The world produces enough food to nourish the global population, but inequitable distribution of food means many people remain at risk for undernutrition. Attainment of Sustainable Development Goal 2 relies on greater attention to distribution processes that match food qualities with dietary deficiencies. We explore this in the context of fisheries. Foreign fishing and international trade divert nutrients caught in marine fisheries from nutrient-insecure toward nutrient-secure nations. Where nutrient-insecure countries do benefit from foreign fishing and trade, there tends to be high vulnerability to future changes in nutrient flows arising from changes to foreign fishing and trade. This research highlights the need for greater transparency around distribution of fish and for nutrition security to be considered more centrally in development of trade agreements. Fish are an important source of bioavailable micronutrients and essential fatty acids, and capture fisheries have potential to substantially reduce dietary deficiencies. Vigorous debate has focused on trade and fishing in foreign waters as drivers of inequitable distribution of volume and value of fish, but their impact on nutrient supplies from fish is unknown. We analyze global catch, trade, and nutrient composition data for marine fisheries to quantify distribution patterns among countries with differing prevalence of inadequate nutrient intake. We find foreign fishing relocates 1.5 times more nutrients than international trade in fish. Analysis of nutrient flows among countries of different levels of nutrient intake shows fishing in foreign waters predominantly (but not exclusively) benefits nutrient-secure nations, an outcome amplified by trade. Next, we developed a nutritional vulnerability framework that shows those small island developing states and/or African nations currently benefiting from trade and foreign fishing, and countries with low adaptive capacity, are most vulnerable to future changes in nutrient supplies. Climate change exacerbates vulnerabilities for many nations. Harnessing the potential of global fisheries to address dietary deficiencies will require greater attention to nutrition objectives in fisheries’ licensing deals and trade negotiations. SI Appendix, Glossary)    . Micronulossary) , 3, preclossary) . In manyt S1, B) , 9. Yet,Supply of fish to many people, particularly those living further from coasts, is dependent on effective distribution networks. Fisheries’ supply chains can be complex, with price, infrastructure, waste and loss, and formal and informal governance of domestic and international trade mediating the quality, quantity, and ultimate consumers of fish. Prior work has shown for a number of countries with inadequate nutrient intakes that the nutrient potential of catches within their exclusive economic zone (EEZ) exceeds the dietary needs of their coastal populations (<100 km from the coast), suggesting fishery supply chains may be diverting fish from vulnerable populations . Foreign10Materials and Methods and SI Appendix, Table S1). We show how accounting for flags of convenience (FOCs), where fishing vessel owners reside in a country other than the flagged nation, affects our understanding of who gains the nutritional benefits arising from foreign fishing. Next, we explore flows in nutrients among countries experiencing varying prevalence of inadequate nutrient intake. Finally, combining nutrient availability with exposure to trade and foreign fishing instabilities, we construct a framework to assess future nutrient vulnerabilities, with and without predicted climate change.Here we use a trait-based model developed by Hicks et al.  to estimSI Appendix, Table S2A) benefit by harvesting fish from foreign waters, but several countries benefit disproportionately, including Japan, South Korea, and China . However, the magnitude of those benefits drops for nations where high percentages of their flagged fishing vessels have owners residing in other nations , and nearly three quarters of nations experience net gains from fish when imports and foreign fishing are summed  with Japan receiving the greatest of such benefits. Few (11%) nations experience net losses in nutrients from both foreign fishing and trade , and 28% of nations experience net losses when foreign fishing and trade are summed . The United Kingdom experiences one of the greatest net losses, but recent policy changes in the UK Fisheries Act (2020) look to give full national control over foreign fishing access  for four micronutrients that are known to be relatively concentrated and bioavailable in fish and where national intake data are available   and second focusing on those nations which were highly dependent on fish . Furthermore, understanding how distribution of fishery-derived nutrients may affect nutrition security is complicated by FOCs and transshipment. To understand the impact of FOCs, we also estimated nutrient flows and yields accounting for nations issuing FOCs.To understand how foreign fishing and trade of fishery-derived nutrients may support or undermine nutrition security, we estimated flows (mass) of nutrients among nations with differing prevalence of inadequate nutrient intake (tamin A) . We exprTop and Middle). For example, the greatest increases in apparent per capita supply of calcium from foreign fishing occur in countries with high and very high levels of inadequate calcium intake . This finding may be influenced by the widespread prevalence of high and very high inadequate calcium intake    but suggble S3B) . For exable S3B) , which mBottom) and predominantly benefit countries with low prevalence of inadequate nutrient intake (light shading). This is not surprising given the small number of high-income countries that dominate fishing in foreign EEZs  are more moderate , ra, raBottoign EEZs , 29, higSI Appendix, Fig. S1 vs. SI Appendix, Fig. S2). However, our findings may underestimate the scale of inequity in nutrient flows arising from FOCs. Our analysis accounted for reduced flows of nutrients to countries issuing FOCs: countries that are often nutrient insecure and reliant on fish as the dominant animal-sourced food . Trade tends to drive flows of nutrients away from countries experiencing high and very high prevalence of inadequate nutrient intake (dark shading), toward countries experiencing low levels of inadequate nutrient intake (light shading). Due to the greater number of countries (and their larger populations) importing versus exporting fish, a decline in the after-trade nutrient yield was observed across most categories of inadequate micronutrient intake . Nonetheless, after-trade losses were greater for countries experiencing greater prevalence of inadequate nutrient intake than countries with low prevalence. Once again, these overall trends hold whether the relative importance of fish to local diet is accounted for or not .Trade also impacts nutrient flows among nations, although the magnitude of these effects is smaller than for foreign fishing . This suggests, at a global scale, redistribution of nutrients from fisheries does not follow consistent pathways of buying power. However, the shifts in per capita nutrient yields  suggest that when nutritional differences among fish species and nations’ nutritional needs are considered, distribution of fish supplies may be undermining nutrition security and equity :To assess nations’ vulnerability to changes in fisheries-derived nutrient supply, we adapted a commonly used vulnerability framework  . The countries exhibiting the greatest vulnerability were primarily in Africa and Pacific SIDS . Sensitivity was also variable across Africa and Pacific SIDS , while adaptive capacity tended to be low in Africa and was variable for Pacific SIDS . The addition of projected climate change exacerbated the nutrient vulnerability of many nations . Developing risk-prepared policies relies on understanding the specific mechanisms underlying a nation’s nutritional vulnerability  and 4. FFinally, supporting food and nutrition security actors in improving nutritional outcomes and reducing nutrient vulnerabilities will be enabled by 1) improved understanding of nutrient flows through illegal, unreported, and unregulated fishing; 2) illuminating the role of legitimate informal sectors; and 3) increased transparency in relation to vessel ownership (FOCs) , transshSI Appendix, Supplementary Methods and Table S5, for more details). We chose this catch database because it was closely matched to the only available global seafood trade database (described below in this section) where broad traded commodities are translated to useful taxonomic groupings required for nutrient calculations. This allowed the comparison of landings and seafood trade between countries.We sourced spatially explicit wild caught marine fisheries data from the catch reconstruction database of Watson and Tidd  .SI Appendix, Supplementary Methods and Table S5). These data uniquely report trade of taxa at a range of taxonomic resolutions (rather than commodities), from species up to broad classifications such as marine finfishes. Trade flows are identified according to importing and exporting country. International trade data for 2015 were used for the analysis of trade in nutrients. Data from 1976 to 2015 were used to assess variability in the tonnage of fish traded over time (see vulnerability framework).We sourced international trade data from Watson et al.  . We multiplied catches for each nation by the proportion of vessels under FOC (averaged across 2013 and 2018). This is a coarse measure of the impact of FOCs on nutrient supplies as 1) the FOC database only included vessels >100 gross tons  wSI Appendix, Table S5). This model predicts the concentration of seven nutrients that are essential to human health and are bioavailable in fish species  from a series of traits linked to the diet (feeding pathway [pelagic or benthic] and trophic level), energy demand , thermal regime , and habitat of species.We estimated the nutrient concentration of all taxa reported at family, genus, or species level, which were caught and traded globally in 2015, using the trait-based Bayesian hierarchical model developed by Hicks et al.   for all fish species identified in the catch and trade data. Where trait data were missing for a particular species, genus-level averages were calculated . Where genus-level averages were not available owing to missing data, family-level average values were calculated.We sourced trait information from FishBase   the majority of landed catch are finfish  in 2015, 49.We explored the nutrient content of fish in relation to seven nutrients that are important for human health and for which fish are an important, bioavailable source , 51. TheSI Appendix, Supplementary Methods).Where catch and trade information were provided at taxonomic resolutions below family and therefore nutrient concentrations were not available from the hierarchical model, the mass of nutrients was estimated using a four-tier interpolation approach   to catchSI Appendix, Table S1).To facilitate comparison of the effects of fishing and trade among the seven nutrients, we expressed the mass of nutrients in terms of the number of reproductive age females  whosnFFi is the number of RNI of nutrient n caught by nation i fishing in other countries’ EEZs or in the high seas and nLossFFi is the number of RNI of nutrient n caught by other countries’ foreign fleets in nation i’s waters. Positive values indicate that nation i gains more of nutrient n from fishing in foreign waters and the high seas than is extracted by other nations’ fleets fishing in i’s EEZ.To estimate the impact of trade and foreign fishing on a nation’s fishery-derived nutrient supply, we calculated the balance between gains and losses arising from either foreign fishing (FFB) or trade (TB) as follows:nIMPi is the number of RNI of nutrient n imported by nation i and nEXPi is the number of RNI of nutrient n exported to other nations by nation i. Positive values indicate that nation i gains more RNI of nutrient n from imports than it exports, that is, the country is a net importer for nutrient n.where Mean foreign fishing balance (averaged across nutrients) was plotted against mean trade balance, to identify which countries gain nutrients from both foreign fishing and trade and which countries experience a loss in nutrient supply due to foreign fishing and/or trade arrangements. For countries that issue FOCs, where the beneficial owner lives in a different country to the flagged nation, we estimated foreign fishing balance both accounting for and not accounting for losses due to FOCs, to understand the potential impact of FOCs on nutrient supplies.SI Appendix, Table S5). Countries were categorized as having very low to very high prevalence of inadequate intake for each nutrient  according to their status in 2011. In this context, inadequate nutrient intake is based on 1) apparent consumption of all foods  not just wild capture fisheries and 2) the estimated average micronutrient requirements of different demographics accounting for the bioavailability of nutrients in different food sources  of fishery-derived nutrients may support or undermine nutrient security, we explored the flow of nutrients due to foreign fishing and trade among countries experiencing different levels of inadequate nutrient intake for the four micronutrients where intake data were available: calcium, iron, zinc, and vitamin A   of nutrients were calculated within the different nutrient intake categories. Specifically, the median yield (percentage of RNI per capita per day) of each nutrient was estimated in relation to 1) foreign fishing catches for the source nation (source) and the nation that owned the foreign fishing fleet (sink foreign fleet) including and excluding high seas catches and 2) trade for the exporting nation and the importing nation. These data were plotted using a log10(x + 1) transformation.SI Appendix, Table S5).To understand if there are correlations between socioeconomic status of a nation and patterns in the redistribution of fishery-derived nutrients due to trade and foreign fishing, we ran Spearman rank correlations between the trade and foreign fishing balance of each nutrient and three metrics of national socioeconomic status—coefficient of human inequality, GDP per capita, and human development index  were normalized on a scale between 0 and 1 at each stage of the framework to ensure equal weighting, regardless of initial units. For exposure and sensitivity, this scaling was reversed for those variables that initially had high values equaling low exposure or sensitivity . For adaptive capacity, scaling was reversed for those variables that initially had high values equaling low adaptive capacity .All variables (gray and blue text in FF) was calculated from the mean of two normalized subvariables: variability in foreign fishing catches over time (CvFF) and diversity of locations where a country undertakes foreign fishing (DivFF). Variability in foreign fishing catches over time (CvFF) was estimated from the coefficient of variation in foreign fishing catches over time. The coefficient of variation was estimated from tonnage of foreign fishing catches by each nation from 1976 to 2015 . The inference is that a high coefficient of variation represents greater volatility in the access to foreign fishing catches and thus greater exposure to changes in nutrient supplies. The location diversity for foreign fishing (DivFF) was estimated using the Shannon Weaver index in the vegan package in R . Low values indicate most of the nutrients caught by a nation’s foreign fishing fleet are being sourced from few locations, whereas high values indicate the nutrient catch from a nation’s foreign fishing fleet is spread more evenly across many locations. The inference is that a high diversity of locations will help mediate volatility in foreign fishing catch and changes to foreign fishing access agreements, as loss of access to one EEZ (or high seas) is unlikely to have a large impact on nutrient supplies.Nutrient supplies from fisheries will be affected by changes to foreign fishing access agreements, for example, through loss of access to a particular EEZ, and by changes in trade patterns. Exposure to foreign fishing changes (Eage in R  and averIMP) was calculated from the mean of two normalized subvariables: variability in imports over time (CvIMP) and the diversity of nations suppling imports (DivIMP). Variability in imports (CvIMP) was estimated from the coefficient of variation in imports over time. The coefficient of variation was estimated from tonnage of imports by each nation from 1976 to 2015 . The inference is that a high coefficient of variation represents greater volatility in imports and thus greater exposure to changes in nutrient supplies. The diversity of nations supplying imports (DivFF) was estimated using the Shannon Weaver index and averaged across the seven nutrients used in the earlier analyses . Low values indicate most of the nutrients imported by a nation are being sourced from few countries, whereas high values indicate the nutrients imported by a nation are sourced more evenly from many countries. The inference is that high diversity of import sources will help mediate volatility in imports as loss of supplies from one source is unlikely to have a large impact on overall nutrient supplies.Exposure to changes in imports of nutrients (EFF) and imports of nutrients (EIMP) were weighted by the contribution of foreign fishing (FFF) and imports (FIMP), respectively, to a nation’s fishery-derived nutrient supply  in relation to the seven nutrients focused on in this study . As a result, the exposure metrics were down weighted if foreign fishing and imports contributed little to national nutrient supply, e.g., if domestic catch dominated supply. These weightings also used national catches adjusted to remove catches from FOC vessels. Total exposure for each country was then estimated from the mean of the constituent exposure metrics . The results were mapped using the rnaturalearth package in R.To account for variability in the relative importance of foreign fishing and trade to different nations, exposure to changes in foreign fishing  and the prevalence of inadequate micronutrient intake index  . While this list of micronutrients differs slightly from those used in the exposure metric, it provides a broader picture of prevalence of inadequate levels of micronutrient intake and thus the sensitivity of the country to changes in nutrient supplies. Overall availability of adequate energy may also impact on national sensitivity to changes in fishery-derived nutrients , so we did not include this index in the sensitivity metric. The results were mapped.The sensitivity of a nation to changes in supplies of fishery-derived nutrients from foreign fishing and trade will depend on how dependent the population is on fish for food and the prevalence of micronutrient deficiencies. Thus, sensitivity was calculated from the mean of two normalized subvariables: the proportion of animal protein supplied by fish (Sd zinc])  (SI Appeutrients . HoweverSE), expenditure on health care (ACN), and status as a food importer (ACIMP). The results were mapped.Finally, the capacity of a nation to adapt to changing nutrient supplies from fisheries will depend on many latent factors that we have estimated using a series of measurable proxies, including socioeconomic status, health care, and food trade balance. Thus, adaptive capacity was estimated from the mean of three normalized metrics: socioeconomic status (ACSE) was calculated from the mean of two normalized subvariables : GDP per capita (ACGDP) and conflict and political stability (ACS) . GDP per capita  so we did not include this index in the socioeconomic metric.The socioeconomic metric  as a percentage of GDP , was used as a proxy of health care and thus the ability of the nation to either address inadequate nutrition or the health consequences of inadequate nutrition . Status of each nation as a net importer of food  was used as the third component of adaptive capacity as it indicated the broader capacity of the nation to counter changes in imports of fishery-derived nutrients with domestic production. The inference is that being a net importer would reduce adaptive capacity.Health care expenditure (ACe of GDP  (SI AppeCCE) was calculated from the mean of two normalized subvariables: predicted change in domestic catch from 2010 to 2050 (CpDC) and species diversity of domestic catch weighted by nutrient supply (DivDC) .Food and nutrient supply are not only affected by foreign fishing and trade arrangements, they are also affected by climate variability . Indeed,CCE) was estimated from projected mean relative change in maximum potential fish production from 2010 to 2050 (CpDC), under the business-as-usual representative concentration pathway (RCP) scenario (RCP 8.5). These estimates were obtained from ref. SI Appendix, Table S5), which used the marine model intercomparison project model ensemble outputs, consisting of four marine ecosystem models forced by two Earth system models. Model outputs were mapped and spatially averaged to each country’s EEZ. The inference is that large declines in domestic catch production represent greater exposure to declines in nutrient supplies due to climate change.Past research assessing the exposure of fisheries to climate change has used changes in temperature to 2050, e.g., ref. DivDC) was estimated using the Shannon Weaver index and averaged across nutrients . Low values indicate most of the nutrients caught by a nation’s domestic fleet are being sourced from a few species, whereas high values indicate the nutrient catch from a nation’s domestic fleet are spread more evenly across many species. The inference is that a high diversity will help mediate declines in domestic catch as declines in one species are unlikely to have a large impact on nutrient supplies from domestic catches.The species diversity of domestic catch weighted by nutrient supply (CCE) was weighted by the contribution of domestic catch to fisheries-derived nutrient supply .To account for variability in the relative importance of domestic catch to different nations, exposure to climate change (Supplementary FileSupplementary File


Falls and depressive symptoms are prevalent and costly to Chinese older adults. Although falls and depressive symptoms are frequently interrelated, previous studies were mainly based on cross-sectional data, and the nature of interrelationships between them were not well understood. In this study, we aimed to examine the longitudinal bidirectional relationship between falls and depressive symptoms among Chinese older adults, and whether this bidirectional relationship is different for males and females, given that females are found to suffer from falls and depressive symptoms significantly more than males. Older adults aged 60 years+ who completed all three waves of data from the China Health and Retirement Longitudinal Study on falls and depressive symptoms between 2011 (wave 1), 2013 (wave 2), and 2015 (wave 3) were included in the current analysis . Data were analyzed using random intercept multilevel models that adjusted for demographic information . Overall, there is a relatively stable rates of comorbid falls and depression (about 10%) over time among Chinese older adults. Significant bidirectional associations at between-person and within-person levels were observed between depressive symptoms and falls over time, with greater depressive symptoms associated with higher risk for falls and vice versa. However, such associations were not different between males and females. Taken together, these findings indicate the importance of addressing both depression and falls at the same time to prevent falls in the clinical practice for both males and females.


Publication of patient images contributes to research and education in dermatology. However, it is important to protect patients’ privacy and rights. The Committee on Publication Ethics (COPE) and the International Committee of Medical Journal Editors (ICMJE) have provided best practices and recommendations, respectively, for the protection of patients’ rights in scholarly publications ,2. NonetThis study was exempt from institutional review board review as data were publicly available. Themes regarding the publication and deidentification of patient images, as well as the acquisition of consent, were extracted from COPE and ICMJE ,2. On JuA total of 19 (95%) journals’ online instructions instructed authors to obtain written consent or permission for the publication of patient images . The speInstructions regarding the deidentification of patient images and acquisition of consent for publication differed across dermatology journals and incorporated various elements from COPE and ICMJE ,2. Most


Integration of HIV prevention with sexual and reproductive health servicesEditorial on the Research Topic Sub-Saharan Africa (SSA) has the highest burden HIV infection globally, and over 57% of those infected are adolescent girls and young women (AGYW). AGYW of reproductive age in this region are at heightened risk of HIV infection, unplanned pregnancy and sexually transmitted infections (STI) due to a host of socio-behavioural, contextual, gender and relationship dynamics compounded by challenges related to access to sexual reproductive health (SRH) services. Annually, more than 200 million women globally experience unplanned pregnancies due to lack of access, uptake or awareness of availability to reliable contraceptive methods. The vast majority, 70%–80% of these women, reside in SSA. Consequently, almost 50% of pregnancies are unintended and 35 million unsafe abortions occur annually in this region.Despite efforts to scale up SRH initiatives for the general population, progress made to reduce rates of HIV amongst the most marginalised groups are sub-optimal and high infection rates persist. As highly effective HIV prevention methods including treatment as prevention, HIV pre-exposure prophylaxis (PrEP), condoms and male circumcision have been available for more than a decade now, there are increasing challenges related to measuring impact of a single HIV prevention effort as combination prevention is usually recommended. Furthermore, evidence of pockets of HIV micro-epidemics  exist, rAside from HIV, STIs are underdiagnosed in public healthcare facilities due to clinical management being driven by a syndromic symptom-based approach in SSA. Often asymptomatic or having non-specific symptoms, STIs are often unmanaged, increasing HIV transmissibility. Data from ECHO conducted among women seeking family planning (FP) services in HIV burdened settings in Africa demonstrated high HIV incidence of 3.8 per 100 woman-years with higher incidence in some community settings  and finaThe World Health Organization (WHO) recommends that SRH services, including contraceptive method delivery, be integrated within HIV prevention and care services. Integration is associated with increased offers and uptake of SRH services, including contraceptive uptake, and STI services and reducing unwanted pregnancies, perinatal HIV transmission and maternal and infant mortality among people living with or without HIV. It is envisaged an integrated SRH model would improve equitable access, yield holistic and comprehensive care, raise the quality of maternal and antenatal care, be cost-effective to the client and the health system, increase financial sustainability with co-location of services and diversify healthcare provider capacity. Most critically, it would reduce stigma being a barrier to access due to shifts away from siloed care. With scale-up of oral PrEP and multiple novel HIV/STI prevention products on the horizon, it would offer a unique opportunity to expand innovative approaches to deliver comprehensive, integrated HIV prevention/SRH services.However, despite the WHO call and theoretical support for integration, SRH services continue to remain predominantly distinct in most African countries. This may be attributed to the impact of legacy siloed structures that are challenging to modify due to lack of widespread funding or national ministries of health support, need for investment in provider training to support shifts to integration and concerns related to sustainability in this new model. Despite these limitations, research efforts continue to be encouraged to identify approaches for streamlined integration of SRH services. In an ideal world, provision of a comprehensive SRH programme should incorporate five major components: maternal and newborn health; family planning; prevention of unsafe abortion; management of reproductive tract infections and STIs, including HIV/AIDS; and promotion of sexual health all integrated within one discrete cohesive health care facility.Researchers continue to launch and refine programs to provide evidence of best practices to inform wider scale-up and implementation. These programs span the breadth of HIV care – from testing to prevention to treatment and ongoing management – and leverage the breadth of SRH services – for pregnancy, family planning, and STI prevention and management – to offer myriad opportunities for client-centred, efficient, and comprehensive care. HIV/SRH service integration must be built on evidence of best practice implementation by those who have made efforts for better efficiency in processes. In order to showcase such evidence, a special Research Topic focussing on “Integration of HIV Prevention with SRH Services” was opened and invited submissions for consideration. Two guest editors facilitated the solicitation, peer-review and publication of manuscripts from multiple studies. A total of 14 manuscripts were received; one was rejected and 13 accepted for publication post peer review informed updates were made. By January 2022, the series achieved over 14, 000 views. The breadth of coverage within the series showcased evidence from across Africa and the United States and assesses ongoing integration efforts from different perspectives.Drake et al., Mugwanya et al., Pleaner et al., Kasaro et al.) to a focus on the structural and motivational challenges faced by healthcare providers delivering PrEP alongside SRH services . There was also focus on design of PrEP-FP integration matrices and assessing country-specific progress to identify common enablers of and barriers to PrEP-FP integration but also propose the matrix use as a potential roadmap to guide work towards more efficient achievement of integration . Utilizing access to AGYW FP services attendees, Nyaboe et al. sought to better understand young women's risk profiling using contraceptive option selection as a proxy to determine risk categorisation when assessed alongside behavioural risk factors and how they may infer potential preferences for a range of short and long term PrEP delivery modalities. There was also evidence of a step further in integration beyond services to a focus in on products with dual or multiple indications within one modality offering both HIV/STI and pregnancy prevention . These were recognised conceptually as options that are appealing with potential to revolutionise women's health – all with balance to also recognising opportunities and challenges that would accompany multi-indication product delivery and roll-out. The potential impact and appetite for discrete products with multiple indications would offer an alternate but very appealing integration of SRH services for AGYW who may face challenges disclosing use of methods for indications often stigmatised .Publications include desktop scoping and landscape analyses across a number of African countries offering HIV testing services and PrEP delivery with family planning (FP) and SRH services to AGYW within the public healthcare space, in programmes and research studies (Overall, the evidence suggests more is needed to support SRH integration. Despite integration being theoretically and conceptually sound, there is insufficient evidence from the real world to demonstrate long term impact and benefit due to low uptake. Purely offering services in a facility does not speak to actual process integration and natural seamlessness of routine care. A standardised offering with opt-out options vs. opt-in may be useful to inform better SRH care. Evidence indicates that a one-stop women centred care approach would provide holistic care and reduce burden on the service dispersed models. One caveat remains; lack of adequate self-assessed risk awareness. AGYW generally have inaccurate and often low perceptions of their own risk. Design of age appropriate risk assessment tools with repeated opportunities for use will ultimately impact individual uptake of SRH services decreasing incidence of unplanned pregnancies, HIV and STIs.


To date, no gold standard exists for the assessment of unilateral spatial neglect (USN), a common post-stroke cognitive impairment, with limited sensitivity provided by currently used clinical assessments. Extensive research has shown that computer-based (CB) assessment can be more sensitive, but these have not been adopted by stroke services yet.We conducted a systematic review providing an overview of existing CB tests for USN to identify knowledge gaps and positive/negative aspects of different methods. This review also investigated the benefits and barriers of introducing CB assessment tasks to clinical settings and explored practical implications for optimizing future designs.We included studies that investigated the efficacy of CB neglect assessment tasks compared to conventional methods in detecting USN for adults with brain damage. Study identification was conducted through electronic database searches , using keywords and standardized terms combinations, without date limitation (last search: 08/06/2022). Literature review and study selection were based on prespecified inclusion criteria. The quality of studies was assessed with the quality assessment of diagnostic accuracy studies tool (Quadas-2). Data synthesis included a narrative synthesis, a table summarizing the evidence, and vote counting analysis based on a direction of effect plot.A total of 28 studies met the eligibility criteria and were included in the review. According to our results, 13/28 studies explored CB versions of conventional tasks, 11/28 involved visual search tasks, and 5/28 other types of tasks. The vote counting analysis revealed that 17/28 studies found CB tasks had either equal or higher sensitivity than conventional methods and positive correlation with conventional methods (15/28 studies). Finally, 20/28 studies showed CB tasks effectively detected patients with USN within different patient groups and control groups (17/28).The findings of this review provide practical implications for the implementation of CB assessment in the future, offering important information to enhance a variety of methodological issues. The study adds to our understanding of using CB tasks for USN assessment, exploring their efficacy and benefits compared to conventional methods, and considers their adoption in clinical environments. Unilateral spatial neglect (USN) is one of the most common post-stroke cognitive impairments with a prevalence of up to 80% early after stroke  tasks may be able to make a significant contribution. These tasks can provide higher sensitivity and diagnostic accuracy  and better psychometric properties  with low cost and short administration time . Previous reviews have focused on VR -tasks (immersive and non-immersive) used in the assessment and rehabilitation of USN, demonstrating that VR assessment can effectively detect USN  framework was adopted  stroke survivors or patients with other types of brain damage with or without USN.Intervention: CB tasks .Comparison: Conventional tests  or CB design based on PnP.Outcomes: A variety of outcomes were accepted such as .The review was conducted based on the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines , AMED, CINAHL (EBSCO), WEB of Science, PubMed, Scopus) using keywords and a combination of standardized terms was conducted.The last search was conducted on 08/06/2022 with the following search strategy keywords:-  AND*”) AND-  AND- (assess* OR computer OR computerized OR computer-based OR phone OR smartphone OR tablet)- ].In order to retrieve further published, unpublished and ongoing studies, manual searches were utilized through the references of included articles, gray literature was identified through Google Scholar and registered ongoing trials were searched  and task demands   target detection   was explored by 22/28 studies, with 2/28 reporting limited  for demonstrating the clinical validity of the CB tests and control demographics among patients  can be more effective in detecting neglect symptoms. It was revealed that these types of tasks can capture more mild/chronic/subclinical cases than simple versions. Similarly, more complex designs, combining a variety of task types with different task demands, can maximize sensitivity by providing a wider data collection. These results are in line with existing evidence that presenting greater task difficulty can enhance sensitivity Bonato, . These fThe results of this study explore the potential superiority of some outcome measures' sensitivity for detecting spatial bias and visual search deficit, such as RT and accuracy for visual search and comparable target detection tasks. This has previously been observed in a variety of other studies exploring the advantages of these measures . In recent years, the global technological expansion and digitalization of everyday life have minimized the practical constraints of CB assessment concerning requirements for hardware access. Additionally, technological advances have allowed the creation of more accessible designs, with some authors reducing further the practical boundaries by providing access to online/offline software for analysis and assessment (Rorden and Karnath, The evidence presented in this review demonstrates that CB neglect assessment methods are feasible, valid, flexible, reliable, and user-friendly tools. Our results are in accordance with the findings of multiple studies exploring the advantages of these methods (Halligan and Marshall, p-values (McKenzie and Brennan, Most of the included studies suffer similar limitations. In order to overcome these issues and minimize bias, it is recommended that future studies avoid selection bias by including a consecutive or random large sample of control subjects and patients from a wide stroke population with equivalent demographics (Chassé and Fergusson, Our review of major studies confirmed that CB assessment of USN can offer higher acceptability, flexibility, and feasibility compared to conventional methods. Extensive data show that CB methods have been proved to provide a wider variety of data than PnP tasks which can be crucial in understanding patients' profile and severity, as well as monitor progress and the effect of rehabilitation. There is a strong body of evidence demonstrating that CB assessment can be more sensitive and overcome conventional methods' practical issues such as compensatory strategies and ceiling effects, especially with more complex designs and combinations of different task types. The results obtained here may have implications for understanding essential features affecting the efficacy of CB tasks and indications can be implemented as a guide to improving future designs. The findings of this review complement those of earlier studies and suggest that CB tasks for USN assessment should be implemented in clinical settings.The original contributions presented in the study are included in the article/IG and DP conceived the presented idea. IG developed the methodology, conducted a comprehensive literature search, performed and expressed the data synthesis of the selected studies, and wrote the original draft. IG and DL performed the final study selection, data extraction, and quality appraisal of the studies. DP verified the findings of this work and was involved in expert review and editing. All authors contributed to the article and approved the final manuscript.The authors received financial support for the publication of this article from the University of Birmingham.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Graduate medical education (GME) and Clinical Competency Committees (CCC) have been evolving to monitor trainee progression using competency-based medical education principles and outcomes, though evidence suggests CCCs fall short of this goal. Challenges include that evaluation data are often incomplete, insufficient, poorly aligned with performance, conflicting or of unknown quality, and CCCs struggle to organize, analyze, visualize, and integrate data elements across sources, collection methods, contexts, and time-periods, which makes advancement decisions difficult. Learning analytics have significant potential to improve competence committee decision making, yet their use is not yet commonplace. Learning analytics (LA) is the interpretation of multiple data sources gathered on trainees to assess academic progress, predict future performance, and identify potential issues to be addressed with feedback and individualized learning plans. What distinguishes LA from other educational approaches is systematic data collection and advanced digital interpretation and visualization to inform educational systems. These data are necessary to: 1) fully understand educational contexts and guide improvements; 2) advance proficiency among stakeholders to make ethical and accurate summative decisions; and 3) clearly communicate methods, findings, and actionable recommendations for a range of educational stakeholders. The ACGME released the third edition CCC Guidebook for Programs in 2020 and the 2021 Milestones 2.0 supplement of the Journal of Graduate Medical Education (JGME Supplement) presented important papers that describe evaluation and implementation features of effective CCCs. Principles of LA underpin national GME outcomes data and training across specialties; however, little guidance currently exists on how GME programs can use LA to improve the CCC process. Here we outline recommendations for implementing learning analytics for supporting decision making on trainee progress in two areas: 1) Data Quality and Decision Making, and 2) Educator Development. CBME prelopment . ‘Learnielopment ,16.Learning analytics is the interpretation of multiple data sources gathered on trainees to assess academic progress, predict future performance, and identify potential issues to be addressed with feedback and individualized learning plans (ILPs) ,17,18. WThe ACGME released the third edition CCC ‘Guidebook’ for Programs in 2020  and the In this paper, we outline recommendations for implementing learning analytics for supporting decision making on trainee progress in two areas: (1) Data Quality and Decision-Making and (2) Educator Development.prior to CCC meetings. In addition, active engagement of residents in the evaluation process [We outline our long- and short-term recommendations for data quality and decision making in  process ; and mon process . Aspirat process  and autoAccreditation guides should point to strategies that can aid data analysis and decision-making ,32. AspiEducators and trainees need to learn how to manage large streams of quantitative  and qualIn terms of educator development, the 2021 JGME supplement  proposesIn the more distant future, GME would benefit from faculty trained in educational research through formal training and clinical informatics programs sponsored by the National Library of Medicine , ACGME , and/or CCCs engage core GME faculty and program coordinators who balance multiple competing demands . IdeallyMechanisms for funding GME need to change to enable these kinds of innovations. Applying for grants to support this work as educational innovation is possible, but would not lead to a sustained infrastructure to support improvement . The avaIn summary, action is needed to fully realize CBME in residency training. Evolutionary pathways for inclusion of LA and educator and trainee development in guiding literature, such as the next CCC Guidebook  and ACGM


Women and disabled IDPs are recognised as under-researched populations, with differences in vulnerabilities to displacement and resettlement prospects. This thematic network analysis employs an intersectional approach to consider This is a qualitative analysis of a subset of data collected by the second author and her research team in 2017–18, as part of a larger action research project. Participants were randomly selected from the Victim's register in an industrialised municipality of Colombia. A subsample (n = 20) were invited to participate in life and family histories. Units of analysis were individual (n = 11) and family interviews (n = 9), with a mixture of self-identifying disabled and non-disabled men and women. River and tree of life tools were used to elicit culturally sensitive discussion of significant life events and ongoing distress. NVivo software and hand coding techniques were used to operationalise thematic webs. The analysis employed a grounded approach to thematic network analysis.Environments and contexts of displacement, considers the loss of land and community alongside the myriad of social institutions, legal entitlements, family circumstances, cultural expectations and stigma influencing participants' access to resources. The second, Making sense of it all, represents the emotional and cognitive responses to perceived injustices and eroded trust. The third, Mechanisms for managing distress, represents strategies employed by IDPs at individual and family levels. Relationships between employment status and gendered divisions of labour were noted, suggesting that non-disabled women were able to meet increased domestic and paid work demands following displacement, though this was a considerable source of stress. Concepts around racial, indigenous and class identities were alluded to by several participants but could not be fully developed due to relative scarcity of accounts within the dataset.Three global themes, each underpinned by several organisational themes, were developed. The first, The thematic networks presented illustrate several compounding and interrelated oppressions faced by IDPs, offering explanation as to how this produces and sustains emotional distress. Participants’ well-founded worries about economic security and childcare alongside concerns for safety and acceptance in host communities require co-ordinated, locally informed responses. Prevention and recovery programmes should consider interventions at a family level, whilst strengthening participants’ self-developed strategies for managing distress.


Through a competitive proposal process for a recent funding opportunity, 38 community based organizations submitted proposals that addressed vaccine hesitancy among adults who are members of racial or ethnic minority communities. Proposals were required to include discussion of barriers identified in the community of focus and evidence to support all assertions. Submissions ranged from single employee projects to large collaborative networks, and were submitted from all regions of the US, including both tribal and territorial areas, including more than 45 ethnic and language groups. Barriers were coded by two reviewers and six (6) primary themes were identified: access related to transportation, distance, or time; lack of culturally responsive materials or sensitivity of providers; structural issues such as poor data collection, historical inequity, mistrust, or systemic racism; messages coming from untrusted sources; misinformation or no information available; and differing cultural perspectives. The most commonly identified issues were related to mistrust, historical structural issues or fear and racism (n=23), and lack of access due to transportation, distance, or time (n=17). This group of proposals for funding represent a small cross-section of communities who continue to have significant pockets of unvaccinated persons. While it is possible to see themes for barriers that are encountered in increasing vaccination rates among adults, communities demonstrate extremely nuanced realities, filtered through a range of culturally and paradigmatically different ways of knowing. Success in public health initiatives requires intensive focus on the variance across these different perspectives and careful attention to appropriately focus outreach and messaging.


Occupational exposures may result in Canadian military Veterans having poorer health and higher use of health services after transitioning to civilian life compared to the general population. However, few studies have documented the physical health and health services use of Veterans in Canada, and thus there is limited evidence to inform public health policy and resource allocation.In a retrospective, matched cohort of Veterans and the Ontario general population between 1990–2019, we used routinely collected provincial administrative health data to examine chronic disease prevalence and health service use. Veterans were defined as former members of the Canadian Armed Forces or RCMP. Crude and adjusted effect estimates, and 95% confidence limits were calculated using logistic regression . Modified Poisson was used to estimate relative differences in the prevalence of hypertension. Poisson regression compares rates of health services use between the two groups.The study included 30,576 Veterans and 122,293 matched civilians. In the first five years after transition to civilian life, Veterans were less likely than the general population to experience asthma , COPD , hypertension , diabetes , myocardial infarction , and rheumatoid arthritis . Compared to the general population, Veterans had greater odds of visiting a primary care physician  or specialist physician  at least once in the five-year period and lower odds of visiting the emergency department . Risks of hospitalization and of receiving home care services were similar in both groups.Despite a lower burden of comorbidities, Veterans had slightly higher physician visit rates. While these visits may reflect an underlying need for services, our findings suggest that Canadian Veterans have good access to primary and specialty health care. But in light of contradictory findings in other jurisdictions, the underlying reasons for our findings warrant further study.The online version contains supplementary material available at 10.1186/s12889-022-14053-4. Globally, there are approximately 17 million military Veterans living in the United States , and appWhile there is a wealth of data from the US –10 and on = 2,755) and may not be representative of Canadian Veterans residing in Ontario. Population-based routinely collected administrative health data have considerable advantages over survey data for estimating the prevalence of physical health conditions and the rates of health service use amongst Canadian Veterans relative to the general population. Primary amongst these is that studies using de-identified population-based administrative data do not rely on a sample, but instead capture the whole population of interest. Administrative data also do not rely on self-report, avoiding participation bias and recall bias in survey responses.Only a small number of studies on post-discharge health risks and healthcare seeking behaviours among Canadian Veterans exist. Most of these studies focus on mental health –24, and In this study, we used population-based administrative health and health services data from Ontario to compare the prevalence of health conditions  and health services use, defined as use of primary care, specialist care, emergency department visits, hospitalizations, and home care by CAF Veterans with the general population of Ontario, Canada. This information will be valuable to Canadian healthcare planners and providers in managing the health of Veterans in their home communities.We used a retrospective, matched cohort design of Veterans and the Ontario general population. Ontario is the most populous province in Canada, with an estimated 14.7 million inhabitants as of March 31, 2020 . It is aThe data for this study are held at ICES , a not-for-profit health services and policy research institute that provides stewardship over Ontario’s administrative health data. We linked the following ICES administrative datasets at the individual level using unique encoded identifiers: the Ontario Health Insurance Plan (OHIP) database ; the Ontario Drug Benefit database ; the National Rehabilitation Reporting System (rehabilitation stay); the Registered Persons Database ; the ICES Physician Database ; the Canadian Institute of Health Information (CIHI) Discharge Abstract Database and the CIHI-Same Day Surgery databases ; the National Ambulatory Care Reporting System ; and the Home Care database .We defined Veterans as former members of the CAF or RCMP who provided evidence of their military service to the Ministry of Health and Long-Term Care (MOHLTC) at the time of enrolment in OHIP. Health insurance coverage transitions from federal to provincial oversight at the time of departure from the CAF and RCMP. In Ontario, standard waiting periods for provincial health insurance are waived when evidence of CAF or RCMP service is provided; an administrative military service code and service start, and end dates are linked to the individual’s provincial health card. The MOHLTC provided an anonymized list of individuals with an administrative military service code linked to their health card number to ICES. Data anonymization, linkage to the unique encoded identifier (ICES Key Number), and removal of the health card number were performed according to standard ICES protocol by the ICES Data Acquisition team. Identifying information was removed from the cohort prior to access by the study authors.Veterans were included in the study if they registered for OHIP between January 1, 1990, and December 31, 2019. The date of OHIP registration is a close approximation of the Veteran’s release date from the CAF or RCMP . We exclVeterans were matched with up to four members of the general population with replacement. Each Veteran’s OHIP registration date was used as the index date for the matched civilian reference groups. Eligible members of the general population were alive at the study index date. To reduce the likelihood of the healthy worker effect, where people who are employed generally experience lower mortality and morbidity than the general population (which includes those who cannot work due to disability or illness) , we seleThe study had two primary outcome categories: chronic disease prevalence and health service use. Both categories were measured in the five-year period following the index date. Persons were followed until end of OHIP coverage , death, or until the end of the study period . Asthma, COPD, diabetes, hypertension, myocardial infarction, and rheumatoid arthritis were identified using standard algorithms at ICES, which are based on validated algorithms using data from physician visits, emergency department visits and hospitalizations –37. The Covariates for models assessing chronic disease were held at their baseline status and included: age (continuous), sex, residential geography, socioeconomic status, and rurality of residence. Socioeconomic status was characterized by median community income quintile (1 = lowest to 5 = highest) using Canada Census data linked to postal codes. The Rurality Index of Ontario (RIO)  and partDemographic characteristics between the Veteran and general populations were compared using standardized differences and variance ratios . PrevaleWe created matched comparator cohorts using hard matching with replacement on age and sex alone, as well as on age, sex, and residential geography for comparability with other studies contrasting Veteran health with the general population . We alsoA total of 36,163 Veterans were eligible for inclusion in this study and, after applying the exclusion criteria, the study group comprised 31,760 individuals . Results were also robust to excluding those with less than one year of potential follow-up data (results available from authors).Military service places greater physical and mental stress on its members than many other occupations and there is potential for members of the service to be exposed to environmental stimuli and/or physical conditions that could exacerbate chronic illness. On the other hand, a healthy worker effect, i.e., a tendency among people who are actively employed to be healthier , would nDespite lower prevalence of common chronic illnesses, our study found the odds of using health services were higher or similar for Veterans compared to the general population. In particular, we documented higher rates of primary care and specialist physician visits and lower rates of emergency department visits among Veterans. Hospitalization rates and rates of receiving home care services were similar in both groups. Veterans’ health service use patterns reported in the literature are mixed. In the US, higher health service use among Veterans is often linked to elevated likelihood of adverse health outcomes, particularly among older Veterans: risk factors like smoking and alcohol misuse and higher rates of cardiovascular disease , mental This study contributes novel information on Canadian Veterans’ health and health services use with important implications for health system and public health planners. Like civilians, Veterans are users of the Canadian healthcare system and must be accounted for when considering the overall health of the population and how health system resources are distributed. Veterans may leave military service with better health than the general population, but there is little understanding of military culture among healthcare providers , 60, makAlthough the use of population-based administrative health data has many advantages, there are also some limitations related to the datasets used in this study that are worth noting. Veterans Affairs Canada estimates that approximately 1,050 Veterans are released from the CAF and take up civilian residence in Ontario each year . While tOur study found that more Veterans visited a physician visit than the general population, a striking finding given the lower burden of comorbidities amongst Veterans. While this may reflect a need for services for diagnoses, disabilities or illnesses we did not measure in our study, our findings suggest that Canadian Veterans have good access to primary and specialty health care. However, there continues to be room for improvement and lessons that could be learned from Veteran health and health service use patterns. Calls to action to better support CAF Veterans have included increasing cultural competency among healthcare providers , increasAdditional file 1: Supplementary Table 1. Unadjusted and adjusted risk ratios of chronic disease stratified by sex . Supplementary Table 2. Relative odds ratios of health care visits, by sex, visit type and Veteran status. Supplementary Table 3. Relative rate ratios of health care visits, by sex, visit type and Veteran status.


Artificial intelligence (AI) has revolutionized health care delivery in recent years. There is an increase in research for advanced AI techniques, such as deep learning, to build predictive models for the early detection of diseases. Such predictive models leverage mobile health  data from wearable sensors and smartphones to discover novel ways for detecting and managing chronic diseases and mental health conditions.Currently, little is known about the use of AI-powered mHealth (AIM) settings. Therefore, this scoping review aims to map current research on the emerging use of AIM for managing diseases and promoting health. Our objective is to synthesize research in AIM models that have increasingly been used for health care delivery in the last 2 years.INFORMS, e-journal archive at MIS Quarterly, and Association for Computing Machinery (ACM) Digital Library using keywords such as “mobile healthcare,” “wearable medical sensors,” “smartphones”, and “AI.” We included AIM articles and excluded technical articles focused only on AI models. We also used the PRISMA  technique for identifying articles that represent a comprehensive view of current research in the AIM domain.Using Arksey and O’Malley’s 5-point framework for conducting scoping reviews, we reviewed AIM literature from the past 2 years in the fields of biomedical technology, AI, and information systems. We searched 3 databases, PubsOnline at We screened 108 articles focusing on developing AIM models for ensuring better health care delivery, detecting diseases early, and diagnosing chronic health conditions, and 37 articles were eligible for inclusion, with 31 of the 37 articles being published last year (76%). Of the included articles, 9 studied AI models to detect serious mental health issues, such as depression and suicidal tendencies, and chronic health conditions, such as sleep apnea and diabetes. Several articles discussed the application of AIM models for remote patient monitoring and disease management. The considered primary health concerns belonged to 3 categories: mental health, physical health, and health promotion and wellness. Moreover, 14 of the 37 articles used AIM applications to research physical health, representing 38% of the total studies. Finally, 28 out of the 37 (76%) studies used proprietary data sets rather than public data sets. We found a lack of research in addressing chronic mental health issues and a lack of publicly available data sets for AIM research.The application of AIM models for disease detection and management is a growing research domain. These models provide accurate predictions for enabling preventive care on a broader scale in the health care domain. Given the ever-increasing need for remote disease management during the pandemic, recent AI techniques, such as federated learning and explainable AI, can act as a catalyst for increasing the adoption of AIM and enabling secure data sharing across the health care industry. Initially, information technology systems were mainly used to record patient data , but theWith the increase in mHealth research, there have been significant improvements in the level of AI available to researchers as well. These improvements offer more accurate insights and results than does traditional ML while simultaneously preserving patient privacy and ensuring a high data security standard. Deep learning (DL) and federated learning (FL) ,20 are sRecently, research related to AI techniques in the mHealth sector has increased considerably . This caUsing mHealth sensors, researchers have documented disease progression , depictiAIM devices can power ubiquitous health care solutions through remote patient monitoring , which iPrior research focusing on the application of AI in the health care domain noted that certain implementation factors exist that prevent large scale automation of the health care sector . HoweverOver the last couple of years, there have been significant advances in both the usage of AI and mHealth. In this regard, several recent studies share an overlapping context  -57 in seScoping reviews are used to examine the extent, range, and nature of research activity in a particular domain. In this context, we used Arksey and O’Malley’s  5-step sWe started by identifying our research questions (RQs) and aimed to survey the literature on the current use of AIM to identify and manage different health conditions. We also investigated the use of data collected from wearable sensors and mobile devices for building AIM models.INFORMS and the e-journal archive at MIS Quarterly for information systems (IS) articles. We used the Association for Computing Machinery (ACM) Digital Library, which catalogs research from top conferences and journals in the AI domain, for AI articles. We also used a search query in Google Scholar with a 2-year filter (since 2019) for including recent articles on specific advancements in the field of AIM related to the use of FL and explainable AI (XAI). The state of the art in AI until 2019 had been covered by previous researchers in surveys and reviews on AI in the health care sector [After specifying our RQs, we identified relevant studies to be screened in this review. This involved searching electronic databases including PubsOnline at e sector ,51,53; tJournal of Biomedical Informatics, Journal of Medical Internet Research, and Nature Medicine for biomedical technology articles. For AI, we focused our efforts on recent top conferences including the Conference on Neural Information Processing Systems (NeurIPS) and the Association for the Advancement of Artificial Intelligence (AAAI). Within these conferences, we looked at ML for health, ML for mobile health, ML for public health, and web search and data mining. As for IS, we searched articles in the top journals of Management Information Systems Quarterly (MISQ), Information Systems Research (ISR), and ACM’s Transactions journals. These studies are related to the use of health care technology combined with a behavioral component that seeks to explain how AI can define patient well-being. We used the keywords “mobile health,” “mHealth,” “mobile healthcare,” “mobile sensors,” “wearable sensors,” “medical sensors,” “smartphone data,” “ML,” and “AI.”The articles screened for this review were published in the 3 major domains of biomedical technology, AI, and IS. In this regard, the journals and articles searched were from top venues in these domains. We searched the After selecting relevant articles, we defined our study selection metrics based on the inclusion and exclusion criteria as specified in Table S1 in After selection of the studies for this scoping review, we segregated articles according to research streams , type of data used (public vs proprietary), and health conditions . Articles related to physical health examined the use of AIM for disease management of chronic health issues, such as asthma and diabetes, and neurological illnesses, such as Alzheimer and Parkinson disease. These severe health conditions are difficult to manage without active support from physicians, and thus, the application of mHealth sensors can be used to track patients with these conditions. Studies focused on general health promotion and wellness were related to nonchronic conditions that do not require constant medical supervision, such as leading an active lifestyle and engaging in regular exercise. mHealth sensors can notify and remind people to engage in physical activity to have an overall better level of physical health. Articles related to mental health focused on using AIM to facilitate the detection of mental health issues among the population by collecting data from personal devices.Since public data has massive potential for enabling broader collaboration in health care technology usage and AIM adoption across organizational, national, and international boundaries, we also divided articles based on the data set they used. Studies using publicly available data sets are more effective in bringing out the potential impact of AIM and inspiring confidence among the public and medical institutions in the efficacy of AIM models.Finally, in the results section, we collate, summarize, and report the findings from this review. We discuss their implications for future AIM research in the discussion section and present results of the PRISMA  technique we used to identify and select articles for this review. We also discuss the selected 37 articles using AIM capabilities for disease management and monitoring physical and mental health conditions. Furthermore, some of the articles focused on using AIM models for enhancing general health promotion and wellness of people.After careful consideration and discussions, we decided to define the scope of our review paper based on the shared capabilities of AI and mHealth. Through deliberations, we decided to focus on the emerging uses of AI in the current state-of-the-art mobile health care domain. In this regard, we identified the following 3 RQs of value for both researchers and practitioners in this scoping review: (1) What are the major health conditions being researched in the AI-powered mHealth (AIM) domain? (2) How do AIM techniques use the data collected from wearable sensors and mHealth devices? (3) What are the requirements for facilitating the rapid adoption of AIM models in hospitals and medical institutions in the health care sector?MISQ, n=27; and ACM Digital Library, n=40) and 7 articles through reference checking in search engines.We initially started with 108 articles related to each of the 3 domains in this study: biomedical technology, AI, and IS. We identified 108 relevant studies in total: 101 from our selected databases  and then using the data collected to train AI models to automatically detect such conditions; otherwise, they were analytical studies that applied AI models to publicly available data sets. The final set of 37 articles included in this review are presented in Table S2 in Of the 37 articles, 31 were published in 2020 (84%), and 23 out of the 37 (62%) articles were from AI databases which represented the largest domain included in our review. Of the 23 articles within the AI domain, 17 (74%) mainly focused on physical health and chronic health conditions. Both these conditions were researched in most of the articles included in the review. Physical health articles primarily focused on using AIM models for human activity recognition and analyzing people’s activities of daily living. The data used in these studies were collected using multiple mHealth devices, such as object and motion detection sensors. However, accessing large repositories of such data is difficult because data sharing among medical institutions, hospitals, and clinical studies is often restricted [The results from our scoping review help to answer our RQ1 about the major health conditions being researched in the AIM domain and our RQ2 about how AIM data collected from wearable sensors and mHealth devices are used by researchers. In terms of RQ1, 3 major categories are being researched in the AIM domain: mental health, physical health, and chronic health conditions. For RQ2, most of the studies use data collected from AIM devices to build and train advanced AI models that seek to detect, predict, and manage health conditions in general.As we discussed the results of our scoping review of articles on AIM, we observed the research in this domain is concentrated in 3 distinct categories of physical health, mental health, and chronic health conditions, as presented in Most of the studies in the scoping review focused on chronic health conditions, such as cardiovascular conditions related to heart disease, stroke, arrhythmia, and atrial fibrillation; respiratory conditions, such as sleep apnea, asthma, and COVID-19 monitoring; and other conditions chronic conditions, such as diabetes, arthritis, and Parkinson disease. These studies explain how AIM models are used to enable greater self-management of chronic diseases by providing real-time health insights to patients and doctors ,60. AIM After chronic conditions, the next major category of studies focused on mental health conditions for which research has recently increased . IncludeThe final category of studies focused on the use of AIM devices to monitor people’s physical health. The articles studied different mental, social, and physical activities that people engage in and collected data using AIM devices. These data were used to build AIM models that detect when people were not engaging in their regular activities, such as exercising and walking. Once a lack of social or physical activity is detected, the AIM model sends out personalized suggestions encouraging people to lead an active lifestyle ,79. SuchThe findings from our scoping review showcase the benefits of using AIM in applications ranging from clinical care  to improThis review surveys the recent developments in the AIM domain, and based on our findings, we present some practical recommendations for future research. First, by using the recent advances in AI techniques of FL and XAI, AIM could facilitate an even broader expansion and provision of mHealth services which is also evidenced by its significant use during the pandemic . Second,Given the growing importance of remote health and telehealth facilities during the COVID-19 pandemic, we conclude that it is important to facilitate greater adoption of remote health monitoring devices, protect patient privacy, and increase people’s trust in smart wearable health devices. This is because our findings show that mHealth indeed plays a significant role in shaping the future of how citizens access health care facilities in testing times such as a pandemic. In this regard, some recent AI techniques that can accelerate its adoption and enable faster implementation across hospitals, medical institutions, and users at large are discussed. The discussion of these techniques also answers RQ3 about the requirements for facilitating the rapid adoption of AIM models in hospitals and medical institutions in the health care sector and how recent AI techniques can be implemented to strengthen research in the AIM domain.To protect patients’ privacy, ML techniques such as DL, FL, and transfer learning can effectively drive the smart health care revolution. These techniques use privacy-preserving feature engineering to translate vast amounts of biomedical data into actionable and potentially life-saving human health outcomes . From thThe DARPA (Defense Advanced Research Projects Agency) XAI program strives to support the development of AI systems whose models can be interpreted, understood, and trusted by end users . XAI is As with most scoping reviews, there are some limitations in this work. First, we only considered research from the 3 domains of biomedical technology, IS, and AI. Second, we did not consider the social aspect of AIM technology in this paper, but it is an emerging aspect of health care research. We will work to address these limitations in our future work. Third, we considered only a limited number of databases for selecting the articles and had to restrict the search so that we could focus on articles that address the latest transdisciplinary research context of AI, biomedical technology, and IS. Such work included papers that were published in niche ML and AI conference proceedings and listed within a particular database, for instance the ACM Digital Library. However, the databases we selected are comprehensive avenues for state-of-the-art research in the AIM domain and include the latest peer-reviewed research literature in the 3 streams.Our findings from this scoping review indicate that there has recently been considerable increase in the research, practice, and adoption of mHealth and AI capabilities in the health care sector, which has resulted in significant advances in both critical and noncritical clinical care. However, certain areas still exist where there is a lack of AI research, such as in addressing mental health issues. A particular reason for this lack of research can be attributed to the nonavailability of public data sets hindering the widespread adoption of the AIM domain. A solution for this problem is to ensure collaboration and data sharing among different medical institutions. Such collaborative efforts will ensure the better utilization of AI tools by doctors, physicians, and hospitals alike. Furthermore, new and advanced AI techniques, such as FL and XAI, are rapidly being developed by researchers, and their subsequent adoption in real-world scenarios will likely have life-saving consequences in the future.


The enhanced recovery after surgery (ERAS) program is aimed to shorten patients' recovery process and improve clinical outcomes. This study aimed to compare the outcomes between the ERAS program and the traditional pathway among patients with ankle fracture and distal radius fracture.  This is a multicenter prospective clinical controlled study consisting of 323 consecutive adults with ankle fracture from 12 centers and 323 consecutive adults with distal radial fracture from 13 centers scheduled for open reduction and internal fixation between January 2017 and December 2018. According to the perioperative protocol, patients were divided into two groups: the ERAS group and the traditional group. The primary outcome was the patients' satisfaction of the whole treatment on discharge and at 6 months postoperatively. The secondary outcomes include delapsed time between admission and surgery, length of hospital stay, postoperative complications, functional score, and the MOS item short form health survey-36. P < 0.001). In the subgroup analysis, patients with distal radial fracture in the ERAS group were more satisfied with the treatment (P=0.001). Furthermore, patients with ankle fracture had less time in bed (P < 0.001) and shorter hospital stay (P < 0.001) and patients with distal radial fracture received surgery quickly after being admitted into the ward in the ERAS group than in the traditional group (P=0.001).  Data describing 772 patients with ankle fracture and 658 patients with distal radius fracture were collected, of which 323 patients with ankle fracture and 323 patients with distal radial fracture were included for analysis. The patients in the ERAS group showed higher satisfaction levels on discharge and at 6 months postoperatively than in the traditional group ( Perioperative protocol based on the ERAS program was associated with high satisfaction levels, less time in bed, and short hospital stay without increased complication rate and decreased functional outcomes. Previous studies have shown that the implementation of the ERAS clinical pathway shortens the length of hospital stay and reduces the medical costs, complications, and readmission, while satisfaction and safety after discharge are increased [Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach for the care of the surgical patient based on published evidence, aiming to reduce physical and psychological stress and achieve rapid recovery . This concreased –4. Due tncreased –7. Nonetncreased , 9. HoweAnkle and distal radial fractures are the two common fractures managed by orthopedic surgeons. Although indications for surgical intervention for the above two fracture types are well defined, the standard perioperative protocol based on the ERAS program remains unclear. Based on the updated ERAS guidelines of other operations, the perioperative pathways for ankle and distal radial fractures have been optimized in China, focusing on short perioperative fasting duration, minimally invasive approaches, minimizing drains and tubes, multimodal pain control, and early mobilization.In this study, we compared the process and outcome measures between the ERAS and traditional pathways among the two target populations: patients with ankle fracture and distal radial fracture undergoing open reduction and internal fixation. Thus, we determined the effectiveness of the ERAS program.This study was a prospective, multicenter clinical controlled study approved by the ethics committee of Beijing Jishuitan Hospital, Beijing, China . Written informed consent was obtained from patients before participation in the study. No financial compensation was provided to the participants. All centers partook voluntarily, and only centers with valid cases >5 were finally analyzed. Patients with a primary diagnosis of ankle fracture and distal radial fracture were enrolled between January 2017 and December 2018 in the centers included in this study. All patients were treated with open reduction and internal fixation. The inclusion criteria were as follows: (1) age between 16 and 70 years; (2) primary diagnosis of ankle fracture or distal radial fracture ; (3) no serious systemic disease with a preoperative American Society of Anesthesiologists (ASA) classification I-II; (4) voluntary participation with informed consent. The exclusion criteria were as follows: (1) combined with other fractures; (2) old ankle fractures and distal radial fractures; (2) open fractures (excluding Gustilo type I); (3) diagnosis of diabetes mellitus or other severe metabolic diseases; (4) diagnosis of gastric emptying disorders; (5) alcohol dependence or history of drug abuse; (6) breastfeeding or pregnant women; (7) history of allergy to multiple drugs. The centers were considered ERAS centers if they had a multidisciplinary ERAS team and implemented the protocol described in this article. Data were collected at each center by a trained surgeon and deidentified before entry into an internet-based electronic case record form designed specifically for this study.The ERAS pathway in this study was a standard perioperative protocol focusing mainly on pain management, perioperative fasting, and avoiding drains and urinary tubes. For pain management, we prescribed oral multimodal analgesics preoperatively and opioid-free analgesia based on nerve block postoperatively; a standard anesthesia protocol was followed for a painless procedure. For perioperative fasting, we minimized the fasting time as much as possible with low risks of pulmonary aspiration to reduce perioperative stress. For tubes management, urinary catheterization rate was reduced and meticulous hemostasis was achieved intraoperatively to avoid wound drains. The basic components of the multidisciplinary and multimodal ERAS pathway are listed in We evaluated three ERAS perioperative care elements using the following process of care metrics. For perioperative fasting management, we evaluated the perioperative fasting period for solids and liquids. For perioperative time management, the elapsed time between admission and surgery, the elapsed time between injury and surgery, the length of operation, and the length of hospital stay were evaluated. For perioperative nonsurgical management, we assessed the use of regional anesthesia, nonsteroidal anti-inflammatory drugs (NSAIDS), patient-controlled analgesia (PCA), antiemetic, urinary catheterization, and wound drains.Our primary outcome was the patients' satisfaction level of the whole treatment on discharge and at 6 months postoperatively. We divided the satisfaction into four levels A–D: A is the highest and D is dissatisfaction. The secondary outcomes include delapsed time between admission and surgery, elapsed time between injury and surgery, length of hospital stay, postoperative complications, and functional evaluation. Postoperative complications included loss of reduction, screw breakage by routine evaluation of postoperative radiographs, wound infection, deep vein thrombosis, and so on. American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot scale and patient-related wrist evaluation (PRWE) were used to evaluate the postoperative function of the injured ankle and wrist, respectively, at 6 months after surgery. For patients with ankle fracture, the postoperative time in bed was also recorded as the secondary outcome.P < 0.05 indicated statistical significance.Statistical analysis was performed using IBM Statistical Package for Social Sciences Statistics . All quantitative data were tested for normality using the Shapiro–Wilk test. The discrete variables were described as number and percentage, and the differences were compared using Fisher's exact or Pearson test. The continuous data were expressed as median (interquartile range (IQR)) and analyzed using the Wilcoxon rank-sum test. Multiple logistic regression analysis was conducted using patient demographic, injury, and perioperative management characteristics to identify the independent risk factors to assess the satisfaction level of the patients on discharge. The data of 772 patients with ankle fracture in 50 hospitals and 658 patients with distal radial fracture in 41 hospitals were collected . Of thesvs. 13.8 h, P < 0.001) and postoperative solids  and liquids  of the ERAS group was significantly shorter than the traditional group. For perioperative time management, the elapsed time between admission and surgery, the length of operation, and hospital stay were shorter in the ERAS group than in the traditional group. For perioperative nonsurgical management, the ERAS group showed higher rate of regional anesthesia , antiemetic , and PCA  than in the traditional group. In the ERAS group, the patients went through less urinary catheterization than in the traditional group . The process of care metrics is shown in Most process metrics of the included patients demonstrated significant differences between the ERAS and the traditional groups. For perioperative fasting management, no significant difference was observed between the two groups in the perioperative fasting period for solids, but that for preoperative liquids , regional anesthesia , PCA , preoperative fasting period for solids , postoperative fasting period for solids , postoperative fasting period for liquids , length of operation , and urinary catheterization  were identified as significant independent predictors for the satisfaction level of the patients at the time of discharge  0.982, ischarge .Among patients with distal radial fracture, the distribution of the elapsed time between admission and surgery and levels of satisfaction at 6 months postoperatively differed significantly. Patients in the ERAS group had a shorter time between admission and surgery and were more satisfied with the treatment both at discharge and at 6 months postoperatively than those in the traditional group. No difference was noted in the other demographic, medical, injury, and operative characteristics between the two groups .vs 1.4 days, P < 0.001) and the length of hospital stay  were significantly shorter in the ERAS group compared to the traditional group, while no difference was observed in the distribution of the satisfaction levels at discharge and 6 months postoperatively between two groups. Also, no difference was detected in the other demographic, medical, injury, and operative characteristics between the two groups (Among patients with ankle fracture, the time in bed (1.0 o groups .This multicenter prospective cohort study collected the data of 772 patients with ankle fracture across 50 hospitals and 658 patients with distal radial fracture from 41 hospitals and analyzed 323 patients among each population. Pain management, perioperative fasting, and avoiding tubes in the ERAS protocol are the three main constituents. We prescribed multimodal analgesia and minimal fasting time and strived to achieve meticulous hemostasis to reduce wound drains. The results showed satisfactory adherence to the ERAS protocol and demonstrated that the patients in the ERAS group had a higher satisfaction level at discharge and at 6 months postoperatively compared to the traditional group. We also found that age, regional anesthesia, PCA, preoperative fasting period for solids, postoperative fasting period for solids and liquids, the length of operation, and urinary catheterization were independent predictors for the satisfaction level of the patients at the time of discharge. In addition, the ERAS protocol reduced the time in bed and length of hospital stay in ankle fracture patients and elapsed time between admission and surgery in patients with distal radial fracture while maintaining similar early functional outcomes of those treated in the traditional manner and without increasing the rate of complications. These results suggested that the ERAS perioperative protocol was a valuable approach in the management of ankle and distal radial fractures.Nonetheless, ERAS programs often need a multidisciplinary team that provides a multimodal approach to resolving issues that delay recovery and cause complications based on published evidence. Although the protocol might consist of several elements, one aim is common: minimizing stress and improving the response to stress . ERAS isThis study has several strengths compared to previous studies. First, a large number of patients were enrolled in this study. However, we included 646 patients from different provinces of China, which is a larger sample size than other similar studies , 20, 21.Nevertheless, the present study has some limitations. Firstly, the perioperative care was not assigned randomly, which might increase selection bias. Secondly, although there is a standard care protocol for each group, perioperative management may not be homogeneous among different centers because we cannot rule out individualized therapeutic options and measurement errors of some researchers. Thirdly, we only focused on three care elements without assessing the influence of other care elements, such as fluid management and rehabilitation protocol, on patients with common fractures. Lastly, we only evaluated short-term functional outcomes, and additional studies are necessary to assess the long-term effect of the ERAS program on patients with orthopedic trauma.In conclusion, this study established the perioperative protocol based on the ERAS program with high satisfaction among patients with distal radial fracture and ankle fracture, less time in bed, and short hospital stay without increased complication rate and decreased functional outcomes. Thus, we recommend the ERAS protocol in the management of patients with ankle and distal radial fractures.