Insufficient access for population subgroups was common; several examples of horizontal and vertical integration of eye health services within the health system were described.In pursuit of Universal Health Coverage (UHC) for eye health, countries must strengthen services for older adults, who experience the highest prevalence of eye conditions. This scoping review narratively summarised (i) primary eye health services for older adults in eleven high-income countries/territories (from government websites), and (ii) the evidence that eye health services reduced vision impairment and/or provided UHC  (from a systematic literature search). We identified 76 services, commonly comprehensive eye examinations ± refractive error correction. Of 102 included publications reporting UHC outcomes, there was no evidence to support vision screening in the absence of follow-up care. Included studies tended to report the UHC dimensions of access (This work was funded by Blind Low Vision New Zealand for Eye Health Aotearoa. World Report on Vision in 2019, the World Health Organization called for eye care to be included in efforts to achieve Universal Health Coverage (UHC). In 2021, the Lancet Global Health Commission on Global Eye Health supported this call, stating that UHC should not be considered “universal” without including eye health. As the prevalence of eye conditions and vision impairment increases with age, older adults are an important group to consider when strengthening eye health services.In its inaugural Healthy Ageing strategy, but how this eye health check should be implemented was unclear. In July 2020, we conducted a preliminary search of the published literature within the PubMED database , where we observed a paucity of evidence describing adult eye screening services in New Zealand. Widening our search internationally, we identified three systematic reviews , each reporting insufficient evidence that community vision screening services for older people  can reduce vision impairment in this population.In 2020, the government of Aotearoa New Zealand  proposed funding eye health checks for the population ≥65 years. This proposal aligned with New Zealand's Countries such as New Zealand that are attempting to improve eye health among older adults are challenged by the lack of evidence supporting the effectiveness of primary eye health services, and the best way to structure these services within the health system to achieve UHC. We designed this review to fill this evidence gap, and therefore to better inform future eye services in New Zealand and elsewhere.This review provides the practical and theoretical evidence that can direct policy makers in high-income countries towards achieving UHC when designing new eye health services for older people. Firstly, we collated the types of primary eye health services available in New Zealand and comparable high-income countries . A key finding was that community vision screening services for older adults were uncommon . All other included countries, except New Zealand, funded eye examinations (often with refractive error correction) for all older adults, or a subgroup considered most at risk of financial barriers. Secondly, we systematically scoped the literature for evidence of services that reduced population vision impairment or incorporated UHC in its design and implementation  dimensions: integration, efficiency, timeliness, safety, and people-centredness], or financial protection). The identified evidence describes a need for services that prioritise underserved population groups, to avoid further widening existing inequalities ; a lack of evidence reporting financial protection for health system users; and several examples of service integration (e.g. shared care schemes) that may improve access to services via horizontal and vertical integration.Vision screening for older adults  was used in only one of the countries we assessed, and there is no evidence to suggest this strategy reduces vision impairment. Financial protection is a cornerstone of UHC and all countries except New Zealand provided this protection for at least some older adults. We identified a range of strategies that countries can consider when wishing to improve access, quality, or financial protection of primary eye health services for older adults as part of UHC initiatives. Embedding equity into new strategies by prioritising the needs of the historically underserved groups will help avoid intervention-generated inequities.Alt-text: Unlabelled boxWorld report on vision, the World Health Organization called for eye health to be part of efforts to achieve universal health coverage (UHC) through implementing Integrated People-centred Eye Care (IPEC) across the spectrum of promotive, preventative, curative and rehabilitative services.people being able to access the care they need, of sufficient quality to be effective, without suffering financial hardship.Lancet Global Health Commission on Global Eye Health.In its inaugural Eye conditions are strongly associated with increasing age—more than three-quarters of the estimated 43 million people living with blindness and almost two-thirds of the 553 million with distance vision impairment in 2020 were aged ≥50 years.The aims of this review were to summarise (i) the nature and extent of community or primary eye health services for older adults in eleven high-income countries and territories, and (ii) the extent to which eye health services in these settings reduce vision impairment and/or provide UHC of eye health services for older adults. While the lack of synthesized evidence in New Zealand provided the impetus for this review, we believe the findings are relevant for many countries wishing to improve access to eye health services in pursuit of UHC. We have synthesised our findings as a scoping review due to the broad nature of the research questions and the diversity of the included evidence.st October 2020, following input from a stakeholder group.The protocolWe looked for evidence in the grey and published literature by asking two complementary questions.Question 1: Existing eye health servicesWhat government-led community or primary eye health services for older adults are offered in New Zealand and similar countries, and how are they structured within the health system?Question 2: Availability of evidencei)reduce vision impairment? and/orii)provide UHC of eye health for older adults?What is the evidence that eye health services within the selected countries:We envisaged limited evidence reporting outcomes on vision impairment from the specific services identified in the grey literature. Therefore, we sought evidence that described services in the included countries across any of the UHC dimensions of access, quality, equity, or financial protection, with the assumption that services addressing these dimensions are contributing to strengthening eye health services.For both Questions 1 and 2, the included evidence reported eye care services within eleven countries: New Zealand, Australia, Canada, Ireland, United Kingdom , Singapore, Hong Kong, and the United States of America. The included countries were predominantly English-speaking high-income countries or territoriesWe used separate but complementary inclusion criteria to address the two questions .Table 1IFor Question 1, one reviewer (LG) searched grey literature  during August-October 2020, with verification by a second reviewer . Eye care programmes were identified from the national government's website of each included country. Additional searches of state/provincial government websites were also completed, except for the USA, where the large number of states and the complexity of the health system meant only national-level services were included. Parallel programmes available within the devolved countries of the United Kingdom were included separately. General search terms, including “eye”, “vision”, “optical”, “optometry” and “ophthalmology” were used to identify eligible information within each website, and we repeated the search using the Google search engine. Relevant links within documents to other sources of information were pursued. Searching continued until retrieved results were unambiguously irrelevant.th October 2020 (Supplementary Table 2). Grey literature from Question 1 that described programme performance were also included. Screening of retrieved publications was conducted in Covidence . During each round of screening, two reviewers  independently screened i) each title and abstract, then ii) the full-text manuscript of each potentially relevant publication, against the eligibility criteria (n=20 publications). At each stage of screening, differences of opinion were resolved by discussion. The remaining data extraction was performed by a single reviewer (LG).For Question 2, an Information Specialist from Cochrane Eyes and Vision (IG) conducted a search in MEDLINE, Embase, Cochrane Library and the CRD Database  on 19criteria . Data exPrimary eye care programmes included in Question 1 were described using the six WHO health system building blocks outlined in our study protocolFor the evidence describing effectiveness of eye care programmes (Question 2), general information was extracted from each publication and included the country in which the data were collected, the study design, the year of publication, and the eye condition assessed or treated by the service. For the latter category, publications describing vision impairment in general (i.e. not a specific condition) were classified under ‘general’ eye conditions. For each publication, we summarised outcomes that described (i) change in vision impairment, and/or (ii) any of the UHC dimensions Our original intention was to complete a rapid systematic review that could inform New Zealand policy.The funders had no role in the study design, collection, analysis, or interpretation of data for this review.From our website search, we identified 76 eye care programmes relevant to older adults across the eleven included countries/territories. The service structure of the identified programmes across WHO's building blocks are summarised below and in , and keyThe 76 eye care programmes offered a range of assessment and treatment services. Some ran isolated services, while others offered a combination of several services . In geneAll countries had at least one programme offering visual acuity assessment (Singapore) or eye examinations ; New Zealand was the only country without a programme that provided this care without requiring out-of-pocket payments from groups least able to pay. Of the 43 programmes offering eye examinations, 27 also included refractive error correction, and an additional 15 subsidy programmes offering refractive error correction were identified . Fourteen screening services were identified: national-level diabetic retinal screening programmes in nine countries, three glaucoma screening services in the USA packaged within comprehensive eye care programmes, one programme in Australia that encouraged service providers to enrol people with diabetes into a reminder system to promote access to retinal screening, and one visual acuity screening service in Singapore. Two of the screening services included follow-up care within the service itself . These services were provided at healthcare centres  and/or community locations not conventionally dedicated for healthcare (e.g. mobile clinics or community centres).The 76 eye care programmes were administered by a range of service providers, and some programmes by multiple provider types and different locations . CliniciSeventy-four of the 76 identified services were publicly funded , while two services reported corporate funding in addition to public funding .Twenty services required no out-of-pocket payment by the user: nine of these provided eye examinations, six were national diabetic retinal screening services, and four were refractive error subsidies or low vision services. Most services required the user to pay an additional fee or co-payment for basic service. Payment for services were made directly to the service provider or by reimbursement to the service user, although we also identified eight services where monetary vouchers were provided to the service user,  (outlined below in Question 2).n=73) and described eye care services in the UK (n=39), USA (n=21), or Australia (n=15); almost twice as many were published in the second half (n=68) compared to the first half (n=34) of the decade. Forty-two publications reported on diabetic retinopathy, 18 on glaucoma services, and 32 reported general eye care services not pertaining to any particular condition  2-3; Most included publications reported more than one outcome (i.e. (i) change in vision impairment, and/or (ii) any of the UHC dimensions: mediaThe seven publications reporting changes in vision impairment described general eye care services . These i16n=70 publications; n=47), with substantial overlap between publications describing both access and equity , and the included evidence illustrated that even minimal costs present a barrier to accessing eye care. An RCT conducted within the Hong Kong Hospital Authority showed poorer access to diabetic retinal screening when a small co-payment was required compared to a service with no out-of-pocket costs,Financial protection was reported infrequently (n=39) was commonly reported , which frequently overlapped with timeliness  and people-centredness (n=10) were the least reported quality dimensions ; very few publications reported on financial protection. Our review provides some key considerations for decision-makers in pursuit of UHC for eye health in their country.Achieving UHC for eye health among older adults will require decision-makers to incorporate equity into the design of services, including targeting the most underserved populations subgroups. Our included evidence commonly reported inequities in access to eye care for people aged ≥65 years particularly if they were of a non-Caucasian ethnicity, had low education or income, did not have health insurance, or lived in areas that were remote or with high deprivation. To address these disparities, we found evidence that eye care services operated by culturally safe service providers in a community setting rather than formal eye health care setting can reach more older people from minority or underserved groups,Integration and the continuum of care across levels was another common theme in this review, evident in some but not all countries and featured in more than one-third of the literature we identified. Integration is currently a key priority in global eye health. In the World Report on Vision, WHO outlined the need for Integrated People-centred Eye Care (IPEC) to achieve UHC,One horizontal integration example we identified was retinal screening for people with diabetes delivered via general practice, which increased retinal screening rates.Refractive error correction is a condition that highlights the importance of integrated eye care services. Refractive error is the leading cause of vision impairment globally, including among older adults.Comprehensive monitoring to assess effectiveness of the 76 programmes we identified in Question 1 was largely unavailable—we found reports on 11 of these services, the majority from service audits or other grey literature. While most of these reported positive outcomes, including increased use of services or improved efficiency over time, it is unclear whether these services are adequate to meet the needs of the population. Moreover, a lack of evidence within the included UHC dimensions may be a result of under-reporting, rather than a lack of adherence to eye care services within UHC principles. In pursuit of UHC for eye health, more and better evidence is required on what works, for whom, and in what circumstances—this can include better use of routinely collected information, as well as via stronger partnerships between researchers and decision-makers to answer policy-relevant questions. The scoping nature of our review and the heterogeneity of the included evidence precluded critical appraisal of the evidence we identified. As eye health researchers respond to the call made by WHOFinally, we found very few studies reporting outcomes relating to financial protection and those that did highlighted the need for it rather than demonstrating ways in which providing it improved coverage of services. Out-of-pockets costs are a major barrier to eye health,Our review must be considered in light of several limitations. First, we limited our search to English-speaking countries with health services comparable to New Zealand. While the range of programmes identified provide useful information for New Zealand and similar countries, there may be strategies to improve eye health in older adults in countries that are absent from this summary. Second, we accessed information from public-facing websites which meant the details we sought on service structure were not always available. To reduce missing information, where possible we verified our comprehensive search results with researchers familiar with the health system in that country. Third, due to the focus of our search on primary-level services for older adults, we may have missed publications that report on relevant services that are available at other levels and to a larger age range. Despite these limitations, we have found a broad range of relevant evidence that can be considered by countries wanting to improve access to eye care among older adults.In most of the high-income countries included in this review, eye care examinations are available for people aged ≥65 years for little or no out-of-pocket cost. New Zealand is a notable outlier, with no subsidised general eye health services for older adults. Future eye care policies in New Zealand or elsewhere should incorporate UHC in their design, by targeting services towards underserved population groups, and integrating eye health services within the current health system. This could be achieved via horizontal integration with other primary care services and vertical integration that allows shared-care between optometrists and tertiary care providers. Future research in this area could investigate how financial protection for the service user can encourage access to services.The review was conceptualised by JR, JE, and LG. Supervision was provided by JR and JE, and project administration performed by LG. Grey literature searching on government websites was performed by LG with assistance from SM, LK, and BT. IG constructed the search. Screening of abstracts and full-text reports was performed by LG, JR, JB, BT, SM, and SW. Data extraction from included reports was completed by LG, and confirmed by JB, BT, SM, and SW. Data curation was performed by LG. Data synthesis was performed by LG, LH, and JR. Figures were created by LH. LG and JR drafted the manuscript, and feedback was provided by all authors.I/we declare no competing interests.


In today's rapidly developing technological era, the technological revolution triggered by the rapid iteration of artificial intelligence and augmented reality has provided brand-new digital intelligent empowerment for orthopaedic clinical operation. Although traditional arthroscopy has been widely promoted globally due to its advantages such as minimally invasive, safety and early functional exercise, it still has deficiencies in precision and personalization. The assistance of artificial intelligence and augmented reality enables precise positioning and navigation in arthroscopic surgery, as well as personalized operations based on patient conditions, which lifts the objective limitations of traditional sports medicine surgery. The integration of artificial intelligence and augmented reality with orthopaedic arthroscopy surgery is still in infancy, even though there are still some insufficient to be solved, but its prospect is bright. With the leapfrog development of computer technology, artificial intelligence (AI) and augmented reality (AR) technologies have ceaselessly evolved and have been widely applied in various fields such as industry, education and health care. In recent years, as a pioneer in the medical industry exploring the application of high-tech, orthopaedics has taken many “first steps” in the blue ocean of precision medicine with the help of AI and AR technologies. The domestically developed Tianji® orthopaedic surgical AI robot  has becoArthroscopic surgery, which allows surgeons to extend their "eyes" and "hands" into the joint, has been widely performed on joints throughout the body, from large joints such as the hip and knee to small joints such as the interphalangeal joint, owing to its advantages of minimally invasive, safety and early functional exercise since the early twentieth century. Meanwhile, it has limitations such as limited operating space, limited field of view and insufficient surgical precision as is known to all . In receArtificial intelligence is abbreviated as AI, and its principle can be roughly summarized as combining a large amount of data, mighty computing power and intelligent algorithms to build models that solve specific problems, enabling programs to automatically learn potential patterns or features from the data, thus achieving a thinking process similar to humans . AugmentAI surgical systems typically consist of medical imaging module, tracking and positioning module, and display module . FirstlyAR surgical systems consist of three core components: virtual image or environment modelling, registration of the virtual environment with real space and display technology combining the virtual environment with the real world . The firP < 0.05), which indicates that AI assistance can improve the accuracy of anchor insertion, allowing even inexperienced surgeons to easily insert suture anchor along the correct direction, significantly improving the surgical outcomes of beginners and achieving high repeatability and reproducibility of anchor insertion.Jung et al.  comparedCritical shoulder angle (CSA) refers to the angle between the line connecting the upper and lower borders of the glenoid cavity and the line connecting the lower border of the glenoid cavity and the outer border of the acromion. Moor et al. –20 belieGuo et al.  exploredShiode et al.  adopted In elbow arthroscopic debridement, the identification and precise removal of impinging bone lesions present technical challenges. Shigi et al.  utilizedScaphoid injuries are extremely common in wrist injuries as well as have a high non-union rate. Statistics show a non-union rate of 40% in conservatively treated scaphoid fractures with cast fixation. Due to the small size, concealed location, complex and irregular three-dimensional morphology of the scaphoid, it is difficult to insert screws accurately during traditional internal fixation surgery, which can easily lead to complications such as joint cartilage wear and delayed or non-union fractures –29. The Professor Liu et al.  screenedJeung et al.  hold theCam morphology, which refers to a shape of the cam, is one of the important factors leading to hip impingement. The teams led by Nakamura et al.  and Kobaα and γ angles serving as anatomical parameters for femoral head sphericity. After identifying the impingement area, the improvement of range of motion (ROM) following virtual resection was predicted. The model of the preplanned bone volume resection was then transferred to the GUIDING STAR® VR surgical navigation system based on electromagnetic tracking for the purpose of precise surgical positioning and meticulous operation. This approach reduced surgery time and intraoperative fluoroscopy, while achieving near-perfect femoral head sphericity.Stražar et al.  considerAbe et al.  deemed tArthroscopic reconstruction of the cruciate ligament under guidance is one of the earliest arthroscopic procedures that have been assisted by AI technology, as is mainly used for the selection of reconstruction sites and bone tunnel directions. In 2006, Hong et al.  used a cThe disadvantage of knee arthroscopy is the lack of depth information and potential obstruction of the field of view. To address these issues, engineer Ma  and his Raposo et al.  have madThe team led by Xu et al.  retrospeDuring ankle arthrodesis under arthroscopic surgery, even experienced surgeons often spend a certain amount of time and multiple attempts to reach the predetermined target position while performing Kirschner wire drilling. To address this issue, Duan et al.  importedIn spite of significant advantages of AI and AR technologies over traditional arthroscopic surgery, there are still some unresolved issues range over: 1. there is an insufficient interdisciplinary collaboration between biomedicine and engineer in the development of AI and AR hardware and software, without fully utilizing the clinical expertise of specialists. 2. AI and AR surgical equipment development is still in the initial stage, whose accuracy, safety, portability and reliability need to be further improved. 3. System updates, algorithm upgrades and firmware updates regularly require network connectivity, posing risks of patient information leakage. It is necessary to consider establishing legal and ethical regulations for AI medical data . 4. The In recent years, AI and AR technologies have developed rapidly and have given rise to related surgical assistive devices, greatly promoting the advancement of orthopaedic arthroscopy. The application of AI- and AR-assisted technologies in orthopaedic arthroscopy allows for personalized surgical planning based on individual patient characteristics. This demonstrates the advantages of intelligent empowerment technology, personally summarized as the “3 FOURs” means “four increases, four reductions and four transformations”. The “four increases” contains more accurate intraoperative positioning, precise operation, closer approximation to anatomical reconstruction and reduction and improved surgical safety. The "four reductions" involves reduced surgical risks, shortened operative time, decreased intraoperative radiation and lowered risk of postoperative complications. The "four transformations" consists of visualization of blind spots, minimization of invasive conventional surgery, securitization of complex procedures and intelligentization of key operations.The transformational application of AI and AR in the healthcare industry has been identified as a key area for future development by numerous countries and regions. According to the latest annual report released by reputed research firm—ReportLinker, the global healthcare AI market is projected to grow from $14.6 billion in 2023 to $102.7 billion in 2028, with a compound annual growth rate of 47.6% during this period. With the rapid development of related technologies and the establishment of industry standards, it is believed that AI- and AR-assisted orthopaedic arthroscopy systems will gradually overcome the current limitations of insufficient intelligence, algorithmic bias, high technical barriers and expensive equipment. AI- and AR-assisted orthopaedic arthroscopic surgery is expected to achieve more precise and scientific personalized treatment in future operating rooms. Besides the increase in the autonomous decision-making capability of AI, precision, safety and reliability will simultaneously improve. AR device development will be more focused on technology that integrates closely with human organs, such as retina displays and human–machine symbiosis, hence which the performance and portable wearable devices will become research hot spots in the near future. With the combined incubation of global industry demand, financial support and policy driving, the field of AI- and AR-assisted intelligent arthroscopic surgery technology possesses immense development potential and the future looks promising.


Medical devices provide important infrastructural support in modern healthcare systems. However, in low- and middle-income countries (LMICs), inadequate maintenance and management of devices due to a shortage of healthcare personnel  has resulted in inefficient and weak healthcare systems. High-income countries, including Japan, have resolved these problems by developing human resources and technologies to maintain and manage these systems. In this paper, we discuss the possibility of mitigating these problems in LMICs through human resource development and technology, based on lessons from Japan’s experience. The problem of medical device management in LMICs stems from the fact that there are few professionals, such as BMEs, in charge of the management of medical devices and that clinical engineering departments in charge of device management have not been established. Since the 1980s, Japan has introduced a licensing system for BMEs, establishing operational guidelines to clarify their responsibilities within hospitals and using technology to utilize data and reduce workloads. Nevertheless, workload problems and high costs required to introduce computerized management systems persist. Moreover, it would be difficult to implement the same measures as those adopted in Japan in LMICs where there is an overwhelming shortage of medical personnel. It may be necessary to further reduce workloads for data entry and device management; use up-to-date, inexpensive, and user-friendly technology; and train non-BME personnel to operate and maintain equipment. High-income countries (HICs) have responded to this demand by training biomedical engineers (BMEs) in medical device management. However, low- and middle-income countries (LMICs), particularly those with limited resources , often face an overwhelming shortage of health personnel, not only doctors and nurses but also BMEs (2). Consequently, medical devices, (purchased or donated by overseas donors) are often left dysfunctional, unrepaired, or unaccounted for, owing to inadequate maintenance and management. This results in an inefficient and weak healthcare system (3).Advanced medical devices provide the foundation for modern medicine and need proper maintenance to function effectively (4). A study conducted in Nepal reported that access to spare parts was poor, BMEs had only diploma-level training, and about 14% of equipment was non-functional in hospitals without BMEs (5). In Uganda, a quarter of BMEs had a bachelor’s degree (the others had a diploma), 86% of the surveyed equipment had no manuals, and 37% of the equipment was non-functional (6). In Cambodia, where the authors have first-hand experiences, we observed piles of medical equipment in hospital warehouses that were out of order or awaiting maintenance, loss of medical equipment, and the inability to use dialyzers owing to a lack of budget for maintenance.For example, a study in Honduras reported that around 20% of medical equipment was deemed out of service in hospitals without appropriately trained BMEs Although Japan has an adequate medical device maintenance and management system today, it faced similar problems several decades ago: a lack of professionals, difficulties in managing a large number of devices, high costs of medical device management systems, and human error. Japan has gradually solved or at least alleviated these problems by introducing human resource development systems and modern technology, such as the use of databases to manage equipment. In this paper, we describe the problems associated with medical device maintenance and management in LMICs, discuss the history of system improvements in Japan, and examine the possibilities of using the latest technologies to mitigate these problems.(3). Improper maintenance and incorrect operation of medical equipment have been identified as the main causes of this widespread device malfunction (3). Without maintenance, parts needing regular replacement are likely to deteriorate. Medical personnel using such equipment often do not learn its proper use, thus causing them to malfunction. Medical equipment donated to LMICs from high-income countries (HICs) is often of various models, second-hand, lacking manuals, and hard to obtain spare parts for, which, in turn, further aggravate the situation.International medical cooperation projects provide a range and number of medical devices to LMICs as technology transfer, many of which become dysfunctional before their lifespan (1). While outsourcing may function as an optimal organizational model depending on the personnel and resource situation, it is difficult to manage all hospital devices or to ensure maintenance quality through outsourcing without an in-house professional who is responsible for the device (1). Additionally, hospital managers usually allocate low budgets for device management because they do not recognize its importance.Proper device maintenance and usage can prevent such malfunction and contribute to reliable clinical practice. Establishing clinical engineering departments in hospitals, designating personnel for medical device management, and making them responsible for periodic inspections, repairs, and education of medical personnel on proper device use help solve this problem. However, in LMICs, BMEs with medical device management expertise and hospitals with clinical engineering departments remain to be extremely scarce. Device management is often outsourced to external organizations (3). Despite efforts to increase BMEs in LMICs, well-trained engineers tend to quit their jobs for better paid positions  (2).Even in hospitals with clinical engineering departments, engineers/technicians, rather than BMEs, oversee this equipment. Such staff have difficulty maintaining device management quality because of their dearth of medical knowledge and skills to manage medical devices, lack of support from professional associations of BMEs for updating skills and developing their careers, and consequent poor visibility of their roles Insufficient resource input worsens the resource-demand mismatch in device management tasks that are complicated by the large number and range of devices. When a paper-based ledger or simple spreadsheet application is used, all recordkeeping tasks should be done manually, including registering devices and recording information of inspections, maintenance, and utilization, which yields a high workload. In such situations, some devices may easily forego these recording tasks, resulting in skipped regular maintenance or unknown utilization sites.(7). In the 1970s, when sophisticated devices like dialyzers and extracorporeal circulation machines were introduced in clinical practice, BMEs without formal training or licensing began operating and managing these devices. In 1988, the Japanese national licensing system started certifying BMEs as professionals in managing and operating medical devices.In Japan, a licensure system and a standardized educational curriculum to train clinical engineering professionals have been introduced to address this problem In the United States, the Association for the Advancement of Medical Instrumentation has been certifying clinical engineers since 1970s. Owing to the low reliability of medical devices in the 1970s in the United States, these personnel mainly specialized in the inspection and repair of devices. In Japan, the role of BMEs as technician was different as operating these devices is included in their responsibility.The Ministry of Health and Welfare issued “Guidelines for the practice of clinical engineering” in 1988 which governed BME practices, although the human resources environments were not sufficiently arranged to properly manage the devices in medical institutions. The Medical Service Act was amended in 2007 to meet the diversified and high demand for medical devices. It required that medical institutions appoint a medical device safety manager responsible for (1) training, (2) formulating and implementing device management plans, and (3) obtaining information and taking measures to improve medical device safety. The revised “Guidelines for the practice of clinical engineering 2010,” specify the methods to manage medical devices through ledgers and record detailed information such as serial numbers, registration numbers, and utilization history.(8). All device information  can be entered from tablet terminals in the hospital into the system ledger in real time. This allows single data entry even for inspections performed outside the clinical engineering department. Furthermore, creating a database for maintenance and inspection work records of registered devices has made quantitative evaluation of workload and costs possible. Nevertheless, management systems currently in use require manual data input when registering equipment or creating an electronic ledger, which can still result in input errors and a high workload. It also requires a big system implementation budget, which is a major barrier for small- and medium-sized hospitals.In terms of ledger management and detailed record entry for a large number and range of devices, BMEs have faced problems associated with manual input and the accompanying correction of numerous errors, which are time consuming. In Japan, recent introduction of computerized management systems has mitigated these issues. These systems enable centralized registration and device management, reducing the time required for device maintenance and input error correction (4). In Nepal, half as much out-of-service equipment was found in hospitals with BME compared to those without (5).We recommend developing human resources for medical device management, establishing clinical engineering departments in medical institutions, and disseminating operational support systems . The mos(2). Therefore, training and retraining of non-BME personnel currently in charge of medical device management should be strengthened. Additionally, medical device utilization education for all medical personnel has been identified to be crucial in LMICs as improper operation of medical devices can lead to their malfunction. However, providing training in terms of the use of hospital devices without BMEs becomes difficult. Since standardized training courses for medical device management are not readily available in LMICs (1), providing online educational content showing how to use, maintain, and repair medical devices (possibly through smartphones) would be deemed useful. Given the widespread use of smartphones in LMICs, we believe that online educational content accessible from smartphones may prove effective. For instance, a smartphone-based application that provides a step-by-step troubleshooting guide was shown to support BMEs in terms of repairing medical equipment in Ethiopia (9).Given the persisting human resource shortage worldwide, we cannot expect only BME personnel to fill these vacancies: it is reported that by 2030, there will be a shortage of 6.1 million healthcare workers in Africa and 4.7 million in Southeast Asia (7). The responsibilities of medical device management should include designating biomedical engineering department and personnel and developing guidelines that clearly define their roles. This is a universal lesson that can be applicable to all countries, although many LMICs have not yet established such supportive environments.Japan is an example of how human resource development alone is rather insufficient; thus, the creation of supportive environments is deemed crucial (1). This can be overcome with computerized management systems equipped with image recognition technologies using artificial intelligence to improve efficiency. Additionally, computerized system can easily output a list of equipment that is not functioning or requires maintenance. A study in Benin indicated that the introduction of a computerized system has allowed rapid identification and analysis of equipment failure as compared with a paper-based system (10). For example, a function to recognize and register medical devices from an image of their exterior and legal description label can make the device management system user-friendly by eliminating manual input. Such systems would also be beneficial for small- and medium-sized hospitals even in HICs. However, they should be made inexpensive to ensure that they can be introduced even in the poorest countries.Given the human resource shortage and lack of supportive environments in LMICs, improving operational efficiency is a critical issue. Further, this can possibly be facilitated through the use of new, but inexpensive and accessible technologies. Conventional device management systems, usually based on paper ledgers, have workload problems because of large inputs, which can further increase the burden on those in charge of device management, usually non-BME personnel in many LMICs In HICs, inadequate maintenance of medical devices in the past has caused malfunction and even harm to patients, but guidelines and legislations have promoted their safe use. Computerized systems have streamlined centralized management of medical devices and information collection. By contrast, insufficient human resources have impeded improvements in device management in LMICs. Advanced technologies from HICs may be deemed useful to solve this problem. However, existing systems still have entry errors, significant input labor, and high costs. Latest technologies like artificial intelligence for image recognition technology may solve such problems and help construct user-friendly systems. We also believe that providing online education regarding medical device management may fill the existing human resource gap in local healthcare systems.NoneDI is developing a medical device management system to start up a business supported by the Japan Science and Technology Agency. This work was supported by Japan Science and Technology Agency (the program of Start-up incubation from COre REsearch), Grant Number JPMJST2079.Not required because this is an opinion piece.All authors contributed to the conception of this paper, DI drafted the manuscript, and the other authors contributed to the revision of this manuscript. All authors approved the final version.


Background: Global policy to guide action on musculoskeletal (MSK) health is in a nascent phase. Lagging behind other non-communicable diseases (NCDs) there is currently little global policy to assist governments to develop national approaches to MSK health. Considering the importance of comparison and learning for global policy development, we aimed to perform a comparative analysis of national MSK policies to identify areas of innovation and draw common themes and principles that could guide MSK health policy.Methods: Multi-modal search strategy incorporating a systematic online search targeted at the 30 most populated nations; a call to networked experts; a specified question in a related eDelphi questionnaire; and snowballing methods. Extracted data were organised using an a priori framework adapted from the World Health Organization (WHO) Building Blocks and further inductive coding. Subsequently, texts were open coded and thematically analysed to derive specific sub-themes and principles underlying texts within each theme, serving as abstracted, transferable concepts for future global policy.Results: The search yielded 165 documents with 41 retained after removal of duplicates and exclusions. Only three documents were comprehensive national strategies addressing MSK health. The most common conditions addressed in the documents were pain (non-cancer), low back pain, occupational health, inflammatory conditions, and osteoarthritis. Across eight categories, we derived 47 sub-themes with transferable principles that could guide global policy for: service delivery; workforce; medicines and technologies; financing; data and information systems; leadership and governance; citizens, consumers and communities; and research and innovation.Conclusion: There are few examples of national strategic policy to address MSK health; however, many countries are moving towards this by documenting the burden of disease and developing policies for MSK services. This review found a breadth of principles that can add to this existing work and may be adopted to develop comprehensive system-wide MSK health approaches at national and global levels. Implications for policy makersDespite a high burden of disease, very few countries have a national strategy/policy to specifically address musculoskeletal (MSK) health. The development of such national-level policies is hindered by a lack of global policy, technical guidance and health performance indicators that prioritise premature mortality over long-term morbidity. This study has drawn together national and regional level policies addressing a range of MSK conditions to determine key themes and underlying principles to inform the foundations of global policy and advocate for its development. These principles can also be transferred and localised to underpin the development of health systems strengthening responses to address MSK health.  Implications for the public It is known that musculoskeletal (MSK) disorders, including conditions such as arthritis, fragility fractures, low back pain and neck pain are the leading cause of disability worldwide. The complex nature of these conditions requires coordinated models of care that include prevention, treatment and management. In this study we found that many countries are at the early stages of developing strategies to address these disorders or have no strategy at all. This study combined the learnings from many countries about the way they develop strategies and policies to assist in improving services to address these disorders. We then developed a series of content areas and principles that can be used to check, strengthen and monitor health systems to improve MSK health globally.1 Despite MSK health conditions being the leading cause of disability worldwide representing 17% of the global years lived with disability in 2019, global strategy and policy guidance lags behind that for other non-communicable diseases (NCDs), particularly in low resource settings.4 Global policy to guide action on MSK health is in a nascent phase. There is currently little global policy or strategic direction that serves as technical guidance to assist national governments in developing whole-of-system approaches to MSK health.6 Musculoskeletal (MSK) health refers to the integrity and function of the locomotor system, comprising muscles, bones, joints, nerves and associated connective tissues. MSK health is required for mobility, physical function, and dexterity across the life course. Impairments of the MSK system are typically associated with pain, reduced physical function and mobility, often leading to reduced social engagement  and quality of life. Encompassing a suite of more than 150 disorders MSK impairments comprise MSK conditions  pain manifesting in MSK structures  and MSK injury and trauma .7 The goal is the facilitation of policy learning; where unique experiences and local knowledge are observed, combined and analysed to provide a basis for globally-relevant learnings. The challenge is creating global policy that is grounded in local experience but interpreted into principles that find relevance and applicability across contexts. In recent years these development processes have been helpful for rapidly progressing global policy with respect to mental health,8 NCDs,9 antimicrobial resistance,10 tobacco control and alcohol and other drugs.13 Global policy serves to inform best-practice targets and provide guidance on the technical implementation of policies at local, national and regional levels. The development of global policy, however, evolves through a long process of agenda-setting, policy development, debate, legitimation and dissemination, with each stage entailing political, procedural and technical aspects.6 Despite overwhelming and increasing recognition of the burden of MSK disorders,14 recent research has identified gaps in the evidence base in terms of effective policy solutions.15 The purpose of this review is to extend this knowledge base and contribute to the feasibility and promise of global MSK policy. In acknowledging that the development of global policy is grounded in phases of policy comparison and learning from local experiences, we aimed to, (1) perform a comparative analysis of national MSK policies and develop a snapshot of current national MSK policy approaches and priorities; (2) collate themes covered from the combined content of existing national policies; and (3) draw key principles from the existing pool of local policies that can be used in policy learning. Despite the attributed high health and economic burden, MSK health receives little attention on the global stage, and has not featured prominently in recent global goal setting and consequently national policies on NCDs.18 The goal of this paper is to provide the detailed findings from our policy analysis to assist policy-makers at both national and international levels. We also aim to outline a detailed method for undertaking comparative policy content analysis for this purpose, in the hope that it can be useful for facilitating global policy learning for other vital health challenges. This study was undertaken as part of a three-phase project that included key informant interviews with MSK policy experts and a global eDelphi to determine prioritised components for a global strategy for improving MSK health.19 and used by Anderson et al,20 for policy mapping. We undertook a systematic comparative policy content analysis of MSK heath policy documents adapted from the framework proposed by Arksey and O’Malley,3 Policies needed to focus on MSK health generally, MSK pain, or any specific MSK condition. Documents were included where they described national, sub-national or multi-national level health policies for a MSK health condition(s) that were government-issued – or co-sponsored with government – labelled as ‘policy,’ ‘strategy,’ ‘framework,’ ‘action plan’ or similar, consistent with definitions used previously. We conducted a broad search for national MSK policies via four search methods. First, we performed a systematic online desktop search for national MSK policies and guidelines from the 30 most populous countries, informed by United Nations World Population Prospects 2019. A comprehensive search in English was performed for each country using Google as the search engine from July 1, 2020 to August 15, 2020. Authors JJY, SM, and SP used a combination of search terms  AND  along with the country name, to locate potential national policy documents. See 3 The request was deliberately broad to enable the collation of policies that could fit any of the potential criteria for inclusion. Second, we identified policy documents via requests to the Global Alliance for Musculoskeletal Health International Coordinating Council members and policy researchers (expert round), including those with access to raw data from an earlier integrated NCD policy review of OECD (Organisation for Economic Co-operation and Development) member states.17 As part of the eDelphi, panel members were asked to identify national policies for MSK health in their country of residence. The question was posed in an eDelphi survey administered between October 2 and November 8, 2020. Of the 674 respondents to the original eDelphi, which included stakeholders with a policy, clinical, health services or lived experience lens, 22 answered this purposive question, providing links to policy documents. This step represented a secondary data analysis of an existing dataset for which Human Research Ethics Committee approval had been granted by Curtin University, Australia, in 2020 (HRE2020-0183). Third, we extracted data from a related project that used an eDelphi method to collect information from the global MSK community on systems strengthening opportunities and priorities.https://www.onlinedoctranslator.com/en/) as previously.3 Fourth, we examined all documents for reference to additional MSK policy documents following snowballing methods. All documents that were not originally in English or German were translated using an online document translator  government-issued; published by official government departments, or explicitly endorsed by government departments as representing the policy of a specified jurisdiction; (2) targeted at the population-level improvement in MSK health; or containing a substantial sections/chapters dedicated to MSK health  or any of the following clinically meaningful categories: non-cancer pain conditions ; osteoarthritis; injury , excluding trauma; and auto-immune inflammatory conditions with MSK manifestations; (3) was the current version (if regularly updated) with a publication/coverage date not older than 2010; and (4) contains jurisdiction-wide strategies, action plans or system-level models of care. We did not disaggregate classification categories for MSK conditions based on International Classification of Diseases 11th Revision (ICD-11), since many policies pre-dated this classification system and did not describe conditions at the granular level of ICD classification. Rather, we took a pragmatic approach to meaningfully group disease/condition classifications that aligned with classification approaches used across the policies. We defined a system-level model of care as a document including a care pathway that includes prevention, diagnosis, treatment, rehabilitation and recovery, and identified the roles played by different providers within the pathways, their responsibilities, and information on how the different providers connect within the system. Documents that were primarily targeting related aspects of health, such as NCDs, population health, occupational health and injuries were only included if they contained a substantial component addressing the above criteria. Authors CHS and SP performed a review of documents for inclusion/exclusion, with verification of those meeting inclusion criteria undertaken by JJY and AMB. All excluded documents were reassessed independently, with discordance resolved through consensus meetings. Authors SP and CHS collated and prepared all documents for extraction. Two data extraction templates were developed in Excel, one for descriptive level information about the documents and a second for the comparative content analysis and abstraction of principles. Spreadsheets were used for a comparative policy content analysis, undertaken in three steps: (1) categorisation, (2) descriptive thematic analysis, and (3) interpretative analysis. Authors CHS and SP read all policy documents independently and extracted high-level data about each document including, country of origin, jurisdiction, publisher, date, and target condition(s). We then identified and extracted the overarching targets, goals and objectives specified in each policy document and inductively open-coded these texts to identify themes. Open coding was undertaken manually by extracting excerpts for collation using Excel, with regularly review, consolidation and merging.a priori, initially based on World Health Organization (WHO) Building Block elements, given the universal acceptance and familiarity of this model with policy-makers addressing health systems strengthening. We assessed the construct validity and ‘fit’ of this model through a round of inductive coding of 6 policy documents from the yield that appeared in first order through the original search. Following this inductive coding, we added two further categories to the WHO Building Blocks, including “Citizens, Consumers and Communities” and “Research and Innovation.” These categories aligned intuitively with the themes identified in our earlier qualitative research which formed the framework for the ‘Empirically derived logic model for a global strategy for MSK health.’17 These categories were used to deductively code the remainder of the texts. CHS and SP were each allocated different analysis categories and extracted texts that were open-coded to determine the number and type of sub-themes included in the texts within each category. Definitional boundaries around each sub-theme were then agreed upon, in conference between SP and CHS, and reported for discussion to all authors. Sub-themes were refined, expanded or merged as necessary. We identified analysis categories 17 Principles were developed to represent the common underlying purpose of a policy action for achieving policy goals. Abstracted principles were presented at working group and project group meetings and discussed with all authors and refined for internal validity and consistency purposes. To extract key principles underlying the meaning of texts, we read, discussed and interpreted underlying meanings from across multiple texts within each category, reflecting on position, overarching goals, common linguistic patterns and purpose of texts.23 Belgium,24 Canada,27 Chile,28 Columbia,29 Denmark,30 Finland,31 France,33 Hungary,34 Italy,35 Ireland,36 New Zealand,39 Norway,41 Portugal,42 Republic of Korea,43 Spain,44 Switzerland,46 Turkey,47 the United Kingdom (England),50 the United Kingdom (Scotland),52 the United Kingdom ,53 the United States58; and two multi-national regions .We did not identify any eligible documents from LMICs, however, a number of MSK-relevant documents from LMICs were identified from the search  see  than polarch see . Of the  Policies collated via each method, are summarized in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-aligned flow chart . We incl The documents we analysed varied greatly in form and purpose see . Documen Although the documents varied in form and even target condition, there was a commonality in purpose across most documents to improve understanding and awareness of the conditions they addressed and reduce disease burden.61 Of those documents in the preceding list, only 3 were comprehensive national MSK policies addressing all parts of the health system  3).49 A range of MSK conditions were addressed in policies, while very few documents addressed MSK conditions in their full breadth . Only 9 45 Other documents were either cross-jurisdictional, or only addressed parts of the health system . Three countries  appeared to have a series of policies that each addressed different MSK conditions, which combined could be interpreted as entailing a comprehensive MSK policy response. In our pool, six documents were broad national health plans or national NCD plan with substantial component on addressing MSK health .47 contained a substantial focus on different conditions, compared with all other policy documents. While it did address low back pain, osteoarthritis and inflammatory rheumatic conditions, it also dedicated equal specific attention to familial Mediterranean fever and Behçet’s disease, indicating the country-specific burden of those conditions. The most commonly addressed MSK conditions across all policies were pain , osteoarthritis (13 policies) occupational health (12 policies) and low back pain (12 policies) . The MSK Despite the variety in document formats and target conditions, there was a surprising consistency in the themes present in policy targets and goals. Almost all policies aimed to reduce the target burden of the diseases, frequently citing the relatively little attention given to MSK conditions in the health system compared to the known burden. Other key themes are listed in 1. Reduce burden  Measuring and reducing number of people living with MSK conditions.2. Improve access to services  Understanding service availability and moving towards an increased number of citizens that can access MSK services when they are needed.3. Improve patient outcomes  Understanding and improving MSK health following diagnosis.4. Knowledge, awareness and outcomes  Improving knowledge of MSK conditions, how they can be prevented and when to take action among the general population as well as health care providers.5. Improve quality of care  Understanding and improving the quality of MSK services.6. Target priority populations  Understanding who is at risk of MSK disorders and establishing systems to reach those populations. 7. Research and investment Funding to improve knowledge and understanding of MSK prevention and treatment.8. Cost-efficiency  Calculating the broader costs of MSK disorders and the benefits of early detection and treatment.----------------- Abbreviation: MSK, musculoskeletal. Across the 8 policy categories, we inductively derived 47 sub-themes.  The most comprehensively addressed major category across the policy documents was MSK health services. This included the range and types of services needed to promote MSK health, and how these services could be delivered. Many documents included texts that emphasized MSK health impairment as a collection of conditions that impact health and wellbeing over long periods of life and requires multi-disciplinary, coordinated services, individual-level assessment and tailored treatment. We drew a total of 9 sub-themes and transferable principles from the documents as they relate to service delivery. The second most broadly addressed major category in the documents was centred around the health workforce. This is unsurprising considering the close connection between health services and human resources required for care delivery. Furthermore, with MSK being one of the most common reasons people seek primary care, and the recognized lack of primary care availability in many parts of the world by their own governments, particularly in underserved communities, this makes sense to be one of the more common themes. The need for formal and continuing education, as well as workforce planning and support tools were the most frequent sub-themes. In total, we found 8 distinct sub-themes and transferable principles with respect to the MSK health workforce. The next two most broadly raised categories in the texts related to “financing” and “medicines and technologies.” The place of pharmacological and biological treatment in multidisciplinary care, medical education and knowledge for citizens; and the appropriate use, in particular concerning opioid medications, dominated texts around medicines. We determined 6 distinct sub-themes concerning medicines and technologies. Given the prevalence of texts around the appropriate use of opioid medication, we determined this warranted a separate distinct sub-theme. There were very few documents that covered in-depth how MSK services, models of care or other activities addressing MSK health should be financed. We relied on smaller text excerpts from the breadth of documents to draw 6 distinct sub-themes and abstracted principles related to this category. Where financing was discussed, texts focused on ensuring that systems of risk pooling, public funding, safety nets, and reducing out-of-pocket costs should be in place for enabling affordable access to health services. Almost all documents contained policy statements concerning data monitoring and information systems; with a considerable number of common themes and underlying principles. Ensuring that the quality of services and outcomes are measured, and building systems to collate data through standardized processes were key features in most policies. We determined 5 distinct sub-themes and transferable principles related to data and monitoring. We also found 5 sub-themes in texts related to leadership and governance, although this was not commonly addressed specifically as an area for action. Rather we found a reference to the roles and responsibilities allocated to organisations and individuals within the system, as well as the decision-making structures that have been, or will be, established to govern MSK health. We also found a single reference to the roles that non-governmental organisations play in MSK health, particularly in agenda-setting and as issue-area champions. Finally, we drew 4 distinct sub-themes in each of the inductively coded analysis categories. With respect to citizens, consumers and communities, most policies contained strategies or goals to educate and empower citizens with better knowledge of MSK health for both prevention and treatment. Policies also focused on reaching priority populations, either through screening, planning or by developing culturally sensitive models of care. Policy documents that were comprehensive strategies targeting whole-of-systems approaches included calls for increased research and innovation for improving MSK health. This included strategies to ensure investment in research was commensurate with the burden and setting research priorities; for example, by means of establishing high-level research systems and funding mechanisms. Notably, only a minority of policies addressed a life course approach to MSK health or mentioned MSK health in children or younger people. Polices Canada, the United Kingdom, Australia, and France discussed childhood conditions including juvenile arthritis, bone health and pain care, while a life course approach was recommended in policies from Canada, Switzerland, and Australia. Our policy content analysis has found a paucity of policy documents that address the breadth of MSK conditions under one overarching strategy. Critically, very few documents brought together all major policy themes including the WHO Health System Building Blocks, as well as policy themes related to ‘research and innovation,’ and ‘citizens, consumers and communities.’ These findings underline the importance of creating tools and resources to facilitate MSK policy learning and sharing from the breadth of many policy examples, rather than the depth of a few.62 This approach has been used to better understand policy and global priority evolution related to NCDs generally.63 However, even among these few national-level strategies, the variation in format and nature and depth of content, indicates that we are still firmly in a phase of sharing policy experiences and tools, with a focus on engaging in policy learning, rather than supporting widespread implementation and monitoring. Global technical advice to support the establishment of MSK policy has been lacking but could contribute to increased efficiency in the development of MSK policies at the national level, and indeed, an empirically-derived strategic framework has been developed recently for this purpose, as well as more nuanced and context-specific recommendations for low- and middle-income settings.18 In the few countries where a system-wide overarching policy and strategy to guide MSK health has been developed, such as England, Turkey, and Switzerland, this is likely to have been the product of particular policy entrepreneurship and a facilitating policy context. We propose further research into the history of the development of these policies to determine facilitating factors would be important to understand historical context and to inform prospective policy evolution and evaluation.64 Indeed, as the burden attributed to MSK health impairment becomes more widely recognised and countries move towards arresting this burden, as recommended by Global Burden of Disease findings,65 there will be an increasing need to identify extant and transferable policy solutions and foci. These data will be relevant not only to individual nations but also global health agencies such as the WHO, where programmatic activity related to MSK health is emerging. The combination of the evidence of burden, with examples of how strategies can be formulated and implemented can be used to pry open the policy window. This has become even more relevant due to both direct and indirect effects of the coronavirus disease 2019 (COVID-19) pandemic on MSK health – from the complex interlinkages between COVID-19, social circumstances and MSK pain; through the changing policy focus on local and global health authorities. With the COVID-19 pandemic drawing policy attention away from chronic conditions, including MSK health over the past 3 years, strong evidence and feasible policy solution are even more important tools in the tightened space of agenda setting.66 There are opportunities for policy entrepreneurs, from government, industry or civil society sectors to draw on the principles itemized in this review to drive MSK policy evolution locally. This is especially the case in countries that have already invested in monitoring and recording of MSK burden – and we found many examples of this as an incidental finding in our document collection – as well as countries where population health monitoring of MSK health is absent or emerging. Patterns and trends in the documents we analysed indicate that there may be several pathways that can be taken in the development of MSK policy at a country level.67 For example, several countries  have built a series of policies targeting MSK specific conditions, rather than a single overarching MSK strategy. This may be a more feasible approach to developing MSK policy than a single strategy in some settings; while in others an integrated single strategy may be more resource efficient. Another example is dispersing responsibility and authority for policy development. In some countries, notably Australia and, Canada, MSK policies were also authored by non-government organizations  and research institute with expertise in specific MSK conditions; with a mix of funding, endorsement or co-production with government. The relationship between peak bodies, national research institutes and governments differs from country to country but could also provide important resources and capacity in the development of new policy and system strategies.68 As mentioned above, based on our operational definition, we identified a far greater number of clinical guidelines for MSK health, or reports on MSK disease burden, than we did policy documents. This is despite our search not targeting this type of document specifically. Clinical guidelines may be a useful foundation for the further development of MSK policy in more countries around the world, including LMICs, as it signals the challenges and size of evidence-practice gaps at service and clinical levels. Measuring and understanding the burden of disease and having sound best practice person-centred care are the foundations of understanding service and workforce needs and building the resources for system level strategies and MSK models of care.4 Importantly, similar burden of disease documents were also identified from LMICs, potentially pointing to emergent activity for health systems strengthening in these countries, despite a recognised lack of local MSK population health surveillance.69 Most documents were also dominated by goals, targets, service provision and strengthening the workforce, with considerably less focus on governance, technologies and workforce and only a few documents included aspects of monitoring, innovation and community engagement. Apart from a few, we also noted that most policies did not frame discussions around a life course approach or address MSK health in children. This is unusual for policies addressing an NCD where a life course approach is typically a guiding principle, the strong association between disease expression and life course behaviours, and that MSK impairments are common in children. Across all major themes, there is considerable potential for further policy learning and related system strengthening contextualised for country-specific purposes. This finding likely reflects an existing strong research network around disease surveillance and monitoring, including the MSK burden and the ensuing strong evidence base.49 and two at the international level.61 While we identified many national clinical guidelines and reports of national MSK disease burden, there were few system-level policies, strategies or action plans. This suggests that while there has been positive progress in recognizing burden of disease and articulating approaches for clinical management, system-level strengthening is rarely purposively and strategically developed in current policy. We found only 3 documents that could be considered system-wide strategy or policy for MSK health conditions at the national level17 This close alignment between independently collected and analysed data validates the concurrent and construct validity of our findings. Importantly, the priorities and strategies articulated by key informants and the global MSK community sampled in our aligned work18 are also reflected closely in national policy documents, suggesting an evolution of policy that is reflective of community expectations. Collectively, the pool of documents contained a breadth of key issues, themes and principles. The content analysis of the policies triangulated closely with independently collected data from aligned mixed-methods research in our broader program of work on empirically deriving a co-designed health systems strengthening response for MSK health.17 This comparative policy analysis was the first to provide a comprehensive global search through multiple data collection steps, including networks facilitating the collection of documents in multiple languages combined with a global. Our refinement of categories enabled comparisons across a wide range of document types; enabling collation, analysis and extraction of principles in a policy field where complete, comprehensive national strategies were almost non-existent. The use of interpretive analysis methods enabled the extraction of principles that can be interpreted and applied across contexts, while maintaining the policy learning from original local country-level experience. This work was also strengthened by parallel work undertaken within a wider project that included eDelphi expert panel views on key themes and principles thereby enabling concurrent validation. We excluded documents addressing road traffic injury and injury through violent trauma and acknowledge these policy areas as critical for MSK health. We only included policy documents addressing NCDs if there was explicit and substantial inclusion of MSK policy, strategy, or targets, and acknowledge the close interplay between other NCDs and MSK health, and the common shared risk factors. While our initial web-based search focused on the 30 most populous countries; and was then supplemented by an expert round and responses to an e-Delphi with participants from 72 countries, it is possible that our search failed to uncover all relevant documents, particularly those from less populated countries. The development and use of national policies for MSK health is still in its infancy. Very few national policies covered multiple MSK conditions; nor did many documents in our analysis cover all health system building blocks or supplementary categories of MSK policy interest. However, the collective pool of documents contained a breadth of key issues, themes and principles and collated and grouped this content covered key principles and abstract key principles that can helpfully guide policy sharing and learning. Future global guidance to assist countries to develop their own MSK policies and strategies can draw on implemented principles across the health system building blocks, including service delivery, workforce, medicines and technologies, financing, data and information systems, and governance. Existing policy also embody underlying principles of action with respect to citizens, consumers and communities including public education and awareness and working in partnerships. These collective key issues, themes and principles may be helpful in informing the development of a global policy and technical guidance on action to improve MSK health that is grounded in local experiences. This article reports on documentary analysis as well as secondary data analysis of an existing survey dataset for which Human Research Ethics Committee approval had been granted by Curtin University, Australia, in 2020 (HRE2020- 0183). Authors declare that they have no competing interests. CHS and AMB conceptualised the study. AMB, DKG, JJY, SS, CHS, and SJ developed and performed search strategies. CHS and SP undertook data extraction and analysis and AMB and JJY performed verifications. AMB, DKG, HS, and LM contributed additional refinement of definitions and inclusions/exclusions. All authors reviewed the results and participated in analytical cycles. CHS lead the writing of the manuscript together with SP and AMB. All authors contributed to the manuscript including final review. This project was funded by a grant awarded by the Bone and Joint Decade Foundation with additional funding provided by Curtin University, Australia, and guided by an international external steering group of experts in the field of musculoskeletal health.Supplementary file 1. Search Strategy.Click here for additional data file.


Due to interconnected structural determinants including low maternal health knowledge, economic marginalization, and remoteness from low-capacity health centers, ethnic minority women in remote areas of Vietnam face severe maternal, newborn, and child health (MNCH) inequities. As ethnic minorities represent 15% of the Vietnamese population, these disparities are significant. mMOM—a pilot mobile health  intervention using SMS text messaging to improve MNCH outcomes among ethnic minority women in northern Vietnam—was implemented from 2013-2016 with promising results. Despite mMOM’s findings, exacerbated MNCH inequities, and digital health becoming more salient amid COVID-19, mHealth has not yet been scaled to address MNCH among ethnic minority women in Vietnam.qualitatively through adding COVID-19–related MNCH guidance and novel technological components  and quantitatively through broadening the geographical area to reach exponentially more participants, within the evolving COVID-19 context.We describe the protocol for adapting, expanding, and exponentially scaling the mMOM intervention dMOM will be conducted in 4 phases. (1) Drawing on a review of international literature and government guidelines on MNCH amid COVID-19, mMOM project components will be updated to respond to COVID-19 and expanded to include a mobile app and artificial intelligence chatbots to more deeply engage participants. (2) Using an intersectionality lens and participatory action research approach, a scoping study and rapid ethnographic fieldwork will explore ethnic minority women’s unmet MNCH needs; acceptability and accessibility of digital health; technical capacity of commune health centers; gendered power dynamics and cultural, geographical, and social determinants impacting health outcomes; and multilevel impacts of COVID-19. Findings will be applied to further refine the intervention. (3) dMOM will be implemented and incrementally scaled across 71 project communes. (4) dMOM will be evaluated to assess whether SMS text messaging or mobile app delivery engenders better MNCH outcomes among ethnic minority women. The documentation of lessons learned and dMOM models will be shared with Vietnam’s Ministry of Health for adoption and further scaling up.The dMOM study was funded by the International Development Research Centre (IDRC) in November 2021, cofacilitated by the Ministry of Health, and is being coimplemented by provincial health departments in 2 mountainous provinces. Phase 1 was initiated in May 2022, and phase 2 is planned to begin in December 2022. The study is expected to be complete in June 2025.dMOM research outcomes will generate important empirical evidence on the effectiveness of leveraging digital health to address intractable MNCH inequities among ethnic minority women in low-resource settings in Vietnam and provide critical information on the processes of adapting mHealth interventions to respond to COVID-19 and future pandemics. Finally, dMOM activities, models, and findings will inform a national intervention led by the Ministry of Health.PRR1-10.2196/44720 Despite Vietnam’s remarkable progress in improving maternal, newborn, and child health (MNCH) outcomes during the era of the Millennium Development Goals, increasing evidence demonstrates that ethnic minority communities living in remote areas have not benefited equally from this progress—MNCH inequities between the Kinh (ethnic majority group in Vietnam) and ethnic minority communities have in fact widened -3. ThereAmong ethnic minority populations, 75% live in 13 provinces in the northern mountain and central highlands regions, which are known for high concentrations of poverty ,5. An anShaped by decades of structural deprivation and social exclusion, specific factors contributing to the profound MNCH disparities faced by ethnic minority populations are limited access to education, economic marginalization, remote and rural residence , limiTo address MNCH disparities among ethnic minority women in remote areas, the “mMOM” project (2013-2016) piloted and evaluated a low-cost mobile health  intervention in Thai Nguyen province, northern Vietnam. mMOM was developed by the Institute for Population, Health and Development in Hanoi (PHAD) and Simon Fraser University (SFU) in Vancouver and funded by the International Development Research Centre (IDRC) from Canada. The project aimed to determine whether integrated use of an electronic health information system, low-cost mobile technology, a user-provider interaction model, and behavior change communication (BCC) via SMS text messaging could improve access to MNCH information and services among perinatal ethnic minority women and their families. Developed using templates from the Mobile Alliance for Maternal Health  and adapBetween 2013-2016, the mMOM intervention built and implemented an integrated mHealth platform, which sent timely IEC, reminder, and BCC text messages to 961 participating women in 8 communes in Thai Nguyen toward stimulating ethnic minority women’s demand for quality perinatal care. In midterm and final qualitative evaluations assessing mMOM’s acceptability and impact involving over 60 participants, women expressed satisfaction with the intervention’s quality, timeliness, and convenience, and health workers reported increased efﬁciency and quality of care . The mMODespite these findings and mMOM’s promise in promoting MNCH among structurally marginalized ethnic minority women, the intervention’s impacts were limited due its pilot nature and implementation in only 8 communes in a single province in Vietnam. Implementing an adapted and scaled version of the intervention across a broader geographic area, thus reaching more participants, is necessary to generate robust empirical evidence on the potential of mHealth to improve MNCH health equity in Vietnam and to build models that can be replicated and utilized for country-level mHealth projects.Despite the high penetration of mobile services in Vietnam (143 mobile subscriptions for every 100 people in 2020 ), the apCurrent gaps in mHealth research and utilization in Vietnam were rendered even more salient by COVID-19, which exacerbated existing inequities in health access and outcomes globally—particularly for communities already marginalized from health systems including ethnic minority populations, women, immigrants, refugees, and people in rural/remote areas -20. The qualitatively through the addition of COVID-19–related MNCH guidance and novel technological components  and quantitatively through its expansion over a broader geographical area to reach exponentially more participants. This protocol details the adaptation of the 2013-2016 mMOM intervention (SMS text messaging intervention reaching 8 communes in 1 district with 900 participants) to the dMOM intervention , within the unique pandemic context.Despite mMOM highlighting the potential of mHealth to promote MNCH among ethnic minority women in Vietnam, existing severe MNCH inequities among ethnic minority women, and digital health approaches becoming even more salient amid COVID-19, mHealth has not yet been leveraged or scaled to address MNCH in Vietnam. Thus, the objective of this paper is to describe the protocol for adapting, expanding, and exponentially scaling the mMOM intervention The dMOM project will be conducted in 4 phases: (1) updating, adapting, and expanding the mMOM intervention; (2) scoping study and rapid ethnographic fieldwork; (3) dMOM intervention implementation and incremental scaling; and (4) intervention evaluation and documentation of lessons learned. A series of smaller studies conducted through project phases 2-4 will gather evidence on different dMOM facets and models to inform replication and scaling at the country level.For phase 1, the mMOM project components will be (1) updated and adapted to respond to COVID-19 and its impacts and (2) expanded to include a mobile app and AI chatbots to more deeply engage participants. To adapt the intervention to serve perinatal women’s unique vulnerabilities and needs through the pandemic and beyond, a literature review of publications on MNCH amid COVID-19 will be undertaken by a multidisciplinary team. Institutional and governmental guidelines on pregnancy during COVID-19 as well as peer-reviewed manuscripts, conference abstracts, and case studies will be screened and reviewed, with relevant information extracted to inform, revise, and update the original mMOM intervention content. As a result, the IEC, reminder, and BCC messages in the SMS text messaging packages and the mobile app content will include critical information  to support healthy pregnancies and newborn care during the pandemic and postpandemic contexts and ensure that the dMOM intervention reflects international and country-level institutional guidance on MNCH during COVID-19. Particular attention will be paid to emerging evidence and institutional guidelines surrounding COVID-19, mental health, and postpartum depression among perinatal women ,22,27. FTo offer participants a more nuanced, customizable, and lower-cost avenue for engaging with the intervention, the dMOM app will be developed in partnership with computing science consultants to leverage smartphone capabilities and provide a more complex variety of functions to improve MNCH access and health outcomes among perinatal ethnic minority women. Similar to the mMOM SMS text messaging intervention, the dMOM mobile app will provide person-centered, tailored, and timely information according to women’s specific stage of pregnancy/new motherhood. However, the dMOM app will feature more information per message/interaction (messages will not be subject to SMS text messaging character limits); photo, audio, and video messages to increase engagement with participants; and audio-photo messages as an important accessibility consideration for women with limited literacy and/or disabilities. The dMOM app also will reduce the cost of project participation  and support health promotion activities among village health workers through the digitalization of traditional, familiar, and culturally acceptable IEC materials  and their inclusion in the app to reach a broader audience.An assessment of how AI chatbots  can be leveraged in dMOM to promote MNCH care and support project scalability and sustainability will be conducted through a literature review and consultation with AI experts who are members of the research team, and relevant components of existing uses of AI for MNCH will be extracted and adapted for use in the dMOM app. AI chatbots will be developed and piloted, with information collected to train AI models to correct SMS text messages, assess MNCH risks, and provide advice that is responsive to women’s inquiries and enables them to quickly act in a health emergency situation requiring expertise from a health professional. dMOM will utilize the richer technological capacities offered by a mobile app and AI chatbots and evaluate their effectiveness in improving the quality of MNCH BCC.For phase 2, a broad scoping study using mixed methods and rapid ethnographic fieldwork will be conducted at the project outset to involve key stakeholders in the intervention’s codevelopment from its initial stages. The scoping study will begin with preliminary engagement meetings with the Ministry of Health, provincial and district health departments, women’s health service providers, community advocacy groups for women and ethnic minority populations, local authorities, village chiefs, and individual women to ensure that the intervention is shaped by key institutional and community voices.The scoping study will apply mixed research methods including in-depth interviews; focus group discussions led by trained project staff; and survey questionnaires with pregnant and postpartum ethnic minority women, family members, and health workers at diverse levels. It will assess (1) unmet MNCH needs among ethnic minority women and their newborns; (2) roles of husbands, family members, and broader community members as well as their gendered power dynamics impacting MNCH care; (3) existing MNCH communication mechanisms, gaps, and MNCH health service utilization; (4) the extent of mobile phone use of ethnic minority women in the new districts in Thai Nguyen and Dien Bien provinces  and social and cultural factors impacting phone ownership and usage; (5) literacy and language barriers to receiving SMS text messages and using apps; (6) technical capacity of commune health workers and health centers surrounding mHealth utilization and technical constraints ; and (7) long-term, multilevel impacts of COVID-19 on MNCH access and outcomes, ethnic minority health, and broader socioeconomic status of remote communities. The study will also include a rapid ethnographic review of gendered determinants; ethnicity-based barriers; and other key social, cultural, economic, and political factors that may hinder or facilitate project outcomes, as well as in-depth interviews with other potential stakeholders  at district and provincial levels to explore partnership opportunities and policy constraints to project implementation and scaling up.Within the broader scoping study, 2 smaller intersectionality and digital health uptake studies will take place. The intersectionality study will explore ethnicity, gendered power relationships, geographical and social distancing, and other interconnected determinants of MNCH outcomes and mHealth applicability, not in isolation but how they interact dynamically with one another to shape severe health disparities among ethnic minority women in northern Vietnam ,29, partTrained commune health staff will obtain oral informed consent from focus group and in-depth interview participants prior to their participation in the scoping study. The study has been approved by an institutional review board at PHAD, which is registered with and uses ethical protocols of the Office for Human Research Protections of the United States Department of Health and Human Services (2023/PHAD-DMOM-01). Project data are subject to privacy and security protocols of the Office for Human Research Protections. Participants in the focus groups and in-depth interviews will be remunerated 100,000 Vietnamese Dong (~US $4.20) for their expertise, time, and travel.The scoping study’s findings will be used to refine the scope of work, project activities , and timeline in alignment with implementation capacities at the village and commune health center levels. The study’s involvement of stakeholders in shaping the dMOM intervention from the project outset is expected to increase their interaction with the project and empower and strengthen ethnic minority women and their families’ increased engagement in MNCH care . It willUpon completion of the first 2 study phases , for phase 3, the dMOM intervention will be implemented and incrementally scaled. As the project plan will be informed by, updated, and revised based on the scoping study to ensure the intervention’s accessibility and acceptability to the target population, the below protocol represents only a general guideline. Implementation will be initiated with project staff conducting a training-of-trainers activity to (1) train commune health workers as dMOM project implementors including on health management information system operations and dMOM integration and (2) enable them to train village health workers in the intervention’s routine operation . First, the updated SMS text messaging intervention will be implemented in Dinh Hoa, Thai Nguyen  to initiate the intervention and troubleshoot potential challenges related to human resources, project staff training, and health management information system operation. This initial implementation period limited within 1 district will also provide critical ongoing engagement and continuity of the intervention while the dMOM app is being developed and ease the introduction of the dMOM app. Subsequently, the dMOM mobile app will be piloted in Dinh Hoa and 2 new districts in Thai Nguyen province (one remote and one urban district—Vo Nhai district and Song Cong city) and 2 districts (Muong Cha district and Dien Bien Phu city) within the even more remote and mountainous Dien Bien province, where ethnic minorities constitute 82.6% of the population . To compFor phase 4, dMOM will be evaluated to assess whether SMS text messaging delivery or mobile app delivery engenders the most improved MNCH health-seeking behaviors and outcomes among ethnic minority women. The dMOM evaluation will involve data collection via multiple channels. Demographic and socioeconomic data will be collected by commune health staff at the intervention onset intervention when participants are registered. Monitoring and evaluation indicators on health-seeking behaviors and pregnancy and birth outcomes will be collected via automatic individual data collection and questions posed to participants within the dMOM app. The SMS text messaging and app systems will also be mined for back-end information regarding user statistics. Finally, qualitative in-depth interviews and quantitative survey questionnaires will be administered online or in-person, depending on COVID-19–related factors and feasibility. Data from these sources will be analyzed using thematic analysis in NVivo for qualitative data and regression models in Stata (StataCorp) or R  for quantitative data and triangulated to examine how they expand upon one another and explore both intended and potential unexpected outcomes of the intervention, aiming to improve the credibility, integrity, and utility  of the rDuring the evaluation phase, a smaller scalability study will draw on the data collected as part of all dMOM components and assess different scenarios associated with several scaling-up strategies. This study will identify factors that may facilitate or constrain effective and ethical scaling of dMOM models and will investigate the potential of the private sector as a financing mechanism to sustain a broader mHealth intervention for MNCH.The dMOM study was funded by the IDRC in November 2021, cofacilitated by the Ministry of Health, and is being coimplemented by provincial health departments in the 2 mountainous provinces of Thai Nguyen and Dien Bien. The intervention received approval from and completed a memorandum of understanding with Vietnam’s Ministry of Health in May 2022. Phase 1  was initiated in May 2022, and phase 2 (scoping study and rapid ethnographic fieldwork) is planned for December 2022. The entire study is expected to be complete at the end of June 2025.qualitatively through the addition of novel technological components ; quantitatively through its expansion over a broader geographical area; and in its scope through deep, ongoing engagement with the Ministry of Health toward the replication of the dMOM models at the country level. This protocol details the expansion of the pilot mMOM SMS text messaging intervention in 8 communes with 900 participants to an SMS text messaging, mobile app, and AI intervention in 71 communes reaching 9000+ participants.This paper describes the protocol for adapting and exponentially scaling the mMOM intervention This research will contribute to bridging current gaps in mHealth research and utilization in Vietnam, which were rendered even more salient by COVID-19 and exacerbated existing inequities in health access particularly for ethnic minority populations and people in rural/remote areas globally -20. Our Although this study will be conducted within a broader geographical area than the pilot mMOM study, it will only involve ethnic minority populations who are in contact with the health system, as commune health workers will only recruit women who present at the health center. As such, it is possible that the project may exclude members of the target population who are not known to health workers due to extremely remote residence, poverty, or language barriers.The outcomes and findings of the dMOM study will be relevant to future research on the applicability and use of mHealth and AI for MNCH for ethnic minority communities and for improved MNCH and health-seeking behaviors among other structurally marginalized populations and populations living in remote settings.This paper outlines the development of the dMOM intervention and its planned expansion and scaling amid the COVID-19 context. The dMOM research outcomes will generate important empirical evidence on the effectiveness of leveraging digital health to address intractable MNCH inequities among ethnic minority women and women living in remote areas and low-resource settings in Vietnam, build models for utilization and replication in country-level mHealth projects, and provide critical information on the processes of adapting mHealth interventions to respond to COVID-19 and other future pandemics.


The perception of functionality and reliability, and appropriate levels of expert supervision of artificial intelligence (AI) tools are key factors determining their adoption in everyday radiology practice. Research on this topic has mainly focused on general awareness about AI, radiologists’ familiarity with AI tools, and their expectations regarding the future of the profession -3. ExpanWe distributed an anonymous questionnaire among radiologists and radiology residents in the two countries. The respondents were practicing in primary, secondary, and tertiary health care institutions, both in the private and public sectors. We assessed the agreement with nine statements about reliability, trustworthiness, and appropriate levels of expert supervision with responses on the Likert scale (from strongly disagree to strongly agree). We analyzed the responses statistically by dichotomizing them into those expressing agreement or strong agreement with the question/statement and all other responses (including the “no stance” response). The responses, assigned values between 1 (strongly disagree) and 5 (strongly agree), were additionally combined into a single “confidence in AI” mean score (with scoring for negative statements inverted) in order to simplify testing associations with age group, usage of AI tools in everyday practice, and the area of subspecialization.The overall response rate was 34% (212 of 631). Twenty-nine respondents (14%) reported using AI tools in their everyday work. Despite limited exposure to AI tools in practice and standard medical education ,5, and i