Recent research into the role of mental health social work has identified a need for increased critical engagement with accounts of professional role and identity. Notably, a number of studies have found that social workers struggle to articulate their role within mental health teams and services. This study aimed to identify the ways in which social workers in mental health settings defined their professional identity and role. An international scoping review utilizing Arksey and O’Malley’s method was conducted, identifying 35 papers published between 1997 and 2022. A thematic analysis grouped the findings into three predominant themes: (i) distinct social work approaches to mental health, (ii) organizational negotiations for mental health social workers, and (iii) professional negotiations for mental health social workers. These thematic findings are discussed in relation to existing research and critical perspectives, with particular emphasis on accounts of the bureaucratic and ideological functioning of professionalism in mental health services, as well as the global direction of mental health policy. This review finds that mental health social work embodies a coherent identity that aligns with international mental health policy agendas but faces significant challenges in developing and expressing this identity within mental health services. Changing Lives: Report of the 21st Century Social Work Review notably finding that the “crisis” of social work recruitment, retention, and efficacy ‘is mainly a matter of professional identity’ [Studies into the experiences of social workers in mental health settings have identified a professional role that focuses on implementing social approaches to mental health that foregrounds community and social factors alongside political and policy influences on mental distress ,2,3,4. Ndentity’ ,7. Indeedentity’ ,9. ProfeProfessional identity is a negotiated process and phenomenon, formed through education, training, and practice . Cribb aThe form of this knowledge is, however, contested. Whilst Dixon and Richter’s  study fiThe practice context of mental health social work thus reflects challenging organizational, policy, and ideological terrain. Despite mental health services broadly retaining what Gould  (p. 17) The completion of a scoping review, drawing on a global range of papers in a social work context, necessarily requires consideration of regional and cultural relativity . As suchA scoping review provides a means of examining the extent, range, and nature of existing research, as well as identifying gaps in the literature, making it an effective approach to meeting the research aims of the study . Unlike For this study, Arksey and O’Malley’s  five-staProvide an overview of current understandings and perspectives of social workers in mental health settings on their professional role and identity;Identify research trends within the existing literature and research;Identify gaps in extant research;Make recommendations for future research.The scoping review was guided by the overall research question of how mental health social workers understand their professional identity and role within mental health services. In answering this question, the review aimed to:Utilizing a range of sources is central to the scoping review approach and the initial search for this review, conducted in November 2022, accessed 6 electronic databases and 7 relevant peer-reviewed journals see , yieldinInclusion and exclusion criteria were developed to finalize the papers included in the review. Papers were required to be original, peer-reviewed, and English-language studies addressing a population of social workers in mental health practice settings, reporting on matters of professional identity and professional roles in adult mental health services. If multiple professions were reported on in a study, then distinct mental health social worker participant contribution was required. The inclusion criteria of the scoping review also required research to be qualitative but remained open to a wide range of theoretical and methodological approaches; mixed-methods studies required a distinct qualitative aspect. As the scoping review sought to gather a range of international perspectives, there was no practical cut-off date for paper inclusion to align, for example, with a particular national or statutory context. Papers published since 1997 were therefore included to provide a pragmatic 25-year window of publication synthesis.These criteria were applied to the abstracts of the initial results with 113 papers meeting these requirements. This included the exclusion of 9 papers that were not published in English. As outlined by Badger et al. , an abstDrawing on Arksey and O’Malley’s  model, dThis stage of the scoping review process enabled the general characteristics of the literature to be synthesized, as well as the reporting of key themes through thematic analysis (in the Results section below).n = 17, Scotland n = 3, Northern Ireland, n = 2, Wales n = 1, and all the United Kingdom n = 1). European nations were represented in 25 studies , North America in 5 studies , Oceania in 4 studies , Asia in 1 study (Hong Kong), and Africa in 1 study (South Africa). Three studies synthesized data across multiple countries. The literature comprised 35 journal articles. Twenty-one nations were represented in the study. Practice perspectives from the United Kingdom were prominent  distinct social work approaches to mental health, (ii) organizational negotiations for mental health social workers, and (iii) professional negotiations for mental health social workers.A consistent finding across the studies was the distinct professional offering of social workers in the field of mental health through holistic, social, and rights-based approaches. Social workers emphasized the ‘widening’ of perspectives within mental health teams through their professional input, embedding an alertness to social determinants of mental health ,36. SociEmbedding rights and social engagement in practice thus emerged as a fundamental value of mental health social work. Social workers enacted these approaches, both within and against their employing services, with accounts of professional dissatisfaction relating to mental health service provisions failing to adequately engage with social and community resources ,9,41,42.A predominant finding across the literature was mental health social workers identifying legal knowledge as a central and distinctive aspect of their role. This knowledge, particularly of mental health law, not only separated mental health social workers from other healthcare professionals but also from generic social work as a ‘specialized’ professional role . The conThe emphasis on the legal role of mental health social workers was dominated by English and Welsh practice perspectives on the Approved Mental Health Professional (AMHP) role, mandated by the Mental Health Act 2007. Mental health social workers in these contexts viewed their profession as well placed to fulfil this statutory role, applying social perspectives to decisions on compulsory admission to hospitals ,46,47. SStone et al.’s  Europe-wIn a British context, both AMHP and non-AMHP social workers identified organizational dysfunctions, such as a lack of preventative services and late referrals for support, as limiting the fulfilment of social work skills and values in practice ,52,53,54Rigid organizational structures were noted in Hurley and Kirwan’s  study inDespite articulating a values-based skillset that defines professional identity, mental health social workers in the synthesized studies recognized a dominant biomedical outlook to services. This was experienced through an erasure of social perspectives in services, both through an active rejection of social approaches within teams and an overbearing medical outlook of other professionals. Social workers also perceived co-option into medicalized practices within biomedically orientated services.A recurring theme across the review was social workers identifying an erasure of social work concepts within mental health services. Saavedra et al.’s  study coIn many studies, social workers identified a multi-professional apathy toward integrating social approaches within mental health services. This often aligned with a numerical marginalization within teams and, at times, being ‘bottom of the hierarchy’ , with soHamilton et al.’s  study hiThe present study found social workers operating flexibly within services, at times providing a professional role of advocacy on behalf of service users within teams, whilst also looking beyond their immediate organizational role to best meet mental health needs. Social workers in a number of studies identified themselves as representing a bridge between service users and other professionals, acting as mediators in times of challenging clinical treatment and support decisions ,40. ThisSocial workers were also likely to consider certain issues, and seek solutions, from outside of their immediate team, proactively looking beyond specific roles and responsibilities in connecting services, such as health and social care ,59. WhilReflection was understood as central to the ways social workers negotiated their professional roles and experiences, with effective supervision facilitating reflection on the wider contexts of practice and professional identity. Such opportunities were most beneficially realized when social workers were managed and supervised by social workers ,44,58. WSocial workers in Hurley and Kirwan’s  study acWithin the studies, social workers were adept at recognizing tensions between their values and the expectations of organizations, prompting them to consciously assert their professional autonomy, recognize the limits to their role within organizations, and work outside of these constraints to meet their professional values and standards ,57,60.Social workers also demonstrated flexibility in their roles within mental health services, applying holistic relational approaches to inter-professional interactions and recognizing competing priorities and expectations in a manner that enabled leadership in collaborative casework ,41. StonThe thematic findings of the scoping review are discussed in this section in relation to existing critical and global policy perspectives. The discussion also draws on critical accounts of the bureaucratic and ideological function of professionalism in mental health services, finding that mental health social work embodies a coherent identity that aligns with international mental health policy agendas whilst facing organizational and inter-professional challenges in expressing this identity.The synthesized literature presented a coherent and consistent account of social work as embodying a distinctive holistic and social approach to mental health. Such findings contrast with broader perspectives on interdisciplinary social work practice, in which the profession is argued as lacking its own holistic approach informed by distinct social work knowledge .A claim on a distinct framework of knowledge is understood by Beddoe  as a necWhilst the legal duties of social workers were shown in the literature to secure a professional status in mental health services, such responsibilities were also shown to problematize notions of social work professional identity ,50,51. TBoth this review and the existing research find social workers to be attuned to personalized approaches to complexity and risk and such findings indicate the potential for social workers to adopt leadership roles in advocating for, and modelling, personalized and holistic practice ,67. HoweDespite an emphasis within the synthesized literature on English and Welsh practice experiences of organizational and structural challenges for mental health social workers, there was a consistency in the findings across a range of national contexts, with social workers negotiating distinctive professional perspectives and approaches within potentially rigid organizational arrangements and demands. Biomedical approaches to mental health have longstanding and significant prominence in services, both in terms of the number of staff who are trained in biomedical approaches to mental health, and the evidence-based practice underpinnings of services that are, broadly, best suited to quantitative and symptom reduction outcome measures ,55. IndeSuch practice experiences reflect a longstanding critical tension between social work intervention and models of effectiveness guided by New Public Management principles  which, fThe experience of hierarchized professions in mental health services within this review holds significant policy and ideological significance in the formation and maintenance of mental health service delivery and practice. Whilst a distinctive social work approach to mental health can be identified, there remain structural, ideological, and epistemological barriers to a consistent realization of these approaches.As noted by Morriss , and eviThis was notably evident in the review through reported challenges in embedding service user-led recovery approaches in mental health services ,73. NotiBeyond co-opted approaches to mental health, social workers in the synthesized literature also experienced erasure within teams, both through a dearth of social work approaches and the marginalization of the social work role itself. The language of mental health services was found to be a contested site of inter-professional struggle in a range of settings, with language linked to social factors of mental health dismissed by medical colleagues or tellingly absent from the accounts of social workers in mental health teams ,58. WhilRecent global conceptions of mental health services and policy have acknowledged this challenging context for social approaches to mental health, with a United Nations Human Rights Council (UNHRC) Special Rapporteur report acknowledging that:‘the field of mental health continues to be over-medicalized and the reductionist biomedical model, with support from psychiatry and the pharmaceutical industry, dominates clinical practice, policy, research agendas, medical education and investment in mental health around the world’   due to not meeting the language requirements, whilst resource and time constraints meant that translation was not possible. This may go some way to address the relative absence of African and Asian practice perspectives in the study (which accounted for only 6% of the synthesized papers).Given the aims of the study, only qualitative papers were identified and synthesized. The inclusion of quantitative studies of mental health social work professional identity in future research may usefully add to knowledge about the social work role in mental health settings.Future research into mental health social work professional identity could also beneficially explore the experiences of social workers in settings that have a greater prevalence of social workers, such as mental health social care services. There also remains a need for research (or translation of research into English) from regions that were under-represented in the study (such as Africa and Asia) to contribute towards a more representative global understanding of the mental health social work profession.This paper synthesized 35 studies to consider the overarching factors in the experiences of professional identity for mental health social workers. Whilst social workers recognized their professional skills and values as offering a distinct approach within mental health teams and services, the interactions between social and medical models of mental health in these settings and, to a lesser extent, country-specific legal contexts represent a significant challenge to the realization of social work approaches. The study has placed these findings within critical accounts of professional power and influence within mental health services and global policy contexts. Through this, it can be concluded that mental health social work can be emboldened by the resonance of its professional identity with global policy approaches. The promotion of the ‘professional capital’ of mental health social work, through the development of shared connections and networks centered around the knowledge and values that social work brings to mental health services, represents a necessary component of an empowered and effective profession. There persists, however, considerable challenges and negotiations in asserting this identity in organizational and inter-professional frameworks that remain, in various ways, orientated to biomedical approaches.


Rising rates of chronic conditions were cited as one of the key public health concerns in the Fiscal Year (FY) 2021 U.S. Senate and House of Representatives appropriations bills, where a review of current National Institutes of Health (NIH) portfolios relevant to research on women’s health was requested. Chronic conditions were last defined by the US Department of Health and Human Services (HHS) in 2010. However, existing definitions of chronic conditions do not incorporate sex or gender considerations. Sex and gender influence health, yet significant knowledge gaps exist in the evidence-base for prevention, diagnosis, and treatment of chronic diseases amongst women. The presentation, prevalence, and long-term effects of chronic conditions and multimorbidity differs in women from men. A clinical framework was developed to adequately assess the NIH investment in research related to chronic conditions in women. The public health needs and NIH investment related to conditions included in the framework were measured. By available measures, research within the NIH has not mapped to the burden of chronic conditions among women. Clinical research questions and endpoints centered around women can be developed and implemented; clinical trials networks with expanded or extended eligibility criteria can be created; and data science could be used to extrapolate the effects of overlapping or multiple morbidities on the health of women. Aligning NIH research priorities to address the specific needs of women with chronic diseases is critical to addressing women’s health needs from a life course perspective. This manuscript provides an overview of the response to Congress on the topic of chronic conditions in women, including an overview of the public health needs, current research, and opportunities for future research to advance our knowledge on this topic.Rising rates of “chronic debilitating conditions among women” were one of three key public health concerns cited in the Fiscal Year (FY) 2021 U.S. Senate and House of Representatives appropriations bills, where a review of current National Institutes of Health (NIH) portfolios and an expert convening related to women’s health research was requested. The NIH’s Office of Research on Women’s Health (ORWH) responded to this congressional request by reviewing the current NIH activities on the priority topics, as well as collecting input on the priority areas from experts in women’s health and members of the public. Members of the NIH Advisory Committee on Research on Women’s Health (ACRWH) formed a working group to review NIH activities, plan an interdisciplinary conference, and identify opportunities for future NIH-supported women’s health research. On October 20, 2021, ORWH Advancing NIH Research on the Health of Women: A 2021 Conference  is useful when considering women’s health care. Hypertensive disorders during pregnancy, for example, can increase the risk of developing hypertension within three years after giving birth . Menstruhttps://ghdx.healthdata.org/) and wherever possible for diseases and health conditions that overlap with NIH’s Research, Condition, and Disease Categorization (RCDC) system – the official system, of record for annual NIH funding on specific research topics and conditions.Due to the lack of definitions of chronic conditions specific to women, a framework was created for the purpose of fulfilling the congressional request for NIH portfolio analysis on this topic. This framework Table  categoriSpecific challenges persist related to the diagnosis and treatment of female-specific chronic conditions, which are not always included in current multimorbidity indices. Many female-specific conditions remain underdiagnosed with an insufficient evidence-base for diagnosis and treatment, which presumably negatively affects outcomes . ReceiptMany common chronic conditions are not female-specific but occur at substantially higher rates in women compared to men. Women constitute nearly 80% of the population affected by autoimmune disease and bear a disproportionately high morbidity associated with this spectrum of conditions . Other dOther chronic conditions are not female-specific and do not have sex-specific etiologies but remain studied more commonly in men than in women. These include disorders such as HIV and post-traumatic stress disorder that affect women yet remain socioculturally associated with men and largely understudied in women . Other cMany chronic conditions with high morbidity in women go unrecognized as significant women’s health issues. CVD is the most common cause of death among women; and yet, among American women and health care providers, only 45% of women knew that CVD is the leading cause of death among women . The preThe purpose of the NIH Revitalization Act of 1993, which led to the formation of the NIH ORWH was to improve representation of women in clinical research. Today, in overall enrollment to NIH-supported clinical trials, roughly half of participants are women . Yet undNIH spent 10.8 percent of its funding  on women’s health research in FY 2020. NIH supports a wide range of research on chronic diseases—covering screening and prevention, diagnostics, treatment and therapeutics, health disparities, and other activities . However, no single NIH RCDC code captures the breadth of chronic conditions. The lack of a single RCDC code limited the portfolio analysis in response to the congressionally directed review of NIH research activities. In lieu of a quantitative portfolio review, ratios of FY 2020 NIH spending per DALY was calculated within the framework for chronic debilitating conditions  in 2012 to support studies of gynecologic disorders, including endometriosis, adenomyosis, fibroids, and polycystic ovary syndrome [https://www.nhlbi.nih.gov/events/2021/cardiovascular-risk-across-lifespan-polycystic-ovary-syndrome-workshop), a two-day virtual workshop to review the state of science on CVD across the life course of women with PCOS and identified knowledge gaps and opportunities in PCOS-related CVD research.Efforts are underway to advance knowledge about female-specific disorders in some areas of health. The Gynecologic Health and Disease Branch was established within the syndrome . In 2021In 2016, the NIH implemented the Sex as a Biological Variable (SABV) policy, that outlined an expectation “that sex as a biological variable will be factored into research designs, analyses, and reporting in vertebrate animal and human studies” unless a strong justification for a single-sex study exists . ORWH, wIn 2018, several NIH ICOs—the National Cancer Institute (NCI), National Institute of Aging (NIA), National Institute on Minority Health and Health Disparities (NIMHD), the Office of Behavioral and Social Sciences Research (OBSSR), and the Office of Disease Prevention (ODP)—held an expert panel workshop entitled, “Measuring Multimorbidity: Matching the Instrument and the Purpose.” From this meeting, a model and research framework for multimorbidity—depicting relationships among causal factors, disease conditions and interactions, and outcomes of multimorbidity—was developed  prevent women from meeting eligibility criteria Fig. .Fig. 3ExStudies that provide detailed sex-disaggregated and gender-specific clinical outcomes data—tied to critical life course windows, and hormonal transitions, from a diverse population of women, are needed to fill this critical research gap . Large-sRising rates of chronic conditions represent a significant public health challenge, particularly relevant to the health of women. This challenge is exacerbated by the absence of a framework for characterizing and addressing chronic debilitating conditions in women. A review of NIH research activities on chronic conditions in women, completed in preparation for the congressionally directed “Advancing NIH Research on Women’s Health” conference, revealed multiple opportunities to align the NIH research agenda with the health needs of women. Social determinants of health, including factors such as gender, race, ethnicity, socioeconomic factors, and healthcare access, influence the health of women differently than the health of men; the role of social determinants of health on women’s burden of chronic conditions warrants further research and consideration. The 2016 SABV Policy has enhanced preclinical and discovery knowledge of relevant diseases; however, the impact of sex as a biological variable on chronic conditions in women across the life course, including during key hormonal transitions like menarche and menopause, is inadequately understood. Research that utilizes a life course approach, is informed by gender considerations, and incorporates systematic consideration of sex differences aligns with a global agenda for women’s health .


National laboratories are a fundamental capacity for public health, contributing to disease surveillance and outbreak response. The establishment of regional laboratory networks has been posited as a means of improving health security across multiple countries. Our study objective was to assess whether membership in regional laboratory networks in Africa has an effect on national health security capacities and outbreak response. We conducted a literature review to select regional laboratory networks in the Eastern and Western African regions. We examined data from the World Health Organization Joint External Evaluation (JEE) mission reports, the 2018 WHO States Parties Annual Report (SPAR), and the 2019 Global Health Security Index (GHS). We compared the average scores of countries that are members of a regional laboratory network to those that are not. We also assessed country-level diagnostic and testing indicators during the COVID-19 pandemic. We found no significant differences in any of the selected health security metrics for member versus non-member countries of the either the East Africa Public Health Laboratory Networking Project (EAPHLNP) in the Eastern Africa region, nor for the West African Network of Clinical Laboratories (RESAOLAB) in the Western Africa region. No statistically significant differences were observed in COVID-19 testing rates in either region. Small sample sizes and the inherent heterogeneities in governance, health, and other factors between countries within and between regions limited all analyses. These results suggest potential benefit in setting baseline capacity for network inclusion and developing regional metrics for measuring network impact, but also beyond national health security capacities, other effects that may be required to justify continued support for regional laboratory networks. The emergence and international spread of public health threats like the ongoing coronavirus disease 2019 (COVID-19) pandemic highlight the importance of ensuring that all countries have minimum health security capacities in place to achieve adequate preparedness and response for epidemics. Per the International Health Regulations 2005, (IHR) [By 2012, many countries were struggling to meet IHR requirements. These concerns, emphasized by the 2014 West Africa Ebola outbreak, led the WHO to revise the IHR Monitoring and Evaluation Framework  and a voThese updates have galvanized renewed interest in innovative approaches to IHR implementation. Particularly in lower resource contexts, regional approaches to capacity building, like regional networks, are seen as a means of sharing costs across multiple countries. Sharing of resources can also limit redundancy in capacity strengthening and reduce infrastructure development and maintenance costs.Networks can be disease- or syndrome-specific –8, or foAnalysis of infectious disease outbreak risk factors suggests that 22 out of the 25 most vulnerable national health systems in the world are in Africa . SeveralHere, we sought to answer the following question: does membership in regional laboratory networks in Africa have an effect on national health security capacities and outbreak response?An online search was conducted for eligible regional laboratory networks in Africa. To be considered eligible, a network had to meet five criteria: (1) be a formal partnership between countries that are all Member States of the African Union; (2) have three or more countries in the network; (3) be located entirely within a specific region of Africa or contiguous to it; (4) focus on general diagnostics, surveillance, and other laboratory work rather than on specific diseases; and (5) be operational with publicly available information on specific projects as of October 2019.We identified two networks that met these criteria: the West African Network of Clinical Laboratories (RESAOLAB), and the East Africa Public Health Laboratory Networking Project (EAPHLNP). RESAOLAB is described as the first regional network in West Africa to focus on creating a system of biological laboratories offering quality services, and to improve clinical diagnosis for public health aims . EAPHLNPThree tools for measuring national health security capacity were used: the JEE , SPAR 3, and theC5 Laboratory sub-indicators for 2018; and 3) the 34 GHS Index indicators and the three 2.1 Laboratory Systems sub-indicators for 2019.The scores of member countries within each network, as well as non-member countries within the same region of Africa, were collated for: 1) the 48 JEE indicators of the first edition JEE tool; 2) the 13 SPAR indicators and the three National Laboratory System indicators (D.1.1-D.1.4); 2) laboratory-related indicators, which were identified in the literature review as potentially being influenced by laboratory networks or where laboratories were cited in the JEE indicator description; 3) non-laboratory indicators, which made no mention of laboratories in either the JEE indicator description or guiding questions; and 4) other indicators, which included minimal mention of laboratories or laboratory services in the JEE guiding questions or only referenced non-biological laboratories, and which were discarded from further analysis to reduce the number of multiple comparisons. The inclusion of the non-laboratory indicators was used to establish whether there were differences in overall health security capacities between groups.The JEE indicators were additionally sorted into four categories: 1) the four Differences in the National Laboratory Systems, laboratory-related, and non-laboratory JEE indicator scores of network member countries versus non-member countries were calculated using the Goodman-Kruskal (G-K) Gamma statistic. See Supplemental Material for further description of this statistic and corresponding derivation of p-values.Differences in the median 2018 SPAR and 2019 GHS Index scores of network member countries versus non-member countries were calculated using Kruskal-Wallis tests, with adjusted p-values for multiple comparisons. The standard deviation of each average score was also calculated, and the data used to calculate each average score were checked for outliers. Data points were considered outliers if they were more than two standard deviations away from the mean. Sample sizes were insufficient for comparisons between countries that joined RESAOLAB in 2009 versus 2013 and non-members, across all metrics.We also sought to assess whether membership in a regional network might affect laboratory capacities in practice, as opposed to “on paper”. To do so, we collated data provided to the Africa Centres for Disease Control and Prevention (Africa CDC) from Member States on: 1) the date at which testing capability was established in the country; 2) the number of reported severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests performed in the country per day; and 3) the incidence per 100,000 population of laboratory-confirmed COVID-19 cases per country. These data were reported publicly via the Africa CDC COVID-19 Dashboard .To assess the effect of laboratory membership on testing capacity, we fit negative-binomial mixed effects models with number of daily tests as the outcome and laboratory membership as the primary covariate of interest. Further details on these models are available as a supplemental document .The analysis of JEE scores between EAPHLNP member countries and those Eastern Africa region countries outside the network showed no significant differences across any of the analyzed indicators . LikewisAll three SPAR and all three GHS Index laboratory indicators for both EAPHLNP and RESAOLAB showed no statistically significant difference against their respective non-members Figs  and 3. TOur model showed no impact of laboratory network membership on testing rate while controlling for daily incidence of reported COVID-19 cases and time since the first reported test in both networks . The EAPThe lack of statistically significant differences in any of the analyzed health security framework indicators suggests a number of possible interpretations. Despite member countries having numerically higher average scores across most laboratory-related indicators across all three metrics, the small sample sizes limited the power of our statistical analyses, in both regions. This suggests that other approaches that employ qualitative methods might be better suited to understanding potential differences with small samples, in order to further understand the impact of networks in these regions. The small sample sizes also may have overrepresented outliers. Non-network members, Nigeria and Ethiopia, in the Western and Eastern Africa regions respectively, were both high outliers across different SPAR or GHS Index indicators. Neither are network members, but both were priority countries for United States Global Health Security Agenda (GHSA) assistance, of which laboratory capacity strengthening was a core activity. Other countries in the two regions did also benefit from GHSA investment, and may have received other types of bilateral or multilateral assistance. Future analyses of the effect of laboratory networks on national capacities should therefore attempt to consider large-scale assistance and cooperation programs as potential competing or confounding variables.Our analysis of COVID-19 testing data showed no statistically significant relationship between network membership and testing rates. The analysis was limited by focusing only on COVID-19 testing data. A more robust test of national laboratory network resilience would have also measured diagnostic activity for non-COVID suspected specimens , to ensure that the scale-up of COVID-19 testing did not come at the expense of other laboratory activities. Similarly, regional entities, including the Africa CDC, have provided substantial targeted support for various aspects of COVID-19 diagnostic testing since the literature review for this paper took place, as have other bilateral and multilateral donors. Africa CDC support has included the provision of training, supplies, reagents, and web-based resources, any of which could have influenced testing rates independent of network membership , 35. FutOur results provide no evidence of a beneficial effect of regional laboratory networks on national level laboratory-related health security capacities, at least based on the metrics analyzed here. It is worth highlighting that we did not attempt to analyze the existence of baseline capacity inclusion criteria or the success of the networks, based on their own stated goals and objectives; our analysis was limited to the potential influence of network membership on national health security indicators. We also did not seek to examine potential regional level benefits; to our knowledge, such regional level indicators do not yet exist within the context of global health security frameworks. The indicators used by RESAOLAB and EAPHLNP themselves were largely applied at the national, rather than regional, level, but could constitute a starting point for development of relevant regional indicators for laboratory systems, for example with respect to proportion of disease events that receive confirmatory testing, irrespective of whether the test is performed within the same country or another country in the network , 38.There are numerous examples of efforts to establish regional laboratory networks from regions outside of Africa –41. LikeThe ongoing COVID-19 pandemic has highlighted the importance of improving core capacities, like laboratory diagnostics, in health security systems . The panOur study had numerous limitations. It cannot be ascertained whether the scores on laboratory-related indicators reflected membership in the regional networks, a self-selection bias, legacies of pre-membership laboratory capacity status, one or more with unmeasured factors, or a confounding factor. Individual country-level variation in size, political attention or priority given to health security, access to resources, and other bilateral and multilateral relationships and partnerships outside of the networks may influence laboratory capacity, as well as the ability to benefit from networks. Numerous commentators have questioned the value of health security metrics as measures of laboratory and other essential public health capacities. While we attempted to address this limitation by including testing rate data, numerous other factors could have contributed to testing capacity. These include domestic attention to testing as a core response strategy and bilateral or multilateral support from non-network sources.Our study showed no statistically significant benefits of membership in regional laboratory networks on national-level laboratory capacities, in either studied region, nor on any of the other non-laboratory health security indicators analyzed. The lack of observed benefit across these indicators may in part reflect imprecision in the original indicators, the methodological approach, or shortcomings of indicators as a proxy for capacity. Taken at face value, it could be suggested that national health security capacities are, as a stand-alone outcome, insufficiently addressed by these regional networks. However, our analysis did not directly consider network inclusion criteria or other stated goals and outcomes of the selected networks; for example, improved quality of services, which could itself justify continued support for regional laboratory networks. Moreover, there may be opportunities to focus on development of regional capacity indicators as a promising and important area for future exploration.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.


The link between urbanization and mental health is multifaceted and draws considerable attention from researchers and professionals worldwide. The Research Topic “Cities and Mental Health” dives into this theme, illuminating the influences of urban living on mental health and some possible causal pathways. Specifically, this editorial investigates the complexity of the relationship between urbanization and mental health, highlighting the increased interest among scholars and practitioners around the world. Here we present an overview of current studies by synthesizing twelve research articles published in the Research Topic. The majority of these studies are centered on China, followed by two studies from Germany, two from Taiwan and one from Portugal. According to the word analysis conducted with Nvivo 12 Pro software that visualizes the 1,000 most frequent words retrieved from the published articles, terms: “social” “health” and “urban” are the most frequently used by the authors. In Qu et al.). In it, authors demonstrate that fostering social cohesion and promoting social strategies can help alleviate the mental health disparities among this vulnerable population, as well as highlighting the especially vulnerable group of involuntary rural-to-urban migrants, who may require additional social support. Furthermore, the impact of housing tenure mix on mental health is examined in the megacity of Guangzhou, China, revealing that while there is no direct impact, social participation mediates the decrease in depressive symptoms .The social aspects of urban life emerge as critical determinants of mental health. One study in the collection associates perceived social cohesion with depressive symptoms among internal migrants in China, with social adaptation acting as a mediator . Another article explores the protective role of good family functioning against adolescent delinquency in another Chinese megacity . The authors highlight the value of positive behavior recognition in family environments, which is relevant in both urban and rural settings.Moving into family dynamics, a paper from Changsha, the capital of Hunan province, reports increasing trends of various mental health problems among Chinese adolescents in urban areas between 2016 and 2020, emphasizing the urgency to address mental health issues in cities, especially among younger demographics . The paper recommends policy-making for healthier and sustainable cities, emphasizing the considerable mental benefits of green spaces and urban upbringing with high nature exposure as well as the role of air pollution in neurodegenerative process and cognitive decline.A contribution from Ancora and colleagues titled “CiHansen et al.). The paper concludes that, while there were no significant findings in antibodies levels between rural and urban patients, more extensive studies are needed to explore the possible higher prevalence of autoimmune-related psychiatric syndromes in larger cities.Further down this path, the influence of city environments on psychiatric disease development is tackled by a German study that explores the prevalence of neural autoantibodies in urban vs. rural psychiatric patients . In another Taiwanese study the effects of natural environments on mental health are brought to light in a context of creativity in a study titled “The influence of natural environments on creativity” . The authors argue that viewing natural environments fosters flexibility and imagination, highlighting another dimension of how urban greening can influence productivity and wellbeing.The urban soundscape's influence on mental health is broached by a Taiwanese study, reporting on significant associations between road traffic noise at specific frequencies and increased depression prevalence, even when controlling for the effects of pollution . It concludes that natural scents of lemon and lavender showed to be the most effective in treatment of anxiety.Following the research on sensory stimuli influencing the mental health Chinese meta-analysis by Tan and colleagues summarized the existing clinical trials on the essential oils in treatment of psychiatric disorders . In contrast, another study reveals that planned urbanization can improve mental health among middle-aged and older adults in China by promoting social participation and improving living conditions . This dichotomy underscores the nuanced impacts of urban life on mental wellbeing, depending on one's occupation and socioeconomic status.An important aspect touched upon by this Research Topic is the mental health of urban professionals and their productivity, with two papers investigating these issues. One paper documents higher depression prevalence among medical staff in Hainan, China, associating it with anxiety, sleep disorders, and job-related stressors (In conclusion, these papers collectively underscore the significant interplay between urban environments and mental health. The findings affirm the imperative to consider multifaceted factors including environmental, social, and economic aspects in urban planning and health policy-making, and as a whole show commonalities across urban areas in different countries. While a lot of research is yet to be done to identify positive interventions, the effect of natural environments, multi-sensory exposure, and participatory approaches at the neighborhood levels seem to be the most promising tools to alleviate the burden of mental health in cities while promoting productivity and creativity. This collection of studies prompts researchers and policymakers to discuss and work together toward healthier, greener and more supportive cities for better mental health outcomes.AO-G: Conceptualization, Writing—original draft, Writing—review and editing. AR: Visualization, Writing—review and editing. ACR: Writing—review and editing. SK: Writing—review and editing. BM: Writing—review and editing. NT: Writing—review and editing. RH: Writing—review and editing.


Criminal Justice (CJ) settings, that is jails, prisons, and community correctional settings such as probation and parole, provide ample opportunities to engage difficult-to-reach populations who have significant underlying health conditions, including a high burden of chronic  and infeAdditionally, incarceration rates are disproportionately high among people of color as a result of the discriminatory war on drugs and other punitive policies. This systemic discrimination creates a nexus of intersectional burden for communities of color that are simultaneously tasked with supporting and caring for individuals in re-entry –9. RaciaWhile 20 million Americans are currently incarcerated or have been in the past, only a small fraction (∼0.1%) of NIH grants focus on CJ-related research .Compounding the under-investment in CJ-related research, CJ settings can be overlooked for medical and public health-related research partly because of the unique challenges that correctional facilities (both jails and prisons) pose to conducting research-related activities, but also related to the lack of preparedness and infrastructure for people who want to do this research. Additionally, the history of medical exploitation among individuals involved in the CJ system has necessitated more rigorous ethical oversight among research participants within this system –12. PartTo address the substantial health disparities among CJ-involved populations, there must be more investment in translational science involving individuals impacted by incarceration. Jennifer Alvidrez and Nathan Stinson at the National Institute on Minority Health and Health Disparities developed the translational health disparities continuum to advance health disparities research beyond translational stages T0 (identification), T1 (development), and T2 (testing intervention effectiveness) and move towards T3 (implementation) and T4 (dissemination) so that the benefits of translational research can be realized to combat racial health disparities . There rwww.kumc.edu/cjtracs) in order to support translational science across the criminal justice continuum. Initially supported through a CTSA pilot grant to three institutions , the primary goal of the CJTRACS Network is to develop a national CTSA research network to support translational science across the CJ continuum. An ethically sound and structurally competent research agenda is critical to advancing public health among CJ populations and communities that are disproportionately burdened by health disparities and mass incarceration . In this editorial, we outline our vision for a network of researchers dedicated to translational and clinical science across the criminal justice continuum. Such a network would build upon existing infrastructure at CTSA-affiliated institutions by expanding capacity to address the unique ethical challenges of conducting research among carceral populations, provide training and educational opportunities to investigators to conduct rigorous CJ-related research, and leverage existing CTSA-funded mechanisms, e.g. pilot awards and the KL2 training program, to support innovative research among CJ-impacted populations.In response to this need, we are working toward the development of the Criminal Justice Translational and Clinical Science (CJTRACS) Network  Scholars Program, which provides mentored health equity research training for exceptional underrepresented minority scholars at the predoctoral, postdoctoral, and assistant professor levels. Another opportunity to establish a racial health equity workforce pipeline is through UKY’s Students Participating as Ambassadors for Research in Kentucky (SPARK) program. SPARK provides undergraduate students from underrepresented backgrounds opportunities to take intensive short courses on Health Equity and Research Methods while engaging in book discussions, professional presentations, and conducting research in their home communities under the mentorship of a faculty and community member. The Kansas University Medical Center extends training through the TL1 Trainee Program, which targets pre- and postdoctoral students to provide trainees with the skills, confidence, motivation, and enhanced career trajectory to move to the next stage of their translational research career. All of these training programs are potential “homes” for specialized CJ-related research training.The pilot project CTSAs all offer training opportunities and support for scholars from underrepresented groups as well as in health disparities research career development. UAMS’ programs include the Community-Based Participatory Research (CBPR) Scholars Program which seeks to increase community-partnered research at UAMS to better serve the research needs of the Arkansas community and to reduce health disparities. UAMS also has the Translational Research Innovations and Partners (TRIP) Program which provides research support to first- or second-year medical students who are interested in learning about and participating in community-based research focused on medically underserved, rural, and minority populations, including CJ populations. Through a CTSA Community Engagement & Research Core, UKY has two Rural Research Hubs, which can be a resource for community, clinical, and academic partners engaged in community-engaged research to connect with CJ agencies in rural areas. Finally, KU has the Trailblazer Awards, which fund the development of community-engaged research or engage special populations in clinical and translational research, which could include an additional emphasis on CJ-related research.Extending the community-engagement lens to include people who were previously incarcerated in outreach and training, as well as community members affected by mass incarceration, could be incorporated into existing training programs as well. For example, UAMS has the UAMS Research Academy, which seeks to build a sustainable research community through creating innovative care models and transformative breakthroughs in medicine; the Community Partners Educated as Arkansas Research Leaders (CPEARL) Program, which is a 6-month leadership development training program targeting leaders and emerging leaders within nonprofit community-based organizations located in Arkansas; and the Implementation Sciences Scholars Program, which provides didactive and research support to UAMS faculty seeking to learn how to implement new practice guidelines and/or other implementation or deimplementation approaches that will improve medical care.Each institution has unique programing to meet translational research directives which could be directly applied to CJ-related research. The UAMS Translational Research Institute offers numerous training and research development programs focused on training a diverse research workforce to address key scientific challenges related to health disparities. In addition to the aforementioned, these include the Professional Student Mentored Research Fellowship Program (PSMRF), which provides individually tailored mentored research fellowships in clinical and translational science for professional students .The UKY CTSA also supports the Frontiers, addresses the science and healthcare workforce needs for clinical and translational research (CTR) in the Midwest. Alumni of Frontiers career development programs are not only emerging as regional and national leaders in research, but they also drive research that sets the foundation for improvements in clinical and public health practice – advancing the delivery of innovations to the patients and communities that need them. Collectively, the Frontiers programs bring together more than 200 federally funded investigators in CTR drawn from eight regional Midwestern institutions with strong track records of working across state lines and institutional boundaries to advance interdisciplinary research.The KUMC CTSA, These are just some of the existing programs that each of these institutions support, in addition to a KL2 Scholars program offered by each institution which fosters career development to ensure a firm grounding in CTR competencies and preparation to conduct rigorous and reproducible research. These programs, while not specific to CJ-related research, can be leveraged to support a program of CJ-related research at each institution and at other CTSAs nationally. Harnessing existing research mechanisms as resources for translational researchers interested in CJ and health will help support a more robust program of health disparities research among CJ-impacted populations. Much of the work originating from these centers and institutes could form the basis of future NIH grants geared specifically towards criminal justice populations using a translational science lens. A growing network of CJ scholars will expand the reach of these organizations through inter-institutional partnerships, open communication platforms about mutual interests and emerging research topics, and continued engagement with community members most affected by mass incarceration.


This Special Issue, entitled “Recent Advances in Oral Drug Delivery Development”, aims to demonstrate new advances and future trends in the field of oral drug delivery. Although oral administration is the most commonly used treatment due to its obvious benefits, oral drug delivery may be limited by factors such as gastroduodenal anatomy, chemical substances interfering with bioavailability, and physiological characteristics unique to the individual ,2,3. BecOur call for papers for this Special Issue drew great interest from a broad spectrum of researchers working primarily in pharmaceutical technology, hospital pharmacy, clinical research, and basic medical research. A total of 40 authors from all over the world  contributed to four research papers and one review. The published articles highlight various experimental or clinical aspects of oral drug delivery development to ensure appropriate medications.Since marketed liquid formulations are not always available for younger pediatric patients, Annereau et al. described the development of an oral compounded suspension of temozolomide (TMZ) used as the standard of care for many pediatric brain tumors, such as neuroblastoma, glioblastoma, and medulloblastoma . The autLikewise, Secretan et al. proposed the development of a simple oral solution of Epigallocatechin gallate (EGCG) used to reduce oxidative damage to lipids, proteins, and DNA or to prevent tumor progression . Here, tThe third article is focused on the development of a mucoadhesive buccal delivery system for the sustained delivery of metformin (MET) and sitagliptin (SIT) against diabetes mellitus . CurrentSimilarly, Seo et al. presented a review discussing the findings from studies focusing on oral lipophilic drug delivery systems, including self-emulsifying drug delivery systems (SEDDSs) for the treatment of uncomplicated malaria . The autThe last article focused on the evaluation of the subchronic toxicity of oral anthrafuran drug formulations in Chinchilla rabbits. This route of administration is becoming more popular among oncologists since it improves the quality of life of patients and reduces their time in the clinic . The stuIn summary, this Special Issue highlights and presents recent findings on oral drug delivery development. Considering these diverse contributions, the value of multidisciplinary collaboration, combining the expertise of laboratory researchers and clinicians, is obvious. Finally, the Guest Editor expresses heartfelt thanks to all authors for their valuable contributions and would also like to thank Ms. Evelyn Du for her assistance and technical support.


As the United States transitions toward value-based payment, value assessment tools to measure the value of health care interventions are emerging. As the field evolves, it is important to evaluate how these tools are influencing treatment and coverage decisions.To examine payer perceptions and use of US value assessment tools and identify how these tools inform payer decision-making.A double-blind, web-based survey was conducted from June to July 2022 to assess health care payers’ perceptions and use of value assessment tools developed by the American Society of Clinical Oncology, Drug Pricing Lab, Institute for Clinical and Economic Review (ICER), Innovation and Value Initiative, and National Comprehensive Cancer Network.51 respondents completed the survey. 86% of payers were familiar with at least 4 of 5 value assessment tools. Both ICER and National Comprehensive Cancer Network tools are perceived as very useful for informing formulary decisions . When selecting a value assessment tool, payers identified the inclusion of appropriate metrics and outcomes (92%), comparative clinical effectiveness information (88%), and reliance on rigorous, unbiased methods (86%) to be very/extremely important. Payers reported the inclusion of the patient, provider, and societal perspectives as lower importance . Payers reported using ICER evidence reports to both expand and restrict coverage decisions. To advance more useful and relevant value assessment tools, payers identified the need for greater stakeholder awareness of existing tools, and some recommended that value assessors increase the volume of assessments conducted.US health care payers perceive select value assessment tools to be useful for informing health care decisions. As policy momentum behind value assessment builds, additional examination of value assessment tools is needed to inform appropriate application of value assessment in US health care decision-making. Value assessment tools measure the value of health care services like medicines and surgeries. This study describes how US payers perceive and use value assessment tools. Most were very familiar with value assessment tools, and some reported using findings to help make health care decisions about medicines. Payers think more people should know about value assessment tools, and some want more assessments. Our findings show that value assessment tools can impact health care decision-making. Implications for managed care pharmacyAs value assessment tools gain traction in the United States, health care payers are using them to inform their decision-making. This analysis found that health care payers perceive the National Comprehensive Cancer Network and Institute for Clinical and Economic Review tools to be most useful in informing formulary decisions. Payers’ reported use of value assessment tools demonstrates the importance of providing managed care pharmacy professionals with education about the strengths and limitations of value assessment tools.5As the United States transitions to a value-based payment system, health care stakeholders are exploring opportunities to assess the value of health care interventions to deliver more efficient, high-value care. To help define and measure the value of health care treatments and services, several organizations have developed value assessment frameworks or tools, each with their own methodological approach, purpose, and intended audience. For example, the American Society of Clinical Oncology and the National Comprehensive Cancer Network (NCCN) created value assessment tools to guide shared decision-making between patients and their care team, whereas the Institute for Clinical and Economic Review (ICER), the Innovation and Value Initiative (IVI), and researchers from the Drug Pricing Lab developed tools to inform policy discussions and health care coverage decisions.8Over time, value assessment tools have earned traction with payers. In recent years, CVS Health, the US Department of Veterans Affairs Pharmacy Benefit Management Services office, and the New York Drug Utilization Review Board reported using ICER assessments to inform formulary decisions and pricing negotiations.As the US value assessment landscape evolves, it is important to gain a better understanding of how health care payers perceive and use value assessment tools and identify the extent to which these tools are influencing treatment coverage. It is also important to gain clarity on what payers prioritize when assessing treatment value to promote assessment tools that are appropriate and fit-for-purpose.9 However, to date, there is only limited evidence on payer perceptions of US value assessment tools and methodologies or how payers are using value assessment results to expand or restrict access to interventions.11 To expand the evidence base, we surveyed US health care payers on their perceptions of 5 value assessment tools and identified the elements payers prioritize when selecting a tool. We also surveyed payers on their use of ICER evidence reports to inform formulary and coverage decisions.Previous studies have explored how US payers determine the value of pharmaceuticals and how these processes align and differ from payers outside the United States.13We conducted a double-blind, web-based survey to assess health care payers’ perceptions and use of 5 value assessment frameworks and tools, including American Society of Clinical Oncology’s Value Framework, Drug Pricing Lab’s Drug Abacus , ICER’s value assessment framework and evidence reports, IVI’s Open-Source Value Project models, and NCCN’s Evidence Blocks. Tools included in our study represent the predominant US value assessment tools cited in the literature.11 and was supplemented by an informal review of the literature and value assessment landscape . Prior to launch, the survey was validated for duration, ease of use, interpretability, and appropriateness of questions. The survey was fielded through Xcenda’s research panel, the Managed Care Network, from June 30, 2022, to July 19, 2022. The Managed Care Network is composed of national and regional health care decision makers in the United States representing more than 310 million lives.14 Participants were recruited via e-mail, and the survey was fielded using the online Decipher platform. Participation was voluntary, and a modest honorarium was paid to participants who completed the survey.The survey instrument was informed by prior payer surveys15 and an AMCP webinar on October 4, 2022.16Inclusion criteria for this survey required participants to (1) work for a health plan, pharmacy benefit manager (PBM), or integrated health delivery system/integrated delivery network (IDN) that manages at least 50,000 lives; (2) hold the position of pharmacy director, medical director, clinical pharmacist, contracting manager/director, or trade relations; and (3) hold a role in the drug review and approval process at their organization and participate in the pharmacy and therapeutics committee; and (4) have familiarity with ICER’s value assessment framework and evidence reports. The survey contained single-answer 3- and 5-point Likert scale questions and multiple-answer and free-response questions; results were reported descriptively. Selected survey results were shared at an Academy of Managed Care Pharmacy (AMCP) Partnership Forum on August 30-31, 2022,Supplementary Table 1, available in online article).Sixty-six participants responded to the survey invitation, of whom 10 were excluded based on their organization , 4 were excluded because of their organization’s size , and 1 was excluded for not holding a role in the drug review and approval process. No one was excluded because of a lack of familiarity with ICER’s value assessment framework. Fifty-one respondents met the inclusion criteria and completed the survey. Throughout this results section, the number of respondents is 51 except when noted otherwise. Most respondents identified their primary role within their organization as pharmacy director (67%) or medical director (27%). Fifty-three percent of study participants work for a health plan, 24% work for an IDN, and 24% work for a PBM .Overall, payers were very familiar with US value assessment tools, with 86% reporting they were familiar with at least 4 out of the 5 identified tools. Our survey revealed that multiple individuals within payer organizations are responsible for reviewing value assessment results. Respondents cited most frequent use by pharmacy directors (76%), medical directors (59%), clinical pharmacists (51%), and pharmacy and therapeutics committees (41%), highlighting that many individuals or teams review value assessment reports . Payers also identified the inclusion of comparative clinical effectiveness information (88%), methodologically rigorous and unbiased methods (86%), use of a transparent and open process (82%), and assessments conducted by neutral third-party experts (80%) as very/extremely important elements when selecting a value assessment framework or tool . or tool .Conversely, payers reported the inclusion of the patient, provider, and societal perspectives to be of lower importance when selecting a framework . Identification of health disparities (34%) and inclusion of a broad assessment of product value (43%) were also reported to be of lower importance.Payers provided recommendations to improve the usefulness and relevance of specific value assessment tools. Overall, they identified opportunities to improve awareness of value assessment tools and highlighted opportunities to update existing methods and data sources to provide more relevant and transparent information. To advance value assessment tools, payers identified that tools need to become more established and accepted, recommended that models become more user-friendly and generalizable, and underscored the need for more assessments. One-quarter of the respondents had no suggestions for improvement.Our survey also explored payers’ preferred source of value assessment information. Forty-seven percent of respondents reported that they would like to receive value assessment information from public and private organizations, whereas 39% reported that they would solely like this information from public organizations, 8% solely from private organizations, and 6% selected “other.” Other responses included interest in receiving value assessment information from not-for-profit alliances devoted to patient care and education, professional organizations responsible for treatment guidelines, or verified foreign sources.ICER assessments incorporate numerous elements relevant to the payer decision-making context, including value-based price benchmarks, and policy recommendations for the appropriate application of evidence to payer coverage policy. Given this focus on payer decision-making, our survey included additional questions specific to payer use of recommendations from ICER’s evidence reports. Overall, the frequency in which ICER recommendations influence coverage decisions varied across payer organizations. Twenty percent of payers reported that ICER recommendations often influenced their organization’s decisions over the last 24 months, 59% reported ICER recommendations occasionally influenced decisions, and 22% reported no influence. The most prevalent use of ICER reports was noted in high-cost drugs or disease states (78%) followed by rare/orphan disease states (71%) and oncology/hematology (67%).Supplementary Figure 2). Therapeutic areas with at least 15% (n = 8) of respondents reporting changes are included in Supplementary Figure 2. Payer modifications to coverage policies included both expansion and restriction of coverage. In most cases, individual payers differed in their response to the same ICER assessment .Additionally, some payers reported changing prior coverage decisions based on specific ICER evidence reports published within 24 months of the survey date (June 2020 to June 2022)  and health disparities to be of lower importance when selecting a value assessment tool. However, payer sentiment regarding inclusion of the patient perspective and health equity considerations may be incongruous with broader health system and societal goals to reduce historical health disparities and advance patient-centered care. For example, in 2022, ICER and IVI launched initiatives to better integrate health equity in value assessment.20 Payers recommend that value assessors incorporate more payer-centric data  into their assessments, increase the number of assessments conducted, and expand awareness of their assessment tools. Given that payers identified the need for more assessments, further work is needed to address the capacity of value assessment organizations to evaluate product value across multiple disease states and based on new evidence.As value assessment tools gain momentum among US health care decision makers, it is important to consider opportunities to improve the usefulness and relevance of these resources.22Most payers reported that ICER recommendations occasionally or often influenced coverage decisions within the last 2 years. They also reported a higher frequency of use in high-cost drugs or disease states, which is demonstrated by real-world examples of ICER evaluations informing negotiations by the Department of Veterans Affairs and the New York Medicaid Program.A separate analysis of user data from Xcenda’s FormularyDecisions  platform corroborates findings that payers are reviewing value assessment tools. Specifically, health care decision makers are using reports from ICER in their product review and evaluation process, with the highest utilization of ICER’s Report at a Glance compared with other ICER documents. This underscores the importance of resources that provide digestible and summarized report outcomes to enhance utility and facilitate exchange of insights.Payers reported interest in both public and private organizations as sources of value assessment information. These findings provide important insights as policymakers and health care experts pursue opportunities to increase the application of value assessment within the US health care system. The 5 value assessment tools included in this survey were developed by third-party organizations and do not have a government remit. Globally, many nations rely on a public or governmental organization to conduct HTAs to inform decision making on coverage, reimbursement, and administration of new treatments and medicines.23 Additionally, the 2022 Inflation Reduction Act allows Medicare to negotiate the price of select prescription drugs beginning in 2026.24 The law stipulates that as part of the drug price negotiation program, the Secretary of Health & Human Services may consider the comparative effectiveness of alternative treatments, potentially paving the way for the use value assessment tools or methodologies to inform price negotiations. As policy momentum behind value assessment grows, further examination of value assessment tools is needed to ensure application of value assessment in the US is appropriate and patient-focused and leads to high-value care.In recent years, some health care stakeholders have expressed interest in adopting a more formalized, publicly funded HTA body in the United States. For example, a recent white paper developed a set of 6 recommendations for establishing public funding for an advisory-only HTA body in the United States.This analysis is subject to several limitations. First, results of this survey may not be generalizable because of the composition of the study sample and the survey’s screening criteria. Second, this study only surveyed payers on 5 US value assessment tools and may not reflect all value assessment resources that payers rely on to inform their decision-making. Additionally, the survey included more questions about ICER’s value assessment framework and evidence reports than the other value assessment tools, limiting the specificity of information available for those resources. Third, although we reported how payers changed their coverage decisions based on specific ICER evidence reports, these questions were associated with small sample size; all corresponding results are meant to be illustrative and are not intended to draw deductive conclusions about payer coverage decisions. Fourth, it is possible that multiple respondents from the same organization responded to our survey, limiting our ability to accurately assess the representativeness of our sample.US health care payers perceive some value assessment tools to be useful for informing formulary decisions. When selecting a value assessment tool, payers prioritize those that incorporate appropriate metrics and outcomes, include comparative clinical effectiveness information, and rely on rigorous, unbiased methods. Payers are also using value assessment tools to inform both expanded and restricted coverage decisions. To advance more useful and relevant value assessment tools, payers identified the need to improve stakeholder awareness of existing tools and recommended that value assessors increase the volume of assessments conducted. Additional research is needed to better understand the role of US value assessment tools and their influence on payer decision-making. Insights from this research can help inform ongoing policy discussions about the appropriate application of value assessment within the US health care system.


Bisphenol A (BPA) is a known endocrine disruptor found in many consumer products that humans come into contact with on a daily basis. Due to increasing concerns about the safety of BPA and the introduction of new legislation restricting its use, industry has responded by adopting new, less studied BPA analogues that have similar polymer-forming properties. Some BPA analogues have already been shown to exhibit effects similar to BPA, for example, contributing to endocrine disruption through agonistic or antagonistic behaviour at various nuclear receptors such as estrogen (ER), androgen (AR), glucocorticoid (GR), aryl hydrocarbon (AhR), and pregnane X receptor (PXR). Since the European Food Safety Authority (EFSA) issued a draft re-evaluation of BPA and drastically reduced the temporary tolerable daily intake (t-TDI) of BPA from 4 mg/kg body weight/day to 0.2 ng/kg body weight/day due to increasing concern about the toxic properties of BPA, including its potential to disrupt immune system processes, we conducted a comprehensive review of the immunomodulatory activity of environmentally abundant BPA analogues. The results of the review suggest that BPA analogues may affect both the innate and acquired immune systems and can contribute to various immune-mediated conditions such as hypersensitivity reactions, allergies, and disruption of the human microbiome. Bisphenol A (BPA) is one of the most abundant chemicals in the plasticizer industry due to its favourable polymer-forming properties. It is most commonly used as a precursor to epoxy resins or as a building block for polycarbonate plastics and is found in numerous consumer products such as electronics, dental fissure sealants, children’s toys, personal care products, thermal paper, and in various food containers  Regulation ((EC) No. 1272/2008) classifies BPA as potentially toxic to reproduction, possibly irritating to the skin and respiratory tract, and potentially harmful to the eyes , breast cancer, and allergies  are best known for their antigen-presenting role, introducing foreign antigens into cells of the adaptive immune system and trigger primary immune responses. In addition, DCs are also an important factor in the development of immune tolerance to self-antigens, thus preventing autoimmune responses   are a representative model for studying immune processes in the peripheral blood circulation, where contact between foreign chemicals, including endocrine disruptors, and cells of the immune system occurs most frequently. This is precisely the reason for the frequent use of PBMCs as a model in toxicological studies, where the response reflects the behavior of a combination of immune cells such as lymphocytes, monocytes, and macrophages  and centrifugation  and causing genotoxic effects.Overall, bisphenols affect the viability of PBMCs by impairing cellular ATP production, increased CaPrevious studies have already shown mainly indirect effects of endocrine disruptors on gene expression through various epigenetic mechanisms such as DNA methylation, histone (de)acetylation, and RNA interfering  of BPA, BPF, and BPS, showed effects on microbial growth, with the greatest effect on Escherichia coli with BPF exposure, whereas the growth of Bacteroides thetaiotaomicron was most affected with BPA exposure  of polymers of diglycidyl ethers based on bisphenol A (DGEBA/BADGE) and in some cases bisphenol F (DGEBF). Both of the above compounds have a high sensitizing potential and are therefore classified as highly allergenic (O’Boyle et al. Accordingly, several human birth cohort studies have reported an association between prenatal BPA exposure and allergy symptoms such as asthma and wheezing in children at different ages (Gascon et al. Although many articles mention allergen effects as another way to demonstrate the immunotoxicity of BPA, there are currently not many studies investigating the sensitization effects of BPA analogues. Therefore, Mendy et al.  analysedPrevious research has already established a complex relationship between estrogen and the immune system (Steinmetz et al. However, a study by Xu et al.  found coSince the introduction of new regulatory dossiers based on the use of BPA in industry, an increasing occurrence of bisphenol analogues in everyday products and consequently in the environment has been observed (Ye et al.