Background: Food systems affect nutritional and other health outcomes. Recent literature from India has described policy aspects addressing nutritional implications of specific foods , and identified opportunities to tackle the double burden of malnutrition. This paper attempts to deepen the understanding on how health concerns and the role of the health sector are addressed across food systems policies in India.Methods: This qualitative study used two approaches; namely (i) the framework method and (ii) manifest content analysis, to investigate national-level policy documents from relevant sectors . The documents were selected purposively. The textual data were coded and compared, from which themes were identified, described, and interpreted. Additionally, mentions of various health concerns and of the health ministry in the included documents were recorded and collated. Results: A total of 35 policy documents were included in the analysis. A variety of health concerns spanning nutritional, communicable and non-communicable diseases (NCDs) were mentioned. Undernutrition received specific attention even beyond nutrition policies. Only few policies mentioned NCDs, infectious diseases, and injuries. Governing and advisory bodies were instituted by 17 of the analysed policies , and often included representation from the health ministry . Conclusion: We found some evidence of concern for health, and inclusion of health ministry in food policy documents in India. The ongoing and planned intersectoral coordination to tackle undernutrition could inform actions to address other relevant but currently underappreciated concerns such as NCDs. Our study demonstrated a method for analysis of health consideration and intersectoral coordination in food policy documents, which could be applied to studies in other settings and policy domains. Implications for policy makersWhile the disproportionate policy focus on undernutrition is justified, there is a need to also emphasise other health implications of food systems, such as obesity, non-communicable diseases (NCDs), and agrarian distress. Dietary guidelines have been created for the Indian population by government-affiliated nutrition research institutions, but these have not been adequately used to guide food policy. Representation from the Ministry of Health and Family Welfare (MoHFW) was listed in inter-ministerial regulatory, advisory and executive groups of other food-related ministries. While this is encouraging, there is a need for further clarity on whether such representation is influencing food systems to become more health-sensitive. The intersectoral approaches being used and planned for undernutrition can provide a template for addressing other food systems-related health concerns. This would also be relevant towards fulfilling the National Health Policy (NHP) goal of the “Health in All” approach.  Implications for the public Our research identified that undernutrition is a priority concern for various ministries in India. Several measures have been implemented to address vulnerability to undernutrition among marginalised communities, women, and children. Detailed insights are also available for measures towards food safety. However, several other relevant health concerns, such as obesity, cardiovascular disease (CVD), agricultural injuries, agrarian distress, and hazards of food wastes were not adequately addressed, despite being critical population health concerns. In our view, though the health ministry is often represented in inter-ministerial groups to govern food systems, measures to systematically include health considerations in food policy should be explicitly described and further enhanced.1 Food systems include “all the elements  and activities that relate to the production, processing, distribution, preparation and consumption of food, and the outputs of these activities, including socio-economic and environmental outcomes.”2 These elements of food systems involve various actors, each of whom pursues different goals and priorities.4 For instance, farmers are concerned about sustained income, and the public health sector aims to address malnutrition.3 One important outcome of food systems is people’s health and well-being,3 and thus it warrants specific attention. The challenge, however, is that the linkages between food systems and health are manifold and complex.6 A United Nations report highlighted that “Food systems are at the heart of the 2030 Agenda for Sustainable Development.”7 non-communicable diseases ,8 antibiotic resistance (due to indiscriminate use particularly in the livestock sector),9 vector-borne diseases ,11 parasitic infections,12 exposure to pesticides,13 and farmers’ suicides.14 In addition, due to greenhouse gas emissions from food systems, climate change-related health risks such as extreme weather events, malnutrition, and VBDs are enhanced.15 Globally, undernutrition and dietary risks are currently the top risk factors for mortality.8 There is a growing recognition that addressing challenges related to nutrition and NCDs need strong intersectoral coordination.17 Food systems-related health concerns include malnutrition (undernutrition and obesity),18 The role of governments towards healthy food environments for NCD prevention was seen as regulatory  and catalyst .19 Financial and technical assistance towards production of healthier food was reported to have strong potential from a health perspective.20 However, the general challenge towards intersectoral coordination for better health has persisted over decades, which may be driven by the complexity of setting up and managing such a system, its potential to compromise the existing political economy, and importantly, the neglect of preventive measures even within the health sector.21 In situations where systems for intersectoral coordination have been instituted, the impact on health equity was reported to be lower for upstream interventions as compared to downstream interventions.22 In that context, impacts of food systems policies on public health are being examined internationally.23 Subsequently, safety nets for food security and welfare were enhanced,24 and greater thrust was provided for maternal and child nutrition.25 However, India is not on track to meet the Global Targets 2025 on stunting, exclusive breast feeding, and anaemia.26 In addition, risk factors for NCDs are of increasing concern, with one in five adults aged above 30 years having high systolic blood pressure, and 7.7% of adults aged above 20 years showing elevated fasting sugar levels.27 The proportion of individuals who are overweight has increased rapidly between 2006 and 2016.28 Overall, undernutrition and dietary risks were the first and third highest ranked risk factors for mortality in India.29 Meanwhile, agrarian distress, driven by low productivity, poor remuneration, and indebtedness, is also of concern, overtly manifesting through farmers’ suicides.30 Hence, there is a considerable burden of health impacts directly associated with food systems in India, warranting a closer look at how policies are addressing them. It has been suggested that the entire range of food systems policies should be considered to improve health outcomes.31 The policy space in India has been analysed for opportunities to address malnutrition, NCDs,4 and the consumption of fats,32 trans-fats,33 and fruits and vegetables.34 Nutrition, despite being the most obvious health outcome of food systems, was perceived as a minor consideration by food supply policy actors in India,4 which is a matter of concern. Historically, since independence in 1947, the focus of food systems-related policy in India has mainly been on food security. The early focus was on famine prevention, which also included food-for-work programmes.35 Finally, the recent National Health Policy (NHP) indicated the need for a “Health in All” approach,36 but the inclusion in health policies of intersectoral coordination with food systems actors, and the role of the health ministry in food systems governance in India have not been adequately described in the literature. Nutrition is but one of many health outcomes of food systems policies, as discussed earlier. The review of literature did not reveal any studies that have addressed whether and how various relevant health concerns have been considered in food policies in India. Moreover, besides health aspects of food consumption policies and pathways, those related to food production are important in India as the majority of the population is dependent on agriculture for livelihood. This paper attempts to deepen the understanding on how health, including nutrition and several other related health concerns, and the role of the health sector, specifically the Ministry of Health and Family Welfare (MoHFW) and other central health institutions, are included and addressed across food systems-related policy documents in India. The following research questions governed the current analysis: First, what were the health concerns addressed in food systems policies in India? Second, whether and how these concerns were addressed in health policies themselves? Third, what were the roles identified for the health ministry in food systems governance in India? While the first two questions helped us to better understand the consideration for health outcomes, the last question looked at governance avenues for these considerations.i) the framework method, as described by Gale and colleagues,37 and (ii) manifest content analysis, as described by Hsieh and colleagues.38 The framework method is a type of thematic analysis that facilitates the identification of relevant themes to describe the findings.37 This method was used because the breadth of study topics was large, stemming from diverse sectors. This approach also helped contextualise data from individual policies within the pool of analysed policies.37 Manifest content analysis was used to document mentions of specific diseases or risks, and health-related and other institutions.38 A qualitative study design was employed, using two approaches to content analysis; namely . Table provides the list of policy documents analysed in the current paper. Of the 35 analysed policies, 17 were ‘agricultural,’ seven were ‘social,’ two were ‘environmental,’ two were ‘trade,’ and one was ‘industrial.’ Six ‘health’ policies were also included to better understand the health ministry perspective on food systems governance and relevant health concerns. National-level policy documents, including statutory, technical, or official documents, relevant to broad food systems activities and outcomes,i) health and nutrition outcomes addressed; (ii) healthy diets and dietary diversity; (iii) social protection and equitable access for nutritional security; (iv) trade and investment for healthy food systems; (v) environmental sustainability of food systems; (vi) health system role in food systems-related health action; and (vii) intersectoral coordination. The coding scheme was guided by these interests (deductive) and also the data themselves (inductive)  from each data item were charted into a spread-sheet containing the analytical framework.i) the various diseases and health risks, and (ii) the various ministries and health institutions mentioned in each document. For this, during the reading and re-reading of the documents, notes were made about the specific diseases, risks and ministries that were mentioned in the document. In addition, as a second check, the following generic terms were searched for using the search function of the PDF reader: ‘health,’ ‘risk,’ ‘wellbeing,’ ‘disease,’ ‘nutrition,’ and ‘ministry.’ These frequencies were tabulated and presented as figures using Microsoft Excel 201675 and R statistical software version 3.5.1.77 Further details are available under each figure. The manifest content analysis was conducted to document (i) ‘Undernutrition recognised and addressed as a cross-sectoral concern;’ (ii) ‘The focus on NCDs;’ (iii) ‘Supporting healthy and balanced diets;’ (iv) ‘Addressing health concerns beyond nutrition and NCDs;’ and (v) ‘Involvement of health ministries in food systems governance.’ The relevant policies contributing to each specific finding is cited in the text using their respective abbreviations from Table. Findings from the manifest content analysis have been reported using figures, interspersed within the appropriate themes. The first paragraph under each theme summarises the findings from the theme. The findings have been presented under the five themes that helped describe the data: . The focus was primarily on undernutrition . Three policies were dedicated almost exclusively to undernutrition . Moreover, undernutrition was the only health concern to have an agricultural scheme dedicated to it (NFS). Several groups were deemed vulnerable to undernutrition from a social security perspective  and a public health perspective . The factors articulated as contributing to vulnerability were poverty , age , gender , infirmity , caste (NNS), disasters or shocks , and remoteness of residence (NFSA and PDS). Towards addressing undernutrition and the associated vulnerability, the approaches mentioned included provision of food grains (NFSA), food supplementation for target groups , healthcare support , and broader societal interventions related to empowering and enabling vulnerable communities .“Malnutrition in India, especially among children and women, is widespread, acute and even alarming” (NFS). Micronutrient deficiencies and its consequences such as restriction of growth and development were other aspects of undernutrition that received attention (NHP). This included deficiencies of iron, vitamin A, zinc, iodine (NNS), calcium, selenium, and magnesium (NFS). Serious consequences of undernutrition were recognised in health policies (NNS and NHP) and also one agricultural policy (NFS).“The consequences, in terms of malnutrition and health, are devastating and can result in blindness, stunting, disease and even death” (NFS).“Main objectives of scheme are…. enhancing production and productivity, improve nutritional security and income support to farmers” (RKVY).i) the landless and marginal farmers ; (ii) artisans; (iii) slum dwellers; (iv) informal sector workers; (v) the destitute; (vi) households headed by widows, the terminally ill, disabled, or elderly (ARMPD); (vii) HIV positive individuals (ARMPD and NPF); (viii) pregnant and lactating women; (ix) adolescent girls; (x) children (NFSA); (xi) those living in beggar homes; (xii) hostels with students from marginalised communities (ARMPD); (xiii) living in remote settings, including hilly and tribal areas (NFSA); and (xiv) communities facing shocks such as agrarian distress, seasonal migration, disruptions in access to services, disease outbreaks, endemic disease areas, and natural disasters (NNS and PDS). The only mention of “caste” was in the context of ensuring representation of scheduled castes in vigilance committees of the NFSA. In effect, various criteria such as socioeconomic, demographic, gender, shocks, caste, and health were used to identify beneficiaries or vulnerable groups, covering large section of the total population. From a social security perspective, several population groups were indicated as vulnerable: , their focus was on vulnerability of women, adolescent girls, and children to undernutrition and micronutrient deficiency (ICDS and NNS), and the strong gender and inter-generational dimension to the problem (NNS).“The girl child goes on to become an undernourished and anaemic adolescent girl, often deprived of … nutritional support, educational opportunities, … married too early, with early child bearing and inadequate inter-pregnancy recoupment. This perpetuates a vicious cycle of undernutrition and morbidity…” (NNS). Women and children from scheduled castes, scheduled tribes, and particularly vulnerable tribal groups  were indicated as especially vulnerable (NNS), additionally in the context of climate change (NAPCCHH). Therefore, considerations for gender, demography, caste, and remoteness of communities were acknowledged. In effect, the population addressed by nutritional and health policies and programmes is a sub-set of the population recognised as food insecure. Agricultural, industrial, or trade policies did not include any explicit considerations on nutritional vulnerability.Antyodaya Anna Yojana (a scheme for the poorest sections). Support is based on the number of members in the eligible household (NFSA). The food supplementation approach for women and children used by the health sector is a more targeted version of the broader food welfare approach. Nutritional supplementation is provided to pregnant and lactating women through the local anganwadi . Schemes for improving nutrition of adolescent girls through additional foodgrains were also introduced (ARMPD). For children, meals are provided at anganwadis or government schools free-of-charge. In addition, state governments have been directed to identify and provide meals to malnourished children based on prescribed standards (ICDS and NFSA). Subsidised foodgrains and pulses has been the main approach towards ensuring household food security, covering priority households and those under the “Every child has a right to adequate nutrition and to be safeguarded against hunger, deprivation and malnutrition” (NPC). In remote tribal areas, grants for setting up village grain banks were provided in some areas to store one quintal of grain per family to protect children in times of scarcity.“As a part of the Government’s efforts to prevent deaths of children in remote and backward tribal areas due to malnutrition, a Village Grain Banks scheme was launched in 1996-1997” (PDS).anganwadi worker for childcare and nutrition counselling through home visits (ICDS). In addition to food supplementation, the health sector also screens and treats severe nutritional deficiencies within the target groups. Pregnant women are monitored for weight gain (ICDS), screened for anaemia and managed accordingly (NHP). Screening for other micronutrient deficiencies was recommended (NHP). Support was also encouraged for enhanced care during and after illness for severely and acutely undernourished children (ICDS and NNS). Proposed steps towards this also include a second  Additionally, broader interventions such as female literacy, women’s empowerment and autonomy in decision-making and use of resources have been listed as critical towards improved maternal and child nutrition (NNS). Engaging vulnerable communities in decision-making, seasonal nutritional screening, and scaling-up nutrition action were recommended (NAPCCHH). Only one agricultural policy mentioned nutritional support, through the development of backyard poultry among “below poverty line” families, for whom livestock rearing was identified as an important intervention for livelihood (NLM). NCDs, while recognised as a major problem, were only mentioned in few health policies  and none of the food systems policies. The interventions to tackle these challenges were largely biomedical. NCDs were addressed in some health policies, with particular emphasis on obesity, CVD, diabetes, hypertension, stroke, and cancer (NHP and NPCDCS). Two health policies mentioned overweight and obesity (NNS and NPCDCS), with one policy identifying obesity as being especially prevalent among urban, wealthier, and older adults, and also discussed childhood obesity as a concern indicating a double burden of malnutrition in the country (NNS). Reduction of premature mortality due to CVDs, cancer, and diabetes by 25% by 2025 was listed as a priority (NHP). However, they were not listed as cross-sectoral goals, unlike stunting (NHP), despite unhealthy diet being a major risk factor for NCDs. Though the risk of NCDs is largely determined by circumstances created by non-health sectors, the analysed policies of those sectors conspicuously make no mention of NCDs.Non-communicable diseases are expensive to treat. National strategies have to focus on prevention and health promotion as key to reduce disease burden. Health education programme that promote exercise, weight reduction, early diagnosis, screening are some of the key interventions that need to be promoted at various levels of health facilities” (NPCDCS). “ Interventions for those vulnerable to, or affected by, hypertension and diabetes, were primarily biomedical and operationalised through the healthcare sector under the aegis of the National Health Mission in urban and rural areas (NHP). Early detection has been emphasised (NHP), and screening of blood pressure and sugar has been supported from the primary care level  through auxiliary nurse midwives (ANMs), along with a referral system. “NCD clinics” were planned at sub-district and district hospitals (NPCDCS). Health promotion and counselling for behaviour change has been encouraged at all levels from sub-centre to district hospital, about diet and lifestyle management (NPCDCS). No specific interventions to prevent or control NCDs were found in agricultural, social, industrial, trade, or environmental policies.i) health implications of various food groups ; (ii) dietary diversity ; and (iii) food safety . Several interventions for supporting healthier diets were discussed: (i) food supplementation ; (ii) fortification ; (iii) health promotion ; and (iv) regulatory and fiscal instruments . Various policies have mentioned healthy and balanced diets in the context of , edible oils and fats (ARMPD) have been explicitly mentioned as important towards a balanced diet. Other food groups listed as (or implied to be) contributing towards nutrition included fruits, milk, eggs (NNS), coarse grains (NPF), and meat (PDS). However, there was inadequate coherent and nuanced articulation on healthy diets. Only the nutrition policy explicitly referred to a dietary guideline  for informing food supplementation programmes (NNS). The health policy identified healthy diets as a priority area, but offered no further details.The policy identifies coordinated action on …priority areas for improving … health:… balanced, healthy diets…” (NHP). “ Diet has been recognised as a main risk factor for both micronutrient deficiency (NFS) and NCDs (NPCDCS). Relatively high intake of staples, such as wheat and rice, and low intake of fruits, vegetables, and animal products were associated concerns (NFS). Food groups of concern towards NCDs were:Unhealthy diet including high intake of salt, sugar and trans-fats and low intake of fruits and vegetables” (NPCDCS 2013). “ Improving dietary diversity was identified as contributing to a healthy diet  and as an avenue for “coordinated action” (NHP). However, it was seen as not feasible from a short-term perspective.While dietary diversification remains the most desirable way forward, supplementation and fortification require to be considered as short- and medium-term solutions to fill nutrient gaps” (NHP). “ Standards for fortification of wheat flour and oil have been prepared (ARMPD). The use of iron and iodine-fortified salt has been recommended (NNS). The nutrition policy has encouraged other ministries to promote local processing of nutritious foods through training women’s groups, strengthening supply systems , and improve quality of mid-day meals for children (NNS).Use SSA  flexi funds for kitchen gardens in/around school premises contributing to addition of local/seasonal vegetables and fruits…” (Recommendation to Ministry of Human Resource Development in NNS). “ The health sector has also used health promotion through awareness for addressing undernutrition (ICDS) and NCDs (NPCDCS). The engagement of local mothers of well-nourished children through positive-deviance-hearth approach was suggested to help mothers optimally utilise local resources for higher quality diets (NNS). State NCD cells were tasked with the responsibility to make the public aware about dietary risk factors and healthy foods. Folk media has been suggested to reach rural and urban poor communities (NPCDCS). ANMs were also expected to create awareness about healthy foods (NPCDCS). Climate change, nutrition, and health was also planned to be incorporated into school and college curricula (NAPCCHH). A role for Indian Systems of Medicine (AYUSH) in health promotion for lifestyle modification was also recognised (NHP). Some of these systems have a substantial focus on dietary interventions. However, this was not described in further detail.Promotion of healthy living and prevention strategies from AYUSH systems… has a special appeal and acceptability in the Indian context” (NHP). “ A regulatory approach has been in place to ensure that food products produced by manufacturers, and claims made about food products by manufacturers or advertisers are in accordance with standards that safeguard health (FSSA).… endeavour to achieve an appropriate level of protection of human life and health and the protection of consumer’s interests…with reference to food safety standards and practices” (FSSA). “ Several regulatory and fiscal instruments have also been used to control prices of staple, nutritionally important foods such as pulses (MEFS), with recommendation to also cover milk, eggs, fruits, and vegetables (NNS). Regulations have also been made in the context of foreign direct investment in food retail, agriculture, livestock, and aquaculture (FDIP) but there was no explicit health consideration. It was also suggested that fiscal instruments could be considered to modify behaviour, but no further details were provided on commodities to be targeted.The Government could consider imposing taxes on specific commodities - such as … foods having negative impact on health…” (NHP). “Moringa oleifera) and effective supply to target communities was also tried in a pilot scheme (NFS). The inclusion of “nutritious millets” in the food security programme was recommended (NPF). Bio-fortified food crops were identified and promoted in a pilot scheme (NFS). Agricultural policies also supported horticulture  (MIDH), and encouraged backyard poultry among poor families (NLM). To promote access of vegetables in urban areas, production through cluster approach was also supported (VIUC). Year-round availability of certain fresh produce is an emerging demand (RKVY), with potential negative implications for seasonal foods. The promotion of several micronutrient-rich varieties of staples, sweet potato, and drumstick (i) food production-related health concerns included antibiotic resistance (NHP), agricultural injuries , agrarian distress , and pesticide poisoning (PMB); (ii) consumption-related health concerns (besides undernutrition and NCDs) include food poisoning (FSSA) and food-borne infections (NAPCCHH); and (iii) waste management-related health concerns included various hazards associated with crop waste (NPMCR) and food waste . Concerns related to new technologies were also discussed . Few documents only mentioned a generic concern for health , for instance: Nutrition-related concerns were not the only food systems-related health concerns in the reviewed policies . HoweverSafety and health norms applicable to domestically produced goods shall apply, mutatis mutandis, to imports, unless specifically exempted” (FTP). “ To address antimicrobial resistance, strengthening pharmacovigilance against the use of antimicrobial agents as growth promoters in livestock was recommended (NHP). However, this was not discussed in the livestock policy, where the focus was more on vaccinations, animal health, and other biosecurity threats (NLM). A common concern across health and agricultural policies was to reduce agricultural occupational injuries ), and this was identified as a cross-sectoral goal (NHP). Towards this, agricultural policies have supported mechanisation and better-adapted instruments as key interventions, especially to reduce drudgery among women .Horticulture mechanization is aimed to improve farm efficiency and reduce drudgery of farm work force” (MIDH). “ Further mitigation of agrarian distress was recommended (NPF). The categories of farmers identified as vulnerable included tribal farmers, pastoralists , plantation farmers (market fluctuations in price), and island farmers  (NPF). There was cognisance about the potential impact of climate change, which was expected to “reduce farm incomes by up to 20-25 percent in the medium term” (ESCB and NAPCCHH). Awareness campaigns about debt waiver schemes (ADWDR), farming insurance schemes (NPF and MIDH), and general extension services towards various schemes (RKVY) are planned or recommended. Assistance has been provided for promoting farmer-interest groups and farmer-producer organisations, which may strengthen their bargaining position, make production more efficient, and also reduce risk (MIDH). Heat stress was also mentioned as a concern for farmers (NAPCCHH), and the employment scheme recommended that shade, drinking water, and childcare facilities be provided at the worksite (MNREGS). Occupational health of workers of pesticide manufacturing plants and of farmers using pesticides was of concern. Regular medical examination of pesticide industry workers was recommended (PMB). Management of misbranded or damaged pesticides were also discussed, alongside the mandated notification of cases of pesticide poisoning (PMB). Various agricultural policies supported or encouraged progressively shifting to eco-friendly technologies, conservation of natural resources, location-specific agronomic practices, judicious use of chemicals, crop diversification, and adoption of crop-livestock farming systems . While these may have an important bearing on health, it was not explicitly discussed in these policies. Food-borne infections were mentioned in the context of climate change, with recommendations for additional capacity in food safety and nutrition monitoring (NAPCCHH). Food poisoning cases are notifiable, to enhance food safety (FSSA). Another important concern is indoor air pollution from unclean fuels in kitchens (NAPCCHH and NHP), but this topic is beyond the scope of this paper. To alleviate health concerns raised by air pollution and carcinogens due to the prevalent crop residue-burning practices, various approaches were suggested, such as through mulching or use in industry (NPMCR). The waste management rules aimed to minimise fire hazard and nuisance of rodents, flies, birds and animals at landfills (SWM), all of which are related to food waste. Moreover, equipment, including gloves, coats, masks, and footwear were required be provided to handlers of solid waste (SWM)... minimise impact of solid waste on human health and environment” (SWM). “. Agricultural policies have discussed biosecurity threats through import of pigs (NLM) and birds (NPF), which may carry disease-causing agents. The approaches adopted to address this include regulation of import and facilities for quarantine. Policies also mentioned human health-related concerns or discussed approaches to regulate new food products (FSSA), new pesticides (PMB), living modified organisms (BDA), plant varieties with restriction use and “terminator technology” (PPVFR), and imported products (FTP). It was stated that genetic technology also needs to be assessed for risks and benefits (BDA and NPF).…to regulate, manage or control the risks associated with … living modified organisms … likely to have adverse impact on the conservation and sustainable use of biological diversity and human health” (BDA). “i) health policies encouraging other ministries towards nutrition-sensitive planning; and (ii) inclusion of health ministry representatives in inter-ministerial bodies. Intersectoral coordination for health in food systems governance was found to have occurred in two ways: . “ Such articulation for inter-sectoral coordination was stronger and more specific for undernutrition, where the role of the MoHFW has been proposed as convenor of inter-sectoral action (NHP and NNS). Addressing stunting has been mentioned as a “cross-sectoral goal.” Health policies mentioned other ministries more often as compared to food systems policies .A wide spectrum of national programmes contribute to improved nutrition outcomes…These include the Integrated Child Development Services…Targeted Public Distribution System, National Food Security Mission, Mahatma Gandhi National Rural Employment Guarantee Scheme…among others” (NNS). “Policy envisages that the MoHFW would take on the role of convener to monitor and ensure effective integration of both nutrition-sensitive and nutrition-specific interventions for coordinated optimal results” (NHP). “ While “convergence with other related departments” was also mentioned in the NCDs policy document (NPCDCS), it is unclear whether it meant convergence of departments within the health ministry or outside it, and what the objective of this convergence was. The nutrition policy has provided specific suggestions for agricultural and other sectors to focus on food and nutritional security of vulnerable groups (NNS).Promote processing of locally available nutritious foods through training of women’s (groups)… and use this for nutrition communication” (suggestion to the Ministry of Food Processing Industries in NNS). “anganwadi (ICDS). For the priority concern of maternal and child undernutrition, leadership was under Ministry of Women and Child Development, with the MoHFW as a key partner in all the envisaged programmes (ICDS and NNS). The interventions go beyond biomedical approaches, through convergence with other ministries, such as public distribution and agriculture at the level of the  Food systems policies either engaged MoHFW representatives in their respective inter-ministerial advisory or steering groups, or involved health institutions such as the Food Safety and Standards Authority of India (FSSAI) and the Indian Council of Medical Research (ICMR) . For exaGeneral Council will be the formulation body giving overall direction and guidance to Mission, monitor and review its progress and performance” (MIDH). “ Of the 35 analysed policy documents, 17 had instituted inter-ministerial steering or executive groups. Of these, nine had involvement of a health-related ministry . Of thes Among the analysed policies, the nutrition policy cross-referenced policies from agricultural and social sectors (NNS), whereas policy documents on agricultural programmes and missions only cross-referenced other agricultural policies (i) nutrition ; (ii) other health concerns (covering theme 4); and (iii) intersectoral coordination (covering theme 5). Some of our inferences used the Health in All Policies paradigm, to consolidate our arguments on health considerations in food systems policies. The findings have been discussed in three sections, namely  have not been included. The disproportionate policy attention to undernutrition may be because it is an older problem, has relatively higher burden, and hunger is deemed unacceptable.78 Undernutrition received relatively high policy attention. Literature affirms that there has been a strong degree of political will for addressing undernutrition in India for several decades,82 The gap in health consideration in trade policies is also related to similar factors, such as the primary objective of trade policies being economic development, neoliberal ideology, and power disparities between actors,83 and shifting the health responsibility to the consumer.84 These aspects have also been reflected in multi-country trade deals involving high-income countries.85 The challenge is further explainable from the continuing difficulties of health consideration even in tobacco trade policies.87 On a similar line, “counterproductive policies,” such as those increasing access to highly processed foods, were also of concern.4 Empirical insights on mechanisms through which food trade may impact health are available,89 and there are also calls for specifically improving coherence between trade policies and nutrition goals.90 We found some coherence in identification and targeting of vulnerable groups for undernutrition, but not for other challenges. Recent literature has described policy opportunities from the perspective of policy actors to tackle the double burden of malnutrition in India.4 In contrast, NCDs were addressed only by health policies, for which only biomedical solutions have been instituted. This neglect of NCDs in food policy is important due to the burden of NCDs on families and the health system, and also the potential for prevention. This may be explained by the larger neglect of social and commercial determinants of health, which include, among others, the strong influence of corporations on food environments and consequently on NCDs.28 and the other guideline was Dietary guidelines for Indians, put forth by the National Institute of Nutrition.91 The latter claims that it could be considered towards reaching “the goals specified in the National Nutrition Policy.”91 Our research also showed that dietary guidelines were ignored by food systems policies. There are at least two guidelines developed in India on healthy diets. The NNS was the only policy document that mentioned one of them,4 The nutri-farm scheme was the only agricultural policy explicitly addressing undernutrition (NFS). However, while the objective of the NFS was to improve dietary diversity, it surprisingly focused predominantly on cereals. This may reflect the perception of fortified cereals as a ‘silver-bullet’ for undernutrition, and also the preoccupation with production and food security. A few other policies, such as the livestock and horticulture missions, have potential for stronger nutritional thrust, as was recognised for the latter in an earlier study.92 designating agricultural injuries as a priority concern was understandable. However, aspects related to mental93 and social well-being of agrarian households94 was not adequately addressed. For instance, there was no mention of farmer suicides. As these challenges are driven by agricultural and economic policies, they may be most efficiently dealt with at that level. Concerns related to agricultural injuries, antibiotic resistance, food safety, crop-residue burning, and food waste disposal were identified. With the majority of India’s working population dependent on agriculture,95 has recently started receiving attention from the public health sector.96 Avian flu and other zoonoses were inadequately discussed in the included policy documents, but health system measures to address these for humans97 and animals98 were in place. While antibiotic resistance due to use in livestock production was mentioned as a concern in the health policy, it was missing from the livestock mission, demonstrating another gap in coherence. Overall, the impacts of food system policies on various health risks and outcomes (whether positive or negative) are potentially incidental rather than planned. Health impacts due to crop-residue burning25 From the NHP, it appeared that the health ministry felt it within their power to employ nutrition-specific interventions such as food supplementation, but beyond their immediate power to address dietary diversity. The NNS and the NHP emphasised intersectoral coordination to address undernutrition, possibly also because they were released in 2017 after the launch of the 2030 Agenda for Sustainable Development. A cautionary note is that similar calls for intersectoral coordination were made in the 1993 National Nutrition Policy, but those aspirations were not adequately realised.21 and hence, involvement of the health ministry in “advisory” roles in many of these groups may be an adequate starting point. The impact of this involvement would have to be studied through different data. The NHP recognised the potential of inter-ministerial bodies “to optimise health outcomes,” bearing relevance for operationalising “Health in All.” Literature suggested that there were limitations to positing health as the main argument for developmental planning and interventions,99 To foster healthier food systems, there were suggestions to improve the understanding about nutrition among agricultural policy-makers,100 linking policy agendas across sectors,34 advocacy,4 and also build relationship between food systems actors,101 which the nutrition policy (NNS) has shown some intention of doing. Another recommendation was for improved data from the health and agricultural sector to provide feedback on the impact of policy interventions,34 but approaches to strengthen data systems were only discussed in passing in the health policies (NNS and NHP). The ICDS scheme is an example of a programme incorporating nutritional and other goals at upstream planning level with downstream coordinated implementation at creches. Health considerations in food policy may also be more challenging due to the complex nature of causal linkages, as compared to, for example, asbestos regulation, for which the health basis for policy intervention is straightforward.i) factors contributing towards vulnerability to undernutrition; (ii) responses towards undernutrition; (iii) topics pertaining to healthy and balanced diets; (iv) non-nutritional health concerns of food systems policies; (v) broad approaches to intersectoral coordination for health; and (vi) specific types of involvement of the health ministry in food systems governance. Each of these may be of value for research in other settings and/or for policy analyses of other sectors. To our knowledge, this is the first paper that considered a broad range of health outcomes while studying food systems policies, in contrast to the usual focus on undernutrition and NCDs. Our method helped navigate and weave together diverse findings from a range of sectors. The empirical findings on the policy focus on undernutrition may resonate with other low- and middle-income countries, but those on the involvement of the health ministry in food systems governance may be more widely relevant. Various typologies were offered through the study:  pandemic further highlighted the vulnerabilities of food systems and their health ramifications in India and elsewhere, This study obtained ethical approval from the Padmashree Institute of Clinical Research in Bengaluru, India  and the Ethics Commission of Northwestern and Central Switzerland . No data were collected from people or animals. Authors declare that they have no competing interests. Conceptualisation: AP; supervision: AM, JU, and MSW; data collection and analysis: AP; review of analysis: AM and MSW; preparation of first draft: AP; review of drafts: AM, JU, and MSW. No specific funding was received for the study. The first author is a PhD student from India on a Swiss Government Excellence Scholarship (ESKAS), which covers his fees and living costs. ESKAS did not have any role in the design and execution of the study and the decision to submit for publication.Supplementary file 1 contains Tables S1- S2.Click here for additional data file.


With the increasing requirements of healthy habitat environments, landscape microclimates have been widely concerned. To comprehensively grasp the development history and research status of the landscape microclimates in China and other countries, CiteSpace software was used to comparatively analyze and visually present the literature related to landscape microclimates in CNKI and WOS databases for the past 20 years. The results show that: (1) The number of publications on landscape microclimate research shows an increasing trend in China and other countries, and the number of publications increased significantly after 2016. Although the number of publications by Chinese scholars is less than that of foreign scholars, they have developed rapidly in recent years, and their international influence has increased significantly. (2) A positive exchange has been formed among international scholars, and the number of collaborative studies has been increasing. China’s microclimate research has formed relatively stable teams that have conducted numerous studies in the fields of urban communities, street greening, and plant communities, respectively. Although the links between research teams and institutions in China and other countries are relatively close, they still need to be further strengthened. (3) In the past decade, the theoretical system of landscape microclimates has been improved, and the research themes have become more concentrated, but it still has remained close to the early basic research. (4) Future research will remain centered on “mitigating the urban heat island effect” and “optimizing human heat perception”. New topics such as “biodiversity”, “carbon cycle”, and “climate change” have been added. In conclusion, the research needs to continue to explore the evaluation system of microclimates and verify the evaluation index of outdoor thermal comfort for human thermal adaptation in different regions. The standards and systems of human habitat adapted to different regional characteristics should be formed. At the United Nations General Assembly’s 75th session on 22 September 2020, General Secretary Xi Jinping declared that “carbon dioxide emissions will strive to peak by 2030 and to achieve carbon neutrality by 2060“ . It provThe literature data were obtained from CNKI and WOS databases. The Chinese literature was selected from CNKI databases of academic journals, master’s, and doctoral databases. Among them, academic journals include five core databases: SCI source journals, EI journals, core journal papers, Chinese Social Sciences Citation Index (CSSCI), and Chinese Science Citation Database (CSCD).CNKI was used as the source of data for Chinese literature. Based on the experimental study site, search articles were TS =  AND TS = (microclimate). A total of 964 relevant papers were obtained. After further reading and screening, 760 valid articles were finally collected.WOS core collection was used as the data source for foreign literature. The search formula was: TS = (microclimate garden) OR TS = (microclimate park) OR TS = (microclimate plaza) OR TS = (microclimate square) OR TS = (microclimate campus) OR TS = (microclimate campus) OR TS = (microclimate street) OR TS =  OR TS = (microclimate outdoor) OR TS = (microclimate open space) OR TS = (microclimate green space) OR TS = (microclimate green space) space) OR TS = (microclimate neighborhood). The time period was from 2002 to 2022, and the type of literature was research articles and reviews (the search deadline was 1 April 2022). A total of 2238 articles were obtained. Excluding invalid and low relevance literature, 2156 valid articles were collected.CiteaSpace is a data visualization software based on JAVA program. It can predict the current status and development trend of research in related scientific and technological fields by analyzing the number of literature, authors, institutions, and keywords . CompareAs shown in Since 2002, the amount of landscape microclimate publications in other countries have shown a trend of rising–steady–rising again. The 2022 eighth Conference of the Parties (COP8) of the United Nations Framework Convention on Climate Change (UNFCCC) emphasized the severity of climate deterioration and provided an opportunity for the developments of landscape microclimates . With thCiteSpace was used to analyze the data of author teams in landscape and urban microclimate research in China and other countries, which derived the author collaboration graph. The brighter the color and the larger the node size, the more recent the author’s publication date, and the more articles; the darker the color of the line connection, the closer the collaboration between authors. The Chinese graph (CNKI database) has 486 nodes, 321 connections, and a network density of 0.0027 . The ChiThe authorship mapping of other countries (WOS database) had 355 nodes and 539 connections with a network density of 0.0086, which was greater than the network density of the authorship mapping of Chinese publications . InternaThe visual analysis of the publishing institutions was performed using Citespace. The node size represented the number of publishing institutions, and the nodes with purple outer circles were considered high-centrality nodes, and the centrality was usually greater than 1 . The anaThe mapping of foreign publishers had 512 nodes, 445 connections, and a network density of 0.0034 . ArizonaThe literature co-citation analysis provided an overview of the knowledge structure and evolution of research . A literMicroclimate simulation is a common tool for exploring microclimates at this stage. Compared with traditional microclimate research using measurement instruments experiments, numerical simulation can simulate and predict faster and more accurately. Among the studies with the theme of buildings, Ariane Middel and Yuepeng Wang focused on buildings and studied pollutant dispersion  and builIn urban design, landscape gardening can create a healthy and comfortable urban environment through the rational layout of garden elements. Scholars consider afforestation as one of the effective means to combat urban heat islands and improve thermal comfort. However, plants of different tree species  and morpThermal sensation is investigated to minimize the body temperature of pedestrian travel and to improve human comfort. In thermal perception research, the predicted mean vote (PMV) was first proposed by Professor Fanger in Denmark . In ordeMutability and clustering analysis of keywords for landscape microclimate were performed by Citespace . The burThe research hotspots of Chinese landscape microclimates are shown in In climate analysis, a microclimate evaluation system adapted to the Chinese characteristics has not been fully formed. Numerical microclimate simulation research in China still needs to rely on foreign research of technology. In the future, further and more comprehensive research on actual measurements and numerical simulations are required. On the premise of meeting the demands of different stakeholders, it is necessary to sort out and summarize the objectives and tasks of landscape gardening climate, explore the evaluation system of microclimates, and verify the evaluation index of outdoor thermal comfort for human thermal adaptation in different regions. Based on the objective human thermal comfort evaluation index, it is necessary to introduce the psychological thermal comfort perception to achieve the unification of physiology and psychology. Additionally, how to balance the relationship between the microclimate environment and visual aesthetic demand in urban green space is also a problem we need to consider.The clustering of landscape microclimate keywords for other countries are shown in From 2012 to 2016, mitigation strategies for the urban heat island effect began to be extensively studied. The cooling and humidifying effects of plants and urban layouts on heat island effect mitigation have been demonstrated. With the expansion of research objects, recreational squares , universFrom 2017 to 2022, testing the accuracy, applicability, and validity of human thermal indicators has become a systematic issue. It becomes another important segment of the landscape microclimate. For outdoor thermal comfort in urban spaces, scholars have proposed different thermal comfort indices. Among the 165 developed human thermal indices, only four indices  have been widely used in outdoor thermal perception studies . At thisA comprehensive bibliometric analysis of the evolution of the landscape microclimate was conducted based on Citespace software. Landscape microclimate has become an important topic for enhancing the habitat and has achieved fruitful achievements.First, we found that the authors and institutions represented in the landscape microclimate were associated. Most of them were university researchers or professors. Therefore, we can assume that universities may devote more financial, and other, resources to help scholars to pursue their research. It also confirms the finding that the major research institutions for landscape microclimates, both domestic and abroad, are universities. In addition, the research dimension of landscape microclimate is always closely related to geographical location, climate, and population. For example, the harsh northern region and the humid and hot southern region are the most productive regions for landscape microclimate research in China.Second, the study organized the complete development lineage of landscape microclimates. It was found that landscape microclimate started early and had a rapid development trend, with a relatively complete theoretical system. The high-cited keywords of the literature emphasized the relationship between landscape microclimate and healthy cities, which indicates the future research direction. For example, many scholars have studied how to improve microclimate environments to provide comfortable outdoor open spaces by combining simulation software with measured data in recent studies . PopularLast, but not least, the research focused on landscape microclimate differed from domestic and abroad. Chinese scholars preferred to start from the research objects, which were divided into the following categories . At the A visual comparative analysis of the landscape microclimate literature published both domestically and abroad in the last 20 years was conducted by Citespace software, and the following conclusions were drawn.(1) The analysis of the number of publications shows that the number of landscape microclimate research, both domestic and abroad, has shown a sustained increasing trend since 2002, and the number increased significantly after 2016. Although the number of articles published by Chinese scholars on microclimate research was less than that of foreign scholars, it has developed rapidly and increased significantly in international influence over recent years.(2) The analysis of author co-occurrence shows that international scholars have formed a positive exchange among themselves. The number of collaborative research has increased. Microclimate research in China has also formed relatively stable teams, which have carried out fruitful research in the fields of urban communities, street greening, and plant communities, respectively.(3) From the keyword clustering analysis, it can be seen that the main basic directions of abroad landscape microclimate research are (1) the influence of outdoor thermal environment on human comfort; (2) numerical simulation of science and technology; (3) the influence of local microclimate among landscape factors. The research hotspots published by Chinese scholars in international journals were consistent with foreign scholars.(4) The future research trends of landscape microclimate include the following. (1) Mitigation of the urban heat island effect and optimization of human thermal perception will remain to be studied. However, it is no longer limited to analyzing the cooling and humidifying effects of plants, but more to explore the correlation between different landscape factors and human comfort. Alternatively, it can determine the best microclimate effect model for the study sites, based on the healthy city. (2) With the emergence of hotspots for habitat improvement, the conservation and development of biodiversity has also become an important concern. It includes “synergistic relationship between microclimate and biodiversity at regional scales”, “creation of suitable environment for different biological species at local scales”, and “prediction study on the relationship between climate change and biodiversity in cities”. (3) In recent years, how to reduce urban energy consumption, increase urban greenery, and create a comfortable microclimate environment through carbon cycle has become another research hotspot. In the future, the tasks and goals of landscape microclimate need to be sorted out and summarized under the premise of meeting the requirements of different stakeholders. It is necessary to explore the evaluation systems of microclimates and verify the evaluation indexes of outdoor thermal comfort for human thermal adaptation in different regions. Habitat standards and systems adapted to different regional characteristics should be formed as soon as possible.


Previous work analyzing the health and wellbeing correlates of caregiving has found increased rates of depression , anxiety , and elevated risks of health problems, specifically cardiovascular-related incidents like hypertension , cardiovascular disease , and strokes . Research on specific cognitive effects that this responsibility may elicit has been less of an area of focus, especially when examining domains related to executive functioning. The present research investigated whether executive functioning mechanisms  are impacted in caregivers and if their function is mediated by interpersonal factors like birth year, gender, education, and depressive symptomology. Using the Health and Retirement Study, we compared spousal and parental caregivers of persons with medical conditions (n = 143) and non-caregivers (n = 975) who completed the 2015 Consumer and Activities Mail Survey (CAMS). Additional demographic and cognitive performance information was paired from the corresponding RAND 2016 data and the 2016 Harmonized Cognitive Assessment Protocol (HCAP) data. Preliminary ANCOVA results indicated, surprisingly, that spousal/parental caregivers were more likely to exhibit better executive function performance (p < .05) compared to non-caregivers, while delayed recall measures were not linked to caregiving status. These results indicate that intact executive function might be linked to one’s ability to provide caregiving for parents and/or spouses; while the HCAP was only administered at a single time point, future research should examine the longitudinal effects of caregiving on cognitive function.


Research suggests that advanced technologies, such as wearable technology and tablets, can serve an important role in the cost-effective, accessible delivery of health promotion that is individualized, immersive, and engaging for users. The present study was designed to test the feasibility and acceptability of two integrated technologies among assisted living facility residents: CareBand’s wearable technology and Eperture’s RememberStuff (R/S) tablet platform. The purpose of the qualitative component of the project was to provide preliminary information from the perspective of the assisted living facility participants on these two technologies. Another goal was to assess the challenges of their participation. Drawing on qualitative thematic analyses of data collected from semi-structured interviews with 16 participants (four staff members and 12 residents) prior to and following the 6-week integrated technology program, three themes emerged as positive outcomes of the technology experiences: (a) leisure activity engagement, (b) exploration of tablet features, and (c) cognitive stimulation. This finding suggests that these technologies may enhance leisure engagement and cognitive function. On the other hand, there were three challenges that participants experienced while participating in the program: (a) inability to grasp functionality, (b) need for continued education for the technology, and (c) negative stereotypes toward technology use. These challenges provide guidance for future protocol design in follow-up studies to further explore the integrated technology efficacy for older adult users. The practical implications of this study and suggestions for health professionals are discussed.


The control and prevention of public health emergencies can face severe challenges, especially financial and material challenges during the coronavirus disease 2019 (COVID-19). Enabling and ensuring smooth financial and material flows across levels, within the country, and across countries are essentially important to preparedness for global health emergencies, which cannot easily be achieved without being facilitated by preferential tax policies. China’s preferential tax policy practice developed at early stages of the COVID-19 pandemic could be useful experiences which can be adapted to unique contexts of other countries, so different stakeholders including citizens could be effectively motivated and involved in the fight against the COVID-19 pandemic. However, we should see that these policies are temporary and issued as an afterthought. There is still much to learn about how epidemic responders and policy-makers can make the most of each other’s expertise to fit into the wider information architecture of epidemic response. Even the global support may not be able to reach every country equally or timely, due to, for example, the sudden shift of urgent need for COVID-19 prevention materials from eastern to western countries during February-March 2020. This has left many vulnerable regions or communities disproportionately suffered from the local pandemic. Enabling and ensuring smooth financial and material flows across levels , within the country , and across countries  are essentially important to preparedness for public health emergencies. This may be temporarily realized by some short-term stimulus measures that could help individuals and businesses cope with the ravages of the COVID-19 and produce short-term results at best.5 However, long-term goals including economic recovery cannot easily be realized without being facilitated by an invisible hand behind – preferential tax policies. The control and prevention of public health emergencies can face severe challenges, especially social and economic challenges, which, according to what has been happening in different countries during the coronavirus disease 2019 (COVID-19), could be not necessarily related to socioeconomic status of the country.6 China’s preferential tax policy practice developed at early stages of the COVID-19 pandemic could be useful experiences which can be adapted to unique contexts of other countries, so different stakeholders including citizens could be effectively motivated and involved in the fight against the COVID-19 pandemic. In February 2020, the Chinese government issued a series of preferential tax policies in relevant areas and industries to strengthen COVID-19 prevention and control, which have gone in effect since January 1, 2020 .6 They include exempting personal income tax of temporary subsidies and bonuses of health professionals for their work related to COVID-19 control and prevention; increasing the refund and deduction of the enterprise income tax and value-added tax (VAT) of enterprises producing and transporting COVID-19 prevention materials; removing customs duties for imported COVID-19 prevention materials; increasing tax deduction for expenditures of COVID-19-related personal and enterprise donation to governments, public charitable organizations, or directly to hospitals; alleviating the income tax and VAT of enterprises seriously affected by COVID-19; and reducing or exempting the employers’ and employees’ contribution to pension, unemployment, and work injury insurance premiums . The issuance of these preferential tax policies, benefiting many aspects of public health affected by COVID-19, is a timely tax policy response. These policies are not only an encouragement for individuals to be involved, but also an incentive for enterprises to participate in COVID-19 control and prevention through practical actions, such as producing more prevention materials or providing more services. In fact, what has happened, motivated by these policies, is as expected: more and more healthcare professionals have been willing to participate in front-line prevention work because they are not only encouraged in spirit, but also well treated in financial compensation; also, the situation of having insufficient supplies of prevention materials in China has been quickly reversed and gradually returned to normal. Stimulated by both market demand and temporary tax policies, the production costs of products have been reduced, which made many enterprises attempt to expand their production capacity or add new production lines to meet the needs of domestic markets. The tax policy measures taken so far in China have demonstrated a high premium placed on COVID-19 prevention and control in the agenda of the central government. They have benefited not only China, but the whole world, especially after the COVID-19 epidemic became a pandemic . For example, some enterprises under such tax policy motivation have produced more COVID-19 prevention materials and goods, which are being exported to other countries in the fight against COVID-19: nearly 700 000 mouth masks from China arrived in the Netherlands on March 21, 2020, which is the first shipment of a multimillion-dollar order that will arrive in the Netherlands in the coming weeks; a total of 5 million COVID-19 rapid test kits were purchased from China and will be delivered to Brazil by middle April; 145 life-support machines and emergency ventilators were sent to Serbia on March 25, 2020, which is just one of many purchasing orders from 35 countries. These goods have been distributed as quickly as possible to the places where the need was the greatest, which have played a critical role in their fight against COVID-19 before local enterprises can meet their demand at a much less extortionate price.7 all countries should think about questions such as: can such tax preferential policies be integrated into the national basic tax system, making them an integral part of the national system of public health, especially in disease control and prevention?8 Can they play a role in alleviating adverse (side) effects of public health emergency events? Only combining financial policies and public health governance in an efficient way can make it possible to enable a larger supportive role to be played by financial policies in public health governance. Also, such considerations can provide financial and tax assistance not only to those enterprises and their employees that are affected by emergency events, but also to those directly suffering as a result of emergency events from a humanitarian perspective, such as health professionals working in hospitals and in the field for epidemic control, patients and their families. Although such tax policy responses reflect the flexibility of China’s tax policies when dealing with public health emergencies and well reserved tax policies, we should also see that these policies are temporary and issued as an afterthought to respond to the COVID-19 epidemic that has already occurred. They are not stably embedded in the current tax law system in China, which otherwise would have comprehensively strengthened the public health capacity of the country. There is still much to learn about how epidemic responders and policy-makers can make the most of each other’s expertise and how preferential fiscal and tax policies can fit into the wider information architecture of epidemic response. In the future, with the increase of environmental and public health risks,9) and developing countries . Special and urgent attention should be given to both low- and middle-income countries whose fragile fiscal and health systems and relatively lower tax morale may be challenged by the forthcoming pandemic,12 and also to high-income countries whose existing high tax rates have left citizens less capacity to support public health emergencies without additional preferential policies; for example, a call for lawmakers to avoid arbitrarily limiting tax provisions and raising taxes during this time has been made in the United States.9 Some challenges should be foreseen when implementing such measures in other countries with different public health emergency and disaster response systems. For example, it may be difficult to implement financial incentive policies or measures consistently across the US, due to the bottom-up design of their emergency and disaster response system4; the effects of doing so would be more heterogeneous due to the varying financial positions before the COVID-19 outbreak.13 China’s public finance practice in the fight against the COVID-19 pandemic could be useful and adapted to other countries to incentivize corporations and individuals to participate in COVID-19 control and prevention under their respective cultures and institutions. Some efforts are also observed in other countries, such as tax relaxation in both developed  and the International Institute of Spatial Lifecourse Epidemiology (ISLE) for the research support. Not applicable. Authors declare that they have no competing interests. PJ conceptualized and designed the study. All authors collected the data, wrote and revised the initial manuscript, and approved the final manuscript.1School of Public Finance and Tax, Central University of Finance and Economics, Beijing, China. 2International Institute of Spatial Lifecourse Epidemiology (ISLE), Hong Kong, China. 3West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China. 4Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, China. 5Department of Land Surveying and Geo-Informatics, The Hong Kong Polytechnic University, Hong Kong, China.


Health-related quality of life (hrQoL) is a core outcome in evaluating interdisciplinary pain rehabilitation (IPR). This systematic review aimed to identify prognostic factors for hrQoL at least six months after IPR in chronic pain patients.A systematic search was conducted in MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science and Cochrane CENTRAL until September 2020. Included were prognostic studies on the outcome hrQoL in adults aged 18 to 67 years with chronic pain  who had undergone IPR. Studies were assessed with The Quality in Prognostic Studies-tool. Potential prognostic factors at baseline for the domains pain, psychological and physical functioning were qualitatively synthesized for hrQoL. Grading of Recommendations Assessment, Development and Evaluation was used to evaluate the level of evidence.Fourteen studies on 6,668 participants (mean age 37.4–52.8 y), with musculoskeletal pain/fibromyalgia and a pain duration ranging between 13.1 and 177.4 months were considered eligible. With a very low certainty of evidence, pain intensity, emotional distress, and physical functioning at baseline were inconsistent for prediction of hrQoL and pain duration was not predictive. With low certainty of evidence, fewer pain sites, lower levels of negative cognitive behavioral factors, and higher levels of positive cognitive behavioral factors predicted a better outcome.The overall certainty of evidence was low to very low, making it difficult to reach definitive conclusions at present. Future studies with a predefined core set of predictors investigating hrQoL in patients with chronic pain after IPR are needed. The International Association for the Study of Pain (IASP) defined chronic pain, such as chronic musculoskeletal pain, chronic widespread pain or fibromyalgia, as pain in one or more anatomic regions that persists or recurs for more than 3 months; is associated with significant emotional distress and/or significant functional disability and the symptoms are not better explained by another diagnosis . WorldwiPrevious systematic reviews identified prognostic factors for patients suffering from pain in primary care , 15 or fThe aim of this systematic review was to evaluate and meta-analyze published data on prognostic factors for hrQoL at least six months after IPR in patients with chronic pain.This systematic review with planned meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  and adapA protocol was registered a priori with PROSPERO, Centre for Reviews and Dissemination, University of York, CRD-register (registration number: CRD42020195885).Eligibility criteria were defined with the modified PICOTS system, which frames all important parts of the research question and is helpful at different stages of the process: e.g., study identification and selection, and adapted for reviewing prognostic factor studies ; P , PsycINFO (Ovid), EMBASE (Elsevier), CINAHL (EBSCO), Web of Science , and the Cochrane Central Registry of Controlled Trials (CENTRAL). The search algorithms were created with the help of a professional librarian and are presented in the All studies found in the databases were downloaded and organized using Endnote Software  and duplThe included studies were assessed for internal validity with The Quality in Prognostic Studies (QUIPS)-tool, which is a Cochrane-based tool for evaluating validity and bias in studies of prognostic factors . QUIPS aFor each included study, the six domains were rated as high, moderate, or low RoB by two researchers  independently and disagreements were discussed to find a consensus. A threshold for the levels of RoB was set a priori for some characteristics, that is, permitted participation and attrition rate, according to previous recommendations for a pain rehabilitation perspective as derived from our research group . The oveData extraction was guided by the adapted checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies (CHARMS-PF) checklist for primary studies of prognostic factors . Data onP values < .05 and was taken as evidence for the factor’s potential prognostic value. The association was classified as either positive, negative or absent. For all statistically non-significant prognostic factors, the direction was recorded if reported. In the conceptualization of potential prognostic factors, we followed the study by Tseli et al. and organized the factors into the following domains [A narrative synthesis of the included studies was performed to present the direction of the association between the prognostic factors at baseline and the outcome hrQoL. A statistically significant association with the outcome was defined as a univariate association or an association adjusted for confounders or other prognostic variables, with a  domains : pain-reThe Grading of Recommendations Assessment, Development and Evaluation method (GRADE) tool adapted for reviews of prognostic studies was used to rate the certainty  of scientific evidence in this systematic review . In the A total of 2027 records were found /Central n = 63). After elimination for duplicates in Endnote, 1678 studies remained for further evaluation. Titles and abstracts were screened on the inclusion and exclusion criteria and 123 studies were read in full text for PICOT eligibility. Fourteen studies remained after screening these full texts and were included for synthesis in this review . The intThe 14 included studies were published between 2007 and 2020 and were all conducted in Europe : 10 cohoThe intervention profiles of the included studies were described as multidisciplinary (pain) treatment , 37, intGeneric or disease-specific measures for the outcome hrQoL were extracted. Questionnaires used in the included studies were the Fibromyalgia Impact Questionnaire (FIQ) , 41, theIn total, 49 different prognostic factors were identified. Pain-related factors were mostly assessed with, for example, the Numeric scale 7 days (NRS-7d), pain duration in years or the pain region index (PRI). Examples of measurement instruments used for psychological-related factors include the Hospital Anxiety and Depression Scale (HADS) for emotional distress. For cognitive behavioral negative factors, for example, the Tampa Scale of Kinesiophobia (TSK), and the Pain Catastrophizing Scale (PCS) was used and correspondingly, for cognitive behavioral positive factors the Coping Strategies Questionnaire (CSQ) and the Pain Self-Efficacy Questionnaire (PSEQ). All prognostic physical functioning-related factors were self-reported such as the SF-36 PF.Nine out of the 14 studies were classified as studies with a high RoB, while one study was classified as having moderate RoB  and fourThe detailed results  from the included studies are presented in The modified GRADE assessment is presented in pain intensity and the outcome physical hrQoL was assessed in seven studies [The narrative analyses concerning the association between  studies , 42–44 a studies  showed t studies , 42, 44  studies , 35, and studies . Concern studies , 35 in a studies  found noIn summary, the results on the association between pain intensity at baseline and hrQoL at follow-up was found to be inconsistent, since both higher and lower levels of pain intensity at baseline were associated with positive outcomes. The GRADE analyses showed that the certainty of evidence for this finding was very low .Pain duration at baseline displayed almost no associations with the outcomes physical and mental hrQoL in four studies [ studies , 36, 44  studies , 36 poin studies  showed a studies , 36, 44. studies  showed t studies  showed n studies . Sensitipain sites indicated that patients with fewer pain sites at baseline had a better outcome for hrQoL (The analyses of the four studies , 42, 44 or hrQoL . For phyor hrQoL .emotional distress (The narrative analyses regarding the psychological predictors are shown in distress . Six studistress .cognitive behavioral negative factors showed lower levels of cognitive behavioral negative factors at baseline predicted a better outcome for hrQoL (In six studies , 40, 43 or hrQoL . One [34or hrQoL .Cognitive behavioral positive prognostic factors in six studies [ studies , 43, 44  studies , 43, 44  studies , 44 show studies , 36 who  studies . Subgrouself-reported physical functioning at baseline and the outcome hrQoL, with inconsistent results (Five studies , 43, 44  results . Lower s results .This review showed that pain intensity, emotional distress and physical functioning at baseline is inconsistent for prediction of hrQoL, 6 or more months after IPR in chronic pain patients. Additionally, pain duration has no predictive value for this outcome. Furthermore, we found that fewer pain sites can predict a better outcome, that lower levels of cognitive behavioral negative factors, and that higher levels of cognitive behavioral positive factors predict a better outcome of hrQoL. However, the certainty of evidence was low to very low, therefore no firm conclusion on prognostic ability of these factors can be drawn.The results of previous reviews regarding pain intensity as a predictor are also inconclusive: van der Hulst et al. showed that high pain intensity at baseline had a negative predictive value in chronic low back pain patients for the outcome activity and participation limitations , de RooiRegarding pain duration our review showed that there is very low certainty of evidence that pain duration did not have predictive value, and similar to the findings of van der Hulst et al. in fibromyalgia patients for the outcome activity limitations and participation restrictions . NeitherIn summary, caregivers should be aware that pain intensity levels may not influence the prognosis. These results affirm the biopsychosocial approach of IPR, which primarily aims to restore physical and psychological functioning, whereas pain reduction is a secondary objective . HoweverIn our review, we found with a very low certainty of evidence that emotional distress, such as depression, at baseline had inconsistent predictive value for hrQoL at follow-up. These results are in line with the findings of van der Hulst et al. . HoweverWe found low certainty of evidence favoring low levels of negative behavioral factors, such as fear avoidance and pain catastrophizing, as predictors for increased hrQoL outcomes. These factors were also shown of importance for other outcomes of previous reviews , such asIn our review, high initial cognitive behavioral positive factors such as self-efficacy showed a better outcome for hrQoL at follow-up. These results are supported by previous reviews on mixed chronic pain population , 50. SomOur results support the current evidence that psychological factors are strongly related to chronic pain . ChronicIn our review, results for baseline self-reported physical function as predictors for hrQoL are inconsistent. However, previous systematic reviews conclude that exercise and physical activity as intervention have positive effects in terms of improved quality of life in chronic pain patients , 58. HowThe systematic search in the electronic databases was carried out in September 2020, but the search string was not rerun. Therefore, it cannot be excluded that relevant studies published after September 2020 were missed. Moreover, we included only studies from 2000 or later, since we believed that the comparison with IPR studies from before that time are difficult to compare with the IPR of today. Still, we could have missed some important studies that could have altered the results. A strength of this systematic review is that the search strategy was developed with an epidemiologist from the field and a librarian, and we searched in six electronic databases. Furthermore, at least two researchers were involved in all stages and despite the heterogeneity of the selected studies the researchers agreed to the results with a moderate interrater agreement . The disA major difficulty of this study is the heterogeneity of the included studies. First, the heterogeneity is already given by the study population, the different interventions regarding chronic pain, and the heterogeneity for the prognostic factors within the same domain. With the intention of capturing dimensions of the same construct, the grouping of the domains was done with experts from the field and measurement properties that were considered too inaccurate were not included in the analyses . Still, Two-thirds of the studies included in the present review were at high risk of bias and mainly the domain Study Attrition followed by Study Confounding were responsible for this result. Three of the studies were register studies , which aThis systematic review showed low certainty of evidence that cognitive behavioral factors at baseline influence hrQoL at follow-up which is in line with the theoretical approach upon which IPR emanates. For pain factors the results were inconclusive. Moreover, the prognostic factor of initial emotional distress and physical functioning remained unclear. The overall quality of evidence in this review was very low to low, which makes it likely that future studies could impact our findings. To increase the value of prognostic factor investigations of future studies, a predefined core set of predictors investigating hrQoL is needed in patients with chronic pain after IPR. Furthermore, analyzing additional data such as mediating factors and post-intervention outcomes should serve to further contribute to increasing our knowledge in this field.Pain Medicine online.pnac098_Supplementary_DataClick here for additional data file.