Clinical laboratory testing provides essential data for making medical diagnoses. Generating accurate and timely test results clearly communicated to the treating clinician, and ultimately the patient, is a critical component that supports diagnostic excellence. On the other hand, failure to achieve this can lead to diagnostic errors that manifest in missed, delayed and wrong diagnoses.Innovations that support diagnostic excellence address: 1) test utilization, 2) leveraging clinical and laboratory data, 3) promoting the use of credible information resources, 4) enhancing communication among laboratory professionals, health care providers and the patient, and 5) advancing the use of diagnostic management teams. Integrating evidence-based laboratory and patient-care quality management approaches may provide a strategy to support diagnostic excellence. Professional societies, government agencies, and healthcare systems are actively engaged in efforts to advance diagnostic excellence. Leveraging clinical laboratory capabilities within a healthcare system can measurably improve the diagnostic process and reduce diagnostic errors.An expanded quality management approach that builds on existing processes and measures can promote diagnostic excellence and provide a pathway to transition innovative concepts to practice.There are increasing opportunities for clinical laboratory professionals and organizations to be part of a strategy to improve diagnoses. Improving Diagnosis in Health Care, highlighting the critical need to understand and address shortcomings in the diagnostic process [Medical errors are estimated as the third leading cause of death in the United States with up to one third of these associated with diagnostic errors , 2. A 20 process . The rep process . This naLaboratory Medicine, A National Status Report, advocated that the clinical laboratory has value beyond test performance through enhanced engagement with other health care providers to improve health outcomes [For the purpose of this manuscript, we define diagnostic excellence as a systems-level state that effectively integrates health care knowledge, skills, and resources for continuous and measurable improvement of diagnoses, and reduction of risk or occurrence of diagnostic errors, while continuing to meet overall needs of patients and health systems. The intersection of diagnostic excellence and laboratory practice can be traced to the conceptual development of the total testing process. Lundberg first described the “life cycle” of a clinical laboratory test in 1981, which was subsequently defined as the “total testing process” (TTP) by the US Centers for Disease Control and Prevention (CDC) in 1986 and revisited in 2011 [outcomes . At the Antimicrobial stewardship provides an illustrative example of practices that support diagnostic excellence –14. AntiAntimicrobial stewardship is closely linked to making an accurate and timely diagnosis, sometimes referred to as “diagnostic stewardship”. The practice of testing for blood culture contamination to differentiate between blood stream infection and an external contamination event  provides as an example that links microbial/diagnostic stewardship to diagnostic excellence . Blood cThe TTP is often described in terms of the pre-analytic, analytic, and post-analytic phases of testing . While tEfforts to quantitate diagnostic errors linked to the TTP are primarily available through medical liability claims and voluntary reporting from patient safety organizations. A study by Coverys, a medical liability insurance and risk management service organization, examined 3,466 claims across medical practice settings from 2013 through 2017 and reported that 52% of claims and 55% of indemnity paid were associated with steps in the TTP that linked to diagnostic errors . A 2014 The following examples highlight a selection of initiatives that laboratories are taking or can take to reduce or prevent diagnostic errors, or otherwise promote diagnostic excellence with respect to vulnerable steps of the TTP. Areas of focus include improving test utilization, leveraging clinical and laboratory data derived from the electronic health record to improve diagnoses, promoting effective use of credible information resources, improving communication among laboratory professionals, other health care providers, and patients, and using a diagnostic management team (DMT) approach to support diagnostic excellence .Diagnostic error can result from inappropriate test utilization  where practices are not consistent with current subject-specific expert knowledge or evidence-based standards for usage and cost-effectiveness . Zhi et Another example looks at an initiative designed to review test orders to determine whether the test(s) requested is appropriate to the indication for testing stated on the test requisition. A 2014 publication reported a reduction in unnecessary testing by a reference laboratory, achieved through follow-up with the ordering clinician following laboratory-based genetic counselor review of genetic test orders . Findinghttps://permanente.org/reducing-diagnostic-errors/, accessed November 4, 2020). This is one of the few examples that was both evidence-based and implemented to sustainably collect and analyze data that link clinical laboratory testing to a identify patients at risk for a debilitating disease where early diagnosis has significant value to reducing morbidity and mortality. A similar approach was taken to diagnose patients at risk for early organ dysfunction who were prescribed disease-modifying anti-rheumatic drugs (DMARDs) [The evolution of health information technology (IT) systems is providing essential tools to improve test utilization and demonstrate measurable improvements to making accurate and timely diagnoses. For example, SureNet, a program developed within the Southern California Kaiser Permanente healthcare system, is an innovative program that uses a tracking and alert system based on clinical and laboratory data abstracted from patient electronic records . This pr(DMARDs) . This stClinical laboratory professionals continue to explore ways to improve the TTP, taking advantage of assets that may not have been readily accessible, such as using data abstracted from patients’ electronic health records for novel applications. For example, to reduce false positive test results indicative of the presence of certain drugs in urine, data from electronic health records corresponding to nearly 700,000 urine drug screens across 10 assays were used to assess patients’ previous medication exposures . ResultsClinical laboratory tests are increasing in number and complexity, necessitating an understanding of their uses and limitations to support accurate and timely diagnoses. This requires specialized knowledge that is within the domain of clinical laboratory professionals. From a clinician perspective, test selection and ordering , interpretation and application of the test result to clinical decision making  require knowledge of the uses and limitations of available tests. Maintaining adequate knowledge is challenging considering the rapid evolution, complexity and increasing number of tests available to clinicians , 44. Onehttps://bcrisktool.cancer.gov/calculator.html, accessed November 4, 2020). Conversely, the credibility of test-related and other healthcare information available on the Internet varies and this can potentially compromise accurate and timely diagnoses depending how this information is understood and used by the patient to inform decisions [From a patient perspective, clearly communicated test results that include information about the test’s uses and limitations are important for making informed health care decisions. Patients and the public in general, have access to test-related information beyond what is shared by their health care provider. Patient portals, available in both independent medical practices and larger institutions, provide the opportunity for access to abstracted information contained within the patient’s electronic health record that includes test-related information . In the ecisions , 54.A growing number of diagnostic evaluations are complex and require specialized medical knowledge across medical disciplines. This complexity can translate to multiple medical referrals where diagnoses are made and vary among physicians. This can compromise establishing an accurate and timely diagnosis . One appAnother innovation is the development of Doctor of Clinical Laboratory Science (DCLS) programs. These programs are designed to develop professionals to support the laboratory to meet demands as the health care system continues to evolve. These degrees are inherently multi-disciplinary, rather than focused on a single traditional laboratory discipline. The need for these professionals was formally envisioned at a conference in 2000 hosted by the National Accrediting Agency for Clinical Laboratory Sciences with programmatic elements collaboratively developed over the next decade with the involvement of several professional organizations . As of 2Advancing diagnostic excellence in a meaningful way requires measurement. For example, Medical Quality Indicators developed by the International Federation for Clinical Chemistry Working Group on “Laboratory Errors and Patient Safety” (IFCC WG-LEPS) spans key laboratory processes, laboratory support processes, and laboratory outcomes; while full validation of these indicators is ongoing, and can be expected to evolve over time, they represent an essential contribution to laboratories seeking to systematically prioritize improvement actions in view of patient safety and ISO 15189’s robust quality management perspective , 61. Sevhttps://www.ncqa.org/hedis/measures/, accessed November 4, 2020). Advancing diagnostic excellence will rely on quality indicators that connect elements of the TTP to the diagnostic evaluation that occurs in the patient care setting. One promising model to build upon, and which is amenable to an enhanced laboratory component, is the framework described within the NAM report, To Err is Human, Building a Safer Health System, which details quality domains that include patient safety, effectiveness, equity, patient-centeredness, timeliness, and efficiency [http://www.qualityforum.org/Publications/2019/10/Reducing_Diagnostic_Error_-_Measurement_Considerations.aspx, accessed November 4, 2020). This report details 17 new measures associated with diagnostic efficiency and accuracy sub-domains of the diagnostic process and outcome domains. Another model informed from the earlier NAM efforts mentioned above is the Safer DX Framework that describes a process to integrate elements of the diagnostic process with metrics constructed to collect data that can inform policy and practice in support of health care value [As of 2020, only a few quality indicators link laboratory testing and processes to clinical diagnoses. For example, a Healthcare Effectiveness Data and Information Set measure was developed to assess accurate screening methods for high-risk human papillomavirus testing relevant to the timely diagnosis of cervical cancer in the patient care setting  that include laboratory professionals to assure accurate, timely, and effective communication of diagnoses and assure the overall quality of patient care .To Err is Human: Building a Safer Health System [https://www.who.int/ihr/publications/lqms_en.pdf, accessed November 4, 2020) [In 2020, the Agency for Health Care Research and Quality (AHRQ) published a brief that addressed the importance of measuring diagnostic process performance as essential to engaging in efforts to reduce diagnostic errors and improve patient safety . AHRQ reh System . This wo4, 2020) , 69–72. Improving Diagnosis in Healthcare, described several goals considered essential for improving diagnoses and reducing diagnostic errors [The NAM report, c errors . The conc errors , 73. Furc errors , 75. DiaSignificant challenges to change include the need to prioritize efforts based on limited organizational resources, lack of effective information exchange among medical disciplines and leadership, and resistance to change and in part based on a culture that has separated laboratory from clinical care practices and processes . Other cIn crafting strategies and launching initiatives to advance diagnostic excellence and address barriers to practice changes, laboratory engagement is important. While not intended to be exhaustive, examples provided within this report suggest that laboratory practices and expertise can support a broad range of actions that lead to accurate and timely diagnoses and a reduction in diagnostic errors. Emerging technologies and communication channels provide additional opportunities for laboratories to leverage data and engage with other healthcare professionals. These include laboratory-informed decision support tools to aid clinicians in test selection and interpretation. Two advancing areas of practice worth commenting include telemedicine and point-of-care testing. Telemedicine uses technology to make remote diagnoses that include the use of various testing modalities, and is very useful for populations that do not have easy access to medical services . Point-oWith an enhanced appreciation among the practice community and patient population to improve diagnosis, it is now incumbent for healthcare professionals to continue pushing forward strategies to improve diagnoses across the medical spectrum. Integral to success for many diagnoses is engagement of clinical laboratory professionals and appreciation of the total testing process to derive accurate and timely diagnoses to inform clinician and patient decision making that ultimately contributes to improved health outcomes.


Generalised joint hypermobility (GJH) is highly prevalent among children and associated with symptoms in a fifth with the condition. This study aimed to synthesise outcome measures in interventional or prospective longitudinal studies of children with GJH and associated lower limb symptoms.Electronic searches of Medline, CINAHL and Embase databases from inception to 16th March 2020 were performed for studies of children with GJH and symptoms between 5 and 18 years reporting repeated outcome measures collected at least 4 weeks apart. Methodological quality of eligible studies were described using the Downs and Black checklist.Six studies comprising of five interventional, and one prospective observational study  met the inclusion criteria. Interventional study durations were between 2 and 3 months, with up to 10 months post-intervention follow-up, while the observational study spanned 3 years. Three main constructs of pain, function and quality of life were reported as primary outcome measures using 20 different instruments. All but one measure was validated in paediatric populations, but not specifically for children with GJH and symptoms. One study assessed fatigue, reporting disabling fatigue to be associated with higher pain intensity.There were no agreed sets of outcome measures used for children with GJH and symptoms. The standardisation of assessment tools across paediatric clinical trials is needed. Four constructs of pain, function, quality of life and fatigue are recommended to be included with agreed upon, validated, objective tools. Children with generalised joint hypermobility (GJH) and associated symptoms have been described within the literature under multiple diagnostic labels which have differed over time. Generalised joint hypermobility (GJH) describes abnormally high joint ranges of movement in multiple joints  with appChildren with GJH and associated symptoms report chronic pain , fatigueValidated, reliable outcome measures enhance our understanding of the natural history of a condition and aid evaluation of treatment effectiveness. Despite the importance of such validated outcome measures in paediatric populations  there arThis systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . The proThe 9-point Beighton score (BS) is a dichotomised standardised method , 29 wideAlthough the cut-off of ≥ 4/9 is the most commonly used BS, however this score is largely influenced by age, gender and ethnicity –34. TherMedline (via PubMed), CINAHL and Embase databases were searched from inception to 16th March 2020 using the terms and strategy presented in Table Randomised controlled trials (RCTs), quasi-RCTs, longitudinal and cohort studies were included. The study populations were restricted to children and adolescents aged between 5 and 18 years, diagnosed with GJH, as defined by the authors of the studies, and associated lower limb symptoms. Given the considerable heterogeneity of cut-offs for Beighton score reported in literature its limitation as a clinical diagnostic tool , 31, we Studies focusing on upper limb only outcome measures, or studies including children with other hereditary connective tissue disorders or syndromic conditions associated with GJH, were not included.Titles, abstracts and full-text article screening was performed independently by two authors (MM and AC) against the inclusion/exclusion criteria. Any discrepancies were resolved either by discussion between the two reviewers or by a third author (DS) until consensus was reached.Two reviewers (MM and CW) independently extracted relevant data from included full text articles. Data extraction was performed on a standardised template and included: the primary author of the study, year of publication, country, study design, participant demographics , intervention characteristics  where applicable, and outcome measures used to assess change. Any unresolved disagreements were mediated by the remaining authors .The methodological quality of all eligible studies was reviewed independently by two authors (MM and DS) using the Downs and Black checklist. Any disagreements were discussed until a consensus was reached or resolved by a third author (AC). The Downs and Black checklist  is a valDescriptive statistics were used to characterise the included studies participant population, duration and intervention. Outcome measures used were categorised into patient- or parent-reported (PRO) or clinician-reported (CRO) outcomes, and the broad constructs which were being assessed. The frequency of individual outcome measures used to assess each construct was then tallied. A narrative synthesis of the outcome measures used across study type and participant age was performed, including presentation of the baseline scores on measures. To provide a description of the change over time, the mean change, and variance in this, was also presented. Where 95% CIs were not presented to represent the variance in change, they were calculated.From a total of 1136 articles identified through the searches, 57 articles were deemed eligible for full-text screening with six studies eligible to be included in this review  , PGIC 4 and PediThere was significant heterogeneity in the use of instruments across studies included within this systematic review. Multiple studies measured pain intensity, function and quality of life constructs; however fatigue was measured in only one study, which found it to be an independent predictor of functional deterioration. All measures used demonstrated change over time.The identified PRO measures used similar item sets without taking into account lifestyle or severity of the condition. This limits their translational capabilities into clinical practice. Despite the advantage of assessing the same outcome repeatedly in a clinical trial for research, measuring changes in symptoms tailored to the child’s individual presentation may be more beneficial to inform clinical decisions . ChildreTherapy aims to improve quality of life and reduce disability in children with GJH and associated symptoms . It is uStudies of intervention effectiveness and/or change with time in well described and defined populations with symptomatic generalised hypermobility using well validated robust measures that can be used in both the research and clinical contexts will support easier interpretation and comparison across both contexts. Each individual study provides valuable additional original information, but analysis of multiple studies will provide a higher level of evidence in the future This allows for comparisons between settings, interventions and patient groups to get a broader understanding of the measures used and provide meaningful informed assessment of therapies. Lack of standardisation, together with the limited number of interventional or prospective cohort studies, has hampered quantitative synthesis of efficacy of interventions using meta-analysis in previous systematic reviews . In other paediatric rheumatological health conditions, such as Juvenile Idiopathic Arthritis (JIA), established and revised core sets of outcomes determined through expert health professional consensus , 69 haveThere is a substantial impact of fatigue on quality of life of children with GJH and associated symptoms , 19, 70.Studies have also reported children and parents describing systemic symptoms such as gastrointestinal involvement and stress incontinence associated with poorer quality of life relating to hypermobility , 71, 72.This review was strengthened through the registration of a protocol, adherence to established PRISMA guidelines, and appraisal of methodological quality using a tool with substantial inter-rater reliability , and oneWe are also not able to comment on the association between degree of joint hypermobility and the outcomes of pain, fatigue, quality of life and function since there is no available clinical diagnostic markers for hypermobility disorders or tools to assess such relationship. The application of BS as a dichotomise measure can only provide information on presence of hypermobile joint , 5, 31. An agreed set of core outcome measures for children with GJH and associated symptoms is warranted. More precisely defined diagnostic criteria for children with hypermobility related disorders, in conjunction with standardised reporting of the effectiveness of interventions using similar outcome measures in future studies will produce better quality evidence to facilitate translation into healthcare services. We recommend the development of a core set of outcome measures based around the four constructs of pain, function, quality of life and fatigue. Mixed methodology, including the views of children living with GJH and associated symptoms and their families on what is important to them, combined with expert consensus, validation of generic outcome measures in this population and development of condition specific outcome measures, would provide the ideal final core outcome set for future use.


NICE guidelines recommend that patients under Early Intervention (EI) in Psychosis Services have systematic monitoring and intervention of cardiometabolic risk factors. We undertook a Quality Improvement Project (QIP) in the Bath and North East Somerset (BaNES) EI Team to improve rates of compliance with national guidelines. We aimed to increase the percentage of service users with a physical health assessment documented in the past 12 months. Other aims included improving monitoring of physical health parameters in those taking antipsychotic medication and increasing the delivery of interventions for abnormal results.The most common cause of premature mortality in people who experience psychosis and schizophrenia is cardiovascular disease. The 'Standards for Early Intervention in Psychosis Service' states that patients should be offered personalised healthy lifestyle interventions, including advice on diet, physical activity, and access to smoking cessation services. Physical health should be monitored at least annually, with more frequent assessments if antipsychotic medication is prescribed.We identified seven key factors for improving physical health: Body Mass Index (BMI), Blood Pressure, Glucose Regulation, Blood Lipids, Smoking, Alcohol and Illicit drug use. Baseline compliance and intervention rates were measured in March 2019. Six ‘Plan, Do, Study, Act’ Cycles were completed over the following ten months. Examples of the changes made included: a new online diary and whiteboard, abbreviation of the assessment form, teaching for the EI team, and a new weekly ‘Physical Health and Wellbeing’ (PHeW) Clinic. This clinic involved phlebotomy, discussions around lifestyle choices, review of medication side effects, and neurological examination.We measured the compliance with guidelines each month and the total number of interventions delivered at three-monthly intervals. We collected qualitative feedback on these changes in team meetings and with written questionnaires (including feedback from patients).Documentation of all key factors doubled from 30.2% at baseline to 63.3% in January 2020. The total number of interventions for raised BMI and lipid levels also increased. Feedback from staff and patients was positive. The clinic helped start conversations with patients about lifestyle choices, prompting improvements in weight, physical activity, lipid levels, and alcohol intake. Patient awareness and ownership over their physical health also improved.This project utilised multiple strategies to reduce health complications for BaNES EI service users. A structural change in the assessment and management of physical health proved to be an effective and sustainable solution to optimise the health and wellbeing of this patient group.


Participatory design.Activity-based therapies (ABT) have physical and psychosocial benefits for individuals with spinal cord injury (SCI). A Canadian ABT summit was held to: (1) identify methods used in stroke rehabilitation that may be appropriate for SCI; (2) understand the current state of ABT activities in Canada; and (3) identify priorities for ABT research and care for the next five years.Stakeholder-engaged meeting at a tertiary rehabilitation hospital.Thirty-nine stakeholders, including individuals with SCI, frontline clinicians, healthcare administrators, researchers, funders and health policy experts, attended. Two participants were note-takers. Priority identification occurred through input from stakeholder groups, followed by individual voting. Conventional content analysis was used to synthesize the information in the meeting notes.The strengths of ABT in stroke rehabilitation included clear and clinically feasible definitions, measurements and interventions, and recognized requirements for implementation . Knowledge gaps concerning ABT activities in Canada were identified for acute and community settings, non-traumatic populations, and the interventions, equipment and standardized measures  used. Five priorities for ABT across the continuum of care were identified: (1) Identify current ABT activities; (2) Create a network to facilitate dialog; (3) Track engagement in ABT activities; (4) Develop and implement best practice recommendations; and (5) Study optimal timing, methods, and dose of ABT. Working groups were formed to address priorities 1–3.The priorities will guide SCI research and care activities in Canada over the next five years.Praxis Spinal Cord Institute. Spinal cord injury (SCI) is a life-altering condition associated with low prevalence and high cost. Roughly 86,000 Canadians live with the effects of SCI , which oThe emphasis on neurological recovery during SCI rehabilitation led to the development of activity-based therapies (ABT) . ABT tarDefining characteristics of ABT include activation of the neuromuscular system affected by SCI and a high training dosage . Training at a higher locomotor exercise intensity has been linked to increased peripheral levels of brain-derived neurotrophic factor  and greaTo stimulate advances in ABT research and care in Canada, an ABT Summit sponsored by the Praxis Spinal Cord Institute was held in 2019 to create a Canadian ABT Strategy for SCI. Individuals with lived experience, frontline clinicians, healthcare administrators, researchers, funders of SCI research and health policy experts participated in the meeting. The summit aimed to synthesize current knowledge about ABT in Canada as well as identify what is needed to advance the field and inform a five-year action plan. The summit objectives were to: (1) Review the evolution of similar work in stroke rehabilitation, which may serve as a model, and identify potential methods for SCI. (2) Understand the current state of ABT activities in Canada across the continuum of care. (3) Identify priorities for ABT research and care in Canada for the next five years. Here we report the processes and outcomes of the summit, which form the Canadian ABT Strategy for SCI that is currently being actioned by the Canadian ABT Community of Practice.A summit meeting lasting 1.5 days occurred in March 2019 in Toronto ON, Canada. A participatory design approach was followed such that the meeting consisted of knowledge-sharing presentations amongst a diverse group of stakeholders, as well as small and large group activities. The meeting was facilitated by the three summit leads . Two summit attendees (HJR and NT) were designated note-takers that recorded the content of the summit.Thirty-seven individuals attended the summit meeting in person and two individuals participated virtually (six provinces represented). For the full list of summit attendees, including their areas of expertise and affiliations, see Supplementary file Summit activities focused on exploring the current state of ABT for SCI in Canada and considered potential priorities for ABT research and care over the next five years. The FAME  Framework , 19 was Summit attendees discussed and identified the strengths of the prior work in stroke rehabilitation that may be applicable to the research on, and implementation of, ABT in the SCI field (summit objective 1). A mapping exercise was completed to document the ABT research and clinical care activities that were currently in progress across Canada (summit objective 2). To further describe the current state of ABT across the continuum of care, moderated panels and presentations were included. For SCI in Canada, the continuum of care includes acute care (i.e. emergency and acute inpatient services) and hospital-based rehabilitation services (i.e. inpatient and outpatient rehabilitation) provided by provincial and territorial governments, as well as for-profit and non-profit community-based services that are typically accessed following discharge from hospital-based rehabilitation. Panels consisting of 2–3 summit members each were formed to discuss ABT in acute care and community settings, as well as the lived experience with ABT and/or engagement in exercise. See Table n = 5), innovators (n = 7), health care administrators/health policy experts (n = 8), researchers (n = 7), and frontline clinicians (n = 10). As some participants identified with more than one group, the assignment was completed with the aim of maintaining roughly equal numbers and geographical diversity within each group. Each stakeholder group was asked to discuss the following two questions: What would success look like for research? What would success look like for care? Following discussion, groups were asked to use a standardized form to generate a list of priorities for each of research and care, organizing the priorities according to what was feasible to complete in 1–2 years versus 3–5 years. Generation and sharing of priority lists by each stakeholder group ensured that each group’s perspectives were reflected in the large group discussion that followed.To begin generating priorities (summit objective 3), summit attendees were divided into five stakeholder groups: individuals with SCI  tallied the votes for each category, with the aim of identifying the four priorities (one per category) with the highest number of votes. She also completed a conventional content analysis  on the tSummit attendees identified numerous strengths of the prior initiatives in stroke rehabilitation Table . Many stThe mapping exercise identified areas in which Canadian ABT activities and data currently exist and areas that may be lacking activities and data , high staff turnover in the acute care environment and limited time for occupational and physical therapy. A high training dosage was not thought to be an appropriate focus for this setting; however, the panelists had several ideas for how ABT could fit within the acute care environment. Specifically, acute care may be an appropriate time to prepare patients, both physically and mentally, for ABT. For example, physical preparation might include maintaining range of motion to facilitate participation in treadmill training at a later stage of recovery. Mental preparation may include educating patients about ABT so that they know what to expect in rehabilitation. The panelists also stressed the importance of messaging that retains hope for patients during this early stage post-SCI.Members of the community panel shared four pieces of advice for others planning to establish a community-based ABT facility. First, as non-profit charities, they were eligible for grants, donations, and fundraising that enabled them to acquire equipment and staff training. Second, they emphasized the need to focus on patient safety and achieve spotless safety records. Third, they also emphasized the value of the social aspects of community-based ABT facilities; this is an environment where patients obtain peer support and create social connections. Lastly, the community panelists highlighted the importance of establishing supportive relationships, and having open communication, with their local rehabilitation hospitals and other community centers (e.g. YMCA).The panel of individuals with SCI shared their vision for ABT in five years. They hope ABT will be viewed as an integral part of rehabilitation after SCI, just like transfer training, for example. If ABT is part of regular clinical practice, it will no longer be viewed as an additional activity that requires extra time, which panelists felt was a barrier to its use. Their vision also includes effective mechanisms for patient education and knowledge translation concerning ABT, and greater access to ABT in the community.The summit attendees decided against separating priorities into research and care since research and clinical care are integrated entities that involve bidirectional flow of information. The five identified priorities Table , presentThe ABT Summit participants were tasked with identifying priorities for ABT research and clinical care, with a long-term vision of increasing the access to, and quality of, ABT for Canadians living with SCI. Five priorities were generated that recognized the need for: cooperation and communication across the continuum of care, increased knowledge of current ABT activities, standardized methods to track participation and outcomes in ABT, the generation of new knowledge concerning dose and timing of ABT, and the development of clinical recommendations for ABT. To achieve these goals, it was recognized that behavioral change strategies, economic analyses, technology innovations, collaborations, and data linkages would be required.Following the 2019 summit meeting, working groups were formed to address the first three priorities for ABT research and clinical care Table . In the The summit highlighted a potential role for ABT across the continuum of care, including in acute care. As outlined by the acute care panelists, acute care clinicians have the potential to play an important preparatory role for ABT. Exploring if and how ABT is operationalized in the acute care environment would be beneficial, along with consideration of methods of ABT delivery that may be particularly appropriate for acute care, such as motor imagery. There is preliminary evidence that motor imagery can normalize cortical recruitment and decrease movement variability in individuals with cervical SCI . FurtherThe latter three priorities for ABT research and clinical care Table  are broaThere were several strengths of the process used to generate the priorities for ABT research and care in Canada. First, best practices for stakeholder engagement were followed , 30. ForUpon reflection, there was at least one stakeholder group missing from the summit, which is a limitation of our process. Family members of people living with SCI were not targeted for inclusion in the summit, yet their support is likely important for ABT participation. The social support and encouragement of friends and family are known to influence whether physical rehabilitation is perceived as having a positive or negative impact by individuals living with SCI . When coIn conclusion, the priorities for ABT research and care for Canadians living with SCI were identified through a stakeholder-engaged summit meeting. These priorities will guide the activities of the Canadian ABT Community of Practice over the next five years to increase the access to, and quality of, ABT for Canadians living with SCI.Appendix


Following resettlement in high-income countries, many immigrants and refugees experience barriers to accessing primary healthcare. Local non-medical settlement organizations, such as the Local Immigration Partnerships in Canada, that support immigrant integration, may also support access to mental health and healthcare services for immigrant populations. This scoping review aims to identify and map the types and characteristics of approaches and interventions that immigrant settlement organizations undertake to support access to primary healthcare for clients. We systematically searched MEDLINE, Social Services Abstracts, CINAHL, and PsycInfo databases from 1 May 2013 to 31 May 2021 and mapped research findings using the Social-Ecological Model. The search identified 3299 citations; 10 studies met all inclusion criteria. Results suggest these organizations support access to primary healthcare services, often at the individual, relationship and community level, by collaborating with health sector partners in the community, connecting clients to health services and service providers, advocating for immigrant health, providing educational programming, and initiating community development/mobilization and advocacy activities. Further research is needed to better understand the impact of local non-medical immigrant settlement organizations involved in health care planning and service delivery on reducing barriers to access in order for primary care services to reach marginalized, high-need immigrant populations. Given the growing numbers of culturally and linguistically diverse newcomers settling in Canada annually, pressure is being placed on provincial and federal governments to involve local non-medical immigrant settlement organizations in the development of accessible equitable healthcare and welfare services to meet the complex needs of expanding marginalized populations such as immigrants and refugees ,2. AsyluThe focus on access to quality primary healthcare services is important, since these populations may be vulnerable and often experience considerable barriers to accessing quality primary healthcare, including limited English language proficiency, culturally inappropriate care and varying health beliefs, transportation difficulties, a general lack of social support, health system and health literacy issues, and high service costs ,6,7,8,9.Local non-medical immigrant settlement organizations that support immigrant integration can facilitate collaborative efforts to increase access to mental health and healthcare services for migrants. They can also support information sharing by acting as a platform to connect various actors horizontally across sectors and vertically within sectors. These partnerships create a social space where civil society, businesses, private-sector stakeholders, local municipalities, and other stakeholders can discuss priority issues . VariatiThere has been some mixed-methods research, conducted with providers, refugees and interpreters, to gain insight into how these non-medical immigrant settlement organizations collaborate with the health sector ; howeverWe developed a protocol for this scoping review using Arksey and O’Malley’s 2005 five-stage methodological framework , and refIn consultation with an expert health sciences librarian (LS), we developed a strategy to systematically search—using keywords, MeSH terms, major subject headings and/or the thesaurus functions—the following four electronic databases from 1 May 2013 to 31 May 2021: MEDLINE, Social Services Abstracts, PsycInfo, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). An expert social sciences research librarian (PL) reviewed our social services abstracts search strategy, which consisted of terms such as refugee, immigrant, asylum seeker, local, community, partnership, organization, collaboration, primary health care, clinical care, health services accessibility, mental health services, Canada, United States, and Australia; the search terms were combined using Boolean operators (see We included articles that met the following criteria: (1) included refugee, asylum seeker, or immigrant populations; (2) described local non-medical immigrant settlement-type organizations that support immigrant access to primary or clinical health care services; and (3) were conducted in industrialized countries with demographic, economic, political, and social characteristics comparable to those of Canada, and that are ranked on healthcare system performance by the Commonwealth Fund ” in BMC Public Health, since it analyzed peer-reviewed literature in global migration health published worldwide . Based oSearch results were imported into COVIDENCE, an online systematic review software . The incA standardized data extraction template, informed by framework analysis using the social-ecological model, was developed with input from the entire review team . We chosWe did not appraise the methodological quality or risk of bias of the included articles, which is consistent with guidance on scoping review conduct . As a scAs Carroll et al., 2013 recommended, we used a framework analysis method to structure our results . SpecifiA total of 3299 records were identified through database searching. After removal of duplicate citations, 1799 records were screened by title and abstract. Title abstract screening resulted in the exclusion of 1760 records, leaving 39 potentially relevant full-text articles that were sought for retrieval and assessed for eligibility using the inclusion criteria. Of the 10 articles, eight were carried out in Canada , one was in the USA (study 3), and one was in Australia (study 2). Three studies were published in 2019 , one in 2018 (study 3), one in 2015 (study 1), two in 2014 , and three in 2013 . Study designs included qualitative interviews , qualitative surveys , quantitative survey analysis (study 1), intervention development/piloting (study 2), before/after repeated survey design (study 7), focus groups , and other research methods such as direct observation, document/database analysis . Local non-medical immigrant settlement organizations in the 10 studies were described as settlement service organizations (study 1), local settlement support agencies (study 2), local refugee resettlement agency (study 3), community-based organizations , immigrant-serving agencies , and local receiving center (study 7).In the 10 articles reviewed, the local non-medical immigrant settlement organizations’ priority populations served included recent immigrants in small or large urban centers (study 1); asylum seekers newly released from detention (study 2) , Sri Lanka (25.3%), Iran (19.2%), Pakistan (10.7%), Other (6%), Stateless (3.7%), Vietnam (3.3%), and Iraq (1.4%)); Burmese-speaking refugee women (study 3), recent immigrant families in urban centers ; Punjabi and Korean-speaking immigrants (study 6); government-assisted refugees (study 7)  and females (49.1%) with a large percentage under the age of 18 (49.2%), primarily coming from Northwest Africa, the Middle East, and Southeast Asia); immigrants and refugees (study 8); and at-risk immigrant and refugee women and their families .The findings from our study are presented below according to the various levels of the Social-Ecological Model . The firTwo studies fell under this theme. Study 3 evaluated a pilot health education intervention delivered to Burmese-speaking refugee women, clients at a resettlement agency in Houston, Texas. Developed in partnership with the University of Texas Health Science Center, the intervention provided learning events to develop new skills to navigate health services, held discussions on health topics and question and answer (Q&A) sessions with medical providers, and disseminated health education resources. The increased opportunities to practice English and develop vocabulary allowed participants to be more confident in executing skills such as calling a doctor’s office to make appointments or taking the bus. The study noted that lack of compatibility and agency buy-in were two main barriers to creating a feasible and sustainable intervention.Next, study 8 focused on service providers’ perceptions of immigrant and refugee access to and use of mental health services. Findings showed that immigrant-serving agencies played a significant role in identifying clients experiencing a crisis or struggling with mental health conditions and connecting these individuals to mental health services. Further, these providers also evaluated the fit of an interpreter or cultural broker  with a client. In terms of challenges, the participants noted a desire for increased mental health training on identifying client needs and referring clients to specialized mental health services.Relationship level was examined in two studies. In study 5, the focus was on community-based organizations’ trust in the cultural competency of other local service providers and its influence on meeting the complex healthcare needs of recent immigrant families. Cultural competency in this study refered to the ability and preparedness of a service organization to understand and respond to the health needs of immigrant families. Competence trust among service organizations was key for families to have access to healthcare services, whereas a lack of trust led to constrained workflow within the system, more avoidance behavior, and less interaction. The study found settlement service organizations to be exemplars of cultural competency.Study 6 explored immigrant-serving agencies’ roles as partner organizations to dementia service institutions and in facilitating access to dementia diagnosis and care services and supports provided by dementia service institutions. Findings from focus groups with older immigrant adults showed that the immigrant-serving agency connected with immigrant clients and was able to engender trust and provide culturally responsive health information as well as support in navigating the health system. The immigrant-serving agency lacked specific knowledge on dementia .Study 4 addressed community-level relations by uncovering the role of settlement service organizations as broker organizations supporting a network of community-based services that meet the primary healthcare needs of immigrants. For example, settlement services in this study function as brokers by acting as a hub for health information for immigrant clients, by being a source of referral to primary care services for immigrant families, and by fostering collaboration in service delivery to high-needs immigrant families while building system competencies with partners. Further, compared to other service-sector organizations, immigrant settlement services in this study were found to have the greatest numbers of strong ties to partners in their community network. Barriers for settlement service organizations to assume the broker role included funding issues or capacity-building resource issues.While no study examined relations solely at the society level, a total of five studies addressed healthcare issues at multiple levels. Study 1 covers individual, relationship and community levels. Specifically, it examined the relationship between recent immigrants’ self-perceived mental health and social supports available for them. Findings revealed that each settlement service organization provided social support by engaging in private meetings with clients or providing referrals to community agencies, local organizations for psychological/clinical counseling, or community group programs. Settlement service organizations in small urban centers offered more tangible social supports compared to those in large urban settings; these included resources to primary healthcare services such as appointment accompaniment and additional referrals to healthcare service providers outside the clients’ community. A limiting factor to being able to provide these social supports was the amount of dedicated staff time needed.Study 10 explored the successes of community health workers at the individual, relationship and community levels in facilitating access to healthcare for recent immigrants and refugees through a case study of a Multicultural Health Broker Co-op collaborating with a health services public health unit. Findings from this study show the complementary role that multicultural health brokers and community health workers fill within the health system. Multicultural health brokers and community health workers work towards breaking down barriers  to accessing healthcare services for immigrant and refugee families. For example, multicultural health brokers/community health workers accompany clients to appointments or clinics, organize community development initiatives, and offer educational outreach programs on chronic disease prevention and management. A challenge for these community health workers and multicultural health brokers is not being formally recognized as part of the human health resource workforce.As another study considering the individual, relationship, and community levels, study 7 assessed the impact of a refugee health clinic’s partnership with a local refugee receiving center and community providers on referrals and wait times. The refugee health clinic model uses integrating mechanisms to deliver culturally appropriate and responsive primary care. Within this partnership model, gateway services are provided by the local receiving center’s case workers/settlement workers and professionals from the family practice . The health clinic delivers comprehensive care via family physicians; interpreters (if needed) are funded by the refugee receiving center. The model also includes ancillary services that are delivered in a community setting by providers willing to treat government-assisted refugees. Study findings demonstrated a 30% decrease in wait times for an appointment with a healthcare provider; an 18% increase in government-assisted refugees securing a permanent family doctor within a year after arrival; and almost a doubling of referrals to non-physician primary healthcare providers . The study notes that this partnership model is built on goodwill; no formal contracts or funding beyond regular settlement services support was pursued.Study 2 describes the Asylum Seeker Integrated Healthcare Pathway, an intervention influencing factors on the relationship and community levels, created to improve linkage to health services for asylum seekers newly released from detention. The Pathway consists of settlement support agencies in partnership and collaboration with local primary and emergency healthcare services in Melbourne. The Pathway intervention embeds a clinical health screening and triage process, facilitated by settlement support agencies, into existing community orientation programs for asylum seekers. Findings showed agencies supporting the coordination of healthcare appointments; assisting clients to appointments; and linking clients with culturally responsive care options. Through this initiative, clients had timely access to services. The study noted that an ongoing consideration for the success of this intervention is the capacity of the primary healthcare practices to meet the unique health needs of asylum seekers.Study 9 addressed individual, relationship, community, and society levels. It discussed the community health worker role in a Multicultural Health Broker Co-op (MCHB Co-op) that supports at-risk immigrant refugee women and their families by contributing to their settlement and integration into communities. The study aimed to better understand the health promotion functions and programs of the MCHB Co-op model and health brokers practice and found that both are able to offer a variety of supports to immigrant and refugee families; the Co-op provides educational support to help them realize their rights in order to overcome access to care barriers as patients , as program users , and as citizens . Two factors that could have negative implications on the community capacity-building programs and the services delivered by the MCHB Co-op were unstable funding and heavy caseloads.Findings from this scoping review show that local non-medical immigrant settlement organizations in the 10 articles had established approaches/interventions to support immigrants’ access to primary healthcare services. Further, most of the studies show that mental health support was an important component of the established approaches/interventions. These include: connecting to healthcare services and/or collaborating with health sector institutions; providing health promotion programs; undertaking community capacity-building and policy advocacy activities; and providing ‘on the ground’ assistance to clients. Using the social-ecological model to map these approaches , we founOut of the 10 studies included in this review, eight were Canadian; this highlights the uniqueness of the Canadian settlement model and long experience of the settlement sector in collaborating and partnering with organizations both within the sector and across other sectors. A case in point is the creation and deployment of LIPs since 2008, and the work they have done to coordinate service provision, for example, by launching numerous innovative initiatives, some focused on primary healthcare, during Canada’s Syrian Refugee Resettlement Initiative in 2015−2016 [As seen in this scoping review, local non-medical immigrant settlement organizations support immigrant access to primary healthcare; however, the scope and quality of services available to immigrants may not be uniform across settlement organizations. Settlement service organizations in Canada receive funding from multiple sources including the federal and provincial governments , which cLocal non-medical immigrant settlement organizations may not be structurally or financially able to take on extensive activities to increase access to primary healthcare themselves, however, they have a place in the health system. Consistent with previous literature, community-based organizations are increasingly recognized for their importance in primary healthcare; their unique closeness to immigrant populations and their ability to understand and respond to these populations makes them a valuable partner, source of knowledge, and gateway to marginalized populations for primary healthcare providers and institutions ,46. HealThis scoping review contributes to the literature by making visible the work that local non-medical immigrant settlement organizations do to advance health equity. Nevertheless, more international consensus is needed on terms for community settlement programs and more research on the collaborative relationships that exist or do not exist between community programs and community primary healthcare clinics to explore the impact on health outcomes for immigrant populations. Future research and development in this area is needed to better understand the impact of local non-medical immigrant settlement organizations involved in healthcare planning and service delivery on reducing barriers to access in order for primary care services to reach marginalized, high-need immigrant populations. Further studies could also look at what local non-medical immigrant settlement organizations do to advance health equity in areas linked to the determinants of health, which influence the health outcomes of individuals. This work requires multi-sector response, including but not limited to dealing with migration status, food security, and discrimination. Lastly, it would be beneficial for future research to build on this review by specifically considering the addition of gray literature from different countries and their local non-medical immigrant settlement organizations; gray literature can be very current, detailed, geographically specific, and in essence provide a rich and balanced picture of approaches/interventions to complement these foundational review findings.Strengths of this scoping review include its methodological approach—that is, using a predefined protocol aligned with Arksey and O’Malley’s framework and the JBI guidance, along with the use of predefined eligibility criteria by two reviewers when selecting the articles ,20. TherUsing a social-ecological approach, this scoping review mapped and highlighted current approaches/interventions relating to how local non-medical immigrant settlement organizations support access to primary healthcare services for immigrant populations. Although these findings may not be globally representative and, therefore, not generalizable, they suggest that these organizations are able to support access to primary healthcare services by collaborating with health sector partners in the community network, connecting clients to health services and service providers, advocating for immigrant health, providing educational programming, and also taking on community development/mobilization and advocacy activities to promote access to healthcare. Including these local non-medical immigrant settlement organizations in healthcare planning and service delivery may provide more scope to respond to and reach marginalized, high-need immigrant populations. Strategies to encourage the involvement of local non-medical immigrant settlement organizations in healthcare planning, implementation, and service delivery are needed. Although most of the articles in this review were Canadian, other countries may consider adapting the approaches and interventions identified to their context and needs. As a next step, we recommend a critical assessment of each identified approach/intervention to better understand the feasibility to implement the necessary elements , and the extent of its effectiveness. A critical assessment can help relevant stakeholders decide if the identified approaches/interventions in this review are worth adapting.


The associations of family duration of WIC participation, a proxy for the amount of WIC services received, with daily intake of total SSBs, fruit-flavored SSBs and water were assessed in race/ethnicity strata with multivariable negative binomial and Poisson regression models. Among English-speaking Hispanic children, those of families reporting 10 years of WIC participation consumed 33% and 27% fewer servings of total and fruit-flavored SSBs compared to those of families reporting 1 year on WIC. Among Black children, those from families reporting 5 and 10 years of participation in WIC consumed 33% and 45% more daily servings of fruit-flavored SSBs than those from families reporting 1 year on WIC. Disparities in daily total and fruit-flavored SSB intake between Black and White children increased with longer family duration on WIC. Duration of family WIC participation is associated with healthier beverage choices for infants and children, but does not appear to be equally beneficial across racial/ethnic groups in Los Angeles County. This study assessed relationships of duration of family Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participation with racial/ethnic disparities in child sugar-sweetened beverage (SSB) and water intake. Child beverage intake and family duration on WIC were collected during three cross-sectional surveys of WIC-participating families in Los Angeles County, California (2014, 2017 and 2020;  The prevalence of childhood obesity in the United States is high ,2. RecenChildren from low SES households are more likely to consume sugar-sweetened beverages (SSB) compared to children from high SES households, and Black and Hispanic children are >40% more likely to consume SSBs than White children . Among cwithin all racial/ethnic groups, and whether disparities in SSB and water intake between race/ethnicity groups would be reduced by longer family duration on WIC. It was hypothesized that children of all race/ethnicity groups would demonstrate lower daily SSB intake and higher daily water intake with longer family duration on WIC, and that racial/ethnic disparities in SSB and water intake would be reduced by longer family duration on WIC.Associations of WIC participation and improved diet quality among children have been reported previously, particularly for consumption of the healthy foods provided as part of WIC supplemental food packages, such as fruits and vegetables . WIC nutn = 3644), 2017 (n = 3658) and 2020 (n = 4180) administrations of the LA County WIC Survey [The sample for this study includes respondents to the cross-sectional Los Angeles (LA) County WIC Survey, a triennial phone survey conducted in a random sample of WIC participants from the largest local population of WIC participants in the nation. A county-wide random sample was augmented with random samples within 14 specific communities  and Asian and Black families across the county (2020). The survey aids planning efforts by WIC and community organizations serving LA County families with children under 5 years of age. This study includes data from 11,482 WIC participants 4 to 59 months of age, collected during the 2014 , health insurance, social support, household composition, food security, duration on WIC, diet, and demographics. Survey data were merged with WIC administrative data of the respondents. WIC administrative data are collected during initial program eligibility certification or annual recertification, and include directory information and characteristics of participating children , their mothers , and their households .Data on daily servings of beverages consumed by WIC-participating children between 4 and 59 months of age were obtained from parent responses to a battery of validated questions about child beverage intake . Items aWIC exposure was assessed as the cumulative duration of family participation in WIC . Family duration on WIC can exceed the duration of participation for the child for whom SSB and water intake is evaluated because it is inclusive of all children and pregnancies within the family. WIC offers participating families nutrition education a minimum of four times annually in addition to WIC food benefits, redeemable at approved vendors for supplemental healthy foods and beverages including fruits, vegetables, whole grains, low-fat milk, 100% juice, eggs, and cheese, which are provided monthly. Duration of WIC participation therefore served as a surrogate for each family’s cumulative WIC food package and nutrition education exposure. The self-reported duration on WIC was previously found to be valid using administrative records .2) based on self-reported weight and height, and education ; household Supplemental Nutrition Assistance Program (SNAP) participation (yes and no), income , food security status assessed with the 6-item USDA household food security screener , number of persons (continuous), presence of an older sibling (yes and no), and presence of another WIC-participating child (yes and no); and year of survey administration . The frequency of park/playground utilization (≥3 days/week and ≤2 days/week) was included as a proxy for child physical activity.Variables considered as potential covariates for this analysis included child age , sex, maternally reported child race/ethnicity , childcare enrollment (yes and no), and prenatal WIC enrollment (yes and no); maternal age, body mass index Continuous and categorical characteristics of study participants were summarized with means and standard deviations or frequencies and percentages, respectively. Differences in covariate distribution between race/ethnicity groups were assessed with chi-square tests and analysis of variance F tests for categorical and continuous covariates, respectively.within and across race/ethnicity groups, were assessed using multivariable negative binomial  and Poisson (for water) regression models that included interaction terms between child race/ethnicity and the duration of family WIC exposure. Associations were expressed as incidence rate ratios (IRR), which were calculated within race/ethnicity strata comparing children from families with 2, 5 and 10 years of participation to children from families with 1 year of participation. One year was chosen as the referent value for family WIC participation because the survey design (time elapsed between construction of sampling frame and conducting surveys) precluded the inclusion of families with <6 months of WIC participation and standard WIC certification periods are of 1 year duration. IRRs were also calculated across race/ethnicity groups, at 1, 5 and 10 years of cumulative participation in WIC, to determine whether longer family duration on WIC reduced the magnitude of disparities in SSB and water intake between race/ethnicity groups. The fully adjusted negative binomial and Poisson regression models included terms for the child’s age, race/ethnicity and survey year; maternal education, age, and BMI; household size, income, food security status, and SNAP participation; family duration on WIC (linear and quadratic); and the interaction of family duration on WIC and child race/ethnicity.The associations between WIC exposure and child SSB and water intake, both p-values less than 0.05 were considered statistically significant.Due to distinct patterns evident in associations between duration on WIC and SSB/water intake by race/ethnicity, a sensitivity analysis was undertaken to evaluate whether observed differences between Black and other race/ethnicity study participants could be attributed to SES differences between race/ethnicity groups. For these analyses, race/ethnicity was dichotomized as Black and non-Black. In negative binomial and Poisson regression models, for SSB and water intake, respectively, race was interacted with one of three dichotomous SES indicators that differed markedly between Black and non-Black study participants including household income (<1800 USD/month and ≥1800 USD/month), household SNAP participation (yes and no), and maternal educational attainment (≤high school degree and >high school degree). Dichotomous categories for household income and maternal education were determined based upon homogeneity in observed patterns of associations between family duration of WIC participation and beverage intake within categories on either side of the cut-point. The models also included interactions between race and duration on WIC, the SES indicators and duration on WIC, and three-way interactions between race, SES indicators and duration on WIC. Child activity was considered as a potential confounder, but was not related to family duration on WIC and did not meaningfully alter associations between family WIC participation duration and child beverage intake. Due to potential associations between park/playground utilization and survey year (due to COVID-19 restrictions in 2020) and the oversampling of Asian and Black participants in 2020, it was decided not to include park/playground utilization in regression models. All analyses were conducted using SAS 9.4 . 2), and the lowest mean household size (4.0 people).A majority of respondents to the LA County WIC survey were English- or Spanish-speaking Hispanic  . A majorwithin race/ethnicity comparisons, longer family duration on WIC was associated with lower rate of daily total SSB intake among children of all races/ethnicities except for Black children  and perceived harms of unhealthy beverages  . A studyThis study was conducted in a large and well-characterized sample of WIC-participating families in LA County, randomly-selected from the general WIC population and target geographies and racial groups, ensuring that the sample is representative of the large WIC participant population in LA County. Beverage intake outcomes were assessed with a validated instrument , and matLonger duration of family WIC participation may be associated with general improvement in the healthfulness of beverages selected by participating families; however, this improvement is not evident among Black families. WIC provides the same services and benefits to all participating families, and it is critical to understand whether and how WIC services may be contributing to disparities in healthy beverage choices. Further research into why Black families appear to benefit less from WIC participation should be prioritized. Child beverage choice may need to be given greater emphasis during individual nutrition counseling efforts for Black families. Further evaluation of WIC services for differential impacts across race/ethnicity groups may also need to be considered.


The importance of the status of female health should have research priority due to the unique medical needs of women. Hence this paper attempts to explore the nexus of access to electricity, female education, and public health expenditure with female health outcomes in the SAARC-ASEAN countries.Using the data of 2002–2018, and applying the cross-sectional dependence test, Modified Wald test, Wooldridge test, the Panel corrected standard error (PCSE) model, the Feasible generalized least square (FGLS) model, and the pair-wise Granger causality test, the robust outcomes on female health are found.Access to electricity, female education rate, public health expenditure, economic growth, and immunization rate, all have a positive effect on female life expectancy at birth, and a negative effect on the female adult mortality rate. The urbanization rate has a significantly positive impact on female life expectancy at birth but an insignificant impact on female adult mortality rate. The one-way causal relationship between the variables are also revealed.All the results are rational and have important milestone for the health sector. The health status of females should be improved and protected by formulating effective policies on access to electricity, female education, public health expenditure, immunization, economic growth, and urbanization. The importance of the status of female health cannot be overlooked and should be prioritized in order to balance gender equality and fulfil the unique medical needs of women. Female health status is often ignored, especially in developing countries, due to the disadvantaged conditions they face, created by discrimination which is deeply rooted in biological, socio-economic, cultural, political, and spiritual grounds , 2. To eAgainst this backdrop, our present study is an endeavour to probe the determining factors of female health in the selected 10 SAARC-ASEAN countries.Some empirical studies can be found in the literature , 62, 72 The rationale for selecting the variables is that: (i) access to electricity ensures better health outcomes for females by providing health related facilities, like getting more health related knowledge from TV, Radio, etc. and become more health conscious, and receiving more medical benefits from electricity run appliances; (ii) female education creates awareness and provides proper guidelines about the healthy life to ensure better health for females; (iii) public health expenditure provides various medical facilities at a lower cost for the improvement of female health. (iv) economic growth ensures better living standards that facilitate improved female health; (v) a higher immunization rate generates protection against infectious diseases and safeguards female health; and (vi) urbanization creates different modern facilities that may positively affect female health. More rationalization of the selection of variables is provided in Sect. (i)To identify the impact of access to electricity, female education, public health expenditure economic growth, immunization rate, and urbanization on female health outcomes in the SAARC-ASEAN countries.(ii)To detect the causality between access to electricity, female education, public health expenditure, economic growth, immunization rate, urbanization, and female health outcomes.The major objectives of this study are:The main contributions of this study are: (i) this is the first study in the literature, to the best of our knowledge, that identifies the impact of access to electricity, female education, public health expenditure, economic growth, immunization rate, and urbanization on female health outcomes in the context of SAARC-ASEAN countries; (ii) this study utilizes the updated available and inclusive data considering the period of 17 years (2002–2018); (iii) the outcomes are achieved by using robust econometric tools: cross-sectional dependence test, Modified Wald test, Wooldridge test, the Panel corrected standard error (PCSE) model, the Feasible generalized least square (FGLS) model, and the pair-wise Granger causality test; and (vi) the results will provide unique guidelines for policy makers to advance the improved health status of females by considering access to electricity, female education, public health expenditure, economic growth, immunization rate, and urbanization policies.The study is aligned in the following order: following the introduction, Sect. We will discuss the related literature concerning the linkages between our considered variables and health outcomes.Electricity is a vital element of modern society and has a significant impact on the availability and effectiveness of health facilities, as explained in existing literature , 11–14. Because education increases consciousness about important health issues, it is also considered to be an important element for improving health outcomes. The significant role of education on health outcomes is shown by many contemporary researchers like , 15–22. Public health expenditure has a significant role in improving health outcomes globally, as found in current literature . Novignon and Lawanson  for GhanImmunization creates protection against various infectious diseases and therefore ensures a healthier life for the people –34, 61. Economic growth ensures different health related advanced facilities and medical amenities that increase the health outcomes of people as observed in various works like , 35–38. Urbanization has a mixed effect on health status by ensuring different modern medical facilities as well as creating negative penalties for the public –45, 62. From the critical investigation of the aforementioned literature it can be observed that the previous findings are not sufficiently convincing and encouraging to formulate effective policies, particularly for female health. Moreover, unanimous, complete and comprehensive policy outcomes focusing exclusively on female health status are absent, especially in the SAARC-ASEAN countries. This is the main gap in the existing literature, and our current aim is to fill up this gap and provide uniform and inclusive policies to ensure better health for the female, which will be a milestone for the modern health sector.The theoretical justification for conducting this study is based on the different well-known and well-recognized theories and models, for example the human capital theory by Becker , the heaThe rationale of choosing our studied variables is relies on the availability of data, from contemporary and previous literary works. We have considered the variables relating to life expectancy at birth, following Rahman et al. , ShahbazFor this study the female health outcomes are considered as the dependent variables; for this, female life expectancy (FLE) at birth and female adult mortality rate (FAM) per 1,000 female adults (ages 15–60 years) are used as proxy variables. Along with these, the access to electricity (AEL), female education rate, immunization rate (IMM), urbanization rate (URB), gross domestic product (GDP) and public health expenditures (PUH) are taken as the independent variables. Access to electricity is the percentage of population having access to electricity; female education rate is the school enrolment of females at secondary level as a percentage of gross; immunization rate is taken as measles vaccination taking rate as the percentage of children ages 12–23 months; GDP is used to see the reflection of economic growth; urbanization is defined as the urban population referring to people living in urban areas as a percentage of total population; and the public health expenditure is taken as the domestic general health expenditure per capita at current US$ funded by the government.All the data are collected from the World Development Indicator  of the WThe models used for the estimation of this study are presented below:1, β2, β3, β4, β5, β6 are coefficients and εt is the error term.To get the direct elasticity of each variable from the coefficients, we have transformed all the variables of the Eqs.  and 2)  2) into For empirical estimation we employed a number of renowned econometric approaches. We conducted the mentioned tests as: a cross-sectional dependence test to identify the shock effect; the Modified Wald test for group wise heteroskedasticity and Wooldridge test for aut-1ocorrelation in panel data to observe the heteroskedasticity and autocorrelation respectively. We employed the Panel corrected standard error (PCSE) model and the Feasible generalized least square (FGLS) model to obtain results that will show the robust relations between the variables; and the pair-wise Granger causality to determine the direction of causality.Because of the resemblance of the geographic, economic, historical, ethnic and political shocks, the cross-sectional dependence of the variables may be observed. In this study we have employed four well-known cross-sectional dependency tests: Breusch and Pagan  BP LM, PThe Breusch and Pagan  model ofPesaran  developeIf the cross-sectional size is greater than the time dimension, Pesaran  recommen0: denotes no cross-sectional dependence and the alternative hypothesis is H1: prevalence of cross-sectional dependence.Baltagi et al.  developeTo make an efficient and robust estimation of the fixed effect model, the model should be homoskedastic with no autocorrelation. If the model suffers from heteroskedasticity, the estimation may be consistent but inefficient . To deteTo overcome the complications of panel data estimation arose due to cross-sectional dependence, heteroskedasticity, and autocorrelation both the panel corrected standard error (PCSE) and the feasible generalized least square (FGLS) models are considered to be best and most efficient. So, the difficulty created due to the panel nature of data, the PCSE, is the path finder . AlternaTo observe the causality between the studied variables, pair-wise Granger  causalitThe stacked causality test considers all the coefficients are the same across all cross sections as common coefficients , 60. ThiHence the decision rule is H0: Y does not Granger causes X, and H1: Y Granger causes X.The results of the descriptive statistics are shown in Table The values of cross-sectional dependence tests and their probabilities are presented in Table Table After confirming cross-sectional dependence, heteroskedasticity and autocorrelation the (PCSE) model is estimated and the results of both models are reported in Table In case of female life expectancy at birth, from Table These findings show that the access to electricity, female education rate, public health expenditure, GDP, immunization rate, and urbanization rate improves the female life expectancy at birth, which indicates their better health status in the studied regions.In Table The robustness of the results obtained from the PCSE model is confirmed by the FGLS model as shown in Table The result of pair-wise Granger causality test is depicted in Table The outcomes of Tables This paper has explored the nexus of access to electricity, female education, and public health expenditure with female health outcomes in the SAARC-ASEAN countries. Using the data of 2002–2018, and applying the cross-sectional dependence test, Modified Wald test, Wooldridge test, the PCSE model and the FGLS model, and the pair-wise Granger causality test, robust results have been obtained. Access to electricity, female education rate, public health expenditure, economic growth, and immunization rate have a positive effect on female life expectancy at birth, and a negative effect on the female adult mortality rate. The urbanization rate has a significant positive impact on female life expectancy at birth but an insignificant impact on the female adult mortality rate. A one-way causal relationship between the variables is also noted. All the results are logical and generate important milestones for the health sector. These results may be said to apply, not only for the regions studied but globally.(i)Ensuring more access to electricity: More electricity access plays role in increasing female life expectancy and reducing female mortality rate in the studied region. Electricity facility also helps females to be health conscious via electricity run devices and media by and also helps to take proper medical treatment with modern electricity led medications. It also helps female to get employment and thus discourages child marriages. Use of electricity facilitates easy access to print and electronic media that increases female awareness, which plays an important role in reducing early marriage related death and increasing life expectancy. For this reason, an effective and efficient policy formulation to ensure more electricity access should be formulated that will be conducive to female health.(ii)Spreading more female education: More education of female ensures more life expectancy and lower female mortality rate[lity rate, 20). Th(iii)Greater public health expenditure: Our findings of public health expenditure on female life expectancy and female mortality rate plausible. More public health expenditure offers more medical facilities at no cost or minimum costs As a result, people including female can easily enjoy required health facilities which reduces mortality and lengthens female life expectancy.. Therefore, the governments of these countries should increase budget allocation for public health with priority for females’ health as women has unique health issues [h issues . In this(iv)Larger coverage on immunization: As immunization builds herd immunity against different types of infectious diseases, a greater coverage of immunization may help females to achieve better health outcomes [outcomes , 33. Nec(v)Sustainable economic growth policy Our findings of economic growth on health outcomes are consistent too because economic growth brings amenities and ensures modern types of different facilities for better health, which increases female life expectancy and declines female mortality rate. A sustainable and effective economic growth policy can ensure modern health facilities for females. Therefore, effective, efficient, updated, and health-focused economic growth policies should be pioneering across the regions for making sustainable future for ensuring better female health status.(vi)Planned urbanization As urbanization increases female life expectancy, the more panned urban facilities for female should also be ensured. Because unplanned urbanization may create detrimental consequences on human health through creating pollution, unhygienic water and sanitation facilities, congestion, and various socio-cultural mal-adjustments like slums [ke slums , 62. A pThe important policy implications of the study are: the health status of females should be improved and protected by formulating effective policies on access to electricity, female education, public health expenditure, immunization, economic growth, and urbanization. In this context the following specific recommendations should be prioritized:


The proliferation of mHealth solutions and eRecord systems is inevitable in developing countries, and ensuring their bi-directional interoperability is essential. Interoperability has been described as the ability for two or more systems or components to exchange information and use the information that has been exchanged. Given the importance of linking mHealth solutions to eRecord systems in the developing world, a suitable interoperability framework is required to provide an agreed approach to interoperability and specify common elements. Although eHealth interoperability frameworks exist in the literature, none meet all the requirements for linking mHealth solutions to eRecord systems in developing countries. The aim of this paper was to describe the design and development of a conceptual framework for linking mHealth solutions to eRecord systems in Botswana, as an exemplar.An iterative and reflective process was adopted, supported by existing literature and research including consultations with eHealth experts, and guidance from existing frameworks. These collectively identified key elements, concepts, and standards relevant and essential for framework design and development.The mHealth-eRecord Interoperability Framework (mHeRIF) was developed which highlights the need for: governance and regulation of mHealth and eRecord systems, a national health information exchange, and which interoperability levels to achieve. Each of these are supported by integral themes and concepts. It also addresses the need for regular review, accreditation, and alignment of framework concepts and themes with a National eHealth Strategy Interoperability Development Process. To demonstrate the framework’s applicability, a proposed architecture for the Kgonafalo mobile telemedicine programme is presented.Interoperable mHealth solutions and eRecords systems have the potential to strengthen health systems. This paper reports the design and development of an evidence-based mHeRIF to align with, build upon, and expand National eHealth Strategies by guiding the linking of mHealth solutions to eRecord systems in Botswana and other developing countries facing similar circumstances. AccordiThe recently launched Botswana National eHealth Strategy recognises the need for eHealth interoperability, and states, “Interoperability will be supported by establishing an interoperability architecture/platform that simplifies the complexity of interfaces that will be built between different information systems by creating a mediation layer ” . It alsoMany developing countries offer public healthcare services across a decentralised network of health facilities. In Botswana these include 3 national referral hospitals, 15 district hospitals, 17 primary hospitals, 357 clinics, 346 health posts and 1117 mobile clinics , which aA recent review of eHealth interoperability frameworks found none to be entirely suitable nor adequate on their own to address linking of mHealth applications to eRecord systems in the context of the developing world and, more specifically, Botswana . IdentifAnother study, based on local eHealth experts’ opinion and a review of the National eHealth Strategy, described Botswana’s eHealth interoperability landscape and provided guidance on linking mHealth applications to existing eRecord systems . DesirabFurthermore, the National eHealth Strategy review specifically identifies Free and Open Source Software (FOSS) as a desirable resource that will be pursued. In particular, the Strategy identified the open health information exchange (OpenHIE) framework and its reference tool, the Open Health Information Mediator (OpenHIM), as the preferred approach to support eHealth interoperability , 26. Opeand recognise that the lack of a seamless exchange of data within and between health information systems hinders care and leads to fragmentation of systems [and increase mHealth capacity as it has potential to accelerate progress towards achieving universal health coverage (UHC), including ensuring access to quality essential health services”, respectively. Furthermore, the new WHO global strategy on digital health (2020–2025), promotes “syntactic and semantic interoperability according to established norms and standards to enable sharing of information in a connected world” [Given the importance of linking mHealth solutions to eRecord systems in Botswana and the developing world, a suitable interoperability framework relevant to their needs is required. Such a framework would provide for an agreed approach to interoperability for organisations wishing to work together, and specify common elements , 31. Thi systems . Subsequ systems  and the  systems  advocated world” .Building upon prior research findings, the aim of this paper is to describe the design and development of a conceptual framework for linking mHealth solutions to eRecord systems. The resultant mHealth-eRecord Interoperability Framework (mHeRIF) is relevant to both Botswana and the developing world.Although eHealth interoperability frameworks exist in the literature, very little guidance is provided on their design and development, particularly towards linking mHealth solutions to eRecord systems. Similarly, whilst many conceptual frameworks appear in the health-related literature, there is again very little guidance for their design and development. The process adopted in this paper is aligned with published principles and experience , 37. HerThe Donabedian Model, a conceptual model that provides a framework for examining health services and identifies structures, processes, and outcomes, was adopted and adapted to establish a structured approach with inputs, processes, and outputs . Inputs Input: The conceptual framework for this paper is evidence-based, and developed through literature findings, including consultations with eHealth experts, and existing frameworks. These, collectively, identified key elements, concepts, and standards that are relevant and essential for inclusion , 26. SpeProcess: An iterative and reflective process guided framework design and development. Based upon available data sources, key elements were identified, given labels, and grouped. These groups were then mapped and related to one another according to their proximal relationships. A preliminary conceptual framework was devised and its content, elements, groups, relationships, and presentation debated on several occasions by the authors to synthesise and resynthesise the framework until consensus was reached. Over time and several iterations, the framework was progressively transformed.Output: An mHealth-eRecord Interoperability Framework (mHeRIF) was developed Fig. . The fraThe proposed mHeRIF for Botswana and developing countries is presented in Fig. At the top of Fig. Themes, concepts, elements and standards identified from prior studies , 26 infoThe framework also highlights cross-cutting themes. These include the ‘Human Resource Capacity Building’ (left-hand side of the diagram) and all legislation impacting ‘Security, Privacy and Confidentiality’ concerns (right-hand side of the diagram). All of these feed into a comprehensive and informed ‘National eHealth Strategy Interoperability Development Process’ (far right-hand side of the diagram) supporting linking of mHealth solutions to eRecord systems. This would align with the Botswana Interoperability Pillar outlined in the National eHealth Strategy. Although a generic framework, the proposed mHeRIF may require modest adaptation below the ‘legal, organisational, semantic, and technical’ sub-layer that will allow the enterprise architecture to better suit each specific implementation.The current gap in the literature being addressed, and shortfall in Botswana’s (and possibly others’) National eHealth Strategy, is the inability of mHealth solutions to link with eRecord systems. The proposed mHeRIF resolves this shortfall. To demonstrate this, the framework’s functionality was used to propose an OpenHIE compliant architecture for linking the Kgonafalo mobile telemedicine programme to eRecord systems in Botswana Fig. .Fig. 2PThe mHealth solution and eRecord system are identified as Point of Service Applications (POSA), linking directly or indirectly with the HIE. The Mobile Device Translation Layer FIHR Interface supports implementation of various mobile devices and platforms .Here, the Kgonafalo mobile solution would be linked to an EMR system through the interoperability layer supporting specific services including the ‘Case Notification Service (CNS)’. The CNS would be responsible for sending bi-directional medical case notifications across mHealth and eRecord systems, for example, when a new case is registered using the mHealth solution and resolved through the eRecord system .Various repositories , Master Facility List (MFL), Shared Health Record (SHR)) all work within the OpenHIE framework . The arcSpecific interoperability standards supporting the proposed IHE profiles would be embedded within the interoperability layer (OpenHIM). The ‘Mediator’ service of the HIE would handle queries and responses between different database systems and resolve complex orchestration of communications between multiple mHealth solutions and eRecord systems. As noted in the methods, the mHeRIF may require modest adaptation for specific services. In Fig. This paper describes the evidence-based design and development of a conceptual interoperability framework (mHeRIF) for linking mHealth solutions to eRecord systems within Botswana and other developing countries in similar circumstances. The proposed mHeRIF emphasises the need for; Governance and regulation of mHealth and eRecord systems, a national HIE supporting all four interoperability levels , and an IT infrastructure supporting both cloud and on-site servers Fig. . FurtherGrowth in the application of mHealth and eRecord systems can be reasonably anticipated, particularly in developing countries –42. The The proposed mHeRIF has the potential to contribute significantly to health system strengthening and a reduction in health expenditure , 44. HowThe benefits of HIE-based systems in different healthcare settings are well documented –52. In tThe adoption of global goods designed to be interoperable is suggested within the Botswana eHealth Strategy, and is reflected within the mHeRIF. Of importance to their adoption is their usability, to ensure they effectively serve the needs of intended users , 57. PreInteroperability standards for mHealth solutions and eRecord systems including the HL7 FHIR, ISO/IEEE 11073 (PHD), and the Digital Imaging and Communications in Medicine (DICOM) have been previously suggested for Botswana and other developing countries , 60, 61.Associated with mHealth and eRecord systems is the use of a unique patient identifier (UPI) crucial to support interactions with the Master Patient Index (MPI) for uniquely identifying patients. In the absence of a national UPI the mHeRIF uses the national identity number for Botswana, the Omang number, or the passport number of foreigners. Use of biometric identifiers could later be introduced to strengthen the uniqueness of patient identifiers .The proposed mHeRIF emphasises security, privacy and confidentiality across all four interoperability layers. A previous study by Rubio et al. implemented varying security measures across the interoperability levels . They fuAlthough not unique to the developing world, human resource capacity to design, develop and use interoperable eHealth systems is a challenge in Botswana with a previous study showing lack of understanding of the features and interoperability of the eRecord systems and the mHealth application in facilities . This waThe need to constantly review, audit, accredit and align all interoperability efforts with the National eHealth Strategy Interoperability Development Process is crucial since new challenges and scenarios will emerge over time requiring different technology approaches. Regular assessment of interoperability models has been recommended to improve their functionality . SimilarThe proposed conceptual framework (mHeRIF) offers developing countries a means to refine their eHealth strategies to ensure inclusion and interoperability of mHealth solutions and eRecord systems. Given the WHO’s promotion of both mHealth and eRecord systems as essential tools , 65, thimHealth and eRecords interventions have demonstrated potential to strengthen health systems but their combined leverage has been hampered by approaches that did not consider their interoperability. An interoperability framework adaptable to different implementation contexts will alleviate such challenges by offering organised workflows and standardised health information exchanges, resulting in enhanced eRecord data quality for better health system monitoring and patient care. This paper presents an evidence-based mHeRIF developed using prior research findings as well as guidance from the ReEIF and OpenHIE frameworks. The mHeRIF will align with, build upon, and expand National eHealth Strategies by guiding the linking of mHealth solutions to eRecord systems in Botswana specifically, but also other developing countries facing similar circumstances.