Advance Care Planning (ACP) makes up an integral part of the care continuum, especially for those living with chronic conditions such as HIV. Little research exists to understand how intersections of race, gender, sexuality and gender identity combine to influence the choices made by older adults living with HIV regarding ACP. The Research on Older Adults with HIV (ROAH) 2 study collected data from across the US and investigated the incidence and range of ACP amongst those 50+ living with HIV. Correlational analysis indicated that being White was significantly related to having at least one directive  where being African American correlated negatively with several forms of ACP. Additionally, there were also significant relationships between being Transgender, being gay, and being a woman as to the engagement with ACP options. Further analysis explored the impact of finance, self-rated health and social support networks.


In the United States, women are at a higher risk of developing vision impairment or a serious eye disease  than men. Disparities in eye diseases due to biology widen even further when considering factors such as social determinants of health; gaps in research data, literature, and policy; insufficient provider and patient education; and limitations in screening and treatment options. Sex and gender disparities in eye health are clinically under-addressed and burdensome on both patient quality of life and the health care and economic systems, resulting in a pressing population health issue that negatively impacts women.The Society for Women’s Health Research convened a working group of expert clinicians, researchers, and patient advocates to review the current state of science regarding sex and gender disparities in women’s eye health, identify knowledge gaps and unmet needs, and explore better means to advance research, improve patient care, and raise awareness of key issues.The SWHR Women’s Eye Health Working Group identified priority areas in research, clinical care, and education to reduce disparities and improve patient care in women’s eye health. The working group recommends using a systems approach that incorporates a comprehensive research framework with a sex and gender lens to guide future work and that increases health care provider and public education, as well as engagement by expanding partnerships among ophthalmologic providers, researchers, and non-vision stakeholders. According to the National Center for Chronic Disease Prevention and Health Promotion, approximately 12 million Americans ages 40 and older are visually impaired or blind, and more than half of them are women . InvestiResearch often fails to consider the roles of sex and gender in eye health, leaving gaps in our understanding and ability to address differences in patient populations and outcomes. Sex is an important biological variable that can influence the function of biological processes in males and females, as well as how individuals will respond to medications for disease . Gender—The Society for Women’s Health Research (SWHR) assembled a Women’s Eye Health Working Group of researchers, clinicians, and patient advocates to: 1) assess the state of the science regarding sex and gender differences in women’s eye health across the lifespan; (2) examine a spectrum of vision disorders that disproportionately or exclusively impact women to identify key influences and determinants  for these disparities; and (3) develop recommendations to advance the research agenda, diagnostic and treatment strategies and to address gaps in awareness, education, and stakeholder engagement. SWHR selected 12 participants with expertise in women’s eye health and research interests in sex differences in disease manifestation and symptoms to participate in a 2-day roundtable meeting  is the most common cause of irreversible vision loss among older adults (70 years and older), with an estimated 9 million Americans suffering with intermediate or advanced AMD . StudiesSince the introduction of anti-vascular endothelial growth factor (anti-VEGF) therapy to treat AMD, vision loss can now be stabilized in over 90% of patients with neovascular AMD, which generally affects more women than men, regardless of race or ethnicity . Anti-VEAccording to the American Thyroid Association, 1 in 8 women will develop a thyroid disorder or disease, with women at increased risk after pregnancy and menopause. Graves’ ophthalmopathy, also known as thyroid eye disease (TED), is an autoimmune inflammatory condition of the eye and surrounding tissues. The higher prevalence in women is stark, with the disease affecting 16 women vs 3 men per 100,000 people annually . The patBeyond thyroid dysfunction, the impacts of TED can be severe and disruptive to a patient’s quality of life . IndividDry eye disease (DED) is diagnosed in over 16 million individuals in the United States, with prevalence increasing with age, and an additional 2.5% of the population are estimated to experience symptoms without diagnosis . The genMigraine is a chronic neurological disease that affects more than 14% of the adult population worldwide . In the Studies have proposed correlations in the prevalence of migraine with DED. For example, one retrospective case–control study suggested that there is a 20% increased risk of DED diagnosis with an existing diagnosis of migraine . For menPregnancy presents unique circumstances in a woman’s health journey, as the dramatic transformation the body undergoes often acts as a stress test for future health, including eye health . During Another eye condition that can be induced or exacerbated by pregnancy is diabetic retinopathy (DR), a diabetes-related complication caused by damage to the blood vessels of the light-sensitive retinal tissue. If inadequately treated, DR can lead to blindness. Women with pre-existing diabetes mellitus can develop and are more likely to experience worsened DR during pregnancy . In addiFluid retention is a common occurrence during pregnancy, but it can also affect the eye’s corneal thickness and shape, resulting in visual disturbances. When presenting with high blood pressure and protein in the urine, these signs can sometimes indicate preeclampsia or eclampsia. (Pre)eclampsia-related retinal changes and dysfunction can lead to blurred or double vision, sudden transient vision loss, and flashing lights . Visual Opportunities exist within retinal imaging guidelines to increase screening for pregnant women, particularly for racial and ethnic minority patients who experience worse maternal health outcomes than their white counterparts . Vision Women experience societal pressures to keep up physical appearances, which often include the use of cosmetics and personal care products—an industry that is widely under-regulated and has had substantive unintended consequences on eye health, including contact dermatitis, bacterial infections, dry eye, and other serious conditions , 39. ForSociety also imposes responsibilities and expectations on women to prioritize others’ well-being and health over their own. Women typically assume the role of family caregiver for children, partners, and aging parents . This dyThe Flatten Inaccessibility Survey provides insight into the disadvantages that individuals who are blind or have low vision faced early on the COVID-19 pandemic . AlthougWorld report on vision in 2019, proposing an integrated people-centered eye care approach to address persistent challenges and inequalities in health care delivery coordinated across different levels and throughout the life-course [In 2016, the National Academies of Sciences, Engineering, and Medicine commissioned a report  that expe-course . To advae-course .Table 2PExpanding the current research framework is essential to guide system innovations toward a population health approach to addressing women’s eye health vulnerability and disparities. Current eye health research is largely concentrated in clinical research, but evidence-based population health methods are needed to promote equitable awareness and treatments. Using the NIMHD research framework, sex and gender should also be prioritized for guidance on research questions and outcomes data analyses. The role of sex as a biological variable (SABV) in genetics, hormones, environmental exposures, and comorbidities should be investigated and data should be disaggregated by sex. Gender-based research should focus on the roles of behavior, differential access to care, cultural norms, and environmental influences on eye health disparities and inequities. This requires incorporating clearly defined SABV and gender standards and targets in research proposals and communications, which is now required by the National Institutes of Health, but is not currently a regular mandate by many funding organizations . In 2020Advances in health technology have created opportunities to increase access, diagnosis, and quality of vision care at more affordable costs for individuals across socioeconomic groups . Before Improving education efforts at the patient and provider levels is essential to progressing the field of women’s eye health. A survey of 135 member institutions of the Association of University Professors of Ophthalmology and medical schools found that the majority of their respective programs provided preclinical exposure to ophthalmology, while clinical exposure varied widely—from interest groups to required clinical rotations . BecauseBuilding patient awareness and education about eye health aids in behavioral adjustments that could positively impact women’s eye health. Women should be informed of the potential eye health risks throughout the life-course, including issues associated with pregnancy (if part of their life plan) and menopause. Social media and mobile health apps provide accessible avenues to provide educational resources to patients and providers. These platforms also offer opportunities to connect with communities of support along the patient journey. When education efforts are implemented across the patient and provider spectrum, there is optimal opportunity for collaborative goal-setting and improved quality of care for all women.The multi-level population health approach to improving women’s eye health leverages opportunities for partnerships and collaboration amongst eye health providers, non-ophthalmic providers, population health experts, and community stakeholders to create more holistic and comprehensive solutions to barriers to adequate research funding, access to quality care, and patient and provider education. By engaging stakeholders who are specialized for different populations and sectors of interest, efforts can build upon existing relationships and structures within communities. For example, if early childhood educators are aware of vision problems and how this can hinder development and behavior, attention can be given to children with vision issues to prevent them from falling behind academically. Conversely, older women should also be educated on eye health needs, as their risk increases for age-related eye diseases. Public health professionals, senior care specialists, and minority health specialists have the opportunity to integrate eye health education and early detection strategies into established programs that can target diverse populations. Many national nonprofit organizations and professional societies have established networks that can assist with promoting education among health care providers, advancements in research, building public awareness, and advocacy with policymakers. Fostering new cross-sector partnerships and enhancing existing ones between state and federal agencies, non-vision researchers , and public and private organizations would also facilitate system-wide progress.Various biological and social determinants of health contribute to eye health disparities and inequities for women. The solution is not necessarily to create a new system, but to adapt current systems to better address eye disease burden in women. Issues must be targeted through a multifaceted, systems-level approach that integrates women’s eye health as a priority in research, education, and collaboration across individual, clinical, and community-based settings. Finally, elevating the sex and gender lens in eye health research and care is key to advancing our understanding of eye health disparities among women and how these inequities can be rectified.


European Year of Youth’ to accelerate progress in areas previously defined as Youth Goals, including mental health and wellbeing, equality and inclusion, and sustainability.Anxiety and depression are among the top five causes of ill health burden among youth population (age 15–29 years). Youth is the most formative period of life, and for more than half of adults with mental health disorders, first onset occurs during or before adolescence. Social isolation, disrupted education, and diminished job opportunities during the ongoing COVID-19 pandemic have exacerbated the disease burden for mental illness among youth. According to estimates from the State of the World's Children 2021 report by UNICEF, mental health disorders, including depression, anxiety, eating disorders, and attention-deficit hyperactivity disorder, are now present in 16.3% of European youth aged 10–19 years, an estimate that is higher than the global average of 13.2% for the same age group. To support youth population, the European Union (EU) has designated 2022 the ‘study of helpline data in several European countries during the pandemic showed that increases in helpline calls was predominantly due to feelings of anxiety and loneliness rather than suicidal thoughts.The European Year of Youth 2022 is framed explicitly as an opportunity to accelerate the existing EU Youth Strategy (2019–27). The 2021 EU Youth Strategy progress report shows that achievements to date have been limited since the pandemic has stalled many of the youth mobility programmes that provide young people opportunities abroad, and only a few mental health programmes are included. Among these mental health programmes is the Joint Action on Mental Health (ImpleMENTAL) to support youth suicide prevention in EU countries. Suicide remains the second leading cause of death in European youth (after road traffic injuries) and thus strengthening suicide prevention is necessary, however, such a specific focus diverts from more common issues such as anxiety and depression. A In the 2018 report of the Youth Goals, young people expressed their desire for greater access to mental health promotion and prevention programmes within their current environments . Instead of waiting to treat mental health problems, integrating prevention interventions in everyday settings can increase positive mental health and contribute to better health, social, and academic outcomes for young people, an approach known as ‘mental health promotion’. Promoting awareness of lifestyle or behavioural factors that influence the onset of illness is central to any health promotion approach.randomised trial, the school-based MindOut social and emotional learning programme for adolescents, delivered within the SPHE curriculum, significantly improved students' social and emotional skills while reducing symptoms of stress and depression. The inclusion of all youth (instead of only high-risk students) and education for parents and teachers are important aspects of comprehensive health promotion programmes.Mental health promotion programmes in schools specifically aim to teach young people social and emotional skills such as self-awareness and resilience so that they can recognise mental health problems in themselves and their peers and react appropriately. For example, Ireland has made Social, Personal and Health Education (SPHE) a compulsory part of the national school curriculum with an aim to promote physical, mental, and emotional wellbeing. In a In addition to universal interventions, targeted programmes are needed within the school setting to provide more tailored support for students experiencing mental ill health and mental health services are needed outside of the school environment for the highest-risk students. However, interventions designed before the pandemic might no longer fit current needs. Today, digital approaches might be necessary, but the evidence for digital health promotion programmes is still emerging and highlights the need to consider supportive implementation structures to enhance engagement and reduce high drop-out rates. Additionally, specific measures are needed to reach underserved populations who face substantial barriers to online care and disproportionately carry the pandemic burden.To ensure these programmes are tailored to the youth of today, meaningful youth engagement is key. The United Nations Population Fund Youth against COVID-19 campaign shared materials with young people to create video content about mental health that can be used to connect with peers during the pandemic. Such peer-to-peer initiatives allow young people to contribute meaningfully and connect with those outside the conventional setting of schools, universities, or workplaces. Organisations can learn from this example, and instead of designing new top-down campaigns, choose to amplify existing youth-led initiatives or design platforms for youth peer-to-peer contacts.The European Year of Youth 2022 presents a window of opportunity for countries and organisations to enhance health promotion initiatives and to focus on mitigation of mental health problems. Mental health promotion in the youth of today can contribute to a ‘building back better’ pandemic recovery by creating a resilient generation of future EU leaders.


Since chemical research and development lay the foundation for innovative products and solutions, this study presents a novel chemical research and development process backed with artificial intelligence and guiding ethical principles to account for both process- and outcome-related sustainability. Particularly in ethically salient contexts, ethical principles have to accompany research and development powered by artificial intelligence to promote social and environmental good and sustainability ( Artificial intelligence (AI) is a transformative power (re-)shaping businesses by providing new solutions to complex problems, increasing consistency and reliability, while decreasing costs and risks  and preventing any harm . Solving this tension to achieve a “dual advantage” for society  as illustrative R&D objects, since they are beneficent and maleficent at the same time and can be thus considered ethically controversial products. Thereby, our study contributes to the AI ethics literature by showing how ethical principles related to AI can be translated into business and research practice to promote environmental and social good while accounting for multiple stakeholder interests.The remainder of our study is structured as follows. After briefly shedding light on how AI has evolved and is now applied in chemical R&D, we illustrate how chemical R&D powered by AI can be utilized for good through guiding ethical principles and consideration of all stakeholders affected. We conclude with a future outlook and a call for more collaborative, open science approaches to meet the global challenge of sustainable development.vivo methods are often constrained by ethical considerations, time, budget, and other resources  chemical research has always accumulated enormous amounts of  data on chemical and physical properties, chemical reactions and structures, and biological activities, methods from computer science have been developed and utilized in chemistry starting in the 1960s  are used as illustrative R&D objects for two reasons. First, they are central to cost-effective production of food and efficiency gains in agricultural systems  and deliberately (misuse) caused. Thus, it cautions against all potentially negative aspects and consequences of AI development and use  instead of resource-intensive laboratory experiments. That can eventually result in substantial resource-efficiency gains and lower costs , that is, R&D process-related sustainability. The R&D process for synthetic chemicals such as pesticides become more resource-efficient and sustainable, because intended reductions in doses and environmental half-lives of active substances are usually accompanied by more complex molecular structures of synthetic chemicals. They in turn increase the resource utilization during the R&D process  predictions dematerialize and digitalize conventional lab experiments. That is, research questions  are addressed and answered by AI simulations  and potential negative side effects  of substances and prospect product candidates. Generally, the sheer volume, diversity, and intensity of use of chemicals can impede risk assessments and pose substantial environmental challenges  to maximize beneficence while limiting maleficence. Thereby, AI in chemical R&D also account for the green chemistry principles that include less hazardous chemical syntheses, designing safer chemicals, and inherently safer chemistry for accident prevention, among other things  and human oversight .Since artificial moral agency is still in its infancy , an understanding of how the AI works and predictions are derived is essential. That is at the core of intelligibility principle is multi-faceted. While researchers that are directly involved in the AI development process and oversee the R&D process should have an in-depth understanding of underlying data and AI models’ structures and functions, a basic understanding might suffice for other internal organizational stakeholders. Otherwise, too complex and incomprehensible explanations and overly complicated decision pathways can impend  can inform evaluations of the other principles by comprehending if and how AI benefits (beneficence) or harms  individuals and society in a fair and unbiased way (justice) and by drawing conclusions about whether to delegate decisions to AI systems (autonomy)  (Lepri et al., Accountability can create shared responsibility within the organization and responsibility towards external stakeholders, which is particularly relevant in ethically salient contexts. It can be backward-looking, that is, who is ascribed responsibility when something goes wrong, and forward-looking, that is, how can AI systems be designed and used responsibly (Coeckelbergh, On the other hand, explicability of AI-based R&D is pivotal to meet the global challenge of sustainable development and develop joint actions, and it accounts for both the AI-for-good-perspective (Taddeo & Floridi, Taken together, Chemical R&D can be fundamental to solutions that underpin and accelerate sustainable development. Since sustainability initiatives and research always have an ethical dimension (e.g., Schneider et al., Respective scientific data and knowledge are irreplaceable in a volatile, uncertain, complex, and ambiguous environment, and key conduit to knowledge discovery, integration, and innovation (Rüegg et al.,


Events such as the COVID-19 pandemic remind us of the heightened risk that healthcare workers (HCWs) have from acquiring infectious diseases at work. Reducing the risk requires a multimodal approach, ensuring that staff have the opportunity to undertake occupational infection prevention and control (OIPC) training. While studies have been done within countries to look at availability and delivery of OIPC training opportunities for HCWs, there has been less focus given to whether their infection prevention and control (IPC) guidelines adhere to recommended best practices.To examine national IPC guidelines for the inclusion of key recommendations on OIPC training for HCWs to protect them from infectious diseases at work and to report on areas of inconsistencies and gaps.We applied a scoping review method and reviewed guidelines published in the last twenty years (2000–2020) including the IPC guidelines of World Health Organization and the United States Centers for Disease Control and Prevention. These two guidelines were used as a baseline to compare the inclusion of key elements related to OIPC training with IPC guidelines of four high-income countries /regions i.e., Gulf Cooperation Council, Australia, Canada, United Kingdom and four low-, and middle-income countries (LMIC) i.e. India, Indonesia, Pakistan and, Philippines.Except for the Filipino IPC guideline, all the other guidelines were developed in the last five years. Only two guidelines discussed the need for delivery of OIPC training at undergraduate and/or post graduate level and at workplace induction. Only two acknowledged that training should be based on adult learning principles. None of the LMIC guidelines included recommendations about evaluating training programs. Lastly the mode of delivery and curriculum differed across the guidelines.Developing a culture of learning in healthcare organizations by incorporating and evaluating OIPC training at different stages of HCWs career path, along with incorporating adult learning principles into national IPC guidelines may help standardize guidance for the development of OIPC training programs. Sustainability of this discourse could be achieved by first updating the national IPC guidelines. Further work is needed to ensure that all relevant healthcare organisations are delivering a package of OIPC training that includes the identified best practice elements. The importance of regularly attending training programs by healthcare workers (HCWs) has received significant attention in recent years especially during the outbreaks of emerging and re-emerging infectious diseases like Severe acute respiratory syndrome (SARS), Middle East respiratory syndrome coronavirus (MERS-CoV), Ebola and COVID-19 . HCWs arTraining HCWs on standard precautions, principles, and practice needs to be implemented to provide the necessary knowledge on compliance to standard precaution practices in order to protect HCWs at work from infectious diseases . A studyOIPC training programs are developed at local level by hospitals or at national level by ministry of health and/or professional organizations like The Society for Healthcare Epidemiology of America  or Austrhttps://osf.io/ryk9b).For this study we followed the five stage scoping review process outlined by Levac et al.’s . This scThe following questions guided this scoping review for the inclusion of OIPC training related information in the IPC guidelines: What is the recommendation on framework of OIPC training programs? What is the recommendation on mandatory vs voluntary participation of HCWs in OIPC training programs? What is the recommendation on evaluation of OIPC training programs? What is the recommendation on frequency and delivery of OIPC training program? What is the recommendation on topics covered for OIPC training programs?Between January 2020 to September 2020, two strategies were used to identify IPC guidelines of international agencies, countries/region selected for this study. Firstly, the websites of international public health agencies such as WHO, CDC and selected country health departments/Ministry of Health/Department of public health including four high-income countries/regions i.e. Australia , Canada Then, a key word search was conducted using Google, with the first 10 results per page and the first two pages of hits reviewed. We did not impose any language restriction. The publicly available national IPC guidelines of all the selected countries were in English language except Indonesia. Google translate was used to translate the Indonesian IPC guideline in English language and reviewed inhouse for accuracy by a native Indonesian colleague. Key words used for search were semantically related and grouped into four categories: (1) ‘infection control’, infection prevention and control’, ‘occupational infection prevention and control’, ‘occupational health and safety’, ‘workplace health and safety’, ‘occupational health services’, ‘occupational health’, ‘infectious diseases transmission’. 2) ‘guidelines’, ‘policies’, ‘program’, ‘code of practice’, ‘manual’, ‘regulations’, ‘practice guidelines’, ‘training guidelines’; (3) ‘healthcare’, ‘national health care facility’, ‘acute health care facility’ and (4) ‘healthcare personnel’, ‘healthcare workers’, ‘healthcare providers’. Boolean operators were used to combine keywords i.e., AND/OR/*. Results from the search then were refined using the ‘AND’ Boolean operator with the selected 10 organization/country names.IPC guidelines of the selected international agencies and countries published in the last twenty years (2000–2020) were screened for GRADE  and latest version. GRADE is the most widely adopted tool for grading the quality of evidence and for making recommendations with over 100 organisations worldwide officially endorsing it . If two WHO and CDC guidelines were used as a baseline and reviewed to extract the key elements of OIPC training including, application of adult learning principles; evaluation of training programs (review of training programs and assessment of HCWs); mandatory attendance; frequency and delivery of training at undergraduate/post graduate education and/or on joining a healthcare setting (orientation and/or induction), job specific training, outbreak control training; methods of delivery of training like, on the job training, e-learning, simulation training, bed side training, retraining,problem based training, hands-on workshops, focus groups, peer-to-peer training, class room based training, and topics covered in OPIC training program. These key elements were used to form an audit tool to help with extracting information from the other selected IPC guidelines. Key elements were first assessed by the lead author (MOQ) and then validated by co-authors (HS and AAC). Extracted information was then coded and assigned appropriate themes . The leaThe results were organised under the following five themes: framing of OIPC training program, mandatory vs voluntary participation in OIPC training program, evaluation of OIPC training program, frequency and delivery of OIPC training program, and topics covered in OIPC training program see Fig. .Fig. 1StWe reviewed 10 IPC guidelines for analysing information related to OIPC (IPC) training. We reviewed IPC guidelines of two globally recognised public health agencies including WHO . We alsoThe WHO as a part of its multimodal strategy, recommends embedding a culture of infection prevention within the establishment for safe working conditions of the facility. This language is also reflected in the IPC guidelines of CDC, Australia, Canada, India, and Pakistan. The Canadian guidelines goes one step further to also outlines the mechanism for providing a safe working environment by recommending conducting ongoing training programs for HCWs and others working in the healthcare settings. The WHO and CDC, IPC guidelines, recommended that healthcare facilities focus on core components of IPC, of which OIPC training of HCWs should be one. At the country level, all the guidelines except that of UK, outlined HCWs training and education as a core component of IPC and only Pakistan’s IPC guideline included a chapter or a section on ‘education and training’ in their IPC manual.All the IPC guidelines use the terms education and training interchangeably. All IPC guidelines suggest that the aim of OIPC training is to equip HCWs with requisite infection control skills needed to perform their job efficiently and smoothly.Both the WHO and CDC IPC guidelines recommend that OIPC training should be provided to HCWs before being allowed to perform their duties and after they join a healthcare setting. The WHO guideline, however, does not directly refer to the session as ‘mandatory’, nor does the UK national IPC guidelines. Whereas, just like CDC, the IPC guidelines of Canada, GCC, Pakistan, India, Indonesia, and Australia emphasize mandatory attendance of HCWs. In Canada only some provinces mandate periodic OIPC training programs for all HCWs.The WHO recommends periodic evaluations of the effectiveness of OIPC training programs and the assessment of staff knowledge be undertaken on a routine basis. The GCC guideline suggests establishing an OIPC hospital-based certification policy to ensure that HCWs knowledge and skills are reviewed and renewed regularly. Whereas the CDC guideline does not include any reference to the evaluation of OIPC training programs. Similarly, the guidelines of UK, Indonesia, and Pakistan, also do not provide any recommendations regarding the evaluation of OIPC training programs. Indian and Indonesian guidelines only focus on the assessment of HCWs for IPC practices. Indonesia’s IPC guidelines recommend monthly auditing of training programs. It is not however clear if auditing also involves reviewing training programs, assessment of HCWs knowledge or both. All the guidelines recommend reviewing their IPC manual on a regular basis.WHO and Australian guidelines recommend OIPC training as part of undergraduate and post graduate education. WHO recommends that OIPC training be conducted at orientation and then yearly for HCWs, which also aligns with the recommendations from CDC, Australia, Canada and Pakistan. The GCC guidelines on the other hand recommend that it occurs every two years while the Philippine’s guideline suggests conducting it at least twice a year. Indian and Indonesian guidelines both recommend OIPC training at orientation but provide no further comment beyond that. UK and Pakistan’s guidelines also suggested OIPC training at induction. All the guidelines outlined job specific OIPC training. WHO and CDC guidelines recommends outbreak control OIPC training for HCWs, which is also reflected in the guidelines of Canada, UK and India.The WHO guidelines outlines 10 different methods for the delivering of training to HCWs namely, on the job or in-service training, oral instructions, e-learning, simulation, bed side training, problem based learning, hands on workshops, focus groups, peer-to-peer training, classroom based simulation, whilst the CDC guideline specifies only two, namely, on the job or in-service training and retraining. Australian guideline only refers to three namely, on the job or in-service training, e-learning, and hand-on workshops as methods of delivery of training HCWs. Except Simulation, retraining and classroom based training, Canadian guidelines recommends all the other methods of training programs suggested in the WHO guideline. GCC guidelines outlines on the job or in-service training and simulation only. Indonesian and Philippines guidelines recommend e-learning, while as, Pakistan’s guideline recommends hands-on workshop as method of delivery of training HCWs. For OIPC training based on HCWs work status and method of delivery, information was sought but nothing related was found in most of the guidelines.The topics suggested for inclusion in OIPC training vary across guidelines. Like the WHO and CDC, the guidelines of Australia, Canada and GCC recommend tailoring the training curriculum to national and local requirements but emphasise that hospitals include the basic minimum curriculum suggested in their respective guidelines as a part of the training module. Canadian and GCC guidelines suggests that training programs should be based on adult teaching–learning principles, whereas no other guideline mentions about this including WHO and CDC. The Australian guidelines in addition to recommending a minimum number of topics for OIPC training for on-the-job HCWs also suggests including up-to-date information on IPC basics, policy, procedures, quality assurance and incident monitoring, for health-related courses at undergraduate and postgraduate academic level. Further information is included in Table From this review we found similarities, variations, and omissions in the way OIPC training programs for HCWs are framed across high-income countries and LMIC. While all the guidelines suggest OIPC training be delivered to HCWs, there is a difference in how frequently it should be delivered. For example, the WHO , Canada There are significant differences in the OIPC topics, covered in the guidelines of high and LMIC countries. The WHO  recommenWhile education and training are absolutely related, they are by no means the same process. Education refers to the gaining of comprehensive knowledge and skills usually at the college or university level, while training refers to the acquisition of job specific and applied knowledge and skills . In all The impact of education and training programs depends a great deal on the background experience and prior learning of the employee and what they bring to any new learning process. It is thus critical that learning approaches recognise the background and diversity in the content and style of approach, which requires the integration of adult learning principles in the development and delivery of training programs , 33. MalIn order to ensure consistency with current guidelines and best practices, performance standards can be achieved if OIPC training programs delivered to HCWs are periodically evaluated . When itA major project launched in 2013 by the European Centre for Disease Prevention and Control (ECDC) and called by the name of ‘Implementation of a training strategy for infection control in the European Union’ emphasises the importance of attending OIPC training by HCWs . HoweverA limitation of this study is that our findings are not representative of all high-income countries and LMIC. We also acknowledge that there could be other topic specific IPC guidelines adhered by OIPC professionals. Also, countries have different capabilities, so the depth of IPC guidelines would differ from recommendations outlined in WHO and CDC guidelines. Additionally, scoping review of IPC guidelines updated before and after the COVID-19 pandemic could have been conducted.The policies and procedures defined in the international and local IPC guidelines steer the development of OIPC training programs for HCWs. In effect, successful delivery of OIPC training in healthcare settings depend on the recommendations present in national and international IPC guidelines such as WHO and CDC. From the review, significant inconsistencies were identified between the recommendations suggested by the selected guidelines of international health organizations, high- and LMIC. Although all the guidelines suggest OIPC training be provided to HCWs, however, not all the IPC guidelines include recommendations on the key elements of OIPC training outlined by WHO and CDC IPC guidelines, which may lead to undesirable outcomes like poor delivery of quality OIPC training programs. Training alone will not change the behaviour of HCWs and is only one of the ways to protect HCWs from acquiring infectious diseases, however, findings from this study highlight the importance of developing a culture of learning in the healthcare organizations by integrating adult learning principles into the development of OIPC training modules. There is also a need for outcome focused training evaluation framework to capture whether the OIPC training programs have had an impact on HCWs attitudes, understanding and practice. If not, then revisions need to be made to the approach and/or content of the training programs. A competent OIPC training program should entail key elements listed in the IPC guidelines like training curriculum, frequency of training program, mandatory attendance, delivery method, monitoring, and evaluation of training program. Sustainability of this discourse could be achieved by updating the international, national and regional IPC guidelines. Further studies should be followed to explore guidelines available in countries that share a similar socio-economic status.


Limited health literacy negatively impacts understanding of medication-related information. We describe an innovative methodology designed to optimize user understanding of patient medication labeling through the systematic application of evidence-based health literacy principles, using the Patient Package Insert (PPI) for bezlotoxumab  as an example.C. diff, caregivers, and general population members, with a pre-defined target sample of 25% with limited health literacy identified through two health literacy assessment tools: the Single Item Literacy Screener and the NVS.We used a mixed-model, iterative approach consisting of three phases: (1) content development; (2) focus group testing; and (3) comprehension testing. Content development was based on evidence-based health literacy principles and conducted through a collaborative partnership between industry and academia professionals. The PPI was then tested in four focus groups, two in Atlanta and two in Chicago, with an emphasis on collecting feedback from respondents with limited health literacy, evaluated using the Newest Vital Sign (NVS) health literacy assessment tool. Subsequent comprehension testing included patients with n = 34) provided generally favorable feedback, with insights revolving around organization and usability; language and comprehension; and volume of information. Comprehension testing of the revised PPI resulted in average comprehension scores of 96% for the overall population (n = 59), 90% for individuals presenting with limited health literacy (n = 14), and 97% for those with adequate health literacy (n = 45). This PPI development approach was similarly effective for subsequent products across diverse therapeutic areas, with comprehension scores ≥ 86% for all participants (n = 1197).Content development of the bezlotoxumab PPI occurred in May 2015. In June 2015, focus group respondents (This methodology represents a significant advancement for the development of understandable patient medication labeling, especially for people with limited health literacy.The online version contains supplementary material available at 10.1007/s43441-021-00325-5. The United States Department of Health and Human Services defines health literacy as “the ability to obtain, process, and understand health information to make appropriate health decisions” . It is eTo support safe and effective drug use, many countries have regulatory requirements governing medication labeling to ensure that the information is clear and accessible for patients, including those with limited health literacy –12. In tGiven the volume and complexity of prescription drug information, it is critical to ensure that all patients understand the information about their medications, which, in turn, may be expected to reduce medication errors, increase adherence, and promote patient health and safety. Over recent years, the FDA has sought guidance and participation from academia, patient advocacy groups, and the pharmaceutical industry to innovate and develop new strategies to improve patient understanding of drug information. The field of health literacy research has been a valuable resource for identifying ways to help people access and understand written medication materials , 21. TheClostridium difficile (C. diff) infection, which can damage one’s colon and cause stomach pain and severe diarrhea, was selected as an example to fully illustrate the health literacy development process. To inform the reproducibility of results using this methodology, comprehension testing scores of PPIs for multiple medications across diverse therapeutic areas are summarized.In the present report, the PPI for bezlotoxumab , a medication to treat A three-step, mixed-model, collaborative, iterative, health literacy PPI development methodology was used: 1) content development; 2) focus group testing; and (3) comprehension testing  . At the Once completed, the PPI draft was circulated by the medical writer through an open-access cross-functional review process, which included representatives from the following departments of the pharmaceutical manufacturer : Product Labeling, Clinical Development, Regulatory Affairs, Global Clinical Safety and Risk Management, Clinical Research, Marketing, Market Research, Legal, and Health Literacy. The PPI was revised by the medical writer in accordance with the comments from each stakeholder.Following content approval consensus, the PPI draft was submitted by the medical writer for critical review by health literacy experts from academia  who applied evidence-based health literacy best practices based on vast experience working with people across a range of health literacy levels . FurtherC. diff) to ensure that they had no specific prior knowledge of the disease. The population was heavily skewed towards having limited health literacy, which was evaluated using the Newest Vital Sign (NVS) assessment tool, a previously validated measure of health literacy with high sensitivity for detecting people with limited health literacy [Independent focus group testing was conducted by the academic partners and health literacy experts from Emory (K.L.J.) and Northwestern (M.S.W.) Universities. Representatives of the pharmaceutical company neither observed nor participated in the focus groups. Four focus groups were conducted, two in Atlanta and two in Chicago. In Atlanta, a convenience sample of patients was recruited from the outpatient primary care clinics of Atlanta’s inner-city indigent hospital, where patients have been shown to have limited health literacy skills . Patientliteracy . The focA facilitator’s topic guide  was developed to consistently assess participants’ overall comprehension of the PPI and collect feedback about the layout and design across sites. The focus group participants discussed the strengths and weaknesses of the bezlotoxumab PPI and provided suggestions for improvement. Specifically, participants were asked about why this medicine would be prescribed for a patient; how this medicine is different from antibiotics; what are the side effects of the medicine; and if they had any suggestions for improvements in content, logical structure, and level of detail.The focus group discussion results were reviewed, and the final recommendations formed the basis for further refinement of the PPI using the same academia–industry iterative process described for Phase 1. The resulting version of the PPI was forwarded to Phase 3 of the process: comprehension testing.C. diff infection (n = 24), caregivers who were primarily responsible or actively involved in the treatment decisions of patients diagnosed with C. diff (n = 12), and general population members who did not have C. diff, but had similar demographics  to patient populations with the highest incidence of C. diff infection (n = 24). General population participants were included to ensure that even people without prior knowledge of the disease state could understand the information presented in the bezlotoxumab PPI. As C. diff is more prevalent in older people, we ensured that most patients and general population participants were aged 65 and older.The interview flow for comprehension testing is illustrated in Table Research participants were recruited from the Schlesinger national database  either by telephone or online channels and supplemented with participants from literacy centers and senior centers to derive a diverse study sample, representative of broad age groups and health literacy levels. Based on feedback from external health literacy experts and assessment of the feasibility to recruit, a goal of at least 25% of the population with limited health literacy in the total sample was pre-specified. Health literacy levels were assessed during an initial screening process using the validated Single Item Literacy Screener (SILS): “How confident are you filling out medical forms by yourself?” . Prior rC. diff infection; (2) the common side effects associated with taking bezlotoxumab; (3) what patients should tell their doctor before starting bezlotoxumab; (4) how bezlotoxumab is administered; and (5) how long the administration process takes. Comprehension testing entailed a mix of in-depth, qualitative 45- to 60-min interviews conducted either in-person or by phone/Web . Both open-book  and closed-book  approaches to comprehension testing were used. The participant’s comprehension score was calculated as the percentage of correct answers on the test, with a goal score of at least 80% comprehension across all consumer segments, prospectively established based on a U.S. Elementary School-level grading system, in which 80% accuracy is equivalent to a “B” grade [The comprehension test was developed by the marketing research firm (Sommer Consulting) and was composed of multiple choice and true-or-false questions based specifically on the bezlotoxumab PPI. The comprehension test assessed the following topics: (1) what bezlotoxumab is used for and how it is used in addition to an antibiotic to treat B” grade . In addiA summary of the comprehension testing results from participants across health literacy levels was subsequently submitted to the FDA along with the final PPI for informational and approval purposes. Although not a regulatory requirement, the manufacturer believed this would be helpful insight for the FDA to consider during approval of the patient labeling.Following initial content development based on established health literacy principles, the bezlotoxumab PPI draft was provided by the drug manufacturer to health literacy experts at Emory University (K.L.J.) and Northwestern University (M.S.W.) for content review in May 2015. The guiding criteria used for the further refinement of the draft PPI were derived from the Institute of Medicine discussion on health literacy principles, which includes such factors as content, organization, layout, and graphics .C. diff as directed by the physician  organization and usability; (2) language and comprehension; and (3) volume of information . The results consistently demonstrate that this approach optimizes comprehension of PPIs across participant health literacy levels, with average comprehension testing scores ≥ 86% across all products and population segments studied  and representative  samples, with a pre-specified goal to include ~ 25% of participants with limited health literacy. The segment with limited health literacy is identified through validated health literacy screening methodology, using two separate screening tools: the SILS and the NVS. Compared with traditional readability formulae based solely on word length or syllable count, these health literacy assessment tools consider other measures, including structure, content, coherence, and design factors.For a variety of reasons, including fear or embarrassment of literacy abilities , lack ofFor comprehension testing of the PPI, the in-person interview format is effective for respondents with limited health literacy who may be hesitant to participate in research due to an inability to complete a questionnaire or who do not have access to technology. It also allows members of the PPI development team, including representatives from Product Labeling who would not have traditionally participated in comprehension testing, to observe interviews, identify visual cues, and assess respondents’ level of understanding of the materials. The phone/Web interview format allows for a broad, diverse geographic dispersion and reach.The use of both open-book and closed-book approaches to comprehension testing is consistent with health literacy and cognitive factors research recommendations, indicating that the task under evaluation should most accurately mimic what would be expected of a person during actual use. Allowing consumers to review and re-review content in the open-book approach is representative of real-world experience, since the PPI and other forms of drug information are external aids to which patients may refer as needed. The purpose of the closed-book approach is to determine recall and ensure understanding of key information; particularly, important side effects and when to contact a health care provider.The current process has been applied to subsequent development and testing of multiple PPIs. Our approach has been similarly effective for drugs across many diverse therapeutic areas, as evidenced by high comprehension scores among participants with both adequate and limited health literacy. Additionally, this methodology has been successfully used to develop other types of patient labeling, specifically Medication Guides and Instructions for Use. The reproducibility of results suggests that this approach is an optimal model for the development of patient labeling.To our knowledge, our process is the first mixed methods, health literacy approach to PPI development based on a collaborative partnership between industry professionals and health literacy experts from academia. Key strengths of this approach are the inclusion of multiple perspectives, particularly those of the patient/consumer, and incorporation of evidence-based health literacy principles and best practices throughout the entire process. Comprehension testing of the PPI is supported by a sample that is robust and representative of the patient population across health literacy levels. Indeed, the inclusion of 25% of participants with limited health literacy identified by two validated assessment instruments is a key strength. Finally, the reproducibility of results across multiple products in different therapeutic areas permits further confidence in the validity of this approach.The present research also has some limitations. The focus group results are based on a small sample of participants from large, urban US cities and may not be generalizable to different sociodemographic populations or countries. However, the comprehension testing phase recruits from a nationwide sample of urban, suburban, and rural areas across the country to ensure a mix of respondents. Further, only English-speaking (or English as their second or later language) participants were enrolled, as the PPI was written in English. Future research should consider a broader audience, including those from other regions and who do not speak English, especially considering that low English proficiency correlates with poor comprehension of health information. In addition, because there are many different health literacy assessment tools, classification of participants by health literacy level may vary between instruments. To help address this concern, two validated health literacy assessment tools, the SILS and the NVS, were used simultaneously to classify participants by health literacy level.The present health literacy approach represents a significant advancement in the development of prescription drug PPI. The success of this approach is demonstrated by high comprehension across all consumer segments, including people with limited health literacy.In practice, this approach to PPI development empowers patients to better manage their own health by facilitating an improved understanding of their prescribed medications. This approach is expected to culminate in greater medication adherence, fewer adverse drug reactions, and improved health outcomes.Additional research is needed to examine how the implementation of these best practices will improve patient knowledge and compliant use of prescription medications. This methodology may be expanded to other types of consumer health research and adopted by health care organizations and regulatory agencies to support the development of patient drug information that is widely understood across diverse populations and health literacy levels. The adoption of health literacy as a key advocacy initiative is needed to improve the understanding of medication information for all patients.Supplementary file1 (PDF 253 kb)Below is the link to the electronic supplementary material.


Patient blood management (PBM) describes a set of evidence-based practices to optimize medical and surgical patient outcomes by clinically managing and preserving a patient’s own blood. This concepts aims to detect and treat anemia, minimize the risk for blood loss and the need for blood replacement for each patient through a coordinated multidisciplinary care process. In combination with blood loss, anemia is the main driver for transfusion and all three are independent risk factors for adverse outcomes including morbidity and mortality. Evidence demonstrates that PBM significantly improves outcomes and safety while reducing cost by macroeconomic magnitudes. Despite its huge potential to improve healthcare systems, PBM is not yet adopted broadly. The aim of this study is to analyze the collective experiences of a diverse group of PBM implementors across countries reflecting different healthcare contexts and to use these experiences to develop a guidance for initiating and orchestrating PBM implementation for stakeholders from diverse professional backgrounds.Semi-structured interviews were conducted with 1–4 PBM implementors from 12 countries in Asia, Latin America, Australia, Central and Eastern Europe, the Middle East, and Africa. Responses reflecting the drivers, barriers, measures, and stakeholders regarding the implementation of PBM were summarized per country and underwent qualitative content analysis. Clustering the resulting implementation measures by levels of intervention for PBM implementation informed a PBM implementation framework.A set of PBM implementation measures were extracted from the interviews with the implementors. Most of these measures relate to one of six levels of implementation including government, healthcare providers, funding, research, training/education, and patients/public. Essential cross-level measures are multi-stakeholder communication and collaboration.The implementation matrix resulting from this research helps to decompose the complexity of PBM implementation into concrete measures on each implementation level. It provides guidance for diverse stakeholders to design, initiate and develop strategies and plans to make PBM a national standard of care, thus closing current practice gaps and matching this unmet public health need.The online version contains supplementary material available at 10.1186/s12913-021-06484-3. Of the millions of patients hospitalized yearly, a large proportion is anemic at admission. Preoperative anemia rates range from 20 to 75% , and hosHowever, a large body of evidence shows that anemia, blood loss, and transfusion are independent risk factors for adverse outcomes including morbidity, mortality and average length of hospital stay –6. PatieHowever, despite compelling evidence and ongoing WHO policy drive, practical guidance for healthcare providers and national authorities , 19–21 aThe implementation of Patient Blood Management is hampered by barriers mostly related to the difficulty of changing traditional “physicians’ attitudes” towards transfusion  and “traContinuing to ignore the cumulative evidence puts life, well-being and safety of millions of hospitalized patients at risk. Delaying Patient Blood Management implementation also means that healthcare systems forego savings of macro-economic magnitudes from a system-wide implementation of Patient Blood Management . This isFollowing this recommendation, a more in-depth questionnaire was developed in this study to gather, through interviews, the experiences of a diverse group of implementors of Patient Blood Management across countries with different economic and healthcare contexts. The first aim was to describe the status-quo and chosen implementation approach in each of the surveyed countries, and to extract the drivers, barriers, measures, and stakeholders to be involved. The second aim of the study was to analyze this information and synthesize it into an implementation framework for Patient Blood Management which can serve as a comprehensive guidance how to implement Patient Blood Management.Semi-structured interviews mostly lasting 45–60 min were conducted between November 2019 and May 2020 with a multi-disciplinary group of 36 Patient Blood Management implementors leading the implementation of Patient Blood Management in their respective environment. Ten countries from Latin America, Central and Eastern Europe, Asia, Middle East and Africa were selected to reflect experiences from countries with different levels and types of healthcare resources and system , and different developmental stages of Patient Blood Management (from early stage to more advanced). In addition, Australia was chosen as a reference country, where Patient Blood Management is adopted broadly and supported through public health authorities since 2008 and through National Patient Blood Management Guidelines since 2009 , 48, 49.Thirty-six Patient Blood Management implementors, named “Patient Blood Management Implementation Group” with 15 women and 21 men from 12 countries, were interviewed following 11 pilot interviews . The respective perspectives are depicted in Table . Australia, after initial bottom-up implementation in several leading public and private institutions, has fully implemented Patient Blood Management supported by national institutions including the National Blood Authority (NBA), the Australian Commission on Safety and Quality in Healthcare, the Western Australia Department of Health, and the Australian Red Cross Blood Service. In South Korea, Patient Blood Management was implemented in few institutions about a decade ago, followed by a broader strategic approach supported by national authorities. In China, Turkey and Mexico, Patient Blood Management implementation originated with leading clinicians (“champions”) of large national institutions and is now increasingly recognized by the authorities. In South Africa, the implementation of Patient Blood Management is led by the South African National Blood Service and supported by a national Patient Blood Management expert group [The country-level responses for the current level of Patient Blood Management implementation and the approaches  are summarized in Table 2rt group .Table 2Croatia, Greece and Lebanon seek the dual pathway, although the current political situation in Lebanon has put all governmental support to a halt. Brazil, Saudi Arabia, and Switzerland currently rely on local clinician-led initiatives (bottom-up).Of the 11 drivers mentioned unprompted during the interviews . Generation of local data and evidence, education and training for Patient Blood Management, a national Patient Blood Management policy, and strong thought leadership, were the most frequently mentioned factors. Blood scarcity, funding, awareness of transfusion risks, incentives for Patient Blood Management engagement, belief and commitment of care personnel, and quality assurance obligation were also frequently mentioned. During the final six interviews between February and May 2020, the COVID-19 pandemic was newly mentioned as potential accelerator due to increased blood scarcity and potential blood safety issues.The responses for factors accelerating or supporting Patient Blood Management implementation fell into 24 categories as shown in Fig. 2, right part) with the most frequently mentioned being low awareness, no funding for set-up cost, education gaps, and stickiness of the old practice (even stronger if combined with the responses for the closely related resistance against change), lack of interdisciplinary commitment, and resistance against change.The inhibitors or delaying factors fell into 22 categories  identified policy makers  as important stakeholders in Patient Blood Management implementation. As shown in Fig. After translating accelerators and inhibitors into actionable measures and clustering these measures by the type (level) of intervention, six levels for intervention were identified: government/policy, funding, research, healthcare providers, education/training, and public/patients. On each of the six levels specific measures can contribute to the implementation of Patient Blood Management as reflected in Table ). We will discuss each level of the table in more detail in the passages following below.Unless translated into the daily routine and organizational culture, evidence is of limited value . To brid4The Patient Blood Management-implementation matrix, as derived from the interviews, guides Patient Blood Management implementors in systematically identifying effective measures for Patient Blood Management implementation depending on the economic and healthcare context in their country.These measures will be discussed in more detail along six implementation levels and consolidated in the final section into a Guided Implementation recommendation.Patient Blood Management is expected to improve quality of care, reduce dependency on donor blood, and contribute to better access to healthcare and equity . In Western Australia, hospital stays were reduced by almost 70,000 days over 5 years . SuchlikNational policy makers and senior representatives of the Health Ministry are important stakeholders in coordinating Patient Blood Management implementation nationally see Fig. . ReportiHowever, structural changes on government level usually require long time. One implementor stated “it takes more than seven years to introduce a policy in our country”. Creating a sense of urgency through multiple stimuli, including success stories demonstrated in pilots and the generation, publication, or communication of the evidence, can help to overcome the inertness for introducing a new medical model perceived as being complex .Patient Blood Management offers the rare opportunity to improve patient outcomes while reducing resource utilization and cost , 72, 73.Electronic clinical decision support systems for controlling transfusions were deemed effective, also if combined with systems to incentivize and reward the progression towards Patient Blood Management. Electronic transfusion decision support systems can effectively reduce transfusion rate and index in the daily routine , 77 and To avoid asymmetry of information and conflicting behaviors within the hospital, training, and communication on Patient Blood Management needs to address the entire clinical staff including clinical specialists, nurses, pharmacists, and others influencing decisions related to managing patients’ blood. Implementors suggested that clinical knowledge and skills for Patient Blood Management must be embedded in both under- and postgraduate education . However, except for Western Australia, Patient Blood Management is currently not part of the undergraduate curriculum of medical students. Like Patient Blood Management preceptorships, educational and training activities for Patient Blood Management are currently organized for post-graduates, often initiated by the implementors and local Patient Blood Management champions, and mostly industry sponsored. Implementors should liaise with the leadership of academia and medical schools to firmly integrate Patient Blood Management into the undergraduate education in alignment with the federal Ministries of Health and Education, where applicable.Patient Blood Management offers a broad spectrum of new experimental, clinical, epidemiological, and health-economic research opportunities, as evidenced by the growing number of research publications. Benchmarking and reporting of key performance indicators for Patient Blood Management yield valuable insights concerning clinical and economic outcomes related to Patient Blood Management. Further research as well as national and international exchange will help to improve Patient Blood Management techniques as also highlighted by international thought leaders , 78, 79.Public funders may benefit from Patient Blood Management through reduced average length of hospital stay and lower resource consumption, resulting in cost containment and better resource use. Private funders may expect higher profitability, in particular with diagnosis related groups (DRG) or value-based reimbursement systems : in DRGs with high anemia prevalence and potentially high blood loss such as obstetrics, cardiovascular surgery or oncology, the total cost per episode of care have shown to decrease over time, thus leading to reduced tariffs . For GerEven in fee-for-service settings, funders may benefit from Patient Blood Management: currently, they might reimburse hospitals for the number of transfusions administered, while patients pay for their anemia treatment out-of-pocket. Where transparent, implementors in the interviews reported increasing cost of blood components (per unit) due to increasing measures for quality and safety testing. Once funders begin incentivizing (pre-operative) anemia management as an essential part of Patient Blood Management, they foster better outcomes, fewer complications, and shorter hospital stays, thus reducing the overall reimbursement cost per episode of care as compared to the currently established transfusion preferences , 63. TheAppropriate reimbursement of Patient Blood Management including anemia management was a strong request in our interviews, and implementors even proposed to incentivize Patient Blood Management for healthcare providers. Given the documented savings potential with Patient Blood Management , 84–86, According to the implementors, Patient Blood Management and its benefits are largely unknown to patients, despite being the ‘big winners’ from Patient Blood Management with significantly improved clinical outcomes, safety, and reduced average length of hospital stay. Patients usually seek medical treatment based on a proper diagnosis and expect to be treated with safe and effective medical or surgical interventions. Unless being informed by their treating physician and being involved for shared decision making, they would not know that Patient Blood Management improves their chances for earlier discharge from hospital and reduces their risk for hospital acquired infection or even mortality. Patient advocates could contribute by creating Patient Blood Management awareness, but also by educating for and defending patients’ rights. Collaborating and likewise, supporting national campaigns to emphasize safety and the beneficial outcomes of Patient Blood Management, could foster shared clinical decision making and informed consent. Some implementors even saw the potential for patient advocates to approach funders to incentivize and support Patient Blood Management.involve patients more in their own care [‘person-centered healthcare’ [Potential risks were expected by one implementor when entering the public domain too early and thus, creating demand before physicians would be sufficiently familiar with Patient Blood Management and its benefit. Another implementor cautioned, that too much information on transfusion risks may negatively impact on the willingness to donate blood. Involvement of patients or patient advocates should be planned thoroughly within the country culture and context. However, the aim to own care , the strlthcare’ , and thelthcare’ –91 confolthcare’ . InformiIn some of the countries described in this survey, Patient Blood Management was implemented simultaneously from bottom-up  and top-down   resources were identified as the core drivers. The need for Additional file 1.Additional file 2.


Non-communicable diseases (NCDs) are the leading cause of death and disability globally, while malnutrition presents a major global burden. An increasing body of evidence suggests that poor maternal nutrition is related to the development of NCDs and their risk factors in adult offspring. However, there has been no systematic evaluation of this evidence.We searched eight electronic databases and reference lists for primary research published between 1 January 1996 and 31 May 2016 for studies presenting data on various dimensions of maternal nutritional status , maternal weight and/or body mass index (BMI), and maternal dietary intake) during pregnancy or lactation, and measures of at least one of three NCD metabolic risk factors  in the study population of offspring aged 18 years or over. Owing to high heterogeneity across exposures and outcomes, we employed a narrative approach for data synthesis .Twenty-seven studies from 10 countries with 62,607 participants in total met our inclusion criteria. The review revealed considerable heterogeneity in findings across studies. There was evidence of a link between maternal exposure to famine during pregnancy with adverse blood pressure, blood lipid, and glucose metabolism outcomes in adult offspring in some contexts, with some tentative support for an influence of adult offspring adiposity in this relationship. However, the evidence base for maternal BMI, GWG, and dietary intake of specific nutrients during pregnancy was more limited and revealed no consistent support for a link between these exposures and adult offspring NCD metabolic risk factors.The links identified between maternal exposure to famine and offspring NCD risk factors in some contexts, and the tentative support for the role of adult offspring adiposity in influencing this relationship, suggest the need for increased collaboration between maternal nutrition and NCD sectors. However, in view of the current scant evidence base for other aspects of maternal nutrition, and the overall heterogeneity of findings, ongoing monitoring and evaluation using large prospective studies and linked data sets is a major priority.The online version contains supplementary material available at 10.1186/s41043-021-00241-2. We identified several non-systematic, narrative reviews that focused largely on the developmental origins of metabolic risk factors and NCD outcomes –6. In teTo our knowledge, this is the first systematic review to examine the relationship between various dimensions of maternal nutritional status during pregnancy or lactation and blood pressure, blood lipids, and glucose metabolism in adult offspring. Our findings support an association between maternal gestational exposure to famine and offspring metabolic NCD risk factors in some contexts, but reveal no consistent support for a relationship between maternal gestational weight gain (GWG), maternal weight or body mass index (BMI), or maternal dietary intake and offspring NCD risk factors. Our findings also show some tentative support for an influence of adult offspring adiposity in the maternal exposure to famine—offspring NCD risk factor relationship. Importantly, our review exposes the paucity of the current evidence base and considerable heterogeneity across studies.Malnutrition represents one of the greatest global health challenges of our time. In 2015, approximately 462 million adults worldwide were underweight and 264 million women of reproductive age were affected by iron-amenable anaemia, while 1.9 billion adults were either overweight or obese . This coMeanwhile, unprecedented rates of economic and income growth, urbanisation, and globalisation have led to a rapid rise in the burden of non-communicable diseases (NCDs), principally cardiovascular disease (CVD), cancers, chronic respiratory diseases, and diabetes. NCDs are now the world’s leading cause of death and disability, responsible for 71% of deaths and 60% of disability-adjusted life years (DALYs) globally in 2015, with the burden of premature deaths from these diseases also felt disproportionately in low- and lower middle-income countries (LLMIC) .Unhealthy diets constitute the largest behavioural risk factor for NCDs, with 30% of global NCD deaths and 18% of NCD DALYs attributable to dietary risk factors . Mountinundernutrition during pregnancy have suggested a link with offspring risk of NCDs [overnutrition have been more mixed, with some finding a link with the development of offspring NCDs and risk factors [A number of narrative reviews have explored this relationship, with the focus on the underlying theory and potential mechanisms –6. Discu of NCDs , 6. Revi factors , 6, and  factors . To our Decade of Action on Nutrition [Such a review is needed to identify critical windows and intervention focus points for NCD prevention, and to inform the future work of maternal nutrition and NCD sectors. It is also an appropriate time to conduct such a review, given the declaration by the United Nations General Assembly of 2016 to 2025 as the utrition , the resutrition , and theWe conducted a systematic review following PRISMA guidelines . The exposure variable was maternal nutritional status during pregnancy or lactation. We defined maternal nutritional status broadly to include maternal exposure to famine ; maternal gestational weight gain (GWG); maternal weight and/or body mass index (BMI); and maternal dietary intake. The outcome variable was NCD metabolic risk factors in adult offspring. Specifically, we studied three NCD metabolic risk factors: blood pressure, blood lipid levels/metabolism, and blood glucose levels/metabolism  to check percentage agreement. Once Cohen’s κ exceeded 0.75 (excellent agreement [Jessie Pullar (JP), Karla-Maria Perez-Blanco (KP), and Katharine Noonan (KN) independently screened the titles and abstracts of the initial 21,659 records. The Cohen’s greement ), KP, anFrom each included full-text study, EW and JP extracted information on study type; nature of sample, including sample size and percentage male; offspring age; maternal nutrition exposure measures; offspring metabolic risk factor outcomes; and results. Ambiguities were resolved by group consensus. Where data were unclear or incomplete, the authors were contacted by email, and the study excluded if the information was unavailable.We used a modified, design-specific versions of the Newcastle-Ottawa scale to assess the quality of included studies  European Region, two from the Western Pacific Region, and one from the Region of the Americas. When classified by World Bank income group, there were seven high-income economies, two upper-middle-income economies, and one lower-middle-income economy. Seventeen studies were cohort studies, seven were case-control studies, and three were randomised-controlled trials (RCTs). In total, there were 16 high-quality and 11 medium-quality studies  and NCD metabolic risk factors in adult offspring. Six of these studies were of high quality and five were of medium quality. There were six cohort studies of the Dutch famine of 1944–1945, four studies of the Great Chinese famine of 1958–1961, and one study of the 1941–1944 Leningrad siege. Seven of the eleven studies reported on offspring blood pressure outcomes, five on blood lipid outcomes, and seven on glucose metabolism outcomes. Four of the eleven studies, including the single study of the Leningrad siege, found no significant differences in blood pressure , 19, 21,From the included studies, there was no clear evidence of differences by sex of the offspring. Of the four papers that stratified findings by sex, two studies—both of the Chinese famine—observed significantly higher blood pressure and blood lipids in exposed versus non-exposed female but not male offspring , 24; oneHowever, there was some tentative support for a role of adult offspring adiposity in influencing the maternal exposure to famine—offspring NCD risk factor relationship. Of the studies that measured the influence of adult offspring adiposity or indicators of postnatal nutritional abundance , 20–22, low-density lipoprotein (LDL) cholesterol levels [Seven studies examined the relationship between maternal GWG and NCD metabolic risk factors in adult offspring –31. Fourl levels . The othl levels . The reml levels , 29–31, l levels , 29.There was no clear difference in the results of included studies according to specific NCD metabolic risk factor outcome. Only two studies reported results stratified by sex, but the findings were not consistent. There was insufficient evidence from the included studies to draw conclusions about the role of gestational timing of exposure in the GWG-NCD risk factor relationship. Three studies explored the influence of offspring adiposity –28. Of tFour studies investigated the association between maternal weight or BMI prior to or during pregnancy and offspring NCD risk factors , 29, 31.Ten studies examined the relationship between various aspects of maternal dietary intake on the blood pressure of adult offspring. Five were of high quality, and five of medium quality. The findings were again heterogeneous. Of the five studies that measured levels of maternal protein and carbohydrate intake , 35, 36,balance of protein and carbohydrate in the maternal diet and offspring blood pressure. This warrants further investigation. There is insufficient evidence from the included papers to assess the influence of offspring sex or gestational timing of exposure. The findings do, however, show some tentative support for an influence of offspring adiposity in the maternal exposure to famine—offspring NCD risk factor relationship, with several studies reporting stronger associations for offspring with high adult adiposity, or a significant attenuation of associations when controlling for this variable.This systematic review reveals considerable heterogeneity in findings across studies of the impact of various aspects of maternal nutritional status during pregnancy on NCD risk factors in adult offspring. There is evidence of a link between maternal exposure to famine during pregnancy and adverse blood pressure, blood lipid, and glucose metabolism outcomes in adult offspring in some contexts. The evidence base for maternal BMI and GWG is more limited and currently reveals no consistent support for a link between either of these exposures and adult offspring NCD metabolic risk factors. Similarly, there is no indication from the currently limited evidence base of a relationship between the absolute levels of specific maternal dietary nutrients and offspring NCD risk factor outcomes, although there is some tentative support for a possible link between the To our knowledge, this is the first study to systematically review the evidence on the relationship between maternal nutrition during pregnancy and the development of three key NCD metabolic risk factors in adult offspring. Our finding of a link between maternal exposure to famine and offspring NCD risk factors in some contexts is consistent with the findings of existing narrative reviews on the topic , 6. ThisThe absence of evidence from our included studies of a link between maternal BMI and GWG align with the results of a recent non-systematic review, which found no consistent associations between maternal BMI and CVD risk factors in adults . Our finOne key observation to emerge from this systematic review is that of inconsistencies in the results of papers apparently measuring the same maternal nutrition exposure and offspring NCD risk factor. Such mixed findings may stem from differences in sample population, study design including offspring age at follow-up, variation in definitions or measurements, confounding variables, and contextual factors, particularly postnatal environmental life exposures. For the famine studies, for instance, the fact that significant associations were observed for most studies of the Chinese and Dutch famines but not the Leningrad siege might reflect the fact that the former two famines were preceded and followed by sufficient nutrition, whereas the population exposed to the latter was largely malnourished before the siege and remained malnourished for an extended period afterwards .The main strengths of this review lie in its systematic approach and comprehensive scope. Our methodology was designed to capture all studies on a wide range of maternal nutrition exposures and three of the four main NCD metabolic risk factors. To our knowledge, this is true of no other study to date. One consequence of this broad scope, however, is the inclusion of heterogeneous exposure and outcome measures, which limit our ability to synthesise findings. Moreover, the large volume of data returned precludes an in-depth analysis of each risk factor.In terms of individual studies, the risk of residual confounding is a major source of bias. Important potential confounders include fixed genetic variants common to both mothers and offspring, as well as shared postnatal dietary and lifestyle factors. Whilst ethical considerations restrict the use of strict RCTs to minimise confounding in dietary studies, sibling comparison studies present an opportunity to reduce confounding due to familial/genetic factors. There was considerable loss to follow-up in many cohort studies, a trade-off of the need for long follow-up periods in the assessment of NCD risk factor outcomes. A further source of bias relates to the ascertainment of maternal nutritional exposures. Most existing famine studies lack reliable information about the food intake of individuals during the famine period. Moreover, associations are complicated by the absence of appropriate tools to measure dietary intake accurately in humans.One of the main contributions of this systematic review is its exposure of the paucity of the current evidence base on the intergenerational links of maternal nutrition during pregnancy and NCD risk factors in adult offspring. Existing studies are drawn disproportionately from high-income countries, particularly in the European Region, which limits the generalisability of the findings. Moreover, while a number of studies have examined the effects of maternal gestational exposure to famine, our search revealed no records investigating the effects of chronic energy deficiency, arguably a more prevalent problem in LMICs today. There are also relatively few studies investigating maternal BMI, GWG, and specific dietary factors, making it difficult to draw clear conclusions about the role of these influences on offspring NCD risk factors. Furthermore, no studies examined the impact of maternal nutrition during lactation. Each of these constitute priority areas for future research, particularly the area of nutrition during lactation given the potential capacity of good nutrition during this time period to offset negative effects of poor nutritional exposure in utero . Future This systematic review reveals considerable heterogeneity in findings across studies. The evidence supports a link between maternal exposure to famine during pregnancy and offspring NCD metabolic risk factors in some contexts, with some tentative support for an influence of adult offspring adiposity in this relationship. Based on an admittedly more limited evidence base, there is no consistent support for relationships between maternal GWG, maternal BMI, or maternal dietary intake and NCD risk factors in adult offspring. Overall, our findings support calls for increased collaboration between maternal nutrition and NCD sectors but suggest that a greater focus on research is needed to identify how these two sectors can work together to support each other’s aims.Despite calls for increased collaboration and integration of policies and programmes between the maternal nutrition and NCD sectors, there remains weak evidence on the link. Findings of a link between maternal exposure to famine during pregnancy and offspring NCD risk factors in some contexts, plus some evidence of a role of adult adiposity in influencing this relationship, suggest there is potential for significant co-benefits from collaboration. However, more research and evidence are needed to inform how NCD and maternal health sectors can work together to achieve the Sustainable Development Goals (SDGs).Additional file 1. PRISMA checklist.Additional file 2. Search terms.Additional file 3. Quality scoring rubic.Additional file 4. Quality Assessment Scores.Additional file 5. Supplementary Table 1. Findings by maternal nutrition exposure.


OBJECTIVES/GOALS: (1) Determine nurse , and nursing unit  characteristics that are associated with and predictive of nurses’ attitudes, positive emotions, and negative emotions toward caring for adults with ID. (2) Explore nurses’ perspectives of perceived barriers and facilitators to providing nursing care to hospitalized persons with ID and medical comorbidity, and how nursing care differs when caring for a person with ID. METHODS/STUDY POPULATION: This mixed methods nested analysis will employ an internet survey of medical-surgical registered nurses to collect nurses’ attitudes and emotions toward caring for hospitalized persons with ID and medical comorbidity, nurse characteristics, and nursing unit characteristics. We intend to recruit 150 medical surgical nurses currently practicing in the United States via email invitation to the membership of the Academy of Medical Surgical Nurses. Purposeful maximum variation sampling will be used to invite a subset of respondents for qualitative, semi-structured telephone interviews to elicit barriers and facilitators to nursing care of persons with ID and how nursing care differs when caring for persons with ID. RESULTS/ANTICIPATED RESULTS: We hypothesize that lower nurse education level, fewer years of experience, less ID education/training, lower amount of contact with people with ID, increased communication apprehension, and lower beliefs about the quality of life of persons with ID will be associated with negative nurse attitudes and emotions toward caring for people with ID. Further, we hypothesize that lower levels of nursing unit teamwork, staffing and resources, and person-centered care practices will be associated with negative nurse attitudes and emotions toward caring for people with ID. DISCUSSION/SIGNIFICANCE OF IMPACT: The proposed research is an important first step in determining potential nurse and nursing unit factors influencing nurses’ attitudes toward caring for people with ID. It will lead to targeted interventions to enhance nursing care quality and reduce hospital-associated healthcare disparities among people hospitalized with intellectual disabilities and medical comorbidities.