In June 2013, Oregon reported 119 cases of ne death . The numThe Oregon Health Authority (OHA) administers the Safe Drinking Water Act (SDWA) and related state laws to ensure that communities on public water systems have access to drinking water that meets regulatory standards. Roughly 80% of Oregonians get their drinking water from public water systems. Oregon regulates public water systems that have four or more service connections or serve 10 or more people per day . ThroughOHA estimates approximately 20% of Oregonians use private domestic wells as their primary source of potable water. The private well-owner has the responsibility to maintain their well and ensure the water is safe to drink. Rural or remote residents served by private wells with low means to assure adequate supply and quality are disproportionately affected by water insecurity. This poses a public health challenge to provide well-testing resources and to educate private well owners on the importance of wellhead stewardship, well maintenance, water testing and treatment if contaminants are present at elevated levels of concern. OHA’s Domestic Well Safety Program encourages well water protection by increasing well-owner capacity to evaluate and manage contamination risks.Staphylococcus aureus (MRSA), endocarditis and urinary tract infections, observations which are consistent with chronic lack of sanitation and hygiene [Water insecurity disproportionately affects populations experiencing homelessness in Oregon. In 2017, a point-in-time count (a count of homeless people on a single night) estimated that 13,953 people were experiencing homelessness in Oregon, a 6% increase since 2015 . Forty p hygiene . The surWater insecurity impacts households with poor plumbing, with wells vulnerable to flooding or with dependence on bottled water for daily use. Water insecurity also impacts those communities suffering from extended drought and those served by coastal aquifers vulnerable to sea level rise or saltwater intrusion. Oregon currently has no public health-focused water insecurity program, but partner programs within OHA such as Drinking Water Services, Domestic Well Safety Program (DWSP), Climate and Health Program and the Acute and Communicable Disease Program (ACDP) are working in this area. Despite current efforts, there is limited understanding of water insecurity risks and interventions to mitigate those risks. Public health-focused water insecurity programs, policies and practices could foster community resilience in the face of climate change, droughts, floods, wildfires, earthquakes and other natural disasters and communicable diseases related to water insecurity.(1)What are the existing evidence-based public health-focused water insecurity interventions?(2)How would one evaluate effectiveness?(3)What is the evidence showing the interventions have successfully mitigated risk?The objective of the systematic literature review was to understand the existing evidence base for developing public health policies, programs and surveillance strategies (collectively referred to as “interventions”) relating to water insecurity in Oregon. The following questions guided our literature review:We conducted a systematic literature search to collect existing documentation of evidence-based public health-focused water insecurity interventions. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to document our literature review process . Our aimWe looked for sources discussing water insecurity at the individual, household, community, state and national level with a public health focus. While we primarily targeted United States-based sources, we also reviewed international literature to understand the current global water insecurity political landscape and to assess the relevance and applicability of global water insecurity interventions in Oregon. We conducted the review using the ScienceDirect, PAIS Index and Nexis Uni databases to search for peer-reviewed journal articles and legislative documents. We also hand-searched the Water Security Journal from the ScienceDirect database and reference lists of relevant articles. Based upon initial search results, key informant interviews and an internet search of “university water initiatives,” we searched gray literature finding 15 separate agency and university water initiatives, their publication lists and research projects. We hand-searched the following institutions: California Water Boards, California Environmental Protection Agency’s Office of Environmental Health Hazard Assessment, Columbia University, the Environmental Law Institute, Harvard University, Northwestern University, Stanford University, Texas A & M University, the UCLA Luskin School of Public Affairs, the University of California Water (UC Water), the University of North Carolina, the University of Oklahoma, the University of Minnesota, West Virginia University and the World Economic Forum.The search strategy used a combination of keywords including “water security,” “water insecurity,” “water scarcity,” “water access” “water stress,” “public health” and “surveillance.” (1)Results for all years.(2)Results in the English language only.(3)Water insecurity-related bills, legislation, policies, journal articles, and agency publications, projects and initiatives.(4)Sources discussing measures to evaluate or identify water insecurity.(5)Sources discussing metrics for surveillance of water insecurity and public health impacts.(6)Sources discussing the application of indicators to identify water insecurity.(7)Sources documenting implementation processes, data collection methods or evaluation protocols for gathering evidence of effectiveness.(8)Sources currently in the implementation or evaluation phase that have documented implementation and evaluation strategies.The screening process used the following eligibility criteria:To conduct data extraction, we made a distinction between systematic review protocols and systematic mapping protocols. The Collaboration for Environmental Evidence (CEE) provides a guideline for authors who seek to document environmental evidence . During Since 1998, literature has cited at least 25 different definitions of water security ,13. The The literature search found one state policy meeting the search criteria and study objectives. The 2012 California Human Right to Water Assembly Bill (AB) 685 recognizes “every human being has the right to safe, clean, affordable, and accessible water adequate for human consumption, cooking, and sanitary purposes .” AB 685There were seven surveillance studies meeting criteria for inclusion addressing water insecurity at the household, community, regional and or state level. For this review, we define surveillance as public health data collection and analysis to identify water access needs, to identify populations experiencing water insecurity and to note existing public health inequities.Two studies assessed water insecurity at the household level, with a focus on poor communities in both international and US-based communities. The Global Household Water Insecurity Study at Northwestern University, launched in 2017, identifies households with high, medium and low water insecurity using the Household Water Insecurity Experiences (HWISE) Scale . It is cThe Jepson household water security study  took plaThe Switzer and Teodoro study analyzed direct and indirect relationships between racial or ethnic populations, socioeconomic status (SES) and Safe Drinking Water Act (SDWA) compliance . The stuThe Gibson et al. study  used proThe Pierce and Jimenez study  used 201Two studies conducted water insecurity surveillance through the development and use of mapping tools. The Mekonnen and Hoekstra study  measuredThe California State Water Resources Control Board recently published the Human Right to Water Portal . The PorOne of the most widely used indicators relating to water and human development is the Water Poverty Index (WPI), first applied at the community level by Sullivan, et al. . The WPISullivan, et al.  demonstrResources ,Access ,Capacity  and,Environmental (septic tank certification and septic tank maintenance in a colonia) .Korc and Ford  applied To create a colonia-level WPI, the study matched a water, sanitation and safety dataset from a 2010 Texas Department of State Health Services community-based survey on colonias with water supplier compliance and enforcement information. Researchers combined the WPI components using a weighted average method, with the weightings indicating the importance of a particular WPI component . ResultsA Framework and Tool for Evaluating California’s Progress in Achieving the Human Right to Water [On January 3, 2019, the California Environmental Protection Agency’s Office of Environmental Health Hazard Assessment announced the release of a draft of to Water . The Frato Water . Individto Water . Since our review does not seek studies with intervention and outcome measures of a clinical nature, and includes a variety of results , we cannot determine risk of bias across studies. We critically appraised the descriptive ,19,26,27Our literature catalog Framework and Tool for Evaluating California’s Progress in Achieving the Human Right to Water [Given the United Nations’ and California’s Human Right to Water Laws, we see increasing global, national and regional efforts to achieve access to safe, sufficient and affordable water for all people. With California’s to Water , policymThe two household water insecurity studies ,19 measuThe colonias experiential survey and scales integrate the point of view of marginalized communities experiencing water insecurity, supplying qualitative data and quantitative analysis to classify varied levels of water insecurity and water security. The three scalograms  together offer information on multiple dimensions of water insecurity and capture psycho-social dimensions  often overlooked in water insecurity measurements . The scaFor instance, water insecurity scalograms can be applied to rural communities with individual surface water domestic withdrawals in Oregon . The risk of selection bias for both studies is low since researchers used random sampling to identify participants. Both studies used primary and secondary data offering a mix of qualitative and quantitative information.Two studies investigated the relationship between race and ethnicity and water insecurity ,21. SwitThe Pierce and Jimenez study  comparedThe Mekonnen and Hoekstra  study onThe Korc and Ford  and SullCurrently, there is no database or centralized source compiling a list of agencies and academic entities with water insecurity initiatives. Since we hand-searched state-and university-based water initiatives, it was difficult to determine if we found all existing initiatives and risk of search bias exists. Much of current literature used “water security” as a key term, yielding more relevant results than “water insecurity”. Most results excluded from the review were conceptual studies discussing varied definitions of water security. This presented challenges with identifying proper search terms and sources specifically addressing a public health perspective and quantifiable solutions. While “water insecurity”, “water security”, “the human right to water”, “household water insecurity”, “water poverty index”, “water scarcity”, “water stress”, “water service reliability” and “water access” surfaced as key terms in our literature results, it is possible that other key terms are used to encompass water insecurity. These challenges suggest that water insecurity is still an emerging topic with limited publications.At various stages of our systematic review process we interviewed key informants actively involved in solving today’s water insecurity issues in California, Washington and Oregon. Discussions in Oregon focused on natural resources agencies, since activities within the public health system  are already known to the authors. Key informant interviews contributed to the robustness of key words and search terms allowing us to refine our review, expand our understanding of relevant policies and begin identifying potential public health-focused water insecurity interventions. Below are the key activities discussed during the interviews.California’s Human Right to Water Law followed mobilization of multiple communities and nongovernmental organizations focused on water justice. These communities recognized inequities in access to safe drinking water. California is assessing water security needs, setting goals, developing resources, improving water affordability and tracking progress. Washington State is pursuing water insecurity interventions through community education events, drought risk assessment, water loss detection and utility rate capping. Washington’s activities look at water insecurity outside of the regulatory context and aim to increase awareness of the value of water and importance of water conservation. “Water insecurity” is not a widely used term in California or Washington, but both states are developing interventions to meet the unique water needs of their communities.There are recent and ongoing efforts among Oregon natural resource agencies, led by the Oregon Water Resources Department (OWRD), to develop an Integrated Water Resources Strategy, gain a better understanding of the quantity and quality of water in aquifers, prepare for droughts, engage local communities in place-based planning and develop a 100-year vision for water in Oregon. To capture groundwater-level data and climatic and seasonal impacts on aquifers, OWRD continues to develop observation wells throughout the state and in basin study sites. OWRD has completed basin studies in the Deschutes, Willamette and Klamath basins to understand the relationship between and availability of groundwater and surface water. These studies produce information about the geology of the basins and the volume of groundwater recharge, discharge and storage . In respOregon Department of Environmental Quality’s (DEQ) drinking water source protection program  assists The following recommendations are based on key informant interview findings and current water insecurity literature, policies and practices (2003–2019) that aim to identify public health inequities in access to safe, accessible and affordable water. Our goal is to inform public health agencies, water resources management agencies and policymakers about water insecurity inequities and interventions to make the most informed decisions to mitigate risk.Prior to identifying water insecurity needs, state agencies must recognize which communities are experiencing water access disparities. Agencies should study census and property tax data to identify, describe and quantify inequities in access to water. This will help us understand racial and ethnic disparities and water access needs among marginalized communities . Mapping Oregon water systems as done in California’s Exceedance/Compliance mapping tool , and conAssessing water insecurity experiences and needs at the household level using the Household Water Insecurity (HWI) approach  will finThe Water Poverty Index (WPI) identifies more than one influencing factor  of water insecurity, which provides an interdisciplinary picture of the water situation in a given region . The WPIOregon Housing and Community Services (OHCS) developed a Manufactured Home Park Directory map, which includes the locations of all active manufactured homes (including mobile homes), marked census track boundaries, county names, park size or number of manufactured homes and owner contact information . To asseOregon can implement strategies to better understand how climate change and seasonal variability impacts water availability and drought risk by applying Mekonnen and Hoekstra’s water scarcity modeling approach. Researchers can measure water scarcity as the ratio of water consumption over water availability. The U.S. Geological Survey provides water-use data per county, including domestic self-supplied groundwater and surface water withdrawals measured in Mgal/d . Water availability is measurable through surface runoff modeling at the catchment or grid level . Oregon Adopt a state policy, such as the human right to water, that would encourage an interdisciplinary collaboration between public health agencies, water resources management agencies, academia and policymakers to establish accessible, safe and affordable water as a priority in future policy decisions. Resulting data from the preceding recommendations  will inform future policy decisions.Water insecurity as an emerging field opens many opportunities to raise awareness of the evolving and confounding effects to public health, as well as understand how to mitigate and manage risks of human and ecologic impacts. The current evidence base for making policy- and program-development decisions is limited, but there are feasible and relevant intervention options to begin assessing water insecurity needs in Oregon. Work around California’s Human Right to Water and related mapping tool, and additional applications of the Household Water Insecurity Survey by researchers over the next few years will help to grow the evidence base. The United Nations and California establishment of the human right to water suggests policymakers and public health professionals are placing a greater importance on environmental justice and water insecurity internationally and in the US. Meetings with US-based key informants revealed that water insecurity policy and intervention development is underway, but each state interviewed  is pursuing its own approach. While approaches may differ and cater to specific state-based needs, there is great opportunity to learn about varied approaches through continued collaboration. By using mixed methods to collect information at system, community, regional and statewide scales Oregon will be better prepared to develop water insecurity policy solutions that are community-specific and culturally relevant.


Strengthening health systems and maintaining essential service delivery during health emergencies response is critical for early detection and diagnosis, prompt treatment, and effective control of pandemics, including the novel coronavirus disease 2019 (COVID-19). Health information systems (HIS) developed during recent Ebola outbreaks in West Africa and the Democratic Republic of the Congo (DRC) provided opportunities to collect, analyze, and distribute data to inform both day-to-day and long-term policy decisions on outbreak preparedness. As COVID-19 continues to sweep across the globe, HIS and related technological advancements remain vital for effective and sustained data sharing, contact tracing, mapping and monitoring, community risk sensitization and engagement, preventive education, and timely preparedness and response activities. In reviewing literature of how HIS could have further supported mitigation of these Ebola outbreaks and the ongoing COVID-19 pandemic, 3 key areas were identified: governance and coordination, health systems infrastructure and resources, and community engagement. In this concept study, we outline scalable HIS lessons from recent Ebola outbreaks and early COVID-19 responses along these 3 domains, synthesizing recommendations to offer clear, evidence-based approaches on how to leverage HIS to strengthen the current pandemic response and foster community health systems resilience moving forward. In noncrisis settings, effective HIS can be a critical resource in improving health system function and resilience to public health threats.1 In crisis settings, routine and emergency HIS provide real-time, vital information to guide proactive and rapid response activities.4 Despite the value of robust HIS in responding to pandemics, many countries face challenges in coordinating and expanding HIS, sharing data and information, addressing public mistrust and misinformation, and preventing negative health outcomes during and after outbreaks.3Health information systems (HIS) are systems focused on health-related “data collection, distribution, and use that provide information at regular intervals.”5 Three major gaps emerged as opportunities for optimizing HIS: governance and coordination, health systems infrastructure and resources, and community engagement and risk communication. Governance in public health emergencies refers to the political processes and mechanisms that steer response and resilience efforts.6 Health systems infrastructure focuses on providing the foundation and resources for planning, delivering, evaluating, and improving public health.7 Community engagement includes initiatives that ensure individuals and communities are central in public health priorities and action plans.8 As the world responds to the novel coronavirus disease 2019 (COVID-19), recent analysis suggests that strengths and weaknesses in HIS have re-emerged along these 3 domains, offering timely insight on how to scale up evidence-based and efficient HIS to contain the ongoing pandemic.Effective HIS implementation could have improved response to the 2014-2016 West Africa and 2018-2020 Democratic Republic of the Congo (DRC) Ebola outbreaks.These emerging themes portray a cyclical relationship; strengthening HIS may lead to more resilient health systems with community-based approaches to emergency preparedness and response, while strengthened health systems provide the foundation for robust and sustainable HIS. Noting the lack of documentation on the implications and added value of scaling up HIS and related digital innovation during public health emergencies, a critical analysis synthesizing concepts along these domains is needed to prevent and mitigate COVID-19 and other emerging public health threats worldwide.This piece uses examples from Ebola and COVID-19 because of their similarities as fast-moving infectious diseases that have been designated as Public Health Emergencies of International Concern (PHEIC), their high impact on morbidity and mortality, and their disruption of routine health services and economic activity at a global scale. This concept study assesses lessons learned from HIS deployment during the 2014-2016 West Africa and 2018-2020 DRC Ebola outbreaks and recent insights from the COVID-19 pandemic, synthesizing recommendations to optimize ongoing and future preparedness and response actions across 3 overarching domains: governance and coordination, health systems infrastructure and resources, and community engagement.Different government priorities and agendas are reflected in HIS implementation and have varying implications for how preparedness and response interventions are developed and implemented at all levels of the health system. For example, an agenda centered on global health security has different implications for program priorities and resource mobilization than an agenda focused on universal health coverage—both played an important role in influencing the governance of health systems in Ebola-affected countries.9 Meanwhile, the DRC, an active conflict zone with a complex network of informal politics, offered unique challenges and dangers that impacted HIS implementation.10Governance in West Africa during the Ebola outbreak was weakened not only by the governments’ inadequate coordination and capacity to prevent, detect, and respond to the emergency, but also by the public’s deteriorated trust in government intervention.1 For example, during Ebola outbreaks in West Africa, the governments of Liberia, Guinea, and Sierra Leone were slow to initiate necessary emergency response and consistent communication messaging to contain the outbreak.11 This was partly due to the lack of existing information systems in place to understand the extent of the outbreak over an expansive geographic area.12 Politicization of priorities, complicated frontline actions, and an increasingly complex network of international actors made it difficult to transparently share much-needed data and information on outbreak consequences, weakening rapid response and global solidarity.Robust governance and coordinated responses require cohesive health systems with up-to-date information to enable proactive decision-making, rapid resource mobilization, and effective risk communication strategies; the lack of comprehensive HIS can further fragment these priorities.13 This prevented stakeholders from coordinating health system strategies. Furthermore, the Ebola surveillance system in Sierra Leone was kept distinct from the country’s Integrated Disease Surveillance and Response (IDSR) framework, partially due to administrative and operational barriers such as contested ownership and governance over data.15 Effective surveillance systems and proactive community contact tracing require robust, coordinated oversight and capability to share data with diverse stakeholders. Furthermore, integrated national roll out of the District Health Information Software 2 (DHIS2)—a free, open source, and locally customizable health management data platform used by over 50 countries—could provide real-time data that governments can leverage to better inform aligned outbreak responses.16 Promoting efficient and useful HIS solutions, including incorporating epidemic information systems into existing local DHIS2 and IDSR systems rather than running them in parallel, could avert future failures in policy coordination. To improve governance during public health crises, ministries of health should take ownership of and integrate routine and emergency HIS through cohesive governance of data sharing mechanisms and digital risk communication strategies.14For HIS to function effectively, governing bodies and decision-makers need to address barriers to transparent data collection, analysis, and sharing. Notably, the governments of Guinea and Sierra Leone drew criticism for withholding vital information from Médecins Sans Frontières, which was also supporting the Ebola response.The COVID-19 pandemic has exposed how the chronic lack of HIS within and among nations continues to exacerbate the lack of cohesive national and global health governance. Furthermore, little has been documented on how earlier successes have been deployed and leveraged globally in COVID-19 mitigation and response tactics.17 As robust data are the foundation for effective HIS, the World Health Organization (WHO), alongside leaders from low- and middle-income countries (LMICs) and leading scientific journals, developed protocols to streamline the release of data from clinical trials during public health emergencies.17 These policy proposals helped lead to the early public release of the COVID-19 genome sequence and the polymerase chain reaction assay protocols, as well as enabled early detection of cases in the COVID-19 pandemic.18 This highlights accessible and transparent clinical trial data as an important component of HIS during health crises. However, current mechanisms do not similarly obligate the dissemination of information from observational studies, risk analysis and disease monitoring programs, and outbreak surveillance, thus hindering effective pandemic preparedness and response coordination.19For example, the West Africa 2014-2016 Ebola epidemic showed how weaknesses in governance and data sharing mechanisms hindered coordinated response efforts.20 As demonstrated during Ebola outbreaks, timely information from contact tracing, disease monitoring, and surveillance are vital to ensure governments can generate up-to-date data and evidence-based policies to spearhead coordinated public health emergency responses.21 Consequently, data from observational studies, efficacy of mitigation strategies, and transmission statistics are critical for effective national and international resource mobilization, timely allocation, and technical assistance.20 This requires promoting open access distribution and data-sharing mechanisms as an important foundation to improve HIS governance and interoperability before, during, and after health emergencies—building on lessons learned after Guinea and Sierra Leone withheld this vital information during Ebola.18Efficient dissemination of clinical trial results is important to characterize specific disease treatment protocols, but does not fully inform governments on how they should respond to rapidly changing transmission dynamics, asymptomatic reservoirs, and other COVID-19 epidemiological data.22 This absence of timely information and data sharing leads to weak national and international coordination, affecting logistics in triage and testing, quarantine, and treatment options, as similarly demonstrated by Sierra Leone’s struggle to integrate routine and emergency HIS during Ebola.Another important factor that has impaired unified pandemic response policies within several countries and internationally has been the lack of data from cohesive HIS to drive systematic screening. For example, the United States did not begin screening until January 17, 2020, at which point they initially focused only on travelers from China at select airports, even though COVID-19 had already spread to multiple other nations.24 National EMRs can be a constant data stream for HIS during outbreaks, providing detailed information at the individual and population levels to identify cases, track transmission, and support unified government priorities. The success of integrated EMRs has been demonstrated by Taiwan’s response to COVID-19. By leveraging robust information communications infrastructure, national EMRs, and transparent data sharing practices developed following the SARS outbreak, Taiwan has used real-time analytics to stratify risk, screen potential cases, quarantine positive individuals, and treat patients.25 Despite significant inbound travel from the epicenter of the COVID-19 outbreak in mainland China, Taiwan continued to have fewer cases than many neighboring countries, with fewer than 450 confirmed cases as of May 5, 2020.26One critical HIS solution to streamline screening and build local and national government capacity for informed decision-making is the implementation of a national electronic medical records (EMR) system. Previous studies on national EMRs have demonstrated their ability to enhance screening, reduce medical errors, improve treatment of acute and chronic diseases, and save up to billions of dollars in health-care costs annually.The COVID-19 pandemic exposes weaknesses in governing bodies to coordinate responses across diverse contexts and in conjunction with varying global commitments, such as the WHO International Health Regulations (2005) and UN Sustainable Development Goals. While multiple factors play a role, integrated data and information sharing systems are essential in outbreaks like Ebola and COVID-19. Future commitments should include (1) bolstering international cooperation and global solidarity for openly publishing a wide variety of research during health emergencies, and (2) strengthening contextual HIS within countries, including centralized EMRs and interoperable digital platforms that integrate routine and active HIS at all stages of an epidemic.15 To facilitate health-care infrastructure capacity-building, HIS could help countries equitably optimize available local and international resources. In the West Africa Ebola outbreak, challenges in health systems infrastructure included scarcity of both physical and personnel resources. Guinea, Liberia, and Sierra Leone have among the fewest physicians per capita worldwide.27 Meanwhile, the shortage of personal protective equipment (PPE) was further exacerbated by a lack of procedural systems and accountability mechanisms in place for safe use and removal of PPE.28 These scarcities limited the capacity of health systems to mitigate and respond to case management needs in both Ebola treatment centers (ETCs) and other health facilities. Often, assistance was diverted from routine health services, leading to inaccessible care and higher mortality from other diseases  than from the outbreak itself.29HIS have been leveraged to broadly strengthen health systems and enable the monitoring of ongoing health service utilization during outbreaks.30 Following the West Africa outbreak, partnerships were developed to strengthen digital health infrastructure to support health emergency preparedness.31 When the first Ebola outbreak occurred in the DRC in May 2018, the Ministry of Health “called on digital systems” as a key tool in response efforts.32 This digital infrastructure would enable HIS to rapidly share and connect up-to-date data, therefore providing greater insight on day-to-day changes at the facility level during outbreaks.In West Africa, information about stockpiles and available resources was also hindered by poor telecommunication  and a lack of information technology (IT) equipment and expertise, which is vital to capture HIS data during public health emergencies.5 Furthermore, at various points throughout the outbreak in Sierra Leone, some hospitals were overrun and had to turn away suspected cases while others were only half-full.33 Here, a coordinated HIS could have allowed for more efficient resource and patient allocation across clinics, improving overall care by reducing strain on health facilities. Insight provided by HIS, thus, can be used to inform decisions about physical resource allocation. For example, an integrated HIS in West Africa to provide timely updates on disease hotspots and health facilities could have been leveraged to equitably allocate the limited PPE and avoid stockpiling or supply chain disruptions.34Building up IT and digital resources strengthens surveillance and response systems, which provides early information on case numbers and contact tracing. A study in 2017 evaluating DRC’s Technical Guide for IDSR found that developing an adequate surveillance system was limited by the capacity of the health system itself, including low levels of training and inadequate supporting resources.31 However, there is still an opportunity to better develop HIS and related IT to maximize resource allocation and quality health service delivery in resource-limited settings.These experiences in West Africa highlighted the critical role of IT infrastructure in HIS for outbreak preparedness and response. Therefore, it was promising to see growing use of digital technology to scale up HIS in the DRC 2 years later to guide decision-making where public health infrastructure may be inadequate to meet patient needs.36 Healthcare workers globally have been working without adequate protective equipment and have been forced to decide who should live and who should die through allocation of limited ventilators.37 Without information on access and delivery to guide effective redistribution, the lack of these vital resources leads to higher rates of disease transmission and increased mortality, especially in underserved communities—just as they did in West Africa and the DRC during Ebola outbreaks.36 Furthermore, mandating increased production of required equipment may only be possible in resource-rich contexts and may still be inadequate to fulfill demands in high-burden areas.37 However, strong HIS are essential for the equitable allocation of critical resources in pandemics such as COVID-19, as supply chain requirements vary significantly across locations.In the current COVID-19 pandemic, the scarcity of PPE and emergency supplies has been an issue for even the most well-financed countries and health facilities.25HIS can redirect the allocation of resources precisely to where they are most needed across regions and over time, so that total demand is met within the constraints of limited resources available. Taiwan successfully demonstrated this by leveraging its integrated HIS to analyze multiple national datasets for transparent distribution of PPE to citizens in locations of greatest need.38 As Ebola outbreaks earlier demonstrated, many LMICs do not have the ability to scale up supply of PPE, and often have inadequate supporting infrastructure to effectively implement nonpharmaceutical interventions, such as physical distancing.38 Current trends suggest that LMICs, including Sudan, Nigeria, and Kenya are at heightened risk of being devastated by COVID-19 due to dense populations, local conflicts, and fragile infrastructure.39 Without the ability to efficiently identify and reallocate excess resources from countries that have reached epidemic control to the most vulnerable regions with unmet demand, COVID-19 is likely to disproportionately impact these vulnerable communities.40 Effective HIS can address this gap by identifying areas with real-time shortages in supplies and personnel, just as they did toward the end of the DRC Ebola outbreak. This is even more vital in LMICs that cannot rely on other mechanisms to feasibly “flatten the curve.”While nations should incorporate HIS to survey and track internal stockpiles and allocate supplies based on current and predictive needs, the global context must also be considered. Though the majority of COVID-19 cases were initially confirmed in HICs, transmission of the virus exponentially increased in LMICs.41 Developing HIS within nations could increase global commitments to quality data collection and analysis for evidence-based decision-making. Therefore, global solidarity and investments should be directed toward scaling up HIS and related digital technologies, including real-time data on existing country resources, shifts in geographic hotspots, and infrastructure gaps to curb the spread of COVID-19.Timely support and technical assistance from multilateral organizations, such as WHO and UNICEF, could provide resource development and joint expertise in improving health systems governance and programming through strengthened domestic and global HIS implementation.42 This delayed control measures, as sociopolitical factors were not integrated into HIS to guide pragmatic response strategies at the local level. For example, in West Africa, rumors that ETCs were dangerous negatively influenced health-seeking behavior.44 In the DRC, 2 decades of ongoing conflict added layers of community mistrust of government officials and humanitarian aid organizations.45 Low levels of trust hampered outbreak control programs and fueled attacks on health-care workers and ETCs.46 Community engagement and open dialogue involving local leaders gradually restored trust and eventually provided critical pathways for information to support HIS ownership and guide future outbreak preparedness and response.33Public health emergency interventions often target human behavior change; such measures require reliable information brokered through effective risk communication and community trust. During the recent Ebola outbreaks, fear and uncertainty of the disease appeared to spread as fervently as the virus itself. The mounting public panic paved the path for widespread misinformation and rumors, seeded by convoluted messaging and a chronic lack of trust in domestic governments and foreign intervention.49 In Sierra Leone, community event-based surveillance (CEBS) systems were facilitated by information about social and ecological contexts from local community volunteers to detect, isolate, and treat potential cases to prevent further transmission.50 To be effective, CEBS required local buy-in and relied on relationships among volunteers, communities, and external stakeholders to supplement HIS that tracked clinical and epidemiological data but lacked social context.51 Integrated HIS could thus provide guidance to collect and monitor more context-specific information.In West Africa, the transition from ineffective “sensitization” messages solely aimed at correcting misinformation to bottom-up communication campaigns involving local communities was a turning point in the epidemic response, as it empowered community-based management through informal information systems.52 Lessons from West Africa pointed to the significant role of chiefs and local leaders, but also emphasized informal structures of power, suggesting the need for community participation in HIS decision-making and implementation.53 Further strategies included recruiting local staff for social mobilization, working with religious leaders, engaging local radio and journalists, and hosting community meetings—all possible sources for relevant information in HIS.55While the importance of community engagement has been emphasized in outbreak response, established strategies for sustainable integration of relevant indicators into HIS have not been clearly determined.56 This demonstrates how HIS, when leveraged effectively, can be used to incorporate data related to contact-tracing networks as well as relevant experiences, perceptions, and rumors that may hinder response efforts. This work has been conducted mostly by anthropologists, but there is a need to conduct analyses that can be systematically replicated, validated, and compared.49 A robust HIS can offer the possibility of collecting and systemizing salient social data, and allow communities to be actively involved in informing real-time insights that improve preparedness and response efforts.Notably, the International Federation of Red Cross and Red Crescent Societies (IFRC) published a guide outlining a 5-step process for community engagement to collect data for effective decision-making that was implemented in the DRC outbreak, with a network of volunteers and an extensive database to collect and track rumors and community perceptions as the outbreak transpired.53While the role of HIS in bolstering community resilience and engagement to strengthen outbreak response has been documented following the West Africa and DRC Ebola epidemics, similar mistakes are still being made in addressing the COVID-19 pandemic.57 For example, a lack of effective COVID-19 communication in Iran’s response programming continues to fuel mistrust and inhibit adequate emergency measures, mirroring poor risk communication practices from prior Ebola outbreaks.58 While credible authorities, such as the WHO and the Centers for Disease Control and Prevention (CDC), have routinely provided up-to-date information, their social media posts have only reached several hundred thousand social media engagements, such as liking or sharing a Tweet or Web page. This level of credible social media engagement is dwarfed by the over 52 million engagements garnered by hoax and conspiracy theory websites by March 2020, highlighting the challenge of curtailing “viral” fake and misleading news that spreads quickly among the general public.57 Social media posts with disinformation have been increasing, often with racist and xenophobic remarks particularly aimed toward people of Chinese origin living in other countries, as exemplified by the hashtag “#ChineseDontCometoJapan” trending on Twitter.59 The lack of effective surveillance, tracking, and accountability of these xenophobic statements by current systems means governments struggle to forecast their negative effects. This has further isolated key populations, stigmatized reporting of symptoms, and fueled prejudices that may harm communities well beyond the current crisis.60 The WHO refers to this as the “Coronavirus Infodemic” and has noted that tackling misinformation is just as important as fighting the pandemic itself.61 Similar to challenges faced in communicating preventive practices at the start of the West Africa Ebola outbreak, it is clear that initial strategies for disseminating accurate information and risk communication for COVID-19 are not working, and the role of community trust is, thus, more critical than ever.One of the biggest sources of mistrust has been the circulation of false and misleading information about COVID-19 prevention and treatment options.61 HIS could aid in addressing the current COVID-19 infodemic and future health crises through 2 additional mechanisms. First, integrated HIS could help identify vulnerable populations at greater risk of COVID-19 exposure, detailing community engagement methods supported by data collected at the community level. Vietnam, similar to the DRC during Ebola, has ensured a strong focus on engaging communities through media directed by medical experts, which has proven extremely effective in reducing transmission of COVID-19.62 However, more comprehensive HIS could be used to develop individualized programs that meet the needs of specific communities with targeted interventions, including tailored information campaigns, socioeconomic support, and access to health-care resources. Second, just as contact tracing identifies people potentially exposed to COVID-19, HIS could include information about the source and spread of misinformation and create counter-campaigns with accurate information, drawing from IFRC’s 5-step process for community engagement in the DRC Ebola outbreak. Powerful analytics such as artificial intelligence (AI) and big data technologies could be leveraged to ensure that these procedures are conducted effectively while also protecting privacy.63 Robust HIS could, therefore, refine risk communication that builds trust as well as informs new population-specific community engagement methods.HIS have been used to generate valid scientific data, but are not being used to identify at-risk populations to effectively engage. Strategies the WHO has implemented in the COVID-19 pandemic include directly engaging with social media platforms and ensuring partner websites have banners linked with accurate information.Strengthening contextual HIS are critical to inform outbreak response, but also generate evidence to build resilient health systems. Exploring and applying HIS lessons from previous Ebola outbreaks provides an opportunity to improve pandemic preparedness, mitigation, and response strategies for other emerging diseases. These experiences are of particular value to the ongoing COVID-19 pandemic. The uncertainties fueled by rapid disease progression and a lack of effective information systems across local, national, and global levels exposes evolving gaps in global HIS that should be addressed to curb transmission and mitigate downstream health and socioeconomic impacts.39 At an international level, reforms from the Ebola outbreaks have led to improvements in sharing of clinical trial data.18 We recommend further reforms so that other sources of vital HIS data, including observational studies and disease monitoring and surveillance programs are openly shared. This is critical to ensure all countries have the necessary information to implement rapid protocols and strategic plans for potential pandemics such as COVID-19.41Strengthening local and regional HIS governance and coordination provides vital data that allows governments to make real-time policy decisions, allocate resources, and inform preparedness plans. Priorities should be aligned across global health agendas to reduce fragmentation of policies and programs that constrain HIS during health emergencies. At a national level, recent Ebola outbreaks have demonstrated the urgency for integrated routine and emergency surveillance systems to avoid redundant or parallel systems, and COVID-19 has underscored the need for improved data streamlining and data sharing at all levels of governance.44 While the measures implemented in Taiwan may not be achievable everywhere, even small investments in health systems infrastructure may yield massive health gains, before, during, and after a crisis.43 We recommend that as countries strengthen their HIS, they consider investments in IT and national EMRs as mechanisms for responsive, accountable, and equitable resource allocation. Centralized databases of HIS may also enable novel analysis with the help of AI and other innovative technologies.Building health systems infrastructure requires scaling up HIS implementation and integration in primary health-care programs to help efficiently direct key resources like PPE and health workers. The West Africa and DRC Ebola outbreaks demonstrated the need for stronger HIS and enhanced IT capacity to manage limited resources. In contrast, Taiwan’s COVID-19 pandemic response that leverages an integrated, national EMR has shown how robust HIS can be a vital tool to support contact tracing, surveillance, and PPE distribution in the context of scarce medical supplies.25 Second, addressing rumors and misinformation is vital in stopping transmission and improving cooperation for better health outcomes.53 Therefore, HIS should be developed and implemented to address the “infodemic” by helping identify sources of misinformation and generating targeted evidence with relevant information for specific communities.Promoting community engagement and resilience is crucial in responding to emerging disease outbreaks and other health emergencies. The Ebola epidemics and ongoing COVID-19 pandemic demonstrate how local context affects adequate response, thus emphasizing community participation as a critical component at all stages of emergency preparedness. HIS provide a platform to employ and adapt community empowerment and engagement. First, communities can guide consideration, prioritization, and decision-making for which data are gathered and analyzed. This would improve accuracy and build local trust so that HIS could be used as they were in Taiwan to identify, track, and treat high-risk populations with targeted approaches.The failures of health systems in the previous Ebola outbreaks and a globally catastrophic pandemic like COVID-19 are often discussed, but may overlook the critical role of information systems in optimizing decision-making and health emergencies response. Robust HIS that are adequately financed and developed before a future outbreak can cyclically strengthen health systems and pandemic preparedness and response capacities. High-performing and effectively leveraged HIS are catalytic in informing coordinated global health governance and ensuring timely, transparent data sharing. They strengthen health infrastructure by reducing fragmentation and costs while streamlining equitable resource allocation. They offer new ways to foster community engagement, combat misinformation, and cultivate trust.As COVID-19 has shown, major pandemics can drive even the most stable economies into fragile conditions while forcing already-fragile contexts into more vulnerable states. Investments in HIS can prevent this cascading deterioration of global economies and security by offering timely insights as a backstop to enable national governments to quickly prevent, detect, and respond to public health threats, fostering more robust response and recovery interventions and building a resilient post-COVID-19 world.


Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women’s self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state’s population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB’s SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper – the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement – seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the  Key barriers to sustainable impact at scale include insufficient leadership and management capacity across multiple levels, especially at the top; the complexity of implementation across heterogeneous delivery platforms; insufficient development of methodological approaches for monitoring and evaluation (including measures and metrics) that address the complexity inherent to the operation of health systems and services in real-life scenarios; diminished implementation fidelity wherein interventions may be effective during piloting but falter under different conditions or reduced intensity at scale; and lack of engagement of local implementers and communities [20].High-performing primary health care (PHC) systems are essential for attainment of the Sustainable Development Goals (SDGs) and universal health coverage . Several studies – while citing methodological limitations around large-scale studies of PHC initiatives – have captured consistent evidence in multiple low- and middle-income countries (LMICs) that investments in PHC systems can lead to improved health outcomes including increased access to essential health services, reduced child mortality, and reduced wealth-based disparities in mortality . Further, there is a robust body of evidence correlating interventions delivered through specific service delivery channels or platforms with improved reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes, including 1) strengthening the capabilities of frontline workers (FLWs) [4-7]; 2) skill development and staff training at public health facilities [8]; and, 3) exposure to multifaceted social and behaviour change communication (SBCC) programs, community participation efforts, and women’s self-help groups (SHGs), among other channels for individual and collective behaviour change [9-17]. Nevertheless, gaps in knowledge persist regarding how PHC systems in LMICs can acquire and sustain the organisational capacities and human resources required to consistently deliver high-quality services in ways that contribute to sustained and equitable improvements in health outcomes at the population level. Multiple studies have also pointed to significant gaps in PHC performance including major constraints in access to quality care, retention of a competent workforce, and advancement of patient-centeredness in care . Effective scale-up of evidence-based health interventions across populations has been particularly challenging.Designing a roadmap for making smart investments in PHC systems has been obfuscated by a lack of evaluation methods that can yield insights into what, how, for whom, and at what levels of the system interventions work. One review of 106 health system evaluations noted that very few adopted a comprehensive approach to assessing system-wide effects, and most evaluations only targeted one “building block” of the health system [21]. Moreover, only 32% and 5% of 76 evaluations reviewed in one study used quasi-experimental and experimental designs, respectively [1]. Even when evidence is generated that might be useful to policymakers and program designers, it can take many years for research to be widely disseminated, and even longer to become standard practice, while alternative interventions or approaches might continue to be deployed and to evolve further within the program or system where they originated.The Lancet Global Health Commission on High Quality Health Systems in the SDG Era [23], as well as through the identification of critical research gaps . There is a need to identify research methods which can provide policy-relevant learning, including policy and implementation research which seeks to provide generalisable evidence on what works in a variety of contexts and at scale [26].In recent years, there has been a concerted effort to coalesce around the most effective PHC practices and measurement approaches through initiatives such as the Primary Health Care Performance Initiative [22] and Ananya (Hindi for “unique”), a large-scale RMNCHN technical support program funded by the Bill & Melinda Gates Foundation (BMGF) was implemented in the state of Bihar, India, beginning in late 2011. Ananya has important contributions to make to PHC systems research. The Bihar program provides an opportunity to learn how to effectively study a large-scale PHC program and its attempts to address key evidence gaps and yield new insights on improving PHC system performance, strengthen community-based interventions such as SBCC and SHGs, and enhance service delivery across populations. In this series, we share learnings from this technical assistance program beginning with deep implementation support to the Government of Bihar (GoB) in eight pilot districts (which was branded as Ananya) and subsequent adaptation and scale-up of implementation technical assistance under the Bihar Technical Support Program (BTSP) at significantly reduced intensity of support to the GoB across the 38 districts in Bihar. Our aim is to help inform the efforts of policymakers, system administrators and practitioners to more effectively achieve widespread RMNCHN impact at scale. This first paper provides an overview of the context of the Ananya program, as well as the program and evaluation designs. Subsequent papers in this series delve into greater detail on the multiple delivery platforms of the program and their impacts, including FLW capacity-building, SHGs, SBCC efforts, and quality improvement of facility-based care.Ananya began, Bihar had recently emerged from decades of political upheaval and widespread breakdown of the rule of the law. The health sector suffered from pervasive and deeply entrenched deficiencies of leadership, funding, infrastructure, commodities, management, and staffing, and amongst the population, awareness and adoption of critical RMNCHN behaviours were low [27]. Bihar was performing well below India state averages across several surveys of critical RMNCHN indicators (Table S1 A-C in the Online Supplementary Document). [28]. Given the large population and poor health indicators of Bihar, it was clear that improvements in the state’s health system could have a significant impact on progress toward national and global health goals.In 2010 when Janani Bal Suraksha Yojana program − a safe motherhood initiative under the NRHM − provided a conditional cash transfer to women for delivering in a health facility which catalysed unprecedented levels of institutional deliveries [32]. JEEViKA was launched in 2007 by the Bihar Rural Livelihoods Promotion Society under the Department of Rural Development, with the support of the World Bank Group [33]. The program focused on organising women in poor rural households through SHGs and related community institutions, helping them improve their livelihoods and enhance household incomes.Despite its challenges, Bihar was experiencing impressive economic growth as it emerged from prolonged stagnation, and the government was attempting to rapidly modernise its administration, infrastructure, and health services. High-level political committment to improvements in health and human development coincided with increased funds from the central government through the creation of the National Rural Health Mission (NRHM) in 2005, the Ministry of Health and Family Welfare (MoHFW)’s flagship program [29]. The NRHM was focused on RMNCH, with the goal of reaching the most marginalised communities with priority health interventions with flexible funding and space for state-led innovations.. The state’s health expenditure, spurred by NRHM funding, was growing rapidly [30]. A substantial contribution of the NRHM was the number of health workers, particularly District and Block Program Managers, Auxiliary Nurse Midwives (ANMs) and Accredited Social Health Activists (ASHAs) that were being contracted but often not fully trained and prepared to perform their roles [31]. The Concurrently, other development partners and donors were making significant investments in Bihar’s health system. UNICEF and the World Health Organisation had a preexisting presence in Bihar. The United Kingdom’s Department for International Development (DFID) had just launched their five-year $220 million program – Sector-Wide Approach to Strengthening Health in Bihar (SWASTH) – to strengthen health, nutrition, water and sanitation systems across Bihar [34]. The Norway India Partnership Initiative (NIPI) had also started to engage with the state government to support newborn care. Against this backdrop of mounting government and donor commitments to Bihar’s health system, the BMGF began to commit significant resources to Bihar, as complementary to other partner investments, but with a sharp program.Ananya program would focus on testing a range of innovations designed by Ananya partners for implementation across multiple public delivery platforms by GoB functionaries to increase the coverage of critical RMNCHN interventions in eight out of Bihar’s 38 districts , and involved no direct transfer of cash or material from BMGF or partners to the government. Rather, Ananya engaged partners in Bihar to work together with concerned governmental departments and programs in improving implementation design, prioritising interventions for achieving stated goals, and measuring and monitoring progress using indicators and credible sources of data that were otherwise unavailable to the government. The Ananya program’s initial “Theory of Change”  to layer health, nutrition and sanitation interventions within SHGs, coupled with a grant to Population Council to evaluate the impact of the Parivartan program; and 4) a grant to Mathematica to evaluate the impact of IFHI and SDP in focus districts during the pilot phase. Additional investments not covered in this paper collection included grants intended to: 1) Consolidate and standardise primary treatment for childhood illnesses including diarrhea, pneumonia and tuberculosis through a network of private rural medical practitioners  in an Incremental Learning Approach (ILA) implemented through the health subcentre platform, which was formally created by the state government for this purpose  using an intersectional approach based on wealth and caste [61]. Differences in impacts for women at the two extremes – the least vs. the most disadvantaged – by wealth and caste were estimated using difference-in-difference estimators from Mathematica data collected at the beginning (2012) and after two years of program implementation (2014). Changes in disparities over time were also analysed using eight rounds of CHS (2012-2017). Key questions addressed were: were there disparities in indicators at baseline, and did the disparities change over the course of the program during the piloting and scale-up phases? Ananya initiative generated an expansive amount of data which had not been comprehensively analysed, synthesised and widely shared. Therefore, much of the Ananya story – with its invaluable experiences, insights, and evidence drawn from robust quantitative and qualitative data – had not yet been told.The Ananya and subsequent statewide scale-up (Ananya program’s interventions and delivery platforms, the public health system in which it was embedded, and the communities and households that they sought to impact. We also aim to inspire additional analyses of more specific elements of Ananya that will further advance learning from this unique public health program. Capturing lessons from Ananya and the statewide scale-up of Ananya innovations will assist program managers and policymakers in India and across the world to more effectively design and implement RMNCHN programs, and to improve the performance of community-based, outreach and facility-based health systems.To address this gap, this journal has commissioned a series of papers led by Stanford University – authored by multiple universities, evaluators, and implementing organisations – to provide a unified, comprehensive and evidence-based analysis of the successes, challenges, and insights from


Indigenous people continue to experience high rates of multiple chronic conditions (MCC) at younger ages than other populations, resulting in an increase in health and social care needs. Those who provide services designed to address MCC for Indigenous communities require synthesized information to develop interventions that meet the needs of their older adult population. This review seeks to answer the research question: What are the health and social care needs, priorities and preferences of Indigenous older adults (living outside of long-term care settings) with MCC and their caregivers?A scoping review, guided by a refinement of the Arksey & O’Malley framework, was conducted. Articles were included if the authors reported on health and social care needs and priorities of older Indigenous adults. We also included articles that focused on Indigenous conceptions of wellness, resilience, well-being, and/or balance within the context of aging, and articles where authors drew from Indigenous specific worldviews, ways of knowing, cultural safety, cultural competence, cultural appropriateness, cultural relevance and community needs.This scoping review included 9 articles that were examined using an Indigenous determinants of health (IDH) theoretical framework to analyze the needs of older adults and CGs. Five areas of needs were identified: accessible health services; building community capacity; improved social support networks; preservation of cultural values in health care; and wellness-based approaches.The review highlights key determinants of health that influenced older adults’ needs: education and literacy, ethnicity, and social support/network ; health promotion and health care (intermediate); and a combination of historical and contemporary structures . The findings highlight the importance of local Indigenous knowledge and perspectives to improve accessibility of culturally relevant health and social services. The aging of Indigenous populations is pressuring health and social care systems to recognize and account for the needs and cultural values within diverse Indigenous communities , 2. DespIndigenous leaders and those who provide services designed to address MCC for Indigenous communities require synthesized information on emerging social and health care needs. Despite the need for both Indigenous specific and local information to guide effective planning, to our knowledge, there is no review of the health and social care needs of Indigenous older adults with MCC and their caregivers. As a starting point, we aimed to conduct a comprehensive scoping review asking the following research question: What are the health and social care needs, priorities, and preferences of Indigenous older adults (living outside of long-term care settings) with MCC and their caregivers?As Indigenous peoples experience population aging, Indigenous leadership, researchers, and policy-influencers are making efforts to support communities by embracing that Indigenous determinants of health are distally rooted in historical and ongoing acts of colonialism . These eThe Indigenous Determinants of Health theoretical framework is best described by Charlotte Reading using the metaphor of a tree . The IDHIn addition to the IDH theoretical framework, the ICF framework offered a comprehensive, multidimensional, and holistic context at both the individual and population level. This framework implies that the interaction between an individual  and contextual factors  lead to (a) impairments in body functions and structures, (b) limitations in activity, and (c) restrictions in participation , 14. ComThis scoping review was an Indigenous-specific sub-project of a broader review whose review protocol and results have been published , 16. TheFollowing the development of the research questions, two academic health sciences librarians prepared the search strategy in consultation with the original research team, which included one Indigenous researcher (JW). This comprehensive review involved multiple databases including OVID Medline , OVID Embase (1947 to 2017), OVID PsycINFO (1806 to 2017), OVID Social Work Abstracts (1968–2017), EBSCO CINAHL Plus with Full Text (1981 to 2017), EBSCO AgeLine (1966–2017), and Cochrane Central. The search strategies were translated using each database platform’s command language, controlled vocabulary, and appropriate search fields. The search concepts of health and social care needs and priorities, Indigenous populations, and multimorbidity employed the use of MeSH terms, EMTREE terms, APA thesauri terms, CINAHL headings, and text words. Specific search terms for Indigenous populations included those listed in Table S1: Medline Search.We applied a modified adult age filter to the Medline strategy . This fiStudies with any type of design, including quantitative, qualitative, mixed or multi-methods research, arts-based, and comparative methods designs were included for review.Reports on the health and/or social care needs, preferences, and/or priorities of Indigenous peoples, and/or caregivers of older Indigenous adults. This included both informal (family/friend) and formal  caregivers who provided care for an Indigenous community member.Literature with a focus on Indigenous populations and persons with a mean age of 55 years and older or including a sub-group analysis for Indigenous persons living with MCC, their caregivers, or health care providers.Focus on wellness, resilience, well-being, and/or balance within the context of aging.Indigenous specific worldviews, ways of knowing, cultural safety, cultural competence, cultural appropriateness, cultural relevance and community needs.Study selection followed a two-step process : 1) an iExpert opinions, editorials and materials that did not include original data.Publications in languages other than English.The exclusion criteria included:Data abstraction was completed using an Excel Spreadsheet. The data for each study was abstracted by two independent reviewers. Codes representing the World Health Organization’s (WHO) definition of structural and social determinants of health  combinedThe quality of the research studies was assessed using the Mixed Methods Appraisal Tool (MMAT) . The MMATo map the data and conduct a thematic content analysis, we used the two frameworks described above. Where appropriate, we used deductive thematic analysis on relevant extracted data from the published studies to map the studies. We aimed to incorporate a rigorous methodological approach suggested within the literature . ConsultWe present the results in two ways: 1) a numerical overview of the amount, type, and distribution of the included literature; and 2) a narrative synthesis and mapping of the results.Following the previously published protocol , 34,391 The age range of the participants was reported in eight studies, as presented in Table Additional information on older adults as study participants is presented in Table Table Caregivers were not included in five of the studies –3, 6, 26All of the papers were assessed based on the Mixed Methods Appraisal Tool (see Table S2) . Of the The cross-sectional study  was apprData collection methods used in the studies primarily includes one-on-one interviews , 26, 28 Primarily, we applied the IDH framework to examine the needs of older adults and caregivers and this was supplemented by an understanding of the ICF framework. Proximal determinants of health were addressed within all the studies  to better assist older adults to manage their conditions .Indigenous populations have a strong focus on social support which mostly includes family involvement and the need to return to the traditional ways of intergenerational caregiving , 9, 27. Wellness-driven activities include an incorporation of cultural perspectives about relationships, family participation, aging at home, staying on land, wellness/cultural identity on aged care ; connectThe use of the Indigenous Determinants of Health (IDH) theoretical framework , 11, andThe strengths of this review included a comprehensive search of electronic data bases carried out by expert health sciences librarians, which involved some exploration on how to determine search terms for “Indigenous populations,” and two Indigenous reviewers simultaneously abstracting the data and completing multiple checks of the articles in this review. However, a limitation to the search strategy exists in that the database search did not include social programs for Indigenous people that would not be in the health literature. Extending the search to include this will further provide confidence in the representation of the findings related to older Indigenous adults living with MCC.The IDH and ICF frameworks served as a guide to present our findings and the results resonated with our stakeholder group, which helped to validate the results. Although we incorporate spirituality in the theme “the need for cultural preservation in health care, it must be analyzed more clearly and with more vigor than this analysis has attempted. Further studies that incorporate the IDH model as a theoretical framework must pay closer attention to the importance of spirituality in the analysis. The Indigenous spirituality is a core value and central to balancing holistic health; and is considered as equal as physical, mental and emotional health , 27. AltThis scoping review was developed, overseen, and carried out in a collaborative partnership with a research team consisting of knowledge users, health stakeholders and Indigenous scholars. This research is important for health care professionals and leadership working with Indigenous older adults who seek to develop interventions that will meet these needs and assist with improving quality of life. The development of knowledge translation activities needs to reflect an all-inclusive approach between First Nations people and the health sector. Combined with key recommendations from health stakeholders, further thematic analysis of the articles using an approach that reflects local Indigenous knowledge and concepts such as accessible health services and cultural safety will improve findings. The First Nations-specific group will seek further opportunities to expand on the recommendations from this scoping review outside of publishing a manuscript.Additional file 1: Table S1. Medline Search. Table of Medline SearchAdditional file 2: Table S2. Quality Assessment Using the Mixed Methods Appraisal Tool. Table of nine studies assessed using the MMAT


We investigated cardiovascular health, functional disability and leisure activities profiles independently and in relation to cognitive decline and dementia in high and low-medium income countries using data from the English Longitudinal Study of Ageing, Irish Longitudinal Study on Ageing and Brazilian Bambui Cohort Study of Aging. Functional loss among older Brazilians has shown a hierarchical sequence over the 15-year follow-up, with the highest incidence in functional disability reported for dressing, followed by getting out of bed, bathing/showering, walking across a room, using the toilet and eating (de Oliveira). Using the Life’s Simple 7, an ideal cardiovascular health scoring system evaluating the muscular strength, mobility and physiological stress, we showed a reliable prediction of cognitive trajectories in a representative sample of Irish individuals (De Looze). Within the same cohort, we report discrepancies between men and women in functional decline driven by domestic tasks, rather than determining differential cognitive trajectories (McGarrigle). In an English representative sample, we found that participants with an increasing number of functional impairments over almost a decade were more likely to be classified with subsequent dementia compared with those with no impairments and this may imply a more comprehensive ascertainment during the prodromal stage of dementia (Cadar). In contrast, a reduced risk of dementia was found for individuals with higher levels of engagement in cognitively stimulating activities, that may preserve cognitive reserve until later in life (Almeida). Identifying factors that influence cognitive aging and dementia risk in a multifactorial perspective is critical toward developing adequate intervention and treatment.


A thorough bibliographic survey on the use of embryo-tests with aquatic animals for toxicity testing was performed. The data regarding to the compounds sensitivity , the available resources for the different animal models , together with the European pieces of legislation regarding to animal testing and the available testing guidelines of national and international agencies  were gathered, aiming to the standardization of new embryo-test model species for toxicity testing of new and existing compounds. The data contained in this Data in Brief article is presented and discussed in the review article with the title Embryo bioassays with aquatic animals for toxicity testing and hazard assessment of emerging pollutants: a review [1]. The dataset is provided with this article as a supplementary file. The Annex 1 (Resources by species), gathers the available information for each model species and taxa: Guidelines, Life-cycle, Laboratory cultures, Number of embryos and embryo transparency and Genomic and Transcriptomic resources. The Annex 2 (Testing guidelines), compiles the available testing guidelines by model species developed by National and International Agencies . The Annex 3 (European regulations) gathers the current and previous European legislations regarding to animal experimentation and hazard assessment. The Annex 4 (Sensitivity data), gathers the sensitivity data obtained in embryo, and larval tests, with aquatic metazoans for different contaminant classes.2https://eur-lex.europa.eu/homepage.html) and guidelines  were also gathered. The collected information is presented and discussed in a review paper [A thorough bibliographic survey on the use of embryo-tests with aquatic animals for toxicity testing was preformed. Information on the use of embryos, larvae or juvenile aquatic animals on toxicity testing was gathered. NOEC, LOEC, EC50 and LC50s for the different model species using different testing compounds were collected, together with the assay characteristics . Only research papers published in indexed journals were considered for this collection. Sensitivity data were converted to microgram per liter (μg/L) when necessary and no further processing was applied. The available resources by model (bibliographic survey), available legislation (ew paper .


Physician adherence to guideline recommendations for the use of opioids to manage chronic pain is often limited.  In February 2018, we administered a 28-item online survey to explore perceptions of the 2017 Canadian guideline for opioid therapy and chronic noncancer pain and if physicians had altered practices in response to recommendations.  We invited 34,322 Canadian physicians to complete our survey, and 1,128 responded for a response rate of 3%; 687 respondents indicated they prescribed opioids for noncancer pain and answered survey questions about the guideline and their practice. Almost all were aware of the guideline, 94% had read the document, and 89% endorsed the clarity as good or excellent. The majority (86%) felt the guideline was feasible to implement, but 66% highlighted resistance by patients, and 63% the lack of access to effective nonopioid treatment as barriers. Thirty-six percent of respondents mistakenly believed the guideline recommended mandatory tapering for patients using high-dose opioid therapy , and 58% felt they would benefit from support for opioid tapering. Seventy percent of respondents had changed practices to align with guideline recommendations, with 51% engaging some high-dose patients in opioid tapering and 43% reducing the number of new opioid starts.  There was high awareness of the 2017 Canadian opioid guideline among respondents, and preliminary evidence that recommendations have changed practice to better align with the evidence. Ongoing education is required to avoid the misunderstanding that opioid tapering is mandatory, and research to identify effective strategies to manage chronic noncancer pain is urgently needed. Canada is the world's second largest per capita prescriber of opioids , and escThe 2017 guidelines were supported by many Canadian medical organizations, including members of the Pan-Canadian Collaborative for Improved Opioid Prescribing , the Association of Faculties of Medicine of Canada, the College of Family Physicians of Canada, the Federation of Medical Regulatory Authorities of Canada, and the Royal College of Physicians and Surgeons of Canada) . To incrhttps://app.magicapp.org/app#/guidelines), an online platform that provides guidelines in an interactive, multilayered format. We further queried if respondents had made any changes to their practices in response to guideline recommendations. We tested the questionnaire with members of the collaborative, and changes were made to include questions regarding supports needed by physicians. We pretested the final questionnaire on a group of 3 physicians who prescribed opioids for chronic noncancer pain, who also commented on its clarity and comprehensiveness and on the time required to complete it (5–8 minutes). No further modifications were suggested by pretest participants , and most were family physicians  practicing in Ontario . Forty-two percent (282 of 676) reported that >10% of their patients sought care for chronic noncancer pain, and 36% (214 of 596) prescribed opioids to >10% of their patients .Almost all respondents were aware of the 2017 Canadian opioid guideline  and had read it thoroughly  or in part . Similar proportions had read the print  and online MAGICapp  versions; 19% (109 of 588) had read both. The large majority of respondents endorsed both print and MAGICapp formats as good or excellent (82% for both); however, twice as many endorsed the online MAGICapp version as excellent (18% vs. 9%).Eighty-nine percent of respondents agreed the clarity of the guideline was excellent  or good . Some respondents  felt the 2017 Canadian opioid guideline had advantages over competing guidelines, whereas 49% (262 of 538) were unsure and 12% disagreed (63 of 538). Those who reported advantages most often highlighted its national scope  and specific guidance . Sixty percent agreed the 2017 Canadian opioid guideline was evidence-based; 32% were unsure, and 8% disagreed.  When askEight-six percent of respondents felt the guideline was either very feasible  or somewhat feasible  to implement. Of the 14% (79 of 553) that felt the guideline was not feasible to implement, the most common concerns were that recommendations were too restrictive regarding the use of opioids  or that recommendations were impractical .Most respondents acknowledged resistance by patients , financial barriers to nonpharmacologic treatment , and lack of availability of nonpharmacologic treatment  as implementation challenges. Many respondents noted inadequate time to manage complex cases , lack of access to addiction management services , and that it was unrealistic for some of their high-opioid dose legacy patients to engage in tapering  . When asMost respondents felt that increased coverage for chronic pain treatment options by insurers , and greater availability of chronic pain treatment services  would facilitate guideline implementation. Forty percent of respondents (235 of 590) indicated that billing incentives were required to encourage physicians to spend more time with their chronic noncancer pain patients. The most requested topics for continuing medical education (CME) among respondents were for assistance managing demanding, resistant, or nonadherent patients on chronic opioids  and instruction on nonopioid options for managing chronic noncancer pain  . The mosThe majority of respondents  agreed there were areas where their practice had differed from recommendations of the 2017 Canadian opioid guideline, and 79% said they had (70%) or intended (9%) to make changes to their practice because of guideline recommendations. Only 16% (96 of 590) reported they did not intend to make any changes to their practice. Specifically, in response to the guideline, 51% (301 of 590) of respondents had engaged some of their legacy patients in opioid tapering, and 43% had reduced the number of new starts of opioid therapy (254 of 590). Approximately a third  had reduced the number of opioid tablets they prescribed at one time, and 32% (191 of 590) had reduced the dose of opioids they prescribed for new starts. A small minority of physicians had either stopped prescribing opioids for chronic noncancer pain  or increased their prescribing of opioids for chronic pain  .Almost all opioid-prescribing survey respondents were aware of the 2017 Canadian opioid guideline and endorsed its clarity and feasibility of implementation; the majority agreed the guideline was evidence-based. Resistance from patients and lack of access to effective nonpharmacologic therapy for chronic pain were the main reported barriers to implementation, and most respondents wanted assistance with tapering high-dose opioid patients. Only half of our respondents were confident that the guideline did not mandate tapering for patients prescribed high-dose opioid, and the majority had altered their practices as a result of the guideline, most often involving tapering legacy patients and reducing the number of new starts of opioid therapy for chronic noncancer pain patients.The 2017 guideline was published with the MAGICapp online platform due to feedback that print versions were cumbersome to use in practice , and twiPhysicians are well-trained in prescribing, but not always in deprescribing, and a number of our survey respondents highlighted this challenge; the third most requested CME topic was strategies to safely taper opioids. There is likely a dose-dependent increase in the risk of nonfatal and fatal opioid overdose , 15. Morhttp://www.magicapp.org/public/guideline/8nyb0E).It is noteworthy that approximately a third of respondents to our survey felt the 2017 guideline endorsed mandatory opioid tapering among patients prescribed high-dose opioid therapy, and this may reflect confusion between weak and strong recommendations. Recommendation 9 of the guideline, which suggests tapering opioids to the lowest effective dose for patients prescribed ≥90 mg MED, potentially including discontinuation, rather than making no change in opioid therapy, is a weak recommendation. This means that while the majority of informed patients would choose the recommended course of action, an appreciable minority would not. With weak recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and they should help patients arrive at decisions consistent with their values and preferences. The online version of the 2017 Canadian guideline includes patient decision aids for all weak recommendations , the Alberta Medical Association Section of Chronic Pain, and the Pain Society of Alberta signed an Agreement in Principle to support chronic pain patients prescribed long-term opioid therapy (https://www.painab.ca/uploads/1/0/8/0/108066059/aip.pdf). This document, which sites the 2017 Canadian Opioid Guideline for support, advises, in part, that no individual on long-term opioid therapy should be abruptly discontinued. Similar agreements in other provinces may be helpful for re-enforcing this message among prescribers.On October 18, 2019, the College of Physicians and Surgeons of Alberta, HELP Alberta's Pain (a patient advocacy group; Many respondents felt that greater access to effective chronic pain management was required; however, while nonopioid alternatives would be expected to reduce harms associated with long-term opioid use, the incremental benefit for chronic pain sufferers is uncertain. Pharmacologic therapies that have been directly compared with opioids show similar, small effects on pain and function . MoreoveStrengths of our study include a comprehensive sampling of Canadian physicians who prescribe opioids for chronic noncancer pain. Moreover, our survey development and administration was consistent with best practices . Our finThere was very high awareness of the 2017 Canadian guideline for opioid therapy and chronic noncancer pain among respondents to our survey, and most physicians reported changing their practices to align with recommendations. Optimizing opioid-prescribing for chronic noncancer pain should reduce opioid-related harms, but confirmation from rigorously conducted observational studies is required. Further education appears needed to ensure appropriate interpretation of weak and strong guideline recommendations, and re-enforcement that forced opioid tapering is inappropriate. The Canadian opioid crisis has highlighted the urgent need for improved management of chronic pain; however, the lack of highly effective therapies suggests that further research is urgently needed versus simply expanding access to existing treatment options.