The objectives of the study reported in this paper were: (a) to score the coverage of core NCD population-based interventions and individual services in Mauritius; (b) to analyse and score the presence of 15 common health system challenges that impede delivery of core NCD interventions and services in Mauritius; and (c) to provide policy recommendations for Mauritius to address health system barriers to delivery of NCD interventions and services.The Mauritius country assessment applied the guidelines developed by the World Health Organization Regional Office for Europe for systematically scoring coverage of NCD interventions and assessing health system challenges for improving NCD outcomes. The assessment used qualitative research design approach.Of the 24 core population-based interventions for addressing key NCD risk factors, 16.7% were rated extensive, 37.5% moderate and 45.8% limited. Three (20%), 8 (53%) and 4 (27%) of the 15 individual/personal CVD, diabetes and cancer services were rated extensive, moderate and limited respectively. The top five health system challenges hampering scale-up of coverage of population-based NCD interventions in Mauritius were inadequate interagency cooperation; limited application of explicit priority setting approaches; inadequate change management; sub-optimal distribution and mix human resources; insufficient population empowerment; and insufficient political commitment. The top five challenges had average scores of between 3.1 (interagency cooperation) and 2.4 (distribution and mix of human resources).The top five health system challenges constraining expansion in coverage of individual NCD services were limited integration of evidence into practice; limited use of explicit priority-setting approaches; inadequate application of information and technology solutions; insufficient population empowerment; and sub-optimal distribution and mix of human resources. The top five challenges for individual interventions had mean scores varying between 2.6 (integration of evidence into practice) and 1.7 (distribution and mix of human resources).Mauritius needs to increase its domestic general government investments into the national health system and requisite multi-sectoral action to address the priority health system challenges with a view of bridging the existing gaps in coverage of NCD population-based interventions and individual services. Mauritius is an island state in the Indian Ocean located within the continent of Africa; and had an estimated population of 1.274 million in 2018 [Noncommunicable diseases (NCD) are the leading cause of premature mortality and disability in Mauritius. In 2016, the country lost 413,536 disability-adjusted life-years (DALY), of which 340,551 (82%) were from NCD; 43,977 (11%) from communicable, maternal, perinatal and nutritional conditions; and 29,008 (7%) from intentional and unintentional injuries [According to the World Health Organization (WHO) , majoritThe Mauritius health system infrastructure consists of 124 public health-care facilities. Of these, 88.7% are health posts, 1.61% health centres, 1.61% district hospitals, 4.03% provincial hospitals and 4.03% regional hospitals. The health post density is 8.840 per 100,000 population; 0.161 health centres per 100,000 population; 0.161 district hospitals per 100,000 population; 0.402 provincial hospitals per 100,000 population; and 0.402 regional hospitals per 100,000 population .As shown in Table In 2016, per capita total current health expenditure on health (CHE) in Mauritius was US$ 553 (Int$) . About UTreatment of NCDs exerts a significant burden on Mauritius health system and economy. According to Mauritius National Health Accounts 2017, of the Rupees (Rs) 25.3 billion spent on health care in 2016, Rs 16.50 billion (65.2%) was spent on treatment of NCDs. Of the total spending on NCDs, Rs 3.6 billion (21.8%) was on cardiovascular diseases, Rs 2 billion (12.1%) on respiratory diseases, Rs 1.7 billion (10.3%) on diseases of the genitourinary system, Rs 1.2 billion (7.3%) on diabetes, Rs 1.2 billion (7.3%) on mental and behavioural disorders  . In addiThe NCD-associated health and economic losses could be attributed to lack of comprehensive multi-sectoral action and suboptimal health services coverage to reduce the NCD burden. For instance, the UHC service coverage index – which encompasses population access to reproductive, maternal, new-born and child health, infectious diseases, and NCD services – was 64% . This imThe research questions of the assessment were: (a) What is the extent of implementation of the core NCD population-based interventions and individual services in Mauritius? (b) What are the common health system challenges that impede the delivery of core NCD services/interventions in Mauritius? (c) What can Mauritius do to tackle the identified health system challenges (barriers) to effective delivery of NCD interventions and services?The objectives of the study reported in this paper were: (a) to score the coverage of core NCD population-based interventions and individual services that are essential for achievement of good NCD outcomes in Mauritius; (b) to analyse the presence of 15 common health system challenges that impede delivery of core NCD interventions and services in Mauritius; and (c) to provide policy recommendations for Mauritius to address health system barriers to delivery of NCD interventions and services.The current study used guidelines developed by the WHO Regional Office for Europe (EURO) to systematically assess health system challenges and opportunities for improving NCD outcomes . FollowiThe country assessment used qualitative research design. MCAT, working groups and key informants analysed and rated (a) coverage of NCD population-based interventions and individual services; and (b) the degree of perceived hindrance that 15 common health system challenges create for interventions scale-up efforts. All the discussions were closely guided by the questions contained in the WHO assessment guide entitled “Better NCD outcomes: challenges and opportunities for health systems: Assessment Guide” .We explain below the steps followed in Mauritius to achieve the three objectives of the study.The following five steps were followed to rate NCD population-based interventions used:Step 1: Constitution of the MCAT.The MCAT consisted of Ag Director General of Health Services, Permanent Secretary, and Director of Health Services in the Ministry of Health and Quality of Life (MOHQL); Regional Public Health Superintendent (RPHS) in Victoria Hospital; and the WHO National Consultant (team leader), Country Office Operations Officer, National Professional Officer for health promotion and NCDs, and Technical Officer for health systems. The MCAT was purposively constituted by the MOHQL.Step 2: Review of relevance of the core population-based NCD interventions aimed at preventing tobacco consumption, preventing harmful use of alcohol, and improving diet and physical activity. Table Step 3: MCAT review of the three category criteria developed in the WHO  guide foStep 4: MCAT review of pertinent national and international literature to garner evidence of implementation of the interventions in Table Limited: implies limited activities, limited commitment to real change, unimplemented initiatives, and dearth of evidence of population behaviour change for key NCD risk factors (p.12) .Moderate: means that strategies, programmes or interventions exists, reflecting commitment, but either their design is not in line with international best practice or their implementation has been hindered, leading to limited health behaviour change (p.12) .Extensive: implies evidence of extensive commitment demonstrated through strategies, programmes and interventions in line with international best practice, good implementation track record, and evidence of desired behaviour change and outcome improvement (p. 12) .Step 6: The MCAT plus 12 purposively selected key informants had a workshop where they rated each core population-based intervention in Table Among the key informants were the MOHQL senior officials, government officials from other ministries, heads of units/sections, service providers, representatives from the private sector, nongovernmental organizations, health training institutions and professional organizations.Table The rating of NCD individual services in Table Step 1: Review of the core individual services for preventing, detecting, management and follow-up of cardiovascular disease, diabetes and cancer cases. Those services were extracted from the WHO Global Action Plan for the prevention and control of NCD .Step 3: Review of the three category criteria developed in the WHO  assessmeStep 4: The MCAT plus 12 key informants had a workshop where, through discussion moderated by the team leader, they rated each core individual services in Table The MCAT and key informants referred to various national reports and WHO global reports to confirm their ratings of the coverage of both core NCD population-based interventions and individual services..Step 1: Constitution of five working groups (WG) by the MOHQL. Each WG had a chairperson and a report writer. Combined the working groups had 37 core members; 15 government officers co-opted from relevant government ministries when required; and representatives from five non-governmental organizations . The 58 key informants, were purposively selected by overall project coordinators (i.e. ADG and WR), based on their perceived expertise in the relevant health system challenge area. The composition of the five groups  is contained in Additional File 3Step 2: Review of the 15 common health system challenges contained in Table The health system challenges reviewed were extracted from the.WG1: Political commitment to NCDs, explicit priority-setting approaches, and interagency cooperation;WG2: Effective model of service delivery, coordination across providers, and effective management;WG3: Regionalization, integration of evidence into practice, and access to quality medicines;WG4: Distribution and mix of human resources, adequate information solutions, incentive systems, and managing change; andWG5: Population empowerment; and ensuring access and financial protection.Step 3: Assigning of the 15 common health system challenges to the five WGs as follows:Step 4: WGs review and adaptation of the WHO guide for assessing health system challenges and opportunities in tackling NCDs .“1 = Minor: This challenge does not prevent delivery of core interventions and services or has been fully addressed.2 = Moderate: This challenge has moderate impact on the delivery of core interventions and services. Mauritius has already found ways to address it, or has solid plans to do so.3 = Major: This challenge has a large negative impact on the delivery of core interventions and services. Mauritius has been struggling to find the right solutions to address it, or the chosen paths have not worked.4 = Major persistent: This is a systemic problem that is persistently on the health system reform agenda and the country has not found a sustainable implementable solution or has failed numerous times to implement it” (p.30).Step 5: WGs appraisal and scoring of the 15 common health system challenges hindering delivery of core NCD population and individual interventions and services that had moderate or limited coverage. The salience of the health system challenges was assessed using the following scale obtained from the WHO guide :“1 = MinThe WGs were guided by the respective set of questions and matrices in the WHO assessment guide when reviewing and evaluating available information related to NCD outcomes, interventions and services for assigned features to determine how they affect the performance of health systems in delivering primary prevention, secondary prevention and disease management, and treatment of acute events.Each WG led by an expert group chair and under the guidance of the MCAT had at least eight working sessions , each lasting two to three hours.Step 6: For each challenge the scores were summed up in the last row of each matrix to tease out the most important barriers undermining delivery of core interventions and services.Step 7: Preparation of individual WG reports: Each WG prepared a short report summarizing main findings, highlighting the key challenges, and making some initial recommendations for addressing the identified challenges.Step 8: Peer review of WG reports: First, WG chairpersons presented their reports at a one-day stakeholder workshop held on 16 November 2017, and subsequently revised their reports incorporating suggestions and filling any information gaps. Second, the WGs made final presentations of their findings and recommendations to a high-level panel of the MOHQL and development partners which was chaired by the Acting Director-General of Health Services.Step 9: Integration and synthesis of WGs findings: After the high-level panel, WG findings were integrated and synthesized across 15 features by a WHO national consultant, and then reviewed by the MCAT. The latter also reviewed WG rating of coverage of core interventions and individual services; reviewed scoring of health system challenges; analysed the linkages between coverage evaluation and health system challenges assessment; prioritized health system challenges that most significantly undermine coverage of core NCD interventions; consolidated the policy recommendations from WGs; and prepared the draft assessment report.Table The coverage of 4 (16.7%) of the interventions was rated extensive, 9 (37.5%) moderate and 11 (45.8%) limited. Out of the six anti-smoking interventions, two were rated extensive and four moderate. Out of the six interventions to prevent harmful alcohol use, one was rated extensive, one moderate and four limited. Of the six interventions to improve diet, one was rated extensive, two moderate and three limited. Of the six interventions to promote physical activity, none was rated extensive, two were rated moderate and four were rated limited. According to the assessment team’s rating, Mauritius still needs to invest more in scaling up the coverage of population NCD control interventions to the extensive level.Table Three (20%), eight (53%) and four (27%) of the 15 individual NCD services were rated extensive, moderate and limited respectively. With regard to CVD, effective primary prevention in high-risk groups and secondary prevention after AMI were rated extensive; effective detection and management of hypertension, and rapid response and secondary care after AMI and stroke were rated moderate; and risk stratification in primary health care was rated limited. All the individual services for diabetes  were rated moderate. In the case of cancer first line services, prevention of liver cancer through hepatitis B immunization was rated extensive, and screening for cervical cancer and treatment of precancerous lesions were rated moderate. Of the four cancer second line services, only vaccination against human papilloma virus was rated extensive; with the early case-finding for breast cancer and timely treatment of all stages, population-based colorectal cancer screening, and oral cancer screening coverage rated limited.In relation to each intervention/service, the evaluation team assessed each challenge as either 1 = minor, 2 = moderate, 3 = major, or 4 = major persistent challenge. Table The top five challenges had average scores of between 3.1 (interagency cooperation) and 2.4 (distribution and mix of human resources). Additional Files Table The top five challenges for individual interventions had mean scores varying between 2.6 (integration of evidence into practice) and 1.7 (distribution and mix of human resources). Additional Files The remaining part of this subsection present an analysis and scores of the 15 health system features contained in Table The Mauritius Government’s political commitment to continually improve the level and distribution of health is expressed in Mauritius Vision 2030 , GovernmThe Government has enacted various public health legislations targeting various NCD risk factors. For instance, the 2008 public health regulations which prohibit advertisement, sponsorship and sale and consumption of alcoholic drinks in public places . AnotherPolitical commitment to NCDs was rated either major or major persistent challenge for 12 population interventions and for 2 individual services. The average score for population interventions was 2.5 and 1.6 for individual services. Sustaining high-level political commitment through effective budgetary and legislative support and improved coordination of NCD activities across government agencies remains an ongoing challenge.The strategic long term direction for development plans priorities has been spelt out in the Mauritius Vision 2030. The Ministry of Finance and Economic Development (MOFED) strategic plan provides a medium term strategic direction and targets. MOFED three-year strategic budget plan establishes indicative expenditure ceilings for the ministries. The MOHQL proposed annual budget estimates, which are established on historical basis, alongside those of other ministries, are reviewed by the Budget Estimates Committee meeting chaired by the MOFED.The current budget allocation to the MOHQL is divided into five major subheads: general, curative services, primary health care and public health, treatment and prevention of HIV and AIDS, and prevention of noncommunicable diseases and promotion of quality of life  10.9 to 12.3 billion, representing a 13% increase. During the same period expenditure on prevention of NCDs and promotion of quality of life grew from Rs 106.8 million to Rs 137.3 million, accounting for a 29% increase , 51.Application of explicit priority-setting approaches was rated either major or major persistent challenge for 17 population interventions and for 3 individual services. The average score for population interventions was 2.8 and 2.1 for individual services.The use of national health accounts (NHA) to link the process of national health policy development to allocation and reallocation of resources is still in the nascent stage. Moreover, the use of cost effectiveness analysis evidence in allocation of resources has not been institutionalized. Therefore, there is no explicit mechanism for prioritizing health services and public health spending. In addition, there is absence of prioritization of the health budget with regard to burden of disease, cost-effectiveness and equity considerations.The MOHQL recognizes that multi-sectoral action and partnerships are crucial for core interventions and services to have the greatest impact on NCD outcomes; the MOHQL is forming close partnerships with other sectoral ministries and national institutions; and with UN agencies, diplomatic missions, and civil society organizations including NGOs, the media and other relevant stakeholders . For exaInteragency cooperation was rated either major or major persistent challenge for 20 population interventions. The average score for population interventions was 3.1. The assessment team deemed interagency cooperation not application for individual services in Mauritius.The main challenges include lack of functional interagency cooperation mechanism; and dearth of synergy through joint government/NGO efforts for combatting NCDs.The MOHQL has developed infrastructure for planning and implementation of policies, programmes, services and activities aimed at raising health literacy among the population. Some of that infrastructure includes the Health Information Education Counselling Unit; the NCD and Health Promotion Unit; and the Primary Health Care Programme. A Health Literacy Framework was developed by MOHQL in 2013; it incorporated the strengthening of the health literacy components of the different national action plans being implemented to reduce risk factors and premature mortality as well as a strategy to guide actions to improve health literacy across the life course .In addition, health promotion efforts care buttressed by pertinent health awareness raising activities of the Ministry of Social Security, National Solidarity and Environment and Sustainable Development; Ministry of Gender Equality, Child Development and Family Welfare; Ministry of Education and Human Resources, Tertiary Education and Scientific Research; Ministry of Youth and Sports; and Ministry of Agro Industry and Food Security. Four NGOs also contribute to population empowerment and protection of patient rights, including the Link to Life (focusing on breast cancer), TiDiam (focussing on diabetes), APSA (focusing on diabetic foot care) and VISA (targets tobacco use).Population empowerment was rated either major or major persistent challenge for 12 population interventions and for one individual service. The average score for population interventions was 2.5 and 1.8 for individual services.Despite the various strategies implemented for population empowerment, there is high prevalence of NCD risk behaviours and poor adherence to treatment plans, attributed to inadequate empowerment of population to change behaviour towards taking responsibility for their own health; lack of active engagement in decision-making processes around policy issues as well as individual treatment options/plans; lack of structured peer to peer patient support groups; high-risk population groups not adequately targeted for more tailored health promotion; and lack of explicit health literacy approach for the elderly.Mauritius has a strong primary health care system that provides health promotion , disease prevention , curative services (NCD clinics and diabetologist clinics) and rehabilitation . The priEven though the assessment team did not rate impact of effective model of services delivery on population interventions and individual services, the assessment identified factors that undermine referral system, including patients bypassing the PHC providers and going directly to secondary or tertiary hospitals for non-complicated NCD care; lack of patient identifier leading to duplication of care and dysfunctional transition of care; many PHC centres do not have optimum physician consultation time; and dearth of diagnostic and preventive services for a significant segment of the population in prediabetes stage.The coordination across providers at the different levels of care in Mauritius such as home care, PHC, and emergency care, regional and specialized hospitals is patient-focused with a referral system addressing the needs of NCD patients . MultidiEven though the assessment team did not rate impact of coordination across providers on population interventions and individual services, the working groups identified key challenges for coordination across providers to be lack of effective interoperable patient clinical data transfer system; and inefficient functioning of PHC as a hub for general coordination of care and referral to specialists.The overall public health-care system is well structured with three distinct levels of care, namely primary, secondary and tertiary. Effective regionalization of care has been achieved with a regional hospital and an extensive PHC network in each of the five health regions with a defined catchment population . All fivRegionalization was rated as a major challenge for scale-up of coverage of one individual NCD service, i.e. the early case-finding for breast cancer and timely treatment of all stages one individual service. The average score for individual services was 1.4. The key issues surrounding regionalization challenge included lack of clarity in the definition of roles and responsibilities for management of NCD conditions at the different health service delivery levels; and implementation of stroke unit care.The public health professionals receive their salaries and allowances based on recommendations of the Pay Research Bureau (institution responsible for reviewing the pay and grading structures and conditions of service in the public sector) and these are linked to position levels, years of service and responsibilities assigned . ContinuInspite of the fact that the impact of incentive systems on population interventions and individual services was not rated, the working groups assessment revealed that absence of monetary incentives linked to outstanding provision of quality NCD care at individual and institutional levels. Also, since the public health service delivery system provides free access to all core NCD population-based interventions and individual services, there are no incentives for healthy behavior change in population, better self-management for patients with chronic conditions, and adherence with the referral system.Concerning access to quality of medicines, based on the WHO concept of Essential Drugs , the MOHAccess to quality medicines was rated either major or major persistent challenge for none of the population interventions and for one individual service, i.e. effective detection and general follow-up of diabetes cases. The average score for population interventions was one; and 1.1 for individual services.The WGs identified factors accounting for sub-optimal access to quality medicines to include cumbersome administrative formalities in procurement of drugs sometimes cause delays in supply; lack of dedicated quality control laboratory to monitor the quality of drugs in the local market; NPC is not very effective; and existing inventory management sometimes is the cause of stock outs at central warehouses and health facilities.Research , surveysResearch is complemented by other information systems solutions, for instance, the civil registration systems. Morbidity conditions and mortality causes are coded according to the 10th Revision of the WHO International Classification of Diseases . The HeaIntegration of evidence into practice was not rated as a challenge for NCD population interventions in Mauritius. However, it was rated either as a major or major persistent challenge for nine individual NCD services. The average score for individual services was 2.6.Adequate information solutions were rated either major or major persistent challenge for seven population interventions and for none of individual services. The average score for population interventions was 2.1 and 2 for individual services. The assessment revealed that optimal integration of evidence into practice was constrained by a number of factors, including lack of a structured process for coordinated development, reviewing , updating and monitoring of the NCD disease management guidelines and protocols; absence of an action research framework for prevention and control of NCDs; and structures and mechanisms for national NCD registries have not yet been institutionalized.Out of the total number of human resources for health (HRH) in Mauritius, 23.9% are physicians, 40% nursing and midwifery personnel, 4.7% pharmaceutical personnel, 3.6% dentistry personnel, 3% laboratory health workers, 2.2% environment and public health workers, 2.2% community and traditional health workers, 1.4% other health workers, and 19% management and support workers . In termDistribution and mix of human resources was rated either major or major persistent challenge for 13 NCD population interventions and for one individual service. The average score for population interventions was 2.4 and 1.7 for individual services. The main HRH weaknesses relate to absence of written HRH policy and needs assessment which can provide evidence to optimize health workforce performance; and limited up-to-date in-service training for service providers with regard to CVD, diabetes prevention and NCD surveillance capacity.Figure Regional Health Directors (RHD) are doctors with postgraduate training, appointed by the Public Service Commission (PSC) through a procedure of open competition, based on the candidates’ educational qualifications, experience and merit . The autDespite that the impact of effective health system management on coverage of NCD population interventions and individual services was not rated, the working groups assessment revealed that existing management system of health facilities cannot effectively be used as a tool for improving quality and outcomes due to lack of standardized set of NCD clinical protocols and guidelines against which audits can be done. In addition, even though facilities have boxes for receiving patient complaints, system for receiving and analyzing patient feedback to improve patient care and outcomes is inadequate.the regionalization of NCD services with the creation of the posts of Community Physicians and NCD Coordinators to better manage the NCD services in the PHC system;the extension of opening hours of area health centres and mediclinics;early opening of health centres for taking of blood specimens from patients;introduction of staggered appointment system;sorting out exercises (triage) for patients attending the Accident and Emergency Departments at the regional hospitals;introduction of diabetologist and some other specialized clinics in PHC; andintroduction of shift system in hospitals for medical health officers/senior medical health officers .In principle entails making positive changes to attitudes, policies, systems and laws in the health sector. Mauritius has over the years introduced reforms at PHC and hospital levels with a view to improving the health services delivery, e.g.:Change management was rated either major or major persistent challenge for 13 population interventions and for none of the individual services. The average score for population interventions was 2.5 and 1.2 for individual services.top down approach in identifying the changes required for better health outcomes without the involvement of the health personnel and/or recipients directly concerned with the changes;lack of clarity of the change process, expected costs and benefits to health care providers, patients and the population;weak inter-sectoral collaboration mechanism;non-accompaniment of change by appropriate capacity building; andabsence of regular monitoring of the change process.The challenge of bringing about effective change in NCD prevention and control programme persists due to:In relation to access to health services and financial protection, all government health services  are fully tax-funded, and thus, provided for free to all users . SpecialApproximately, 73% of the population attends public health care institutions whereas 27% seek care and treatment from the private health sector on a user-fee basis . OOP expHowever, according to the WHO World Health Statistics 2018, Mauritius has a universal coverage index of 64%, implying that there are other factors at play that account for suboptimal coverage of essential health services  .Financial access and risk protection was rated either major or major persistent challenge for none of the NCD population interventions and for none of the individual services. The average score for population interventions was 1.3 and 1.7 for individual services. The main issues identified by the WGs for financial access and risk protection include: high out-of-pocket expenditure as a percentage of total health expenditure (48% of CHE); significant differences in market prices of medicines; and low health insurance coverage in the population.The study rated coverage of core NCD population interventions and individual services; analysed the presence of 15 common health system challenges that impede delivery of core NCD interventions and services; and summarizes policy recommendations for Mauritius to address health system barriers to delivery of NCD interventions and services.Only four (16.7%) out of the 24 core population NCD interventions and three of the 15 individual NCD services coverage was rated extensive in Mauritius. Therefore, there still remains substantial gaps in coverage of interventions aimed at reducing tobacco use, harmful alcohol use, consumption of unhealthy diet, and physical inactivity. Likewise, the individual NCD services coverage was found to be sub-optimal in the country.Inadequate interagency cooperation and limited use of explicit priority-setting approaches were rated as major challenges to optimal expansion in coverage of population-based NCD interventions. Whereas, managing change, human resources for health, population empowerment and political commitment were other important challenges for population interventions.Integration of evidence into practice was rated a major challenge for individual NCD services. Whereas, other health system challenges in order of priority, included use of explicit priority-setting approaches, adequate information solutions, population empowerment, distribution and mix of human resources for health, and ensuring access and financial risk protection.We chose to compare Mauritius and European region countries core NCD interventions coverage scores due to close epidemiological similarities. For example, 82 and 82.8% of the DALYs lost in Mauritius and the European region were from NCDs, respectively. In addition, the Mauritius life expectancy of 74.8 years was generally comparable to that of the European region of 77.5 years [Additional File (a) Mauritius’s efforts to raise tobacco taxes were rated moderate; Belarus, Croatia, Macedonia, and Serbia obtained similar ratings. Only Estonia and Turkey had an extensive rating. (b) Mauritius’s efforts to combat smoking through provision of smoke-free environments were rated moderate as in Croatia, Macedonia and Tajikistan. Only Turkey had an extensive rating. (c) Issuance of warnings on the dangers of tobacco and tobacco smoke was rated extensive in Mauritius, Macedonia, Turkey, and the remaining countries had lower ratings. (d) Banning of tobacco advertising, promotion and sponsorship was rated extensive in Mauritius, Macedonia and Turkey. (e) Provision of service for tobacco cessation to all those who want to quit (nicotine replacement therapy) was assessed to be moderate in Mauritius and Estonia, and extensive in Turkey. It was only in Turkey where five of the antismoking interventions were rated extensive. There is need for WHO to undertake detailed study in Turkey with a view to documenting best practice aspects that other countries, like Mauritius, can potentially emulate to improve implementation of antismoking interventions related to raising tobacco taxes, provision of smoke-free environments, and provision of service for tobacco cessation to all those who want to quit, that is nicotine replacement therapy.(a) Use pricing policies on alcohol including taxes on alcohol was rated moderate in Kyrgyzstan and Macedonia. (b) Restriction or banning of alcohol advertising and promotion was rated extensive in Mauritius, Tajikistan and Turkey. (c) Restriction of availability of alcohol in the retail sector was rated extensive in Croatia and Turkey; and moderate in Kyrgyzstan, Macedonia and Moldova compared to limited rating in Mauritius. (d) Enactment and enforcement of minimum alcohol purchase age regulation was rated extensive in Macedonia and Turkey compared to limited rating in Mauritius. (e). Implementation of a blood alcohol limit for driving was rated extensive in Estonia and Tajikistan compared to limited rating in Mauritius.(a) Reduction of salt intake and the salt content of foods was rated moderate/extensive only in Turkey and limited in Mauritius and all other European countries in Additional File (a) Implementation of communitywide public education and awareness campaigns for physical activity was similarly rated moderate in Mauritius as in Belarus, Macedonia, Tajikistan, Turkey and Serbia. (b) Provision of physical activity counselling and referral as part of routine primary health-care services through the use of a brief intervention was rated limited in Mauritius compared to moderate in Belarus. Comparison of ratings for the other interventions for promoting physical activity was not possible since information was missing for European region countries.Additional File CVD risk stratification in primary health care was rated limited in Mauritius compared to moderate rating in Croatia, Kyrgyzstan, Moldova, Turkey and Serbia.Effective detection and management of hypertension was similarly rated moderate in Mauritius, Turkey and Serbia.Effective CVD primary prevention in high-risk groups was rated extensive in Mauritius compared to limited/moderate in European region countries.Effective secondary prevention after AMI  was similarly rated extensive in Mauritius, Macedonia, Tajikistan, Turkey and Serbia.Rapid response and secondary care after AMI and stroke was rated moderate in Mauritius compared to extensive in Macedonia.Effective detection and general follow-up for diabetes was rated moderate in Mauritius, Macedonia and Serbia.Patient education on nutrition, physical activity and glucose management was rated moderate in Mauritius, Macedonia, Moldova and Serbia.Hypertension management among people with diabetes was rated moderate in Mauritius compared to limited in Hungary, Macedonia and Serbia.Prevention of diabetes complications (such as eye and foot examinations) was similarly rated moderate in Mauritius, Hungary and Serbia.The following recommendations are made for further development of policies, programmes and interventions to reduce exposure to NCD risk factors, improve diagnosis and treatment of NCDs, strengthen the health system and aim towards UHC in Mauritius. They can also be used as a basis for policy dialogue between the different stakeholders in the development of the Health Sector Strategic Plan and an integrated NCD action plan.Based on the assessment of features as well as the challenges identified and discussions with key stakeholders, a number of policy recommendations emerged.First, it was noted that current interagency cooperation is not fully functional despite a new mechanism for more effective coordination and a little synergy through joint government/NGO efforts . In ordeSecond, the population  is not adequately empowered to change behaviour towards taking responsibility for their own health and engage actively in decision-making processes both around policy issues as well as individual treatment options/plans . Recomme; introduction of incentives for health workers to boost requisite capabilities for controlling NCDs; consolidating National Pharmacovigilance Committee. Furthermore, proposal was made to consolidate and scale up the role of primary health care as the centre of care for NCDs to respond to the ageing population and increasing rates of multi-morbidity. This will require strengthening PHC gatekeeping function and reducing duplication of services at PHC and hospital levels, as well as, reinforcement of the role of PHC in improving coordination between primary, secondary and tertiary care levels, implementing a more systematic screening and management of chronic conditions in PHC including improving links with NCD mobile clinics and risk stratification of patients with assessment of CVD risk factors using CVD risk scores.Third, primary health care (PHC) in the country is inefficient contributing to weaknesses in provision of preventive services, early diagnosis and treatment for those living with NCDs . In ordeFourth, the assessment revealed issues of inadequate access, sharing and analysis of data generated by the health system, unavailability of modern information and technology solutions, and non-institutionalization of national NCD registries . RecommeFifth, the assessment identified lack of explicit processes for prioritizing public health expenditures, leading to very low primary health care budgetary allocations . RecommeFinally, the assessment uncovered weaknesses in human resources for health (HRH) management such as the dearth of HRH planning and assessment, and inadequate NCD-related in-service training for service providers . In ordeThe study had some limitations. First, as mentioned earlier, the MCAT and the WGs members were purposively chosen by the MOHQL. The key informants were also purposively selected by overall project coordinators (i.e. ADG and WR). Critiques might argue that, ideally, the MCAT, WGs and key informants should have been chosen using a statistical sampling methodology to avoid selection bias.Second, the rating of coverage of both population-based NCD interventions and individual services was based on subjective judgements of fact by the MCAT and key informants. Thus, the ratings were dependent on the national reports and WHO reports referred to . Concerning the latter two potential limitations, like NG , we woulThe coverage of majority (83%) of population-based interventions aimed at combatting main NCD risk factors  was rated as either moderate or limited. The sub-optimal coverage of population-based interventions has been attributed to largely to inadequate interagency cooperation, explicit use of priority-setting approaches, change management, distribution and mix of human resources for health, population empowerment, and political commitment.About 86.7% of the individual NCD services coverage was rated moderate or limited. The sub-optimal coverage of individual NCD services has been ascribed to insufficient integration of evidence into practice, use of explicit priority-setting approaches, use of information and technology solutions, population empowerment, and distribution and mix of human resources for health. Thus, persistent health system challenges related to explicit priority-setting approaches, population empowerment and human resource for health hinder both the optimal coverage of both population-based interventions and individual services for NCD.Therefore, Mauritius needs to increase its domestic general government investments into the national health system and requisite multi-sectoral action to address the priority health system challenges with a view of bridging the existing gaps in coverage of NCD population-based interventions and individual services.Additional File 1. Criteria used for scoring coverage of NCD population-based interventions.Additional File 2. Criteria used for scoring coverage of NCD individual services.Additional File 3. Composition of the five working groups members that appraised, scored and ranked common health system challenges.Additional File 4. Scores pertaining to degree of health system challenge for NCD population-based interventions.Additional File 5. Scores pertaining to degree of health system challenge for NCD individual services.Additional File 6. Comparison of Mauritius scorecards for core population-based interventions with those of 10 European region countries.Additional File 7. Comparison of Mauritius scorecards for individual NCD services with those of 10 European region countries.


Rx One Health Summer Institute, jointly led by US and East African partners, provides a model for such a program. In 2017, 21 participants representing five countries completed the Rx One Health program in East Africa. Participants worked collaboratively with communities neighboring wildlife areas to better understand issues impacting human and animal health and welfare, livelihoods, and conservation. One Health topics were explored through community engagement and role-playing exercises, field-based health surveillance activities, laboratories, and discussions with local experts. Educational assessments reflected improvements in participants’ ability to apply the One Health approach to health and disease problem solving, as well as anticipate cross-sectoral challenges to its implementation. The experiential learning method, specifically the opportunity to engage with local communities, proved to be impactful on participants’ cultural awareness. The Rx One Health Summer Institute training model may provide an effective and implementable strategy by which to contribute to the development of a global One Health workforce.The One Health approach has gained support across a range of disciplines; however, training opportunities for professionals seeking to operationalize the interdisciplinary approach are limited. Academic institutions, through the development of high-quality, experiential training programs that focus on the application of professional competencies, can increase accessibility to One Health education. The  Over the next decade, the United Nations Sustainable Development Goals (SDGs) that encompass social development , the environment , and economic progress  are positioned to set the agenda for global health; these goals embody a One Health (OH) strategy  and describe the inaugural course (2017) with an evaluation of the impact of the course on participants’ OH competencies. Educational assessments were conducted as part of the curriculum and are reported here for quality improvement and program evaluation purposes.Herein, we provide an overview of the Rx One Health Summer Institute was grounded in the pedagogical framework of a competency-based curriculum. Schools of medicine, public health, and veterinary medicine have been actively moving to competency-based educational models, and this paradigm is particularly relevant for collaborative problem solving and critical reasoning , governmental  and non-governmental organizations , as well as University of California Davis’ Schools of Veterinary Medicine (SVM) and Medicine (SOM). Instructors represented diverse fields, including agriculture, environmental policy, veterinary medicine, human medicine, and conservation and were selected based on their subject matter expertise and alignment with program goals. Prior to developing their learning experiences, all instructors received a training handbook which outlined course goals, learning theory, tools for effective facilitation, and student biographies to improve the integration of learning objectives and engagement of learners in the community.Rx One Health participants independently completed a series of preparatory readings, tutorials, and assessments that enabled instructors to assess their capabilities prior to the in-country sessions (USAID PREDICT The in-country program was divided into two sessions: Session 1 (Tanzania) and Session 2 (Rwanda). Each session spanned 2 weeks and presented OH challenges, stakeholders, and solutions within the context of the local setting. In each session, the curriculum focused on multiple thematic areas and learning objectives therein (Table Session 1 (June 4–18), held in Tanzania , focused on OH foundations ; health monitoring of livestock and free-ranging wildlife; stakeholder engagement to understand health and economic challenges of local communities; and methods in environmental, infectious disease, and community-based research. Learning experiences included classroom-based discussions, hands-on field exercises , tours and demonstrations , and small group problem solving and role playing  which continually reinforced communication, organization, collaboration, and conflict resolution skills. Examples of learning experiences and the location of field exercises are provided in Table Session 2 (June 19–30), held in Rwanda , continued to emphasize OH foundations, cultural capacity building, leadership skills, human healthcare delivery, and communication with an emphasis on stakeholder engagement. Additionally, this session introduced the concepts of community health, human resource capacity building, food safety, commercial animal agriculture, and public health  in preparation for a capstone immersion exercise. This exercise challenged participants to actively acquire on-site information from local stakeholders on OH challenges  to develop creative and integrative solutions to address some of these challenges. Participants worked together to develop and deliver an oral presentation to propose their OH solutions to a group of governmental and non-governmental stakeholders who provided feedback and discussed the intricate barriers and existing opportunities for implementing proposed solutions.At the start of the in-country session, each participant proposed “Professional Responsibilities for OH Practitioners” (pre) to outline their ideas for core competencies for OH professionals. Responsibilities were updated as the course progressed, and at the end of the program, participants submitted their modified ideas (post) for discussion. Pre- and post-program responsibilities were transcribed, and responses were analyzed inductively using the constant comparison method  and after (post) the program. Assessments included nine paired questions each with five response categories ranging from “Poor” to “Excellent.” This retrospective format, where before and after information is collected concurrently, was chosen to reduce response-shift bias, a source of contamination of self-report measures that often results in overestimation of pretest scores  on self-efficacy assessments. All quantitative analyses were conducted using SAS v9.4 , and a Rx One Health Summer Institute 2017 provided training to 21  participants. Five countries were represented, including the USA (n = 11), Rwanda (n = 5), Tanzania (n = 3), Denmark (n = 1), and Nepal (n = 1). The median age of participants was 26 . The participants were early career professionals and students representing the fields of veterinary medicine, biological sciences, natural resources management, public health, human medicine, agricultural development, and community development.At the start of the training course, participants more frequently emphasized their individual knowledge and skills to solve problems affecting humans, animals, and the environment. At the conclusion, participants more often expressed OH competencies in terms of generating collaboration and communication across multiple disciplines and with communities Table . Before Participant self-efficacy showed statistically significant improvements across all measured competencies. Those that resulted in the greatest difference between pre-training and post-training were: (1) understanding challenges to the implementation of the OH approach and (2) understanding community-based research and engagement within an OH framework. Complete results are provided in Table Rx One Health Summer Institute, described within, provides an example by which to produce a multi-institutional, interprofessional, experiential training program grounded in the core competencies of OH education. Learning assessments provided support of enhanced participant understanding and ability with regard to research and evaluation methods, particularly at the community level. Assessments also suggested an evolution of thought regarding OH topics, including cultural competence and interdisciplinary collaboration. After the training, participants more readily expressed OH competencies in terms of generating collaboration and communication across multiple disciplines. In essence, participants became more aware of the need to build “essential networks” to create and sustain the human assets necessary to implement an OH community network.The development and evaluation of the Rx One Health program’s curriculum, instructors, and participants likely contributed to the broadening of perspectives demonstrated.There was also a clear broadening of participants’ definition of OH challenges and mechanisms by which to address them. There was a shift from a disease-centric perspective of OH challenges to one that more readily considered health in terms of the community—human, animal, ecosystem, and economic well-being. Given the origins of the OH concept in the management of shared disease threats to humans and animals Zinsstag , the empRx One Health instructors and participants facilitates the development of a network of solution-oriented global health professionals, and with each cohort, the network grows. Future iterations of the Rx One Health program may benefit from an even greater representation of disciplines and home countries among participants. In particular, participants from low- and middle-income countries (LMIC), where the likelihood of emerging infectious disease threats are high and human and physical resources are most constrained , United States Agency for International Development (USAID), United States Department of Agriculture (USDA), and Department of Defense (DoD), as well as international organizations such as World Health Organization (WHO) and the United Nation’s (UN) Environment Programme, stand to gain from a more integrated and collaborative OH workforce (Barrett et al. Developing a workforce capable of anticipating and responding to global health challenges is a top priority. Professional trainings like Rx One Health Summer Institute provides a model for increasing accessibility to OH education. Its emphasis on applied and practical training provides opportunities for participants to develop communication and problem-solving skills across disciplinary and cultural settings. These types of training programs can augment OH curricular offerings, generating a workforce that is capable of integrating OH competencies into public and global health practice at multiple levels and converting them into meaningful action.Education is the basis for OH capacity development (Vink et al. Rx One Health Summer Institute, provide an effective and implementable strategy by which to contribute to the development of a global workforce capable of collaborating with communities and other stakeholders to solve complex health challenges at the human–animal–plant–ecosystem interface. Training programs can be used as a forum for collaboration among health disciplines, allowing for the development of multi-national and multi-cultural cohorts of each year’s students and encouraging the ongoing development of a solution-oriented community of global health professionals, a necessary component for success of the OH approach.Intensive short courses, such as the


More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions.The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings.The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care – all within LMICs.Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities. ECSAs Emergency Care System AssessmentsECS Emergency Care SystemsGETI Global Emergency and Trauma Care InitiativeGEM-CARN Global Emergency Care Research Network projectHICs High-income countriesJLA James Lind AllianceLMICs ow- and middle-income countriesRPS research prioritisation settingRPS research priority settingRCEM Royal College of Emergency MedicineWHO The World Health OrganizationUHC Universal health coverageWhile prevention is ideal, there is no context in which all emergencies can be averted, and prevention strategies may take years or decades to show benefit , 2. GlobStudies such as this one highlight the importance of defining research priorities to inform strengthening of Emergency Care Systems, but there is little research to guide policy and implementation in settings where resources are limited and prioritization is critical. World Health Assembly Resolution 72.16 calls for national-level WHO Emergency Care System Assessments (ECSAs) to define system-level gaps and priorities for action and highlights the need for a stronger evidence base to inform policy and implementation . While tThe Global Emergency Care Research Network project (GEM-CARN), an international and multidisciplinary coalition of researchers and stakeholders across different countries and regions, conducted a RPS exercise after the 2019 WHO Global Emergency Care Systems meeting to identify evidence gaps and emergency care research priorities in LMICs. In this article, we explore four phases of research prioritisation, identify seven priorities for improving emergency care systems in LMICs, assess the quality of our RPS exercise and review the current evidence available. Our RPS process was informed by using steps identified during a Cochrane International workshop on Research Priority Setting Methods  , and a consensus-based approach was used. The three groups each ranked the previously highlighted questions according to feasibility and applicability. The roundtable feedback of the scoring from each group enabled a consensus to be reached on the top seven prioritised questions. Of note, between each phase, feedback sessions were conducted.Merging of the ranking of questions from the 3 groups (appendix 1) identified the top questions. The 7 highest-ranking questions to prioritise (in order of decreasing priority) are listed in Fig. We assessed the quality of the RPS exercise using a checklist of nine themes of good practice as proposed by WHO (Appendix 2) . It adheExplicit decisions were made as to who to involve  in setting the research priorities and why . This included representation of expertise  Medicine) and regional participation (stakeholders from 13 LMICs and 3 HICs). We deliberately selected high value information to inform the exercise, such as literature reviews, and key guidance documents  informing consensus-based discussions.We are yet to define when evaluation of the established priorities and the priority setting process will take place but inevitably, the most positive evaluation would result from funding of the prioritised research questions with demonstrable subsequent improvement in corresponding elements of Emergency Care in LMICs.The multinational, interdisciplinary collaboration supported by the GEMCARN project has conducted research priority setting according to published standards and identified seven research priorities for strengthening Emergency Care in low resource settings - to be taken forward through formal funded studies. These highly-ranked priorities are consistent with the challenges identified in World Health Assembly Resolution 72.16. These include “poor coordination of prehospital and facility-based care; limited or no coverage of prehospital systems, especially in rural areas; shortage of fixed staff assigned to emergency units; lack of standards for clinical management and documentation; and insufficient funding.”  FollowinA systematic review of emergency care quality and safety indicators in low resource settings has reported a limited number of metrics, the majority of which focus on structures or processes of care rather than on patient outcomes . A conseA recent systematic review identified six barriers to out-of- hospital care in LMICs . These iStandardized emergency care registries are largely absent in most LMICs, due to a lack of standard clinical management and documentation in prehospital and facility settings , 33. HowEvidence shows that inpatient and emergency department (ED) triage positively predict patient clinical outcomes, safety and waiting times –39. HowePatients who access emergency care mostly consist of children of median age 3.2 years and adults of median age 35 years . These pMost countries currently face shortages in health care staff but the lack of speciality trained or skilled personnel in emergency care is a particular challenge in LMICs –46. It hIn the context of resource constraints common to virtually all health system settings, the cost effectiveness of interventions and services delivered is paramount. The World Bank’s Disease Control Priorities in Developing Countries has identified the most effective and cost-effective interventions across a wide range of disease conditions . Some exUltimately, an evidence-to-policy stance in emergency care will be crucial for effective development in LMICs. Despite the highlighted challenging factors of external environment, research community and conduct of research facing emergency care research in LMICs, this RPS exercise has identified key research priorities to support the development of evidence, research capacity and to inform efforts to improve ECS in low-resource settings. This can guide future research and funding applications to support emergency care development for the world’s poorest billion. Such collaborations as these draw on the strength of the “South-South” cross-learning among LMIC partners in addition to a mutual reinforcement between high-income and LMIC collaborators, allowing for HIC collaborators alike to learn from the relative effectiveness of various emergency care interventions as they seek to further understand and strengthen ECS. Gradually, we will be able to build research capacity such that interventions to improve emergency care systems in LMICs will be led, developed and informed by local researchers most familiar with the context.Additional file 1.


The increasing access to antihypertensive medications has improved longevity and quality of life in hypertensive patients. Nevertheless, hypertension still remains a major risk factor for stroke and myocardial infarction, suggesting the need to implement management of pre- and hypertensive patients. In addition to antihypertensive medications, lifestyle changes, including healthier dietary patterns, such as the Dietary Approaches to Stop Hypertension (DASH) and the Mediterranean diet, have been shown to favorably affect blood pressure and are now recommended as integrative tools in hypertension management. An analysis of the effects of nutritional components of the Mediterranean diet(s) on blood pressure has therefore become mandatory. After a literature review of the impact of Mediterranean diet(s) on cardiovascular risk factors, we here analyze the effects of olive oil and its major components on blood pressure in healthy and cardiovascular disease individuals and examine underlying mechanisms of action. Both experimental and human studies agree in showing anti-hypertensive effects of olive oil. We conclude that due to its high oleic acid and antioxidant polyphenol content, the consumption of olive oil may be advised as the optimal fat choice in the management protocols for hypertension in both healthy and cardiovascular disease patients. Primary or essential hypertension can be currently defined, despite some variations across cardiovascular disease (CVD) societies, as the chronic elevation of blood pressure (BP) values over 130/80 mmHg, with no identifiable cause that, in the long-term, causes end-organ damage and results in increased morbidity and mortality . NeverthBeside genetic components , most ofdiets) is a more general descriptive term applied to dietary models traditionally adopted in several regions close to the Mediterranean Sea [Effective antihypertensive dietary strategies include reducing sodium intake, weight loss, limiting alcohol consumption, increasing potassium intake, and adopting an overall healthy eating pattern, such as the Dietary Approaches to Stop Hypertension (DASH) and the recently recognized potentially antihypertensive Mediterranean diet . While Dnean Sea . In geneWhat substantially differentiates the Mediterranean diets from the DASH diet is its fat content: a low intake of saturated fats but a relatively high consumption of unsaturated fats, mostly deriving from olive oil (OO), which is used daily in stews, fried foods, salads and even desserts .Already Ancel Keys, the father of Mediterranean diet, had identified OO as the key component of the healthful Mediterranean diet . PromotiOlea europaea) can be traced back to the Eastern and Middle East Mediterranean regions. From the Anatolian peninsula it spread out throughout the Mediterranean basin, initially by the Greeks  [In bromatological terms, OO nutritional components are divided into two fractions: a major saponifiable and a minor non-saponifying . The mosopa.eu/) Historically, the first clear epidemiological evidence correlating fat consumption to BP regulation dates back to the end of the nineteen eighties, when Williams et al., in a small cross-sectional study conducted in 76 middle-aged US men, highlighted the existence of an inverse relationship between systolic and diastolic blood pressure  and oleic acid consumption as evaluated by 3-day food records . These pIn the Multiple Risk Factor Intervention Trial, for example, data from 24-h dietary recalls gathered from 11,342 middle-aged men were used to evaluate the relationships between the consumption of various dietary macronutrients and BP regulation. Data analysis showed a clear inverse association between DBP and the intake of polyunsaturated fatty acids (PUFA), as well as with the PUFA/saturated fatty acids (SFA) ratio; unexpectedly, however, the analysis failed to show a protective effect for MUFA . In sharThe first cross-sectional study that investigated the association between specific fat consumption, including OO, and the incidence of hypertension in Southern Europe was conducted in Italy . BrieflyThese results agree with those that recently emerged from the International Study of Macro/Micronutrients and Blood Pressure (INTERMAP) trial, which evaluated the associations among SBP and DBP and an array of food and nutrient intakes in 4680 middle aged women and men enrolled in 17 geographically and culturally different cohorts in Japan, China, the United Kingdom, and the United States . Here, dAlthough from observational studies many positive evidences have emerged linking OO to lower BP, the modest validity of nutritional findings derived from research methods adopted  have pusTo identify and retrieve all potentially relevant articles on this topic, we performed the search utilizing the following expressions: “olive oil” AND “arterial pressure” OR “hypertension” OR “blood pressure” OR “diastolic pressure” OR “systolic pressure” AND “randomized controlled trial” AND “humans”. We searched for articles published in each database from its inception until September 2019. We also performed additional manual search by analyzing the reference list of original publications, reviews and meta-analyses on the same topic. In the final selection, we included and discussed 19 papers specifically addressing the role of OO in healthy subjects and/or in patients at cardiovascular risk, including hypertensive and diabetic subjects. From a chronological perspective, one of the earliest randomized clinical studies assessing the antihypertensive effect of OO dates back to the late 1980s . Here, tFrom this study forward , the numIn recent years, among the minor constituents of OO potentially responsible for the antihypertensive effect, the role of the antioxidant polyphenols has been largely assessed. This was first assessed in a sample of 40 coronary Spanish male patients . Here, pBeing BP the product of cardiac output and systemic vascular resistance, hypertension may follow from an increase in cardiac output, an increase in systemic vascular resistance, or both . Under nPathogenically, functional and structural changes eventually lead to increased vascular stiffness and atherosclerosis in the hypertensive arterial wall, including endothelial dysfunction, abnormal vascular smooth muscle cell (VSMC) growth and migration, inflammation, fibrosis, altered contractility, and vascular hypertrophic remodeling . The undInterestingly, many pro-hypertensive stimuli, including Ang II, aldosterone oscillatory shear stress, as well as pro-inflammatory cytokines and growth factors, exert their pro-hypertensive vascular effects through nicotinamide adenine dinucleotide phosphate (NADPH) oxidase-derived ROS . At the In spontaneously hypertensive rats (SHR), both BP and the vascular expression of the redox-sensitive transcription factors NF-κB and AP-1 were shown to be downregulated by a plethora of synthetic antioxidants , suggestAlthough all the aforementioned antihypertensive mechanisms have been attributed to the potential interference of EVOO antioxidant components within the redox-signaling pathways leading to hypertension , interesAccordingly, in a subsample from the EUROLIVE study , the admSince the first use of antihypertensive agents in the Veterans Administration Cooperative Study in the late 1960s , the incAs a consequence of recent studies showing benefits associated with more pronounced reduction of BP in the hypertensive population, the American College of Cardiology and American Heart Association Task Force have updated the guidelines for the management of BP in adults . BesidesA great deal of population-based nutritional studies have investigated and recognized several dietary components as promoting or protecting from hypertension . Among pTo this aim, we first reviewed all epidemiological evidence investigating the association between MUFA and/or OO and the incidence of hypertension. In agreement with Alonso and coworkers , we obseIn agreement with Nissensohn , more coThe heterogeneity in BP changes found across studies may depend on various factors, including intervention or exposure duration, OO amount and quality, and dietary and genetic background. For example, the CLOCK single nucleotide polymorphisms (SNPs) rs4580704 C > G has been associated with obesity, hyperglycemia, and hypertension . InteresTherefore, to decrease the within-group heterogeneity in terms of outcome, some important issues such as genetic stratification of hypertensive patients  as well Advances in understanding of the complex cellular and molecular pathophysiology of hypertension  have beeBoth experimental and human studies are overall robust in showing anti-hypertensive effects by OO, due to its high oleic acid and antioxidant polyphenols content. On the basis of reviewed results, it is difficult to establish which is the component that most efficaciously contributes to BP regulation. Rather, the whole range of EVOO components appears to express their maximal efficaciousness within the complex of their original matrix. This suggests that formulation of possible functional products should approximate as much as possible the natural environment in which active molecules are found. EVOO thus appears to be the optimal fat choice in management protocols for hypertension in both otherwise healthy and cardiovascular patients.


Dedicated air ambulance services provide a vital link for critically ill and injured patients to higher levels of care. The recent developments of pre-hospital and retrieval medicine create an opportunity for air ambulance providers and policy-makers to utilize a dashboard of quality performance measures to assess service performance. The objective of this scoping systematic review will be to identify and evaluate the range of air ambulance outcome measures reported in the literature and help to construct a quality dashboard based on a healthcare quality framework.We will search PubMed, MEDLINE, CINAHL, Scopus, and Cochrane Database of Systematic Reviews (from January 2001 onwards). Complementary searches will be conducted in selected relevant journals. We will include systematic reviews and observational studies  in critically ill or injured patients published in English and focusing on air ambulance delivery and quality measures. Two reviewers will independently screen all citations, full-text articles, and abstract data. The study methodological quality (or bias) will be appraised using appropriate tools. Analysis of the characteristics associated with outcome measure will be mapped and described according to the proposed healthcare quality framework.This review will contribute to the development of an air ambulance quality dashboard designed to combine multiple quality frameworks. Our findings will provide a basis for helping decision-making in health planning and policy.CRD42019144652PROSPERO  Air ambulances, both fixed and rotary wing, have become essential components in modern emergency healthcare systems. Drawing lessons from military conflict, the aim is to use fast transportation means to provide people with acute illnesses and injuries with access to centralized specialist care. The development of modern emegency medicine has provided a further opportunity to enhance the coordination and clinical standards available for the intended purpose of rapid response medical care provided to seriously sick and injured people .However, the implementation of air ambulances are often tested in austere and unfamiliar situations –7, usingEffective: providing evidence-based care to all who could benefit and refraining from providing services to those not likely to benefit;Efficient: avoiding waste, including equipment, supplies, ideas, or energy;Safe: avoiding injury,Patient-centered: respectful and responsive to patient preferences, needs, and values;Timely: reducing waiting and delays for those that give and receive care; andEquitable: care which does not vary according to gender, ethnicity, geographic location, or socioeconomic status .The Institutes of Medicine (IOM) quality domains and Donabedian quality attributes are two generally accepted frameworks for health service performance measurements. IOM recognized six areas of improvement which are needed in response to inconsistent care across a rapidly changing health system . The sixThe IOM included recommendations for a system redesign to include the development of measures for assessing quality of care .Structure measure: material resources; facilities, equipment, human resources , and organizational structures (funding and reimbursement)Process measure: how healthcare is given and received as guided by policy, standards, and proceduresOutcome measure: the effect of care and its impact on the health status of patients and populationsOn the other hand, Dr. Avedis Donabedian believed that quality assessment should include three critical elements in healthcare delivery: structure, process, and outcome .StructuThe structure of quality healthcare delivery needs to be built upon the material resources such as facilities, equipment, human resources , and organizational structures . In turn, good structure increases the likelihood of good process, which includes how healthcare is provided and received through policy, standards, and procedures. The consequence of good structure and good process increases the likelihood of good outcome, effect of care, and health status of patients and populations .Knowledge of the linkage between the three elements needs to be known before quality assessment can be conducted . DonabedOutcome measure: “An assessment of the results of a program compared to its intended purpose”Output measure: “A tabulation, calculation, or recording of an activity or effort that can be expressed in a quantitative or qualitative manner”Impact measure: “A measure of the direct or indirect effect or consequence resulting from achieving program goals”Input measure: “A measure of the resources used to achieve an outcome ”As our combination of IOM and Donabedian quality framework has developed, other perspectives have emerged which further interpret these foundational criteria. These include further description of performance metric functions. Firstly, the US Government Performance Results Act 1993 (Section 2801)  outlinesProcess measure: a healthcare-related activity performed for, on behalf of, or by a patient  .Patient outcome measure: “a health state of a patient resulting from healthcare”  Secondly, the Agency for Healthcare Research and Quality (AHRQ) states clear differences between a process measure and a patient outcome measure , 33.ProFor example, hospital staff shortage may delay a patient discharge, or inadequate patient teaching may lead to a readmission which may not pertain to patient physiology, but potentially, the process of the hospital or health system .Indicators should be able to be measured either through qualitative or quantitative means.Indicators should be meaningful in that they reflect quality of care and are considered important by both the clients and providers of health services and that they reflect the quality of services provided.Finally, indicators need to be manageable. Service providers need to be able to influence them and improve them. They also need to be efficient: data collection as a byproduct of the services provided and is not costly to collect.Finally, there is a pragmatic consideration in the identification and development of performance criteria. They must be measureable, meaningful, and manageable .IndicatThese conceptual understandings help to create a combined framework which identify and evaluate the range and nature of air ambulance outcome measures of quality care.The aim of this review will be to identify and evaluate the range and nature of air ambulance outcome measures reported in the literature and to construct a quality dashboard based on a sound conceptual framework.What range of outcome measures are used in air ambulance literature?What measurement instruments or tools were used to identify air ambulance quality of care?Which air ambulance performance outcomes are utilized in our refined quality framework?Can our quality framework create a performance dashboard for strategic improvement?The review will aim to address specific research questions:The PICO question is (P) patients critically ill or injured, (I) which require flight in a dedicated air ambulance, (C) we will not use comparison, and (O) air ambulance service outcome measures, constructed in a combined Institutes of Medicine and Donabedian quality dashboard.The review protocol has been registered within the International Prospective Register of Systematic Reviews (PROSPERO) ID no. CRD42019144652 and is being reported in accordance with the reporting guidance Preferred Reporting Items for Systematic Review and Meta-Analyses Protocol (PRIMSA-P) statement  , multi-cultural, all levels of socioeconomic, and national/country of origin contexts.The selected population (P) will include studies involving children, adolescents, and adults who are critically ill or injured (regardless of age or sex). The service intervention (I) we are considering are the following: patients which require flight on dedicated air ambulance missions/tasks , all aircraft type (helicopter/rotor-wing or fixed-wing), and crew mix . The outcome (O) is first, to identify the range of air ambulance service outcome measures and their metric instruments represented in the literature, and second, to create a quality dashboard using a combined IOM and Donabedian framework, relevant to patients, providers, and policy-makers for future service improvement and planning.Studies will be limited to articles published in English (from January 2001 onwards). These dates were chosen to coincide with the International Civil Aviation Organization (ICAO) recognition of new approaches to civil aviation safety risk and quality concerns in 2001 . ExclusiThe PubMed search strategy will use relevant Medical Subject Headings (MeSH) terms  will independently examine study titles and abstracts following the PRISMA process. Screening will be managed in an Excel spreadsheet in descending chronological order of publication year and include complete citation. The authors will screen all citation titles and abstracts according to the selection criteria following the PRISMA process. The authors will record results with a colored Excel cell code and label extraction process. The cell color green means “yes,” red color cell “no,” or yellow color cell “maybe.” The authors will obtain full-text articles for potential relevance and then examine for eligibility. The authors will then assess and discuss the result for agreement. A third author will be included in the event of unresolved discrepancies. The authors will attempt to contact study authors in this event, to resolve uncertainties. Two authors will independently extract study data using a piloted form  : “An assRisk of bias quality will be assessed using ROBIS (risk of bias in systematic reviews)  and the Authors will summarize search results in a PRISMA study flow diagram  and by nA subgroup or sensitivity analysis will not be undertaken in this review. The aim of the review is to identify and evaluate the range of air ambulance outcome measures reported in the literature, not to test the change effect of parameters.Publication bias will not be explored in this review, as the aim of the review is to identify the air ambulance outcome measures and tools, not the positive or negative results of outcomes.Performance quality is able to be measured on many levels within the air ambulance health service: the frontline health providers, individual patient outcomes, the support systems , organizational structures , governance, and legislation. We acknowledge that quality is a challenging construct to define and measure in highly heterogenous, complex and interconnected emergency medical systems –48. Howehttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019144652.We acknowledge potential limitations of the review. These may include study inconsistencies in data collection and recording methods of critical information in the pre-hospital setting, such as field vital signs or response time . StudiesIn summary, dedicated air ambulance services provide a vital link for critically ill and injured patients to higher levels of care. The recent developments in modern emergency medicine create an opportunity for air ambulance providers and policy-makers to utilize a dashboard of quality performance measures. Our systematic review contains the first step toward the development of an air ambulance quality dashboard, designed to combine frameworks of the Institutes of Medicine and Dr. Avedis Donabedian and further refined using the Agency for Healthcare Research and Quality and the US Government Performance Results Act 1993, which aims to provide a basis for strategic health service planning.Additional file 1. PRISMA-P 2015 Checklist.Additional file 2. Medical Subject Headings (MeSH) terms.Additional file 3. Review of selected article format.Additional file 4. Risk of bias in systematic review using ROBIS sample.


In recent years there has been an increasing use of satellite Earth observation (EO) data in dengue research, in particular the identification of landscape factors affecting dengue transmission. Summarizing landscape factors and satellite EO data sources, and making the information public are helpful for guiding future research and improving health decision-making. In this case, a review of the literature would appear to be an appropriate tool. However, this is not an easy-to-use tool. The review process mainly includes defining the topic, searching, screening at both title/abstract and full-text levels and data extraction that needs consistent knowledge from experts and is time-consuming and labor intensive. In this context, this study integrates the review process, text scoring, active learning (AL) mechanism, and bidirectional long short-term memory (BiLSTM) networks, and proposes a semi-supervised text classification framework that enables the efficient and accurate selection of the relevant articles. Specifically, text scoring and BiLSTM-based active learning were used to replace the title/abstract screening and full-text screening, respectively, which greatly reduces the human workload. In this study, 101 relevant articles were selected from 4 bibliographic databases, and a catalogue of essential dengue landscape factors was identified and divided into four categories: land use (LU), land cover (LC), topography and continuous land surface features. Moreover, various satellite EO sensors and products used for identifying landscape factors were tabulated. Finally, possible future directions of applying satellite EO data in dengue research in terms of landscape patterns, satellite sensors and deep learning were proposed. The proposed semi-supervised text classification framework was successfully applied in research evidence synthesis that could be easily applied to other topics, particularly in an interdisciplinary context. According to the World Health Organism (WHO), dengue affects over half of the global population, with an estimated 100–400 million infections each year worldwide .Aedes habitats, referring to dengue vectors. Moreover, our previous mapping review [The spatial concentration and diffusion of dengue vectors/cases can be affected by weather conditions and landscape factors  at different spatial scales  ,4,5. Theg review  focused Information updates can be simply conducted by re-running the process of review, which would mainly include defining the research question, searching for and removing duplicates, title abstract screening, full-text eligibility and inclusion ,11. HoweIn this context, focusing on landscape factors affecting dengue transmission and satellite EO data currently used for identifying landscape factors, this study proposes to build a semi-supervised classification framework of literature by integrating the review process and text classification algorithms and provides an overview of dengue landscape factors and satellite EO data. The proposed framework allows for rational and effective selection of literature relevant to our objective from bibliographic databases.The framework of semi-supervised text classification integrating the review process and semi-automatic text classification , includeTo implement the text scoring in step 3, it is necessary to remove the records that are definitively irrelevant to our topic, which also reduces the amount of data for the BiLSTM-based active learning in step 4. It should be noted that the BiLSTM model was developed and implemented based on titles and abstracts that are different from the full-text assessment in the eligibility step of the review. The detailed information is presented hereafter and no ethics approval is needed as this method is based on published journal articles.The objective of this study is to provide an overview on landscape factors related to dengue transmission and satellite EO data used in the identification of dengue landscape factors. Relevant records should satisfy the following criteria: (1) being an original journal article published in English; (2) highlighting landscape factors derived from satellite EO data or geographic information system (GIS) techniques; (3) being applied to dengue cases or dengue vectors; (4) modelling or correlating dengue with landscape factors. These were defined based on our objective and expert knowledge, and were used for text scoring and record sample selection for BiLSTM models.Aedes) and the words related to “remote sensing”, “landscape” and “weather”  using the Boolean operator “AND”  and their priority levels   from the interval of weights that was set according to its priority level. The higher the priority level of a term, the greater its weight value. We then extracted the key terms Kj  and their corresponding weight values Wj  from the title and abstract using the Natural Language Toolkit (NLTK) in Python. If Kj contains pre-set terms in KEYi, we calculated the score of a record as Score = To efficiently eliminate the definitely-irrelevant records, we used text weighting and text scoring for ranking all the records. First, we pre-set some terms KEYand low)  accordink. Finally, we iterated the second step 20 times, and the records in the 20 subsets Uk  were combined together, and were used for the next analysis. It should be noted that random assignment of weights allows multiple iterations of text scoring that should make the results more reliable.All the records were then ranked in decreasing order according to the scores, and the top 1000 records were selected and merged into a subset denoted as UTo efficiently and accurately select relevant records in the absence of sufficient labelled samples, we performed a BiLSTM-based active learning based on the titles and abstracts of the records derived from text scoring .Prior to training the BiLSTM model  charting the dengue landscape factors and their typologies in order to appraise the current situation, regardless of the differences in study areas, methods and materials; (2) tabulating the key characteristics of satellite EO data.Moreover, the accurate and rational identification of relevant records can be indicated by the following two facts. First, no relevant records were found by manually evaluating the records selected randomly from the unlabelled dataset . This indicated a good performance of the semi-supervised text classification. Second, although each record probably received different scores in 20 text scoring experiments, the number of relevant records per score rank interval showed a consistent decreasing trend . This inThe accurate and rational identification of relevant records can be explained by the facts: (1) A clear topic was defined. In fact, modelling or correlating dengue epidemiological or entomological variables with landscape factors in different geographic contexts often includes the identification of landscape factors, landscape characterization and spatio-temporal analysis of dengue cases or vectors. This interdisciplinary topic provides evident features that meet the definition of appropriate inclusion criteria. These criteria then help to define terms and priority levels for text scoring and active learning. (2) The union of the results of 20 text scoring experiments enable the inclusion of potential records as much as possible, and greatly exclude the irrelevant records. (3) BiLSTM has proved to be especially useful in understanding the context of words , and actLand cover (LC) refers to the physical and biological cover over the land surface, including built-up areas, vegetation, water/wetlands, open land and savannah. Among them, vegetation often has an association with the vectors’ behaviours and biological cycles, which could be linked with the spatial and temporal dynamics of vectors or the potential resting and breeding sites. Water and wetlands often provide information of places of stagnant water, which are potential breeding sites for dengue vectors.Aedes encounters, dispersal of mosquitoes and people movement, which are significantly related to dengue epidemics.Land use (LU) refers to a territory characterized by current and future planned functional or socio-economic purposes, including agricultural areas, commercial areas, construction areas, industrial areas, ponds, religious areas, residential areas, transport, unused areas, urban areas and rural areas. LU types not only indicate whether the areas are favourable to vector breeding, but also provide information of human behaviour and activities in the areas, the levels of human–Topographic factors may provide a proxy of habitat suitability or climate conditions, including elevation, aspect, slope, drainage network, and flow accumulation.Spatially continuous land surface features include spectral indices of vegetation, water and built-up areas , enhanced vegetation index (EVI), vegetation fraction index (VFC), normalized difference water index (NDWI), and normalized difference built-up index (NDBI)). Moreover, land surface temperature (LST) refers to a measure of radiative skin temperature of the land surface, which is a significant factor affecting the dengue transmission.Due to the different study objectives, study areas and spatio-temporal scales, it is difficult to compare the 101 selected studies to find any underlying common viewpoints on the role of landscape factors in dengue transmission. The detailed landscape factors for each study are listed in Among the 101 included articles, only 64 studies used satellite EO data. Although satellite EO sensors and products are pointed out, we do not explain what should be considered while choosing satellite EO data, and making effective use of them. This is an important issue, especially for non-specialized users. Hamm et al.  proposedMore in-depth landscape features  could be explored in future studies. Our previous studies characterized forest/non-forest landscapes by computing various landscape metrics and established their links with malaria cases for understanding the contribution of Amazon deforestation on human–vector contact ,29. We fLU/LC mapping has continued to be an important research area in recent years, in particular urban LU/LC mapping. Gong et al.  proposedMore recently, one study extracted landscape features  from high resolution satellite EO data using CNN models and transfer learning, and added them into time series prediction of dengue outbreaks based on weather data and population density for improving the performance of prediction . This woAedes breeding and resting sites, human–Aedes encounters, human mobility and virus replication in dengue transmission. Moreover, future research directions on how to integrate satellite EO data in dengue research were proposed in terms of landscape patterns, satellite sensors and deep learning. This study is an important step towards an efficient method for research evidence synthesis that could be easily applied to other topics, particularly in an interdisciplinary context.Satellite EO has been increasingly used in dengue research over the past years, especially for the identification of dengue landscape factors. During that time, various types of landscape factors were considered while the study areas and research objectives have become more complex, and the variety and volume of satellite EO data have been growing over these years. There is an increasing need to know what dengue landscape factors have been studied and what dengue landscape factors have been derived from satellite EO data during the past years. In this study, by integrating the review process, AL mechanism, text scoring and BiLSTM model, we propose a semi-supervised text classification framework that enables the efficient evaluation of bibliographic records derived from bibliographic databases and accurately selects the articles relevant to the research objective. In this study, 101 relevant articles were efficiently selected from bibliographic databases using the proposed approach. Among them, 64 articles used satellite EO data. Valuable information on dengue landscape factors and current satellite EO data was reported. A catalogue of essential dengue landscape factors were identified that were divided into four categories: LU, LC, topography and continuous land surface features. These factors were considered as the direct or indirect proxies of