Toll-based congestion pricing (CP) policies are increasingly implemented globally for alleviating road traffic congestion. Several interconnected factors affecting or induced by CP implementation include air quality/emissions, travel time, and road user safety. We sought to examine and characterize research output and patterns across several domains  surrounding toll-based CP policies, in order to identify where research has focused and where gaps exist. We conducted a structured review and identified 2333 relevant publications, using semi-supervised and machine learning strategies combined with manual review. Annual publication counts peaked in 2015 (n = 122). Themes identified from title and abstract terms included policy implementation characteristics, advanced transportation modeling methods and approaches, and public perception and acceptability. Authorship networks indicated a lack of interdisciplinary research. Country analyses identified the US, China, and the UK as the most frequently represented countries, and underrepresentation from low-income countries. Findings indicate that research focused on specific road user types  and safety impacts, and equity considerations were relatively sparse compared to other topics . Additional research on these critical topics is necessary to ensure that such policies are designed to promote positive and equitable effects on road user health and safety. Congestion pricing (CP) is a growing international trend for mitigating road traffic congestion in major cities. CP policies are strategies that work by financially encouraging traffic shifts  that ease congestion in high traffic areas, particularly in urban centers . ResearcWhile CP policies include a variety of approaches, toll-based policies  lanes) are the most widely used. Toll-based policies are generally grouped into the following categories: 1) variably-priced lanes , (2) variable tolls on entire roadways , (3) zone-based or cordon charges (charges to enter or drive within a certain region), and 4) area-wide or system-wide charges (per-mile or per-kilometer charge for travel within a certain region) [ variably area-widProviding a comprehensive examination of which CP policy facets have been studied, when, and by which countries can illuminate the current landscape of research for countries or cities considering initial implementation or refinement of their policies. Although systematic reviews of CP policies have been published, they have focused on specific aspects or consequences of policies in isolation  ,6,7,8. OBibliometric analysis is an innovative and effective tool for examining the breadth of publications over time relevant to a focused research topic and can help identify patterns and trends in research output ,  highlighThe purpose of this study was to examine and characterize research output and patterns surrounding toll-based CP policies, using novel bibliometric methods, to inform future international research efforts. This paper is organized into the following sections: material and methods, results, discussion, and conclusions.To summarize and characterize the current and historical landscape of CP policy research, we conducted a structured search and bibliometric analysis. We searched the following transportation, health, and social science-related databases from their dates of inception through a final search date of 7 February 2021: Transport Research International Documentation (TRID), Web of Science, PubMed, and Scopus. TRID, which includes US and international research, is maintained by the Transportation Research Board (TRB) and sponsored primarily by state and federal (US) Departments of Transportation. TRID includes both publications from peer-reviewed journals and research reports. PubMed is a database of biomedical literature and is maintained at the US National Library of Medicine (NLM) and by the National Center for Biotechnology Information (NCBI), part of the National Institutes of Health (NIH). Web of Science and Scopus are large scholarly research databases that include peer-reviewed literature from around the world and across disciplines, including the sciences, social sciences, and humanities.The search strategy for each database included many keywords describing CP policies, such as “congestion pricing”, “congestion fees”, “zone-based pricing”, “road user charges” and “toll schemes” (see full list in Publications were included if they 1) were either published in peer-reviewed journals or if they were published as reports; (2) contained, at minimum, an abstract or summary in English; and (3) examined a road or traffic-related CP toll-related policy. As defined by the US Federal Highway Administration, CP “is a way of harnessing the power of the market to reduce the waste associated with traffic congestion and works by shifting purely discretionary rush hour highway travel to other transportation modes or to off-peak periods…” [ were eitwww.covidence.org, accessed 7 February 2021), an online screening tool that facilitates bibliometric and systematic reviews, to screen publications. We prioritized publications for manual screening using a two-phase, automated approach that relied on semi-supervised learning and machine learning. We conducted both phases using DoCTER software (Document Classification and Topic Extraction Resource) . DoCTER applies algorithms to text with publication titles and abstracts.The publication selection process included a series of manual and automated steps, described in To complete the first phase, we imported a random sample of 250 publications into Covidence, and two researchers screened them to identify a set of known relevant publications, or “seed” publications. We identified 35 seed publications, which we then used for supervised clustering in which the remaining corpus of publications were grouped with the seed publications. Those clusters containing a higher number of seed publications are expected to be highly relevant . DoCTER’In the second phase, we used machine learning to prioritize those publications with an ES of 1–2 from the first phase. Publications with an ES of 0 were deemed irrelevant and removed from our analysis. We used a set of included and excluded publications from those publications we manually screened in the first phase for training data in this second phase. Through machine learning, DoCTOR provided a probability score for each publication, and we manually screened publications in Covidence with the highest probability scores in batches of 500 until relevance dropped off (probability score of 0.421).Networks were constructed using the VOSviewer application , based on available data fields in the four databases. All publications were included in network maps describing the distribution of and relationships between key terms, and frequency of publications and collaborations between authors. Only those publications in Scopus were used to construct network maps based on authors’ country or territory (due to availability of this field). In all maps, size of each node represented the number of publications, and lines between and proximity of nodes reflect the relative connectivity (frequency of connection) between those nodes.https://cdr.lib.unc.edu/, accessed on 10 April 2022). Network maps can be viewed either in the VOSViewer desktop client or the VOSViewer web interface .Key terms were used to evaluate topic networks. Terms were identified from the title and abstract fields of every publication. Authors reviewed identified terms, consolidated where appropriate , and removed non-topic terms . The resulting list was used to create the final visualizations, including a network map with common clusters of terms (for terms that appeared at least 10 times) and a map with a time overlay for identifying patterns of terms used over time. A similar strategy was used for authorship, where the list of authors was reviewed and consolidated where appropriate. The network map was used to identify author productivity and collaborations, and the map with a time overlay was used to identify patterns of authorship collaboration over time. Finally, the Scopus-only country maps, where ‘country’ was based on co-author countries or territories, were similarly developed to identify collaboration clusters and publications patterns over time. Interactive versions of all network maps included in this paper and the The overall screening strategy followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA ) guideliThe earliest publication included in the analysis was from 1956. The annual publication count remained under 20 until 1990 and was highest in 2015 (n = 122). About 87% of the publications (n = 2029) came from peer-reviewed journals, while the remainder were reports (n = 304). The five sources with the greatest number of relevant publications were Transportation Research Record, Transportation Research Part A, Transportation Research Part B, Transport Policy, and Transportation.Collaboration networks for authors and research organizations from publications meeting a threshold of at least three publications are depicted in Patterns in country or territory  representation were only available for publications indexed in Scopus (n = 1380) and are displayed with a time overlay in We conducted a structured review and bibliometric analysis to understand the scope of existing literature on toll-based CP policies across several domains . The annual number of publications grew significantly between 1956 and 2015, with annual research output increasing from just 1 in 1956 to 122 in 2015. A wide variety of topic areas were studied, including CP implementation logistics, public perception and acceptability, and network algorithms and advanced modeling techniques. Analysis of authorship networks identified a large number of network clusters collaboratively studying a wide range of topics, including factors affecting implementation , modelling/simulation approaches to understand network dynamics and examine specific features of CP policies , and impacts of CP policy implementation . Finally, analysis of country representation revealed notable shifts in research output across the globe as countries explored CP policy implementation, with early research productivity in the United Kingdom, moving to the US , and eventually countries such as China, Germany, and Iran. Overall, more and more countries were represented with each passing year.Analysis of title and abstract terms identified patterns of research focus. We anticipated some terms would be highly prevalent, such as ‘network’, ‘high occupancy toll’, and ‘algorithm’ and found this to be the case. The high frequency of ‘network’ and ‘algorithm’ align with themes identified from publications by top contributors in this analysis, many of whom conducted multiple simulation-based studies to assess potential CP policy effects. The frequency of ‘high occupancy toll’ may reflect the prevalence of this policy in the US, which has the greatest publication representation in this study. Specifically, HOT lanes have been widely considered in the US due to their ease of structural implementation  and high levels of public support ,17. NotaSeveral topic gaps were identified in this analysis. First, CP policies can place a sudden, significant, and disproportionate burden on commuters, yet terms related to equity were only in a small proportion of titles and abstracts. For example, vehicle users may be faced with daily charges for a commute they may not be able to afford or may extend driving travel times that can burden not only vehicle users but also their families. Second, terms relevant to specific road user types and modes , bicycle (ist)) and terms related to safety were extremely sparse in titles and abstracts, yet these are extremely important aspects of CP policies, which encourage travelers to change their route choices, commute patterns, and departure times. Individuals may shift to more affordable modes of transportation such as public transit and motorcycles , or shift to non-motorized modes of transportation  . ResultiCP and other road safety strategies impact numerous domains  and as such will be most successful when designed and implemented with input from individuals with different areas of expertise, such as urban planning, engineering, politics/government, and public health. The analysis of authorship and collaboration networks highlighted the high productivity of not only individual researchers (often from academic institutions) but also major transportation organizations such as the Transportation Research Board and the Federal Highway Administration; yet few organizations from other fields were identified. New interdisciplinary perspectives could enrich future research on CP policies, particularly when addressing the previously mentioned gaps of equity, safety impacts, and specific road user types. Additionally, successful implementation of CP policies requires thoughtful consideration of community needs and evolving technology; however, publications describing community research as well as new technology  were relatively lacking.Analysis of countries represented in the publications from Scopus indicated that research output appeared to roughly align with CP policy planning and implementation. For example, London implemented their first CP policy in 2003 followed by policy modifications in later years, corresponding with an average publication year of 2005 for United Kingdom-based research output ,26. AddiThis study provided a comprehensive examination of research on toll-based CP policies by tapping into four large databases of scholarly literature with no limitations placed on date of publication. Few restrictions were placed on inclusion . Still, the requirement that at least a summary or abstract of the article needed to be available in English may have resulted in the exclusion of topically relevant publications. Additionally, the screening approach was semi-automated and included use of novel machine learning techniques, which streamlined review of a large number of publications for inclusion in the bibliometric analysis. The analytic methods used in this study included network maps with cluster visualizations, which provided a unique way of looking at publication patterns and trends and the relationships that exist within the published literature. However, the types of patterns examined were restricted by field types available in the four databases. For example, the assessment of author/research collaboration networks was based on author fields of publication citations in each database, which is based on the citation of that publication and may include both individual authors and institutions. In particular, analysis of country representation and collaborations was restricted to those publications available in Scopus only and based on the country of the co-author affiliation, and therefore may not be representative of all publications in this study. Still, the analyses conducted provide valuable insights into the magnitude and distribution of toll-based CP literature. Next, the methods used in this study were designed to give a comprehensive picture of existing toll-based CP literature; therefore, in our analysis of title and abstract terms, we conservatively eliminated only terms that objectively provide no useful information, such as ‘and’, ‘the’, and ‘but.’ Finally, inclusion of non-toll-based CP policies  was beyond the scope of this review and analysis.Cities and countries considering CP policies are currently predominantly using toll-based policies; however, future reviews should explore emerging research on non-toll-based policies. While this study sought to understand the breadth of existing toll-based CP literature, future research may focus on specific sub-topics, particularly those that address research gaps identified by this study. Future research should also include multi-disciplinary and international collaborations to assess specific impacts of CP policies on different road user types, particularly vulnerable road users , examine the safety impacts of these policies, and evaluate whether the impacts of these policies are equitable for all individuals affected by CP policy.CP policies have been developed, evaluated, and implemented as a method for managing increased urban traffic congestion. A large body of research, spanning multiple decades, has been published on toll-based policies, as evidenced by the number and distribution of publications identified and analyzed in this study. Findings indicate that relatively low proportions of existing CP publications address equity and health impacts. These aspects are critical for a number of health , safety , and ethical  reasons, and they play an important role in public acceptability—which can serve as a key facilitator or barrier to successful policy implementation. Future research efforts should leverage multidisciplinary expertise and prioritize addressing these gaps to support evidence-based policy implementation in urban city centers.


To compare the application value of dynamic enhanced magnetic resonance imaging (MRI) and ultrasonic diffused optical tomography (DOT) in early diagnosis of breast cancer. n = 50) and breast cancer group (n = 60) according to the pathologic findings. All patients received dynamic enhanced MRI and ultrasonic DOT examinations for the observation of lesion morphology and analysis of relevant parameters, so as to scientifically evaluate the diagnostic value of dynamic enhanced MRI and ultrasonic DOT for early breast cancer.  The clinical data of 110 female patients with breast diseases treated in our hospital from June 2018 to June 2021 were selected for the retrospective analysis, and the patients were divided into the benign lesion group (P < 0.05); parameters such as Ktrans, Kep, and Ve were significantly higher in the breast cancer group than in the benign lesion group (P < 0.05); the ultrasonic DOT diagnosis found that the THC value was obviously lower in the benign lesion group than in the breast cancer group (P < 0.05); compared with the pathologic findings, it was believed that combined diagnosis had significantly higher diagnosis accuracy rate, sensitivity, specificity, positive predictive value and negative predictive value than the dynamic enhanced MRI and ultrasonic DOT diagnosis alone (P < 0.05); and after further analyzing the efficacy of the two diagnosis modalities in diagnosing early breast cancer by ROC curves, the result showed combined diagnosis > dynamic enhanced MRI > ultrasonic DOT.  The dynamic enhanced MRI examination found that the proportions of irregular shape, increased vascular shadow, obscure boundary, spicule sign, heterogeneous enhancement, etc. of lesion were significantly higher in the breast cancer group than in the benign lesion group ( Both dynamic enhanced MRI and ultrasonic DOT present higher diagnostic value to early breast cancer, of which dynamic enhanced MRI obtains results closer to the pathologic findings and has diagnostic efficacy higher than ultrasonic DOT. But the combination of the two can significantly improve the diagnosis accuracy rate for early breast cancer, presenting higher diagnostic value. According to the survey data of the International Agency for Research on Cancer (IARC) in 2018, the incidence of breast cancer ranks first among female cancers, which accounts for 24.2% of the global female cancer incidence . The earn = 50) and breast cancer group (n = 60) according to the pathologic findings. The study met the World Medical Association Declaration of Helsinki  and , the items included were enumeration data and measurement data, which were expressed by [P > 0.05). See No statistical differences in patients' general data including age, BMI, tumor diameter, histological grade, and number of masses were observed (P < 0.05); and parameters such as Ktrans, Kep, and Ve were significantly higher in the breast cancer group than in the benign lesion group (P < 0.05). See Tables The dynamic enhanced MRI examination found that the proportions of irregular shape, increased vascular shadow, obscure boundary, spicule sign, heterogeneous enhancement, etc. of lesion were significantly higher in the breast cancer group than in the benign lesion group (P < 0.05), with statistically significant difference.According to P < 0.05).According to the statistical results in Tables After further analyzing the efficacy of the two diagnosis modalities for diagnosing early breast cancer by ROC curves see , the resP value, when the corresponding value of sig. was less than 0.05 (significance level), it indicated that the regression equation was statistically significant, that is, there was a linear relationship between the independent and dependent variables.Sig. referred to the P < 0.05), and according to the comparison with pathologic findings, ultrasonic DOT diagnosis obtained an accuracy rate of 80.91%, sensitivity of 83.33%, specificity of 78%, PPV of 91.97%, and NPV of 79.59%, which was consistent with the report by Makela and Foster [An important step in tumor cell growth and metastasis is the formation of new blood vessels, and malignant tumors are able to further stimulate the production of new capillaries with angiogenic growth factors, which in turn increase local blood volume and hemoglobin content to meet the growing and metabolic demands of tumor cells , 16. Thed Foster  further P < 0.05), which confirmed the more uniform distribution of tumor morphology and margin characteristics in benign tumors than in malignant tumors, demonstrating the specificity in breast cancer lesion morphology. However, previous studies pointed out that with the increase of early examined cases, a certain proportion of cancer cell lesions with uneven growth do not fully reflect the gross morphology, so the possibility of breast caner cannot be excluded by typical round-like morphology and smooth margin characteristics.The high spatial resolution and contrast of MRI for soft tissues are also superior to other imaging tests, and dynamic enhanced MRI can detect tiny and multiple lesions that are not easily visualized while not being affected by the degree of density of glandular tissue, which provides lesion information by establishing structural relationships of morphology, boundaries, signal intensity with surrounding tissues. Shalin et al.  reportedKtrans, Kep and Ve were significantly higher in the breast cancer group than in the benign lesion group (P < 0.05), indicating that Ktrans, Kep, and Ve could provide a strong reference for early diagnosis of breast cancer. Dynamic enhanced MRI enables clear visualization of lesion morphology and surrounding vascular shadow, and quantitative analysis of vessel structure and function by injecting contrast agent to observe its diffusion pattern among capillaries and lesions and then reflecting the enhancement characteristics of tumor lesions and calculating parameters such as Ktrans, Kep, and Ve. Compared with pathological findings, dynamic enhanced MRI also showed high diagnostic efficacy, but considering the high cost of this method, clinical promotion should be carried out based on local medical and economic levels.Tumor tissue has a good environment of blood flow supply to meet its efficient energy metabolism and supply and provide nutrition delivery, immune regulation inhibition, metabolite exclusion and cytokine secretion, and therefore, the state of angiogenesis often determines the malignant biological behaviors such as tumor growth, infiltration and metastasis , 21. DynP < 0.05); by further analyzing the efficacy of the two diagnosis modalities in diagnosing early breast cancer by ROC curves, the result was combined diagnosis > dynamic enhanced MRI > ultrasonic DOT. Ultrasonic DOT, which effectively combines optical technology with acoustic technology, and can directly obtain the functional information of tissues with convenient operation and no need for intravenous contrast. In addition, it can also carry out comprehensive evaluation of structural information and functional information of lesions, which is a beneficial supplement to the field of modern medical imaging relying solely on morphology to tumor diagnosis, and in particular, presents a potential warning value in atypical hyperplasia. Dynamic enhanced MRI has good accuracy, sensitivity and specificity for breast disease. However, it is complex, expensive, and time-consuming, and requires venography to obtain accurate information of lesions, so it is not recommended as the first choice for early breast cancer screening, but can be used as an important supplement to breast cancer diagnosis and effectively combined with ultrasonic DOT to increase the rate of clinical diagnosis of breast cancer.After respectively comparing the diagnostic results of dynamic enhanced MRI and ultrasonic DOT with the pathologic findings, it was believed that combined diagnosis had significantly higher diagnosis accuracy rate, sensitivity, specificity, PPV and NPV than the dynamic enhanced MRI and ultrasonic DOT diagnosis alone (The shortcomings of this study: (1) It was a retrospective analysis study, thus there may be selection bias and recall bias; patients' data were limited; and relative risks could not be analyzed directly. (2) The sample size was small, so the examination efficacy may not be achieved.In conclusion, both dynamic enhanced MRI and ultrasonic DOT have high diagnostic values for early breast cancer, in which dynamic enhanced MRI obtains results closer to pathologic findings, and has diagnostic efficacy higher than that of ultrasonic DOT. However, the combination of the two can significantly improve the diagnostic accuracy of early breast cancer and has higher diagnostic value, so it is suggested that ultrasonic DOT should be considered as the primary screening method for early breast cancer in the clinic, supplemented by dynamic enhanced MRI.


In 2020, over 1,089,000 new cases of GC and approximately 769,000 GC-associated new deaths were estimated worldwide  ranks 5orldwide . Notablyorldwide .via individualized routes.This Research Topic, which has collected six high-quality original researches, aimed to highlight some of the novel emerging advancements pertaining to chemotherapy for GC, as well as the ways that physician scientists help patients with GC receiving chemotherapy by streamlining the treatment, and by delivering the drugs Chen et al. explored the risk factors and prognostic impacts of delayed (>60 days after resection) or omitted adjuvant chemotherapy, which may be unacceptable, in resected TNM stage II-III GC by retrospectively analyzing data of 1520 patients undergoing radial gastrectomy, and demonstrated that delayed or omitted postoperative chemotherapy was significantly associated with inferior overall survival (OS) and disease-free survival (DFS). Various factors associated with delayed or omitted adjuvant chemotherapy were further revealed, including female sex, old age, history of intraabdominal surgery, serious postoperative complications, etc. These data call for further standardization of GC care.Adjuvant chemotherapy may need to be administered timely in patients with resected GC upon recovery of performance statuses ; Chen etTao et al. analyzed the associations between PNI and efficacy of fluoropyrimidine (FU)-based adjuvant chemotherapy in patients with radically resected stage IB-III GC from two independent retrospective cohorts. Both univariable and multivariable analyses showed that adjuvant chemotherapy was significantly associated with both enhanced OS and DFS only in PNI-positive cases irrespective of cancer stages, but not in PNI-negative ones. For the underlying mechanisms, the authors  chemotherapy and the related adverse events were associated with the risk of postsurgical complications. The authors found that preoperative comorbidities, clinical T4b stage, and more cycles (5-6 vs 3-4) of preoperative chemotherapy were independent risk factors for more frequent postoperative complications, while the presence of preoperative SOX chemotherapy, neoadjuvant chemotherapy-associated adverse events, or their severity was not significantly associated with the occurrence of postsurgical complications.In patients with resectable advanced GC undergoing resection, adverse events associated with neoadjuvant chemotherapy may have an impact on postsurgical complications; during exploration of the safety of neoadjuvant chemotherapy for GC, Feldbrügge et al. for the first time retrospectively evaluated the safety of systemic chemotherapy (with or without the VEGFR2 antagonist ramucirumab) combined with pressurized intraperitoneal aerosol chemotherapy (PIPAC), a local chemotherapy method using the laparoscopic technique, for GC with peritoneal metastasis. Ramucirumab may cause wound healing problems, while the authors found that the addition of ramucirumab to systemic chemotherapy before PIPAC did not increase the risk of postoperative adverse events, regardless of the length of the treatment-free interval before PIPAC , and was thus a safe alternative for the management of GC with peritoneal metastasis , and demonstrated the safety, feasibility, and efficacy of AIC for NGAS after esophagectomy. Further prospective and randomized evidence is needed to confirm the findings.After removal of esophageal cancer, neoplastic gastroesophageal anastomotic stricture (NGAS) is a highly clinically challenging condition. Together, this Research Topic has included interesting and important publications –18 addreIn this era of precision and targeted medicine, future researches may need to focus more on forefront aspects including the application of advanced techniques using artificial intelligence for more personalized prediction of net benefits and noteworthy side effects associated with chemotherapy, novel treatment modalities including immune cell therapies  and treatment based on innovative antibody drug conjugates  , utilizaConception or design: LH and YS. Acquisition, analysis, or interpretation of data: LH and YS. Drafting of the manuscript: LH. Critical revision of the manuscript for important intellectual content: LH and YS. Administrative, technical, or material support: LH and YS. Both authors have approved the current version of the manuscript for submission and publication.Our study was supported by Shanghai Pujiang Program (21PJ1409700), and the Start-up Fund for the Introduction of High Level Talents by Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. The funders had no role in study design; in the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Taxation of tobacco, food, alcohol and other beverages has gained renewed attention in responding to non-communicable diseases (NCDs). While largely built on evidence from high-income countries (HICs), the projected economic and health benefits of these measures have increased calls for their use in price-sensitive low- and middle-income countries (LMICs). However, uptake has been sporadic and there remains little research on why and how LMICs utilise fiscal measures in response to NCDs. Methods: This scoping review analyses factors influencing the design and implementation of health-related fiscal measures in LMICs. Utilising Arksey and O’Malley’s scoping review methodology and Walt and Gilson’s policy triangle, we considered the contextual, procedural, content and stakeholder-related factors that influenced measures.Results: We identified 75 papers focussing on health-related fiscal measures, with 47 (63%) focused on tobacco, 5 on alcohol, 6 on soft drink and 4 studies on food-related fiscal regulation. Thirteen papers analysed multiple measures and most papers  were less than a decade old. Key factors enabling the design and implementation of measures included localised health and economic evidence, policy championing, inter-ministerial support, and global or regional momentum. Impeding factors encompassed negative framing and retaliation by industry, vested interests and governmental policy disjuncture. Aligning with theoretic insights from the policy triangle, findings consistently demonstrated that the interplay between factors – rather than the presence or absence of particular factors – has the most profound impact on policy implementation.Conclusion: Given the growing urgency to address NCDs in LMICs, this review highlights the need for recognition and rigorous exploration of political economy factors influencing the design and implementation of fiscal measures. Broader LMIC-specific empirical research is needed to overcome an implication noted in much of the literature: that mechanisms used to enact tobacco taxation are universally applicable to measures targeting foods, alcohol and other beverages. Research analysing the economic implications of fiscal measures is vast. However, the health literature in this space is concentrated on predictive forecasts and, to a lesser but growing extent, empirical ex post studies focused on high-income countries (HICs).30 Sassi et al,31 Sornpaisarn et al32 have begun to demonstrate the economic impact of fiscal measures in LMICs specifically. While Bump and Reich’s 2013 analysis of tobacco-specific fiscal measures provided one of the earliest political economy examples.33 This paper highlighted the important but under-researched articulation of the influence of political and economic dynamics on policy adoption. More recent work includes Wright and colleagues’ study reviewing global harmful commodity tax measures25; Hagenaars and colleagues’ work on policy content and policy context of energy dense food and sugar-sweetened beverage taxation in 13 (majority HIC) case studies24; and Bridge and colleagues’ overview of LMIC’s experiences in implementing soft drink specific fiscal measures.34 Building on these examples, but utilising a systematic scoping review and focussing on LMIC specifically, this paper aims to: (1) map evidence relating to policy content, stakeholder-related, procedural and contextual factor that shape harmful commodities focused fiscal measures; (2) identify points of convergence and divergence across the LMIC literature; and (3) compare LMIC specific findings with fiscal measures focused literature from HICs. Although still in its infancy, there is growing research interest in fiscal measures in LMICs. Studies by Nakhimosky et al,35 to identify, map and highlight potential gaps in LMIC policy process-relevant fiscal measures research. Detail on the application of the 5-stage framework, encompassing: (1) question identification, (2) study identification, (3) study selection, (4) data charting, and (5) collation and synthesis, is outlined below. This study utilised scoping review methods developed by Arksey and O’Malley35 The research question emerged through iterative exploration of the broad themes of ‘fiscal policy’ and ‘NCDs.’ Acknowledging the breadth of this domain, source and study selection sought to balance comprehensiveness with feasibility. Four databases  were searched using the key terms ‘health policy,’ ‘regulatory,’ ‘LMICs,’ ‘NCDs,’ ‘harmful commodities’ and their derivatives separated by the Boolean operator ‘AND’ for all except NCDs and harmful commodities where ‘OR’ was utilised to more comprehensively canvas relevant papers. We used broad search terms to capture additional fiscal measures content in research discussing policy responses to NCDs and their determinants more broadly. The full search strategy can be found in  Database searches returned 5047 papers, yielding 4669 original English works once duplicates were removed (March 2019). As represented in Figure, articles were then excluded sequentially by the first author in consultation with the third/senior author based on title, abstract and full text. Inclusion criteria centred on papers demonstrating a focus on LMICs and policy process while also exhibiting an explicit link between health and fiscal measures. Application of this criteria led to the exclusion of 3660 papers based on titles. More specific criteria were subsequently applied to abstract and full-text screening to identify papers that provided explicit accounts of agenda setting, design and implementation of fiscal measures. These criteria excluded non-empirical works and prevalence, predictive, experimental, and outcome/impact-focused studies. A summary of inclusion/exclusion criteria can be found in  Grey literature was also sourced through selected agencies: WHO, World Bank, and International Monetary Fund (IMF). The grey literature search strategy applied the same key words and inclusion/exclusion parameters as those used in the academic database search and was undertaken by the first author in consultation with the third author. Publication repositories and search functions on each website were searched first. However, acknowledging the often-limited functionality of these mechanisms, Google domain searches were also conducted. Most of the reviewed reports and publications were excluded given their prospective focus on the projected benefits of measures. A total of 12 grey literature publications were included. A final set of 75 papers, reports and book chapters were obtained for analysis through the combined database, grey literature and hand search strategies.36qualitative data analysis framework. Data familiarisation was undertaken by the first author by generating a list of key ideas covered by the 75 included papers. These ideas formed the basis for an initial codebook workshopped by the first and third author, found in 37 The first and third author reviewed these codes and considered the data in light of various theoretical frameworks. Walt and Gilson’s38 policy triangle was selected to further refine analysis. The policy triangle is derived from LMIC-specific policy analysis and has been used in similar studies, including those by Hagenaars et al24 and Downs et al.39 While acknowledging inevitable overlap, blurred boundaries and dynamic interaction between the domains of policy content, actors, process and context, it was selected given its ability to support the identification of diverse factors and dynamics influencing the design and implementation of fiscal measures. We conducted data charting, collation and synthesis using an iterative approach and following Ritchie and Spencer’s40 framework of situations, structural, cultural and international/exogenous factors.38 Coding summaries were produced and used to visually map findings; these maps supported interpretation and write-up, using both deductive and inductive reasoning. The first author undertook preliminary synthesis of thematic areas, followed by consultation and critical evaluation by the second and third authors to provide additional depth of analysis.  Recoding was undertaken utilising a refined codebook with codes pre-grouped corresponding with each policy triangle domain and, in the case of contextual factors, further refined by Leitcher’s41 low-income countries were the focus of just 2 papers. Nineteen papers (25%) focused on fiscal measures initiated in lower-middle income countries while 28 (37%) analysed upper-middle income countries. The remaining 26 papers (35%) made comparisons across multiple countries with varying socioeconomic statuses. Geographically, Asia (n = 21) and Africa (n = 20) were the predominant regions of focus. South and Central America (n = 10) and the Pacific (n = 6) also featured prominently. While just 2 papers focused on Europe and one paper on the Middle East, this needs to be considered in light of the study’s LMIC-focus. Fifteen papers utilised cross-regional comparisons. A table incorporating the main attributes of each paper and their identification of themes linked to Walt and Gilson’s38 policy triangle can be found in  Results indicate that the study of policy processes of health-related fiscal measures in LMICs is an emerging field. The earliest included paper in this study was published in 1998 while most papers (n = 64) were published between 2009 and early 2019. Of the 75 papers identified, 47 studies (63%) focused on tobacco-related fiscal measures. Alcohol was the focus of 5 studies, while soft drink and food-related fiscal regulation were the focus of 6 and 4 papers, respectively. Thirteen papers sought to analyse more than one commodity-related fiscal measure. Utilising the World Bank 2019 categorization of income status, The prescriptive detail and technical content outlined in policy documents is integral to conveying and achieving policy objectives. Two major themes were identified in the analysis of policy content: earmarking of revenue and tiered taxation measures.42 was a commonly discussed policy mechanism in the reviewed literature. Administered through formal legal process in some instances and more symbolic forms of policy in others, the earmarking of funds garnered support for fiscal measures in some cases while fuelling inter-ministerial conflicts in others. Earmarking 52 Papers identified varied applications of dedicated revenue including additional non-specific budgetary allocations to health51; the development of health promotion funds or foundations52; subsidies for healthier alternatives50; tagged funding for organisational units49; and equity-based measures dedicating funds to universal health coverage or reparations for affected farmers and communities.48 While linked to diverse goals, earmarked funds can garner public and political support for fiscal measures by acting as a traceable policy output; overcoming a common retort that measures purely focus on revenue generation.53 In contrast however, a number of papers also identified earmarking to circumvent general public financial management; fuelling inter-ministerial conflicts and stalling or mitigating fiscal measures.57 Given the overlap between the domains of policy content and policy process, deliberative decision-making surrounding earmarking will be further discussed in the policy process domain. The benefits of earmarking to fiscal measure adoption were examined by 12 papers spanning the Pacific, Asia, South America, and Africa.60 This well-defined focus on a single commodity may permit consumers to substitute purchases with similarly unhealthy products, potentially undermining the health impact of the measure.51 However, as Hagenaars et al24 argue, a well-defined scope strengthens governments’ defence of measures in the face of corporate, community or international trade disputes. The scope of implemented measures may thus reflect a trade-off between public and political acceptability of the measure and effectiveness insofar as its impact on population health. Most fiscal measures in LMICs target single commodities with rigid parameters. Broader measures in some Small Island Developing States and Mexico are rare exceptions.61 to as much as a 300% import levy on turkey tails in Samoa.62 Variability across measures and contexts indicates that fiscal measures are often designed to reflect local needs even if the catalyst for their use was external, such as ‘global best practice’ guidelines or the experience of other nations. Literature also outlined diversity in the type of taxation prescribed. Taxation generally encompassed combinations of specific, ad valorem , value added and import taxations. Taxation rates also varied between and within commodities from as little as US$0.05 per packet of cigarette in Costa Rica,64 yet tiered structures, with rates based on production capacity or concentration of particular ingredients, were also common.68 Tiered taxations are promoted by a growing body of literature, including Baker et al53 and Roubal55 in relation to sweetened drinks, as a means of incentivising product reformulation.51 However, other sources suggest that tiered structures associated with some commodities can reflect industry involvement in weakening measures; ensuring that they are geared towards competitors or smaller fragments of the market.66 This has been the case with tobacco in Indonesia, where tiered measures have embedded conditions favourable to industry.68 As alluded to by Williams64 and Kaiser et al,48 if insufficiently monitored, tiered measures may also complicate administration and risk diminishing the health impact of fiscal measures. Governance and administrative benefits of simplified and uniform taxation measures were explicated by some papers,69 However, who is considered a policy actor, the power they wield and how interests are negotiated in formulating policy, depends on context and process. Policy actors are individuals or groups who, formally or informally, are involved in the policy process. Industry influence was the most commonly identified theme across the literature, covered by 88% (n = 66) of sources. Spanning conceptualisation, design, implementation and sustainability of fiscal measures, industry influence encompassed a range of tactics, criticisms and defences utilised by national and international corporations whose products were subject to proposed or introduced taxations.83 Framing was often coupled with the projection of negative ramifications for economically-vulnerable primary producers.85 This tactic was explicitly used by the International Tobacco Growers Association in response to mounting pressure for tobacco taxation in sub-Saharan Africa.82 Framing of economic flow-on effects permits industry advocates to paint fiscal measures as not only a threat to their bottom line but also to primary producers, employees and national economic prosperity. By extension, Mialon et al86 and Chavez44 also highlight the industry threat of offshoring; claiming fiscal measures to undermine the economic viability of local production. Such threats strike at LMICs’ economic interests and may ignite or fuel inter-ministerial conflicts.88 In some cases, threats have been compounded with real or perceived threats of retaliative trade action.90 The literature describes industries’ use of pre-emptive action to stave off regulatory measures. Intentional framing of industry activity as a significant source of LMIC employment and contributor to gross domestic product was a common tactic used to influence public and political opinion of fiscal measures.97; a shift towards informal home-brewed alcohol48; and food and beverage unaffordability, nutrient deficiency and dehydration.91 Findings from Abedian et al and Coriakula et al98 suggest strategic links to the media, or indeed media ownership itself, to perpetuate this framing in the public sphere. Corporate social responsibility initiatives are also a common industry tactic to seek favourable public positioning.99 These covert industry tactics are also coupled with more overt mechanisms for mitigating the adoption of measures. Common techniques include fostering and embracing ties to the political and economic elite100; funding or supporting political parties86; and establishing lobbying and front groups prone to deception, disputing evidence and directly interfering in policy process.104 Industry interference often results in stalled or diluted fiscal mechanisms; undermining the strength and sustainability of measures.106 Lack of confidence in the relative advantage of different policy options is also commonly exploited by industry advocates as an opportunity to propose alternative, self-regulatory measures.86 Industry advocates also commonly highlight perceived unintended consequences of fiscal measures. Commonly identified consequences include cigarette smuggling100; restructuring manufacturing or labelling to exploit tiered or poorly constructed measures101; pursuing trade or legal recourse53; adjusting price to maintain market share or profitability107; and paying further lip service to, if not actively engaging in smuggling as identified by Van Walbeek.56 Following the implementation of fiscal measures, corporate retaliation is sustained. Responses often align with previous pre-emptive action and seek to minimise impact on profits. Responses include offshoring to more favourable economic conditions, as noted by Holden & Lee in Central America111 Most commonly, this consisted of public advocacy for measures by Presidents, Prime Ministers and national Ministers of Health. However, motivation underpinning elite support varied and included electoral commitments to tax or health reform80; changing political climates, as was the case in post-Apartheid South Africa97 and the fall of the New Order in Indonesia68; and personal convictions such as Prime Minister Erdogan in Turkey,109 President Yar’Adua in Nigeria110 and President Batlle in Uruguay.108 Sources indicate that the efficacy of state actor policy championing improved when advocacy was evidence-informed and recognised the harms associated with particular commodities.101 Mapa-Tassoa et al78 identified that ad-hoc and reactive instances of policy support by political elites were more likely to result in under-resourced, conflicting and piecemeal policy responses. Similar findings were echoed by Vateesatoket,52 who emphasised senior health experts to have a more sustained commitment to measures than career politicians. Forty-six papers (61%) detailed the influence of political commitment and leadership on the design and implementation of fiscal measures. Studies highlighted that effective implementation is contingent upon sustained endorsement and policy championing by executive levels of government.112 Political ambivalence or lack of support at elite levels was often driven by industry framing of the perceived economic and political risks of taxation.93 As identified by Barraclough and Morrow72, the combination of industry framing and political ambivalence commonly resulted in political elites compromising their regulatory responsibilities in favour of potential political and economic gains. The scarcity of financial and human resources in the health sector also resulted in the prioritisation of responses to communicable diseases at the expense of actions to address NCDs.112 Ferreira-Borges et al89 further highlight that insufficient prioritisation of NCDs can be reinforced by the funding priorities of international donors. Papers that analysed unsuccessful measures found that these measures were commonly undermined by a lack of sustained political commitment.82 Spanning diverse contexts and commodities, these bodies often shaped public and political agendas,87 disseminated policy-relevant research,113 countered industry claims,110 and held governments to account.60 As demonstrated by lobbying from health professionals, researchers and civil society activists during the introduction of tobacco-related measures in South Africa,84 effective civil society groups often had high visibility and links to media and government.111 As elucidated by Kaiser et al,48 such groups often work across government and civil society to construct robust measures which bridge tensions and are less susceptible to hijacking by detractors. However, Barraclough and Morrow,72 Higashi et al74 and Mapa-Tassoa et al,78 found that the power of civil institutions diminished when targeted commodities had high public acceptance or where state ownership or sponsorship stifled the proposition of change. Civil society engagement was identified as integral to successful fiscal measures in 35 papers (47%). Civil society groups included local, national and international research agencies and academics, special interest communities, and non-government organisations (NGOs) whose interests were strategically aligned.98 sources also highlighted multisectoral consensus building to derive from engagement with the Food and Agriculture Organization (FAO), IMF, the World Bank, and other national and international NGOs and philanthropic trusts.113 Locally-based offices of multilateral agencies, seed organisations and links between multi-lateral actors and local organisations sometimes blurred the boundaries between multilateral and civil society action. Financing and the supplementation of national economic, technical and legal capacities were the predominant forms of support, with each noted to be beneficial in overcoming common LMIC capacity constraints.61 Direct support by multilateral agencies, NGOs and philanthropic trusts was identified to expedite the design and implementation of fiscal measures. While the WHO was held in high regard for their technical advice,119: the strategic portrayal of policy problems and fiscal solutions – often called ‘framing’120, the forms and use of evidence, inter-ministerial policy dynamics and policy implementation. Literature provided insights into 4 domains, also commonly identified in policy process theory81 As argued by Kaiser et al,48 these three unidimensional frames foster policy coalitions capable of elevating issues onto the political agenda. This was evidenced in links between multinational corporations, small business and unions in response to potential employment repercussions of fiscal measures83; and in coalitions formed between health professionals and families with claims of industry putting profits before health.92 Literature identified three central frames: pro-health, pro-economic and (often industry-induced) scepticism of fiscal measures.53 Onagan et al63 observed that measures framed with exclusive health or revenue objectives gained less inter-ministerial traction than those proposing dual objectives. The ‘win-win’ phraseology,123 often used to account for the projected health and economic benefits of fiscal health policy, is hence a particularly useful and well used frame for uniting otherwise disparate coalitions around mutually-beneficial goals.63 The design and implementation phases of fiscal measures sometimes saw the emergence of nuanced frames capable of bridging more disparate interests.112 and revenue generation to support universal health coverage,48 were also beneficial frames capable of driving implementation. While evidence-based frames, which drew on diverse projections of impacts, were most likely to mobilise ideologically and politically dissimilar audiences; giving political and social traction to measures.104 This dynamic is best demonstrated by the Philippines’ and Thailand’s additional revenue investments in health, which led to policy backing by health-interested parties rather than those solely interested in economic benefits.124 Alignment with the global health agenda, insofar as ratification of FCTC91 As articulated by Higashi et al47 and Hamann et al113 however, the appetite for context-specific evidence is not always matched by research availability, affordability or the capacity of LMIC governments and research institutions. Paucity of local evidence often forced governments to choose between stalling policy to await relevant evidence or, acknowledging momentum and proceeding with suboptimal information.113 Diffusion of regional or global evidence was beneficial in progressing fiscal measures and supported by pro-policy political elites and global health bodies.60 The use of more generalised data however was often criticised by industry and those opposing measures.86 In such instances, the availability of local albeit poorer quality evidence, often favouring or funded by industry, was enough to seed doubt amongst policy-makers, forcing compromise or delay.79 The role of local, regional, global and industry-endorsed evidence was discussed in 45 papers (60%). As a whole, the literature emphasised that fiscal measures gained traction from diverse types of country-specific evidence.111 Commonly identified evidence included consumption patterns, disease burdens, price elasticity and revenue or health projections associated with policy initiation.111 Such evidence was beneficial in countering industry claims,61 supporting technical provisions,55 and mobilising and sustaining civil society groups and messaging.81 However across the literature, evidence was almost exclusively used to justify implementation but not inform the design of policy per se.80 Evidence was predominantly used to justify measures by highlighting the magnitude of health burden or economic deficit.105: that policy success depends as much on forms of “political evidence” as it does the application of health and economic specific knowledge.105 However, even amongst papers where political considerations were acknowledged, there remained limited empiric analysis and continued reliance on commentary, with the noteworthy exception of Kaiser and colleagues’48 political economy insights from the Philippines. As Sanni et al97 attest, technical evidence alone is insufficient to address politically contentious issues. Given the potential for political economy considerations to contribute positively to policy adoption, the deficit of evidence pertaining to political process and power dynamics is likely to be a missed opportunity to improve the design and implementation of measures.105 Further, while few papers explicitly acknowledged the central role of political process on the design and implementation of measures, a handful of papers did recognise what is best surmised by Chantornvong et al97 As outlined by Abediyi et al70 while dependent on framing and government objectives, cross-ministerial negotiations commonly stall or mitigate adoption. Pitso et al49 and Bump et al73 assert that, particularly in LMICs, inter-ministerial power asymmetries often favour financial and trade interests over health. If health measures are designed as part of broader fiscal reform, as was the case in Mexico60 and Tonga’s second and third iterations,58 this can accelerate implementation and permit governments to promote dual health and economic benefits.91 By contrast, when public sector and political officials perceive fiscal measures to challenge trade or economic interests, policy is often thwarted or enacted with health trade-offs.48 Protection of state-owned commodity producers and, as Abedian et al54 identify, the avoidance of earmarking revenue, are identified as 2 common trade-offs.74 In particular, earmarking is likely to draw opposition from national finance departments where, Van Walbeek56 argues, it may be perceived as economically inefficient and a violation of their role as gatekeepers of public financing. A push for earmarking, particularly when there is a distinct power imbalance between health and finance departments, has been identified by some sources to risk destabilising necessary multisectoral support for adoption of such measures.57 The multisectoral nature of fiscal measures requires policy development to bring together an extensive stakeholder base with diverse and, at times, conflicting priorities. At the intersection of health, trade, financial and agricultural interests, fiscal measures commonly fuel conflicts over policy jurisdictions.111 Often linked to strategically developed multisectoral coalitions, the literature emphasised the importance of coordinating policy responses,89 and striving for genuine integration.111 Acknowledging the diverse interests of stakeholders, Coriakula et al101 highlight the effectiveness of inter-sectoral committee mechanisms in ensuring collaborative and iterative policy development capable of harmonising and overcoming potential policy conflicts. Despite the frequency of inter-ministerial conflicts in this space, papers also identified instances of inter-ministerial collaboration and its positive implications on the design and implementation of fiscal measures.125 included literature outlined poor resourcing, vested interests and the lack of timely monitoring as implementation challenges prone to undermining the success of fiscal measures. Insufficient supportive resourcing was identified as significantly impacting implementation.124 As noted by Barber and Ahsan,83 this was particularly apparent in administering tiered taxation measures prone to industry manipulation and insufficient oversight. Producers and suppliers were also found to engage in a range of tactics to undermine the effectiveness of implemented measures, including relabelling,101 absorbing taxation to maintain market share,83 supporting the importation of cheaper alternatives,83 and price over-adjustment to sustain profits.67 These tactics were also commonly aided by concurrent political disunity. Competing government interests and complex policy sign-off processes were identified as factors responsible for delaying the implementation of measures.110 Similar challenges, coupled with ill-defined success, insufficient resourcing and complex causal pathways were also identified as limiting effective policy monitoring and evaluation.83 Thus, frequently, little is known about the intended or unintended consequences of measures, as required to inform future adjustments. Notwithstanding the automated nature of taxation compared to other policy instruments,40distinction between interlinked situations, structural, cultural and exogenous/international factors is a useful heuristic for consideration of contextual factors and their influence on policy. Policy context analysis recognises that policy actors and processes exist within a context that ultimately influences the design and outcome of reform. Leichter’s40 The majority of papers linked fiscal measures to diffuse recognition, while some included papers (n = 23) explicitly delved into the situational “tipping point” responsible for the ideation of measures. From a health standpoint, lobbying from civil society was identified as beneficial in elevating the health burden and potential solution represented by fiscal measures with respect to the public, media and political agendas.110 Comparative analysis of tobacco measures by Sanni et al97 highlighted how the emergence of context-specific, localised evidence justified expedited implementation in South Africa, while similar measures stalled in Togo without such localised evidence. Far more frequently, however, demand for government revenue expansion was used to justify the design and implementation of measures.126 This was commonly linked to shrinking revenue from exports,91 increased demand for public expenditure,91 the ramifications of trade liberalisation on import tariffs100 and state-ownership or monopolies.109 While revenue generation motives were effective in garnering initial support from economically-interested parties, as articulated by Kaiser et al,48 the design of measures necessitates the incorporation of a broader perspective, such as good governance or pro-poor sentiments, to sustain necessary backing from stakeholders. Situational factors encompass focusing events or diffuse recognition of issues which elicit a policy response.110 As a legacy of exiting leaders or the fulfilment of election promises by incumbents, fiscal measures that had already gained recognition on the policy agenda, were often expedited during leadership change-over.110 While not sparking issue recognition per se, election periods and political change-overs commonly enabled the implementation of fiscal measures. Despite the heterogeneity of LMIC contexts, papers commonly outlined demographic and epidemiological challenges; capacity constraints and institutional norms as interlinked structural influences on fiscal measures in LMICs.127 experienced by many LMICs was, as previously articulated, detrimental to NCD prioritisation.112 However, various sources found that globalisation, urbanisation and climate change-induced food insecurity had amplified the burden of NCDs; increasing demand for effective policy responses.62 Population growth and increasing wealth have also made LMICs a more favourable market for the sellers of harmful commodities.124 The economic development status of countries affected political and public receptiveness to proposed fiscal policy solutions to NCDs. For example, the double burden of NCDs and communicable diseases124 insufficient human resource and technical capacities to effectively negotiate trade deals,103 and sufficient resources to monitor and adjust fiscal measures where necessary.112 Development-associated capacity constraints also challenge the design and implementation of fiscal measures. These include financial constraints,104; culture of industry engagement and acceptance of their framing of issues93; inter-ministerial hierarchies82; policy space afforded to civil society104; and, on one cited occasion, neoliberalism,98 as norms that shaped measures. The impact of these norms is best exemplified by the contrasting successes in tobacco-related measures in post-Apartheid South Africa81 and challenges posed by state-ownership and industry influence on measures in Indonesia,68 China,75 and Vietnam.104 The political structure and prevailing institutional norms also govern how states engage in the design and implementation of fiscal measures. Literature identified state-ownership40 Commonly linked to consumption trends and cultural significance98 and historic links between government and local commodity producers98 cultural factors were often identified as key stalling points in the adoption of fiscal measures. As identified by Barraclough and Morrow72 and Ferreira-Borges et al,89 these factors were sometimes exploited by industry and those sympathetic to industry to delay or seed doubts around measures’ viability. By contrast, Achadi et al65 and Hoe et al109 found that religious objections to tobacco were beneficial in fostering a favourable political climate for fiscal measures in Indonesia and Turkey respectively. Growing nationalism also supported fiscal measures in post-apartheid South Africa84 and in response to pressure from the General Agreement on Tariffs and Trade for tobacco market liberalisation in Thailand.105 Papers by Thow et al51 and FAO et al,58 also indicated that measures often faced less objection in jurisdictions with a precedent for taxing harmful commodities. Cultural factors, inclusive of history, religious sentiments and social structures have had a distinct influence on the design and implementation of fiscal measures. The literature demonstrated that international factors had important and diverse influences on policy processes. Global factors supporting and inhibiting fiscal measures were identified in 51 papers (68%) and linked to trade agreements, the influence of multinational corporations and cross-border policy harmonisation.89 trade agreements designed to reduce trade barriers, promote competition, lower prices and encourage consumption generally sit at odds with the goals of fiscal measures. By constraining regulatory action, trade agreements can limit policy space and fuel inter-ministerial conflict between trade and health.89 By provoking disputes or sanctions and impeding access to bodies such as the World Trade Organization (WTO), trade conditions complicate the design of fiscal measures.59 Further, as argued by Baker et al,53 past trade litigation is often a barrier to future measures in different jurisdictions, a condition known as “regulatory chill.” LMICs are particularly vulnerable to the threat of retaliative action given their more constrained trade, economic and legal capacities.53 The imposition of trade agreements on the control of harmful commodities was discussed in several papers. As outlined by Ferreira-Borges et al,62 Bump and Reich33 assert that such action demonstrates the power afforded to industry in influencing countries and, by extension, global trade policy. However, despite the limitations imposed by trade agreements, there is growing potential for evidence-based carve-outs, permitting discriminatory taxes on products proven to be detrimental to health.50 Moreover, the literature also highlighted WTO accession mandates and the threat of sanctions to have instigated government-wide review of fiscal measures. Fuelled by a sense of urgency, sanctions and accession parameters favoured multisectoral-supported fiscal measures in Thailand, the Philippines and Samoa.105 The provision of foreign aid based on particular trade conditions determined by donors can also hamper the implementation of fiscal measures in LMICs. New Zealand’s threat of sanctions against a number of Pacific island nations for their health-related bans and proposed bans on turkey tails and mutton flaps exemplified this.100 outline that the multinational nature of many harmful commodity producers fosters transnational coordination. Transnational action by corporations commonly includes global counter-advertisement and lobbying,100 the development of transnational front groups,103 cross-jurisdictional information sharing,100 and offshoring or restructuring to minimise loss of market share or profitability.107 The transnational nature of negative retaliative action was most apparent in contexts where measures were not unanimously supported by domestic actors; reigniting inter-ministerial conflicts between trade and health.73 The growing transnational nature of industries themselves is also responsible for stalling and impeding the adoption of measures. Holden and Lee103 Examples include the establishment of health promotion foundations, following successes of the Australian VicHealth model,52 and regional harmonisation of taxation to mitigate smuggling.103 Hoe et al109 also emphasised cross-country comparisons to be advantageous in informing policy processes, elevating dormant problems and their potential solutions onto national and international policy agendas. Regional and global coalition building and direct support provision from multilateral organisations has however been advantageous in countering multinational corporations and supporting fiscal measures in LMICs. Information sharing and lesson-drawing commonly influenced policy processes and promoted policy transfer.33 has the potential to trump domestic affairs, dominant global health discourse provides a prominent frame for issue conceptualisation and timely state compliance acts as a signifier of responsive governance. For example, Tobacco-related papers consistently identified FCTC as instrumental in issue identification and the design of state responses.110 As outlined by Tam et al103 and others, FCTC’s legally binding tobacco taxation provisions have fostered a sustained commitment to effective fiscal measures amongst signatory nations.109 Further, despite Indonesia not being a signatory, Achadi et al65 and Rosser68 also identify FCTC to have garnered momentum and supported a review of tobacco control measures in light of the framework’s health and economic provisions. While not legally binding, a range of other global policies, including the NCD Best Buys and global and regional action plans on NCDs have also aided consensus building and mainstreamed fiscal solutions.87 More lateral global health objectives, including the SDGs and universal health coverage, have also been leveraged by states to justify fiscal measures as a means of increasing health budgets.63 Similarly, policies and objectives that have achieved global consensus, such as FCTC and the SDGs, also support the design and implementation of fiscal measures. By fuelling international political momentum which, Bump and Reich argue, Drawing on detail included in  The design and implementation of health-related fiscal measures in LMICs is shaped by a complex network of factors that vary across contexts. Nonetheless some commonalities were identified by this scoping review. Fiscal measures were more likely to be implemented when diverse local health and economic evidence sources were available; policies were championed by those in government and had inter-ministerial support; stakeholders from different sectors engaged in regular, open dialogue; and when regional and global political winds favoured change. Fiscal measures were less likely to be adopted when framing of issues and solutions were influenced by industry; real and perceived retaliative threats were made by powerful actors; during political climates of trade insecurity and regulatory chill; and when disharmony and vested interests prevented policy consensus within government. Overall, these factors suggest some important distinctions between HICs and LMICs in the design and implementation of fiscal measures, as is summarised in 129 Nguyen et al,130 and Brownell and Warner,131 other industries have followed tactics used to resist tobacco regulation, an over-reliance on tobacco-specific literature fails to acknowledge the differences associated with other harmful commodities. There is hence a need for greater depth of research focused on a range of harmful commodity-related fiscal measures to overcome the unstated assumption implied by much of the literature: that mechanisms used in tobacco taxation are directly replicable to measures targeting foods, alcohol and other beverages. For example, the literature’s predominant representation of industry as a homogenous entity risks over-simplifying policy challenges and may negate the influence of consumer perception and the versatility of the food and beverage industry in shaping regulations. This review demonstrated a substantial gap in research focused on food, alcohol or other beverage-specific fiscal measures, with the current literature reflective of the sustained global emphasis on tobacco regulation and taxation. Given the increasing momentum for broader policies in response to NCDs, the lack of in-depth analysis devoted to these areas signifies a failure to provide relevant and actionable evidence to support the design and implementation of fiscal measures. While lesson-drawing from tobacco is valid and, as emphasised by Dorfman et al, This review also highlighted gaps in the breadth of policy actors identified, with many papers focused solely on the influence of industry. While important, particularly given the immense power afforded to industry actors in the political economies of LMICs, the literature’s preoccupation with industry precludes a more comprehensive assessment of the network of actors who influence the design and implementation of fiscal measures. For example, although only 38 studies (51%) examined inter-ministerial dynamics, sound relationships and agreement between state actors was pivotal to the fiscal measures’ success, and inter-ministerial conflicts often stalled or prevented measures. Given that public policy ultimately constitutes decisions made by state actors, the lack of attention to process dynamics and the views and actions of public persons and bodies is a critical gap in our understanding of how state actors negotiate competing interests.98 identifying neoliberalism as an underpinning determinant of private sector power. Global and local ideologies and dominant discourse are important contextual factors influencing the drive for and design of fiscal measures.133 With neoliberal policy preferences explicitly exported to LMICs as loan conditions from the IMF and World Bank in the 1990s,132 the pursuit of freer markets, with the promise of greater personal freedoms, peace and prosperity, remains a dominant global discourse. Encouraging trade, discouraging market regulation and, in turn, arguably promoting ‘consumptagenic systems,’134 neoliberalism sits at the heart of the escalating burden of NCDs and dictates the terms of potential remedial action.135 The scale, reach and wealth of corporations, particularly multi-national conglomerates, and their ability to mitigate and manipulate fiscal measures highlights an important power asymmetry between countries’ health interests and the economic interests of powerful private actors. However, some promise is found in recent support for fiscal measures by the IMF and World Bank and the implementation of measures by conservative governments.126 The altered stance of these agencies and governments demonstrates the possibility of reorientating the neoliberal agenda to recognise the importance and potential returns associated with investing in the health of ‘human capital.’136 Further research is necessary to explore the breadth of neoliberalism’s influence, as we currently have an incomplete picture of the barriers, tensions and political opportunities in assessing the feasibility of fiscal measures as a form of responsive public policy. Despite the emphasis placed on the influence of industry across the literature, very few papers explored potential root causes, with just Mambulu et al137 a deepening of policy analysis and recognition of other types of evidence necessary to inform the design and implementation of public policy is required. For example, integration of political economy considerations into prospective and retrospective analysis is likely to bring to light important dynamics integral to successful policy. Many studies discussed the need for and use of health and economic evidence in the enactment of fiscal measures. However, while plentiful, evidence was almost exclusively discussed in relation to agenda setting. For example, country-specific data on disease prevalence and consumption of harmful commodities were identified as integral in driving public and political momentum for change. Yet analyses of policy design processes and policy content often demonstrated that technical detail became obsolete in negotiation processes, when garnering support from diverse stakeholders was paramount. This demonstrates a disjuncture in the evidence used during agenda setting and that used in the design of fiscal measures. Further, echoing Bump, Reich, Chantornvong and others,33 but is distinct in its inclusion of fiscal measures relating to a broad range of harmful commodities (not just tobacco-related products). Our focus on LMICs also differentiates this analysis from more globally oriented work by Wright et al25 and Hagenaar et al.24 Application of a systematic approach and theory-driven analysis also allow us to add depth to observations made in Bridge and colleagues’ more general exploration of LMIC experiences and potential pitfalls in sugar-sweetened beverage taxation.34 This study draws inspiration from the political economy approach outlined in Bump and Reich’s seminal work, Several limitations must also be noted. The choice of databases, repositories and exclusion of primary policy sources may have inadvertently limited the identification of relevant papers. Given the breadth of languages spoken across LMICs, the exclusion of papers published in languages other than English may also have led to the exclusion of relevant articles. While developed iteratively, predominately single author screening, coding and analysis may also have unintentionally excluded information of relevance although robust discussion between authors and review by the third author was designed to minimise this. The study’s reliance on secondary sources also creates the potential for misinterpretation. Embedding expert consultation as a final stage in the study’s design may also have strengthened findings. This study’s identification and mapping of literature exploring and explaining the policy process of fiscal measures in LMICs reveals important findings for policy-makers and researchers alike. Highlighting critical and interconnected factors influencing fiscal measures in LMICs, this study identifies a number of valuable lessons for future fiscal measures. The use of local health and economic evidence, policy championing, multisectoral engagement and inter-ministerial support, and global or regional momentum and technical support appear beneficial to the design and implementation of measures. By contrast industry framing and potential retaliation, vested interests and policy disjuncture across government were common factors associated with stalled or mitigated measures. Recognition of the presence or absence of these factors and intentional planning with such considerations in mind may hence support LMIC policy-makers in designing and implementing effective fiscal measures. While acknowledging that what is known should inform policy, it is also pivotal that what remains unknown informs future research. As such, this study has highlighted considerable gaps in our understanding of the global, regional and national political economies which shape fiscal measures. A greater emphasis on empirical research that seeks to understand the context-specific power dynamics and the political intricacies of processes associated with the design and implementation of fiscal measures in LMICs is hence integral. The growing burden of NCDs, and how it manifests in LMICs, is itself a product of political and economic forces. Effective policies responses hence demand evidence that acknowledge and account for such political economies. Not applicable. Authors declare that they have no competing interests. LME and SMT conceived of the review. Data collection, charting, mapping, interpretation and analysis tasks were undertaken by LME with guidance from SMT and SLD. LME wrote the first draft of the manuscript and SMT and SLD provided critical input and feedback.1College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia. 2School of Public Health & Social Work, Queensland University of Technology, Brisbane, QLD, Australia. 3Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA. 4Institute for Global Health, University College London, London, UK. 5Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia.Supplementary file 1. Search Strategy.Click here for additional data file.Supplementary file 2. Criteria for Inclusion and Exclusion.Click here for additional data file.Supplementary file 3. Initial Codebook.Click here for additional data file.Supplementary file 4. Included Papers’ Alignment With the Domains of the Walt and Gilson Policy Triangle.Click here for additional data file.


National dementia research priorities call for interventional studies addressing the needs of vulnerable populations experiencing disparities and for greater inclusion of dementia care recipients and their family caregivers in research. While studies document disparities, high needs and experiences of African American dementia caregivers, there is limited translation of this knowledge into the development, implementation, and dissemination of dementia-specific culturally tailored interventions. Research methods that facilitate engagement capable of strengthening data collection and culturally congruent interpretation of caregiving perspectives are needed to inform intervention development. Drawing on a qualitative study utilizing Grounded Dimensional Analysis, we employed a longitudinal engagement method with a Community Advisory Board (CAB) to validate a culturally tailored crisis intervention model for African American dementia caregivers. We identified lessons learned through a review of transcripts, memos and research team discussions. CAB members identified language, family structure, cultural history, knowledge, and respect as important features for cultural tailoring.


Many people receive care near or at the end of life in nursing homes, including 70% of people with Alzheimer’s Disease and Related Dementias (ADRD). Studies have documented unmet needs for symptom management and frequent transitions of care for nursing home residents. Despite this, access to palliative care for nursing home residents is inconsistent. The COVID-19 pandemic both highlighted and exacerbated inequities in access to care, including in US-based nursing homes, as well as globally. COVID-19 specific guidance for nursing homes at state and federal levels, while designed to protect residents, contributed to increased social isolation and functional decline. Drawing upon data from an ongoing study to advance palliative care for residents living with ADRD, this presentation will highlight promising practices and opportunities to deliver palliative care in this setting.


TM) matrix. International food-based dietary guidelines were reviewed to determine common food groups. A six-section matrix was drafted including skill focus points for: (1) Kitchen safety, (2) Food safety, (3) General food skills, (4) Food group specific food skills, (5) General cooking skills, (6) Food group specific cooking skills. A modified e-Delphi method with three consultation rounds was used to reach consensus on the Cook-EdTM matrix structure, skill focus points included, and their order. The final Cook-EdTM matrix includes 117 skill focus points. The matrix guides program providers in selecting the most suitable skills to consider for their programs to improve dietary and health outcomes, while considering available resources, participant needs, and sustainable nutrition principles. Users can adapt the Cook-EdTM matrix to regional food-based dietary guidelines and food cultures. Culinary education programs are generally designed to improve participants’ food and cooking skills, with or without consideration to influencing diet quality or health. No published methods exist to guide food and cooking skills’ content priorities within culinary education programs that target improved diet quality and health. To address this gap, an international team of cooking and nutrition education experts developed the Cooking Education (Cook-Ed Cooking and food skills proficiency, and frequent consumption of home-prepared meals, are factors associated with higher diet quality, meaning dietary patterns more closely aligned with food-based dietary guidelines (FBDG) ,3,4,5,6.Culinary education programs that teach food skills* and cooking skills* for domestic applications consider food agency* to varying degrees and are delivered in a range of settings across education and health sectors  model was published to assist culinary education program providers with the complex task of designing, implementing, and evaluating programs that specifically aim to improve diet and health [TM model [The Cooking Education , dairy and dairy alternatives, fats and oils, and foods and food components to limit. Therefore, columns within matrix sections four and six represent all of these food groups. Step 2. Identifying and Mapping Culinary-Related Skills to Include in the MatrixAuthor RCA  reflected on her training and experience in kitchen and food safety, and reviewed consumer food safety guidelines  to draftStep 3. Modified e-Delphi ProcessThe modified e-Delphi process used in this study is shown in Round one involved nine authors as participants and a fellow researcher from the University of Newcastle who could not continue to contribute due to changing work commitments (see acknowledgements). Six additional colleagues and collaborators joined the team from round two through to completion. In total, 16 team members  completed rounds two and three. Team members have extensive experience and training in one or more of the following fields: nutrition , dietetics , commercial cookery , cooking and food skill (culinary) education research and/or program development , behavioural and consumer sciences , public health , education and curriculum review , and occupational therapy (AR). Ethical considerations: Ethical approval was not needed for this research as the participants were the authors and acted in a consultation capacity. The final matrix includes 117 skill focus points, including 5 kitchen safety skills, 6 food safety skills, 19 general food skills, 24 food group-specific food skills, 5 general food and cooking skills, and 58 food group specific food and cooking skills . WorkingWhile the initial focus of the matrix was to identify food and cooking skills necessary to achieve a healthy dietary pattern, as discussions progressed, the importance of including food and cooking skills to support sustainable dietary patterns for human and planetary health emerged ,42. ThisTM model [TM model has been created to assist program providers in tailoring culinary education programs to the needs of specific groups and guide them through all steps of program creation from conception and development to evaluation [TM model [TM model [Where applicable, food and cooking skills specific to each of the common food groups are outlined in sections four and six of the matrix to ensure the necessary skills required to select, prepare, and ultimately consume a wide variety of foods from each of these groups can be achieved. While the matrix can be used on its own as an applied programming tool to guide content and learning materials, it is highly recommended that program providers use it within the context of applying the Cook-EdTM model  , which may not always have the facilities, resources, or time allocation to practically teach cooking skills). Other examples include learning to recognise key nutrition and culinary terms, planning a menu to meet personal and household needs, and accompanying shopping/grocery list. Furthermore, with the onset of the COVID-19 pandemic, a transition to virtual education modes to deliver culinary education programs has been more common with programs facilitated outside the traditional kitchen space [The Cook-Eden space ,52. TM matrix has broad international relevance, but culinary education providers should consider the items in the matrix within the context of their own FBDGs, food and cooking culture and practices, and food availability and adapt the matrix accordingly. Additional food and cooking skills may need to be considered for the matrix to be applied to programs for other cultural groups and countries with eating patterns other than a Western diet. Similarly, additional food and cooking skills may need to be considered for non-domestic culinary education programs , or programs where skills to improve diet quality and health are not the primary aim. A limitation of the matrix is that it is not a comprehensive list of all food and cooking skills that could be included in culinary programs A strength of this study is that the authors contributing to the development of the matrix are an international team, but it needs to be highlighted that this expertise is focused across countries with similar food and cooking cultural requirements. The Cook-EdA further strength is that the design of the matrix and skill focus point selection process, via a modified e-Delphi process with three rounds, permitted independent and deep analysis to develop the final skill focus points shown in the matrix in TM matrix presented is an evidence-based applied tool to assist in the selection and prioritisation of food and cooking skills for inclusion in culinary nutrition education programs to improve diet quality and health of participants. The matrix can be used in a variety of global settings by adapting outcomes to meet country-specific FBDGs. By detailing the process of developing the matrix and publishing it here as a freely available tool in an open access journal, cooking program providers in a variety of settings will be able to use the Cook-EdTM matrix as a program development tool. To assist with tracking the application and impact of the Cook-EdTM matrix, we encourage users to acknowledge when and how the matrix was used in their projects. When used together with the Cook-EdTM model [TM matrix supports program providers in selecting and prioritising food and cooking skills relevant to their participant group based on program goals, nutrition recommendations for different life stages, and participant skill development needs and preferences. Further research is needed to examine the application of the matrix as an applied tool to guide program content development across a wide range of settings and target groups. The Cook-EdTM model , the Coo