Racially and culturally minoritized persons with serious illness receive subpar and potentially harmful care at end of life. Despite health equity initiatives, little is known about how palliative care clinicians perceive and engage in serious illness communication with persons from racially and culturally minoritized groups. The aim of this study was to explore how 152 nurses, social workers, and chaplains would prioritize communication with a Black, Native American woman with a history of experiencing structural racism and report of severe pain at end of life. Clinicians’ responses were thematically analyzed and reflected the following themes: person-centered, authentic, and culturally-sensitive care; pain control; approaches to building trust and connection; and understanding the communication challenges related to racial differences. Findings support the need for additional interventions that address clinicians’ unconscious biases, better integrate culturally inclusive communication in practice, and improve the quality of end-of-life care for persons from minoritized groups.N = 152) read a detailed case study about a patient self-identifying as Black and American Indian who describes mistrust of the healthcare system. Participants then responded to three open-ended questions about communication strategies and approaches they would employ in providing care. We conducted a thematic analysis of participants’ responses to questions using an iterative, inductive approach. Interdisciplinary clinicians from nursing (48%), social work (36%), and chaplaincy (16%), responded to the study survey. A total of four themes emerged: (1) person-centered, authentic, and culturally-sensitive care; (2) pain control; (3) approaches to build trust and connection; and (4) understanding communication challenges related to racial differences. Significant efforts have been made to train clinicians in culturally inclusive communication, yet we know little about how clinicians approach “real world” scenarios during which patients from structurally minoritized groups describe care concerns. We outline implications for identifying unconscious bias, informing educational interventions to support culturally inclusive communication, and improving the quality of end-of-life care for patients with cancer from minoritized groups. The aim of this study was to examine interdisciplinary clinicians’ perceptions of priorities in serious illness communication and shared decision-making with racially and culturally minoritized persons at end of life. Clinicians ( Palliative care is a person-centered, interdisciplinary approach for patients with serious illness and their families  that is Palliative care provision and outcomes for racially and culturally minoritized persons  with serious illness are substandard when compared to non-minoritized persons. For instance, care inequities for Black and Native American patients and their caregivers exist across the palliative care spectrum, including but not limited to poorer symptom management, disparate medically indicated treatments for pain  ,9,10,11,Communication capacity building and training is one potential avenue for reducing disparities. Empathic communication is the foundation of high-quality palliative care, helping clinicians to effectively elicit patient and family goals, values, preferences, and needs ,26,27. FEvidence-based communication strategies are key to optimizing patient and family outcomes in the oncology and palliative care contexts ,36,37,38N = 152) from across the United States attending the National Cancer Institute (NCI)-funded Interdisciplinary Communication Curriculum (ICC) Project. The ICC is a 3-day, in-person communication skills training program for interdisciplinary oncology clinicians, including nurses, social workers, and chaplains. ICC faculty are senior leaders from nursing, social work, and chaplaincy, and they all hold expertise in communication skills. The main objectives of the ICC course are supporting participants in their ability to (a) understand key domains of quality palliative care, (b) understand and perform effective clinical communication skills, and (c) establish goals to effectively implement communication skills in their daily practice. Primary learning activities in the course include conversation guides, role-play activities, and case studies. The format of the course is dynamic and includes didactics, discussion sections, and small-group activities.Participants in the current study were interdisciplinary cancer clinicians (n = 94) or at 12 months post course (n = 58). Study recruitment and procedures were deemed exempt by the City of Hope IRB given that all data were collected from course participants only (assurance number 00000692).The National Consensus Project for Quality Palliative Care clinical practice guidelines  were useParticipants provided written responses to three open-ended questions pertaining to a cultural diversity-focused case study about an older adult (71 years old) woman self-identifying as Black and American Indian presenting for care associated with end-stage ovarian cancer. Based on key literature and the ICC course content, the composite case was developed by authors WER and BRF  and then reviewed by MM and HB. The patient in the case study describes reluctance to seek medical care due to lack of trust in the health care system and her experiences of racism from medical providers. The complete case summary and case questions are presented in Two authors  conducted a thematic analysis using an iterative, inductive approach. Coding was guided by the overarching research question, “What do interdisciplinary clinicians cite as key components and priorities of serious illness communication with patients from minoritized racial and cultural groups?” Researchers BRF and HB coded participants’ responses to each of the three questions separately, generating unique codes for every question, which were then collapsed iteratively into unique themes for every question. The entire research team  then organized themes for each question into overarching themes and identified key properties of each theme across all three questions. During early coding, BRF and a research coordinator met together and used a consensus approach to apply codes to individual participant responses. The coding team repeated this process for all participant responses to question 1 until an understanding of how to apply codes had been reached. A single member of the coding team independently coded the remaining participant responses, then met with the other coder to review codes. Each coder created memos about key themes and observations emerging from participant responses.After initial coding, codes were collapsed within each question, then into themes. The entire group of authors discussed key findings as a team and identified prominent themes within each question, then examined commonalities in themes across questions. Throughout discussions between the coding team and immersion in participant responses, we identified four themes and collapsed codes into core properties representing each theme. Thematic saturation was reached and was established based on criteria of forcefulness, repetition, and recurrence . Participants were predominantly female (86%) and identified as White (65%). Most participants identified as nurses (48%), followed by social workers (36%) and chaplains (16%). See We identified four themes: (1) person-centered, authentic, and culturally-sensitive care; (2) pain control; (3) approaches to build trust and connection; and (4) understanding communication challenges related to racial differences. Participants’ responses characterize each theme, as well as specific properties of each theme, and provide additional depictions of clinicians’ priorities in communicating with patients from racially and culturally minoritized groups and their caregivers . ParticiParticipants described the importance of delivering person-centered care and communication to the patient, Diane, described in the case study. Responses emphasized the specific value of offering authentic care, such that it would be clear to the patient that the clinician was coming from a place of genuineness and compassion when providing care. Participants went as far as to say that they would explicitly state their desire to help the patient  to make their intentions and approach very clear to the patient. Notably, participants also emphasized the importance of validating the patient and her experiences, focusing on processes including acknowledging her pain and history, normalizing demonstrating humility about her feedback about her care experiences. Participants often reported that a key component of their communication with the patient would involve a focus on pain control and pain management. Their responses reflected participants’ attentiveness to key parts of the case vignette, including the patient’s history with pain control and the patient’s beliefs and preferences about pain control and treatment. Some participants described the importance of assessing the patient’s perspective about pain medication and eliciting information about experiences that may have informed their perspectives. Others pointed to the relevance of asking the patient to explain their fears about pain and pain management. In terms of pain control, many participants also referenced the need to provide education, information, and resources to patients about pain. Some responses also highlighted the role of the clinician to instill self-efficacy about pain management post-discharge or throughout the illness trajectory.Implicit in participants’ responses was an understanding that trust and connection would be critical to build a positive therapeutic relationship with the patient, as well as with patients from other racially and culturally minoritized groups. Participants explicitly referenced that they would offer assurance to demonstrate their commitment to the patient’s care, and that by demonstrating this commitment, they could convey trust and connection. Broadly, participants also spoke of the importance of inviting the patient’s perspectives about care and treatment by asking questions about their needs, preferences, and previous experiences. Responses indicated that participants could use the patient perspective to build trust and connection by asking clarifying questions and maintaining a focus on the patient’s desires for care and support. Participant responses also emphasized the importance of using their language and communication style to convey safety, compassion, and empathy to their patients. Perspectives emphasized creating a “safe space,” “affirming the patient’s identity as an expert,” and allowing time for patient questions, plus responding to those questions openly and honestly.Most participants pointed to several communication challenges inherent to working with racially and culturally minoritized patients. Participants described three convergent challenges related to communicating with patients from racially and culturally minoritized backgrounds: challenges affecting patients, challenges affecting clinicians, and challenges affecting the patient–clinician dynamic. Primarily, the need for clinicians to acknowledge the scope of their own biases and judgments, as well as biases that patients may hold toward medical care based on previous experiences, was something noted by participants to be of utmost importance. Participants spoke of the importance of clinicians addressing their own biases and judgments and holding in awareness beliefs that patients may bring into encounters. Relatedly, participants noted the importance of clinicians having training in cultural competence and working with patients from different racial and ethnic backgrounds. Their comments included concern when clinicians did not have experience—either personal or professional—working with individuals from different backgrounds than their own. Clinicians in the study also described their own fears about saying something offensive to a patient or using insensitive language. Some participants noted that by making a language or communication blunder, they could potentially threaten the patient–clinician relationship. On the patient side, participants reflected a belief that it is important to acknowledge, understand, and validate patient experiences of mistrust and uncertainty with clinicians. Participants were aware that feelings of mistrust held by patients could significantly affect their communication and care. Participants also referenced challenges to the patient–clinician relationship affecting communication, including the issue of patient and clinician identity non concordance. Some participants described their perception that patients may not feel comfortable sharing information with them if they were a different race, or that patients might find language barriers complicated. This study uses a case-based approach to explore the communication knowledge and priorities of palliative nurses, social workers, and chaplains caring for a Black and Native American woman at EOL with severe cancer pain and a history of racism and health system mistrust. Participant responses pointed to significant clinician discomfort in dismantling racism through interpersonal communication while providing dignified care for patients of color. Conversely, participants were self-reflective in their own limitations when providing culturally sensitive care, acknowledging the need for additional training and personal and professional development. Four themes were apparent throughout the qualitative responses, including person-centered, authentic, and culturally-sensitive care; pain control; approaches to build trust and connection; and understanding communication challenges related to racial differences. Findings can inform future communication training content for interdisciplinary palliative care clinicians, health teams, and systems that intend to promote culturally safe care provision and create environments that foster clinician self-reflection and assessment of bias. Empathic communication is central to person-centered, authentic, and culturally-sensitive palliative care (theme 1). The strategies, skills, and process tasks that characterize empathic communication have been shown to mitigate stigma and perceived bias for several populations  have stressed the need for improved cross-cultural communication among clinicians ,45,46,47Research implications include the need to better develop stakeholder and community-informed serious illness communication guides and tools that actively address all levels of racism, personal and social histories of structural discrimination, and recognize minoritized racial and cultural identity as a social determinant of health. Community-based participatory research approaches have proven useful in ensuring patient, family, and community priorities and values into palliative care interventions for people of color ,51,52. TThere are several clinical implications relevant to clinicians and larger health teams, institutions, and systems. It is imperative to note that aspects of the identified themes relate to the holistic palliative care for all patients at EOL, in particular the need for person-centeredness, authenticity, cultural sensitivity, responsible and tailored pain management, building trust and connection, and understanding potential communication challenges that may arise in the context of cross-cultural differences. Clinicians must continue to develop knowledge and measurable skills in cultural humility , which iThe study sample majority was White; however, a range of interdisciplinary clinicians from different racial groups was represented, suggesting that our data reflect somewhat diverse perspectives. In fact, our sample may be reflective of the limited racial and ethnic diversity of the broader United States health workforce . An addiRacism pervades every aspect of health and social care, including palliative and EOL care, increasing the suffering of racially and culturally minoritized people. Effective interpersonal communication is a backbone of clinical care—driving decision-making, intervention delivery, serious illness conversations, patient/family–clinician relationship quality, and clinical and quality of life outcomes. This study sought to elicit interdisciplinary knowledge and priorities related to communication for a patient with cancer, identities as a Black and American Indian person, and a pertinent history of racism and mistreatment in the health system. Findings support the need to equip clinicians with the sensitivity, personal awareness, and skills needed to effectively discuss patients’ racism, dismantle interpersonal and structural barriers to equitable care, and promote antiracist culture through evidence-based communication that is both empathic and person-centered.


Like studiesconducted in other cohorts, Leas et al2provide strong evidence that menthol cigarettes are associated with smoking uptake,progression to regular use, and nicotine dependence in youth. The magnitude of thesefindings, their consistency across samples and over time, and their coherence with theunderlying physiological effects of menthol support that removing menthol fromcigarettes is likely to benefit public health, especially as it relates to reducingyouth smoking initiation.In over a decade since the US Food and Drug Administration (FDA) gainedregulatory authority over cigarettes, menthol cigarettes have eluded regulation. Themost recent year of Federal Trade Commission cigarette sales data (2020) boasted thefirst increase in cigarette consumption in 20 years and the continued increase inmenthol sales, comprising 37% of the cigarette market.2 and others, including ourselves,3 focus on adjusting for potential confounders tocontrol for underlying differences in the people who use menthol cigarettes comparedwith those who use nonmenthol cigarettes. This is valid and important, as we examine theassociation between menthol cigarettes and behavioral outcomes and produce conservativeestimates of their role in smoking uptake and progression. However, in doing so, we losethe broader context of the people who use menthol cigarettes and the critical factorsassociated with menthol use.The modeling approaches used by Leas et al4 Greater use in these groups is no accident; it isthe result of the predatory marketing of highly engineered menthol cigarettes tospecific groups, with lower menthol levels designed to attract youth and young adultsand higher menthol levels to attract long-term smokers. Targeted marketing of theseproducts, particularly to young people, women, and Black populations, has occurred, inpart, through print advertisement placements in magazines with Black and youngerreadership, price discounts for menthol cigarettes in direct mail, point-of-salemarketing in Black and lower-income communities, and lower prices for menthol cigarettesnear public schools.5 These marketingefforts have been augmented by decades of tobacco company investment in Black-ledcommunity-based and national organizations, sponsorships for community activities,support for civil rights organizations, hiring of Black workers, and, recently, publicdisavowal of systemic racism.7 These activities stand in direct contrast to thebusiness imperatives of the cigarette companies and have not resulted in any change totheir marketing practices, which have grown the presence of menthol cigarettes in Black,Hispanic, and lower-income communities.Among past-month cigarette smokers in the US aged 12 years and older, 40% usementhol cigarettes, with higher prevalence in youth and young adults ; Black individuals (85%), Asian and Asian American individuals(47%), those from multiracial backgrounds (51%), and Hispanic or Latinx individuals(50%); lesbian, gay, and bisexual individuals (46%–51%); those living in poverty(47%); and those who receive government assistance (46%).8 In addition, young people who start witha menthol cigarette or flavored cigar are more likely to continue smoking a yearlater.3 The availability ofmenthol cigarettes and flavored cigars threatens to exacerbate disproportionate rates oftobacco-caused morbidity and mortality among Black and other vulnerable populations.Notably, menthol cigarettes and flavored filtered cigars and cigarillos share asimilar history of targeted marketing and patterns of use. These products areinexpensive, mass-merchandised products often marketed at retail outlets inneighborhoods with large numbers of Black residents, youth, and young adults. They arealso heavily advertised online and on social media platforms. Like menthol cigarettebrands, flavored filtered cigar and cigarillo brands have appropriated aspects of Blackand urban culture, including hip-hop music, to normalize and promote brand loyalty andproduct use. Their users are more likely to be young adults (aged 18–24 years vs≥25 years), Black and Hispanic, and daily menthol cigarette users.7 and an opportunity to increase healthequity, particularly for Black populations in the US.9 As described in the popular press and the scientific literature,a significant impediment to the passage of state and local policies restricting mentholcigarettes has been tobacco company recruitment of Black lobbyists and consultants toargue against such policies.10 Tobacco company–tied claims haveexploited legitimate concerns about racist policing and advocated against the passage oflocal and state menthol bans, spreading concerns and misinformation about an illicitmarket and increased crime and policing in Black communities stemming from menthol andflavor bans.10 With 37% market share and 40% menthol cigarette smokingprevalence, there is no question that tobacco companies will fight an FDA mentholcigarette and flavored cigar ban through court battles, advocacy, the perpetuation ofmisinformation and disinformation, and all other means at their disposal. However,further delay will have tremendous costs to public health, including millions of extrasmokers, millions of life-years lost, and hundreds of thousands of premature deaths,with disproportionate impacts on Black individuals.7Researchers and public health advocates have highlighted a menthol cigarette banas a remedy for social injustice9 Youth, African American, Hispanic, and AmericanIndian/Alaska Native populations, along with populations of lower education, were lesslikely to be covered by these stronger flavored tobacco policies.9 FDA’s anticipated product standards onmenthol cigarettes and flavored cigars implemented at the national level will rapidlyexpand coverage of stronger flavored tobacco policies to 100% of the population.Importantly, these policies are likely to improve equity in coverage and health benefitsfor populations at greater risk of menthol cigarette and flavored cigar use, includingyoung people. As such, the potential equity impacts of menthol cigarette and flavoredcigar bans are due to the very characteristics of those most burdened with the use ofthese products, not the population made homogeneous in our statistical comparisons.As of 2018, only 6.3% of the US population was covered by a flavored tobaccopolicy at the state or local level, and only 0.9% were covered by a more robust policythat included restrictions on the sale of menthol cigarettes.Maximizing the public health benefit of FDA’s policies on mentholcigarettes and flavored cigars will require a range of activities: (1) developingculturally appropriate communication efforts to raise awareness and countermisperceptions and disinformation about the goals of flavored tobacco policies; (2)ensuring that policy enactment and enforcement focus on retailers and manufacturers asproposed; (3) limiting policy exemptions that may lead to loopholes and inequitableimplementation; and (4) scaling up culturally appropriate, free, and accessibleresources to support tobacco cessation. FDA’s proposed bans on menthol cigarettesand flavored cigars offer a watershed moment to refocus our efforts and provide tobaccoprevention and cessation resources for the people and communities who have been targetedby tobacco marketing and, by design, are at the greatest risk of tobacco use and itsharms.


In 2016, the Canada-International HIV and Rehabilitation Research Collaborative established a framework of research priorities in HIV, aging and rehabilitation. Our aim was to review and identify any new emerging priorities from the perspectives of people living with HIV, clinicians, researchers, and representatives from community organizations.We conducted a multi-stakeholder international consultation with people living with HIV, researchers, clinicians and representatives of community-based organizations. Stakeholders convened for a one-day Forum in Manchester, United Kingdom (UK) to discuss research priorities via a web-based questionnaire and facilitated discussions. We analyzed data using conventional content analytical techniques and mapped emerging priorities onto the foundational framework.Thirty-five stakeholders from the UK(n = 29), Canada(n = 5) and Ireland(n = 1) attended the Forum, representing persons living with HIV or representatives from community-based organizations, researchers or academics, service providers, clinicians; and trainees. Five priorities mapped onto the Framework of Research Priorities across three content areas: A–Episodic Health and Disability Aging with HIV , B-Rehabilitation Interventions for Healthy Aging across the Lifespan  and C–Outcome Measurement in HIV and Aging . Stakeholders indicated methodological considerations for implementing digital and web-based rehabilitation interventions into research and practice and the importance of knowledge transfer and exchange among the broader community.Results highlight the sustained importance of the Framework of Research Priorities and provide further depth and areas of inquiry related to digital and web-based rehabilitation interventions and technology aging with HIV.The online version contains supplementary material available at 10.1186/s12981-023-00582-4. People with HIV are living longer and aging with increased physical, mental and social health-related challenges . COVID-1The World Health Organization defines ‘healthy aging’ as “the process of redeveloping and maintaining functional ability that enables well-being in older age”, recognizing the interaction between personal and environmental factors that influence health  Lazarus The Canada-International  HIV and Rehabilitation Research Collaborative (CIHRRC) is a network of researchers, clinicians, people living with HIV, representatives from community organizations and policy stakeholders formed in 2009 with an aim to translate knowledge and identify emerging priorities in HIV and rehabilitation research . In 2016Our aim was to review and build upon the previously published Framework of Research Priorities in HIV, Aging and Rehabilitation  to identInternational Forum on HIV, Aging and Rehabilitation Research: Aging in an Uncertain World, held in collaboration with the Canada-International HIV and Rehabilitation Research Collaborative (CIHRRC), at the University of Manchester, UK on May 20, 2023. The objectives of the Forum were aimed at: (1) facilitating knowledge transfer and exchange on HIV and rehabilitation interventions (including online/tele-rehabilitation) to promote HIV and aging research and clinical practice; (2) establishing new research and clinical partnerships in HIV and aging internationally; (3) fostering mentorship and training in HIV and aging research; and (4) identifying emerging issues and research priorities in rehabilitation interventions for people aging with HIV. Our focus in this report is on the research priorities that emerged from this consultation in the context of HIV, aging and rehabilitation.We conducted a multi-stakeholder in-person international consultation with people living with HIV, researchers, clinicians and representatives of community-based organizations to identify priorities related to HIV, aging and rehabilitation. Stakeholders convened for a one-day in-person We reviewed the need for ethics approval with the University of Toronto Health Sciences Research Ethics Board and the University of Manchester Institutional Review Board who confirmed that given the consultative nature of the Forum, this work did not require ethics approval.We invited people living with HIV, clinicians, academics, representatives from community-based organizations, community members, and members of the CIHRRC with interest and expertise in aging, HIV and rehabilitation. We promoted the Forum through email and website communications to members of CIHRRC, the University of Manchester, and community-based local organizations in Manchester, UK. Forum speakers further promoted the Forum via targeted invitations and word-of-mouth among stakeholders with an interest in HIV, aging and rehabilitation. 30 Years of HIV and Rehabilitation Research and how the past may inform future research. The first research evidence session included five speaker presentations focused on the Role of Mental Health in HIV and Aging and Rehabilitation. The second research evidence session included four speaker presentations focused on Frailty and Rehabilitation Interventions Aging with HIV. The panel discussion session with five speakers focused on Technology-Based Interventions for Enhancing Physical and Mental Health Outcomes for People Aging with HIV. The Forum concluded with a large group discussion focused on identifying emerging issues, priority areas and next steps for future research. See Additional File https://cihrrc.ca/forums/2023-manchester-forum/.Fourteen invited speakers from the UK, Canada and Ireland presented on research and models of community and clinical practice delivery among adults aging with HIV. The Forum included one keynote speaker, two research evidence sessions comprised of nine presentations, and one panel discussion with facilitated discussion throughout. The keynote presentation focused on an overview of Prior to the Forum, attendees were asked to submit responses to the following questions, ‘In your opinion, what have been key achievements in HIV, aging and rehabilitation research?’ and ‘In your opinion, what are 2–3 key research priorities in the area of HIV, aging and rehabilitation that are essential for moving the field forward?’ [strategy 1];During the Forum, two graduate trainee rapporteurs documented discussion during presentations and group discussion [strategy 2];During the Forum, attendees documented their ideas related to emerging research priorities on chart paper [strategy 3]; andAfter the Forum, attendees were asked to complete an evaluation form that included the following questions: ‘What are the three most important “take-home messages” that you heard at the Forum?’, and ‘In your opinion, what are 1 or 2 new and emerging issues related to HIV, aging and rehabilitation interventions that were not covered in the Forum?’ [strategy 4]Data pertaining to stakeholder perspectives on research priorities were collected using the following four strategies:We used the collective responses, discussion, and feedback derived from these sources as the foundation for identifying the priorities. We collated and analyzed the data using conventional content analytical techniques . We mappA core team  reviewed all sources of data, coded and clustered codes into categories to represent research priorities in HIV, aging and rehabilitation. These same members of the Core Team , met to review the data, identify research priority areas derived from the coding process, cluster the priority areas into broader content areas, and map them onto the original Framework of Research Priorities for HIV, Aging and Rehabilitation . The priInternational Forum on HIV, Aging and Rehabilitation Research , 35 (65%) attended the event from the UK (n = 29), Canada (n = 5) and Ireland (n = 1). The majority of stakeholders represented persons living with HIV or representatives from community-based organizations  and/or researchers or academics , service providers , clinicians ; and trainees . Researchers and clinicians were primarily rehabilitation professionals , physicians (infectious diseases), and nurses. Stakeholders worked in community-based organizations , academic institutions ; hospital or community healthcare organizations , or in non-governmental or private organization . Of the 35 stakeholders, 19 (54%) were speakers at the Forum.Of the 54 stakeholders who registered for the Evidence presented at the Forum aligned with the Framework of Research Priorities in HIV, Aging and Rehabilitation by addressing the following areas: disability, frailty, social participation, access to and impact of rehabilitation, and patient-reported outcome measures in HIV and aging. The focus on rehabilitation interventions and strategies for healthy aging with HIV included digital health and web-based interventions and supportive networks.Five priorities emerged from the Forum, all of which aligned with the original priorities, and three component content areas of the original 2016 Framework [i.Episodic disability & uncertaintyStakeholders highlighted the importance of examining the nature and severity of episodic disability , and specifically the uncertainty that may be experienced among adults aging with HIV across the lifespan. This included examining episodic disability in the context of longstanding and historic HIV pharmacological interventions among older adults with HIV.ii.Frailty and other concurrent health conditionsStakeholders identified the importance of examining disability associated with frailty in combination with other health conditions across the life span, including but not limited to, osteoporosis, menopause, chronic pain, cardiovascular disease. Considerations of biological age versus time since HIV diagnosis was highlighted by stakeholders and the importance of considering the life course of adults aging with HIV (regardless of time of HIV diagnosis) and distinguishing between different phenotypic forms of frailty: weakness, slowness, exhaustion, low physical activity, and unintentional weight loss. Stakeholders highlighted an evidence to practice gap on frailty, aging and HIV and the need for a better understanding among researchers and clinicians on how to prevent, detect and address frailty in adults aging with HIV.iii.Social participation, engagement and relationships among adults aging with HIVStakeholders highlighted the importance for researchers to consider the social and interpersonal needs of adults aging with HIV and the emotional, sexual health, intimacy and connectedness associated with relationships among adults aging with HIV. While stakeholders acknowledged this priority in the original Framework, they emphasized the relevance of social connectedness due to a lack of in-person interactions during the COVID-19 pandemic. Stakeholders discussed how the COVID-19 pandemic necessitated changes in how people interacted socially and maximized the use of digital resources where possible. While stakeholders acknowledged positively enhancements to social interactions with digital technology, others cautioned the digital divide, lack of access and digital literacy that could limit social engagement among adults aging with HIV.Stakeholders emphasized the importance of addressing i) episodic disability and uncertainty, ii) frailty, and iii) social participation among adults aging with HIV across the lifespan   among adults aging with HIV. Stakeholders highlighted the importance of considering the costs associated with implementation of digital health interventions, and financial barriers to accessing online interventions, which may be limited by financial, policy, or programmatic barriers. Future research should examine different models of implementation of digital health technology, their cost and accessibility in the context of aging with HIV.Stakeholders highlighted the need to examine the role, implementation and impact of digital health and web-based rehabilitation technologies, which aligned with Priority 6 in the original Framework. This examines the role of technology  in augmenting engagement in rehabilitation interventions among adults aging with HIV Table .iv.Role,v. Using digital and web-based rehabilitation health technology to measure physical activityStakeholders identified the potential for evaluating the impact of rehabilitation interventions including web-based interventions and digital health tools  on engagement in social connectedness interventions, and physical activity and the potential impact on disability and health outcomes among adults aging with HIV.Collectively, stakeholders acknowledged that digital health technology in HIV and aging was not a one-size fits all approach, nor a replacement for in-person health and rehabilitation services or HIV care. There still exists a role and importance and need for in-person models of delivery, and while basic forms of technology (e.g. telephone for fostering peer-support) may be simple, they can be effective. While technology may serve as a potential tool to facilitate engagement and mitigate fragmentation of health, social and rehabilitation services for persons aging with HIV, there is a need to balance technology interventions with individual need, access, literacy and comfort.Stakeholders identified the potential role for digital health technology to measure engagement in physical activity among adults aging with HIV, which aligned with Priority 7 in the original Framework  Table .v. UsingFramework of Research Priorities. Stakeholders recommended that researchers consider barriers to engaging in research, such as stigma, and the need for culturally safe, anti-oppressive and age-sensitive approaches to research on rehabilitation to better engage adults aging with HIV. For example, strategies for better engaging women, Indigenous and Métis adults aging with HIV in colonized countries such as Canada, persons who use drugs, racialized groups, individuals in rural geographical regions as well as those who may be experiencing stigma and fear of disclosure. Community-engaged approaches, involving people living with HIV in all aspects of the rehabilitation research is critical for ensuring the research is meaningful and relevant to the community.Methodological considerations for addressing these research priorities also emerged from the consultation that complemented the original Given the focus on rehabilitation interventions, attendees highlighted the importance of implementation science approaches for assessing how interventions are taken up and their impact in the ‘real world’ setting, and how interventions might be adopted in the broader context of policy and programs for adults aging with HIV , 24. AttSome final considerations, recommendations or key messages from the Forum included: recognizing that old and new technologies are both important for enhancing rehabilitation among adults aging with HIV, including engaging in physical activity, and fostering personal connections with other peers, health or rehabilitation providers, or fitness personnel. Stakeholders described technology as a vehicle of communication, and the importance of clear communication to wide audiences pertaining to terms in areas of physical rehabilitation and aging such as frailty, vulnerability, susceptibility and social vulnerability. Of note, the concept, and the very mention, of aging can yield different conceptualizations for different people and is important to consider in approaching research.Framework of Research Priorities in HIV, Aging and Rehabilitation in all areas of disability, rehabilitation interventions, and outcomes focusing on the role, implementation and impact of digital health technology in HIV, aging and rehabilitation. Stakeholders outlined the overlapping importance of examining episodic disability in the context of rehabilitation interventions; and the use of digital health technology dually as an intervention and outcome measure of physical activity.The five priorities raised by stakeholders align with and build upon the original Digital health technology emerged from the Forum as a potential mechanism for rehabilitation, HIV assessment and interventions among adults aging with HIV. This was a reflection of the Forum program, which comprised of research evidence presentations on online forms of rehabilitation and HIV care delivery. The COVID-19 pandemic changed the course of health care delivery and thrust online models of HIV and rehabilitation care delivery into the forefront of care , 25. TheThe role, implementation and impact of digital health technology was closely interwoven with the priority of examining social connectedness and participation among adults aging with HIV. This was not surprising given the impact of COVID-19 pandemic on increases in disability, specifically uncertainty and mental health and social connectedness among persons living with HIV . FurtherFramework of Research Priorities for HIV, Aging and Rehabilitation [The original litation  still relitation , 45. Furlitation . Within Framework of Research Priorities in HIV, Aging and Rehabilitation [These research priorities were developed from the perspectives of a multidisciplinary group of stakeholders with longstanding clinical, research and lived experiential expertise in HIV, aging and rehabilitation. We used a community-engaged approach involving people living with HIV in the consultation and development of the priorities. We built on the foundational litation  which sulitation , ensurinThis study has numerous limitations. We did not use a formal Delphi or nominal group technique to identify the priorities. Nevertheless we used multiple strategies to elicit perspectives on priorities such as web-based and in-person discussions. Our consultation was focused to stakeholders within Canada and the UK, and lacked representation of stakeholders from other high-income countries as well as low to middle-income countries conducting work in HIV, aging and disability. While these priorities were developed through a rehabilitation lens, addressing them will require collaborative and interprofessional and community-engaged approaches involving HIV, primary and geriatric care teams, social work, and psychology, in addition to rehabilitation to move the field forward. We acknowledge the field is continually evolving and new priorities will emerge as the course of HIV progresses and the role for rehabilitation in the context of HIV continues to grow.Framework of Research Priorities in HIV, Aging and Rehabilitation [Results from the stakeholder consultation indicated the sustained relevance and importance of the original litation , while hAdditional file 1: Forum Program at a Glance—5th International Forum on HIV and Rehabilitation Research: Aging with HIV in an Uncertain World.


There is a global shortage of midwives, whose services are essential to meet the healthcare needs of pregnant women and newborns. Evidence suggests that if enough midwives, trained and regulated to global standards, were deployed worldwide, maternal, and perinatal mortality would decline significantly. Health workforce planning estimates the number of midwives needed to achieve population coverage of midwifery interventions. However, to provide a valid measure of midwifery care coverage, an indicator must consider not only the raw number of midwives, but also their scope and competency. The tasks midwives are authorized to deliver and their competency to perform essential skills and behaviors provide crucial information for understanding the availability of safe, high-quality midwifery services. Without reliable estimates for an adequate midwifery workforce, progress toward ending preventable maternal and perinatal mortality will continue to be uneven. The International Labor Organization (ILO) and the International Confederation of Midwives (ICM) suggest standards for midwifery scope of practice and competencies. This paper compares national midwifery regulations, scope, and competencies in three countries to the ILO and ICM standards to validate measures of midwife density. We also assess midwives’ self-reported skills/behaviors from the ICM competencies and their acquisition.We compared midwives’ scope of practice in Argentina, Ghana, and India to the ILO Tasks and ICM Essential Competencies for Midwifery Practice. We compared midwives self-reported skills/behaviors with the ICM Competencies. Univariate and bivariate analysis was conducted to describe the association between midwives’ skills and selected characteristics. National scopes of practice matched two ILO tasks in Argentina, four in India, and all in Ghana. National standards partially reflected ICM skills in Categories 2, 3, and 4  in Argentina (range 11% to 67%), mostly in India (range 74% to 100%) and completely in Ghana (100% match). 1,266 midwives surveyed reported considerable variation in competency for skills and behaviors across ICM Category 2, 3, and 4. Most midwives reported matching skills and behaviors around labor and childbirth (Category 2). Higher proportions of midwives reported gaining basic skills through in-service training and on-job-experience than in pre-service training.Estimating the density of midwives needed for an adequate midwifery workforce capable of providing effective population coverage is predicated on a valid numerator. A reliable and valid count of midwives to meet population needs assumes that each midwife counted has the authority to exercise the same behaviors and reflects the ability to perform them with comparable competency. Our results demonstrate variation in midwifery scopes of practice and self-reported competencies in comparison to global standards that pose a threat to the reliability and validity of the numerator in measures of midwife density, and suggest the potential for expanded authorization and improved education and training to meet global reference standards for midwifery practice has not been fully realized. Although the universally recognized standard, this study demonstrates that the complex, composite descriptions of skills and behaviors in the ICM competencies make them difficult to use as benchmark measures with any precision, as they are not defined or structured to serve as valid measures for assessing workforce competency. A simplified, content-validated measurement system is needed to facilitate evaluation of the competency of the midwifery workforce. Despite focused attention and investment over the last two decades to improve maternal and newborn health (MNH), today there is still an estimated global shortage of 900,000 midwives, whose services are essential to meet the healthcare needs of pregnant women and their newborns . EvidencHealth workforce planners estimate the number of workers needed to achieve population coverage of essential interventions. Without clear, comparable, measurable standards for midwifery practice that policymakers, programmers, and frontline midwifery professionals can implement across countries, national decision makers lack the basic information needed to estimate and ensure a sufficient number of midwives to deliver essential quality MNH care coverage; without reliable estimates for an adequate midwifery workforce, progress toward ending preventable maternal and perinatal mortality will continue to be uneven .Global standards for midwifery practice are described by the International Labor Organization (ILO) and the International Confederation of Midwifery (ICM). The International Standard Classification of Occupations 2008 (ISCO-08), describes the scope of practice for midwifery professionals and associate midwifery professionals based on job tasks with varying levels of responsibility , and perA midwife is a person who has successfully completed a midwifery education programme that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education and is recognized in the country where it is located; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery” [The ICM developed core competencies for basic midwifery practice , referendwifery” –13. Togedwifery” , 11, 14.dwifery” . HoweverThe 2015 “Strategies toward Ending Preventable Maternal Mortality (EPMM)” report . MonitorThe first, Sustainable Development Goal 3.c.1. , focuses on density of the healthcare workforce per 10,000 population , and desFor an indicator to provide a valid measure of the effective coverage of midwifery care , it mustMNH policy indicators are seldom systematically validated  and thisWe sought to identify the most universally applicable and universally recognized reference standards for midwifery professional tasks and essential competencies for basic midwifery practice. and thus chose the ILO and ICM reference standards. We compared legal practice acts and regulatory frameworks that define the midwifery scope of work and essential competencies  at country-level with the global benchmarks set by ILO and ICM. In addition, we investigated the extent to which midwives reported skills and behaviors that matched the ICM competencies. The research, conducted in Argentina, Ghana, and India, explores the following questions:How do the regulatory documents that define scope of practice for midwives and associate midwifery professionals in each country, compare to the global benchmarks from the International Labor Organization and the International Confederation of Midwives?How do self-reported skills and behaviors for midwives and midwifery associate professionals compare to those outlined in the ICM core competencies for the practice of midwifery?Is self-reported possession of essential midwifery competencies associated with any individual or contextual characteristics of respondents?Where do midwives report gaining essential competencies: pre-service training, in-service training or ‘on the job training’ (OJT)?This study is part of a larger research project for which three study settings were selected purposively to represent a geographically diverse set of low- and middle-income countries with a significant burden of maternal mortality and based on local stakeholder interest and research capacity. In each country, four subnational districts or provinces were selected based on an index of key maternal health metrics designed to reflect health system performance. Study sites were selected through a multi-stage sampling approach and include four subnational areas in Argentina , Ghana , and India . First, a state or region in the top and bottom quartiles were selected and within each of them, a district or province in the top and bottom quartile was selected (terciles were used in Argentina due to low population density). More information on selection of the study settings is available in the published study protocol .This observational study explores multiple data sources to assess the validity of the numerator of policy-level midwifery workforce indicators used at global and national level. These indicators were prioritized for validation research through consultation with key national stakeholders including official government representatives in each country.  We performed a desk review of policy, legal and regulatory data in three countries. We also conducted a cross-sectional primary survey with all eligible health providers–those whose job descriptions matched the ISCO-8 occupational classification for midwifery professionals or associate midwifery professionals (henceforth described collectively as midwives)–employed in all eligible facilities in each district/province.To address the first validation question, we conducted a comprehensive desk review of national and subnational laws, regulations, health workforce guidelines and polices in Argentina, Ghana, and India. This included a systematic search of national websites and repositories using keywords related to midwifery regulation and scope of practice; consultations with midwifery experts including those from Ministries of Health and national midwifery institutions; and a hand search of any relevant hard copies from government and nursing and midwifery institutions.planning, providing, and evaluating care and support services for women and babies before, during and after pregnancy and managing complications.’ The initial search for documents at national level took place between May-July 2020 in all three study countries.National policies and guidelines were defined as any document that provided guidance on the scope of practice for midwifery professionals on record, defined according to the ILO classification of occupations as ‘In each country, a standard data extraction form was used to capture and compare data from the source documents to the tasks in the ILO classification system  Box 1),,Box 1), For the second validation question, we surveyed midwifery professionals from all eligible health facilities in the selected provinces/districts of each study setting. For each selected district/province, all public health facilities providing any of thirteen maternal health-related services were eligible to be included in the study. In Ghana, both public and private registered hospitals were included. A list of all such facilities was obtained from the local health department in each study area. The thirteen maternal health-related services are enumerated in the WHO Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey  as essenFacility selection differed somewhat by country. In Argentina, facilities offering all categories of services provided by midwives were first identified, and those that did not offer abortion services or employ midwives were then excluded for feasibility reasons. From the resulting list, a purposive sample of facilities at all three levels  was selected. In Ghana, all eligible primary and secondary health facilities in the four study districts that provided birth-care and/or other maternal health-related services as per the above WHO MNCAH Policy Survey were selected (24). In India, all eligible secondary- and tertiary-level facilities were included, as well as a random sample of 20 eligible primary health care facilities in each study area due to the large number of primary care sites.planning, providing, and evaluating care and support services for women and babies before, during and after pregnancy and managing complications’ in their current job regardless of their title, as per the ILO occupational classification system for a midwifery professional or midwifery associate professional. All eligible health professionals from each study district were invited for interview. The mode of data collection (between May and December 2020) was, determined by in-country guidance regarding the COVID-19 pandemic. In-person interviews were conducted in Ghana, telephone interviews were employed in India, and electronic email surveys were used in Argentina.Each health institution’s human resource or payroll department provided a list of midwifery professionals currently employed in government health facilities  and registered private institutions (for Ghana). Participants were considered eligible for interview if they were old enough to provide consent , and confirmed during recruitment that they were actively engaged in ‘Trained data collectors used a standardized, structured survey questionnaire in all settings. Questions related to respondents’ socio-demographic background, their self-reported level of skill for each competency; locus of training to achieve each competency; frequency and recency of the performance of tasks related to each competency; and the reasons for non-performance of specified tasks in their current job. Questionnaires were translated into local languages, and cognitive testing to pilot the survey questions was conducted in all three countries to ensure consistency in the meaning after translation.The response rate among eligible midwives who consented and completed interviews varied . The reaWe asked participants to report whether they possess the skills and behaviors listed for ICM Competencies in Categories 2, 3, & 4 see , which fnone, some, most, all, and refused to answer. All participants who reported possessing any of the skills/behaviors under a specific task were asked a follow-up question, “How did you gain the skills?” The response options for this question were: “pre-service education/school”, “in-service/continuing education”, and “on the job experience”. Respondents could choose more than one response.Within each category, respondents were asked to self-report whether they believe they possess each skill/behavior described for all included competencies. For example, midwives were asked “Do you have the necessary skills to confirm pregnancy and estimate gestational age from history, physical exam, laboratory test and/or ultrasound?”, for the competency of determining health status of women in the pre-pregnancy and antenatal care category. Responses were captured using the following options: Further, two stratification variables were chosen to analyze the tasks for each competency category: number of years of service, and type of facility. The number of years of service were coded as: <5 years, 5–10 years, >10 years; and the type of facility was coded as: primary, secondary, and tertiary health facilities.For the secondary data, we calculated the percent agreement between the description of the tasks, skills, and behaviors that represent the scope of practice for midwives and midwifery professionals in the international standards (ILO and ICM) and the national laws and regulations. We assigned a score of one for each component of the scope of practice from the international standard-setting documents that was reflected in the national source documents, with 50% of the score attributed if the component was mentioned in general, and up to an additional 50% of the score for mention of specific tasks/responsibilities detailed in the international standard for each component. We then calculated the percent agreement between the ILO tasks and ICM competencies, and the country-specific national laws and regulations, for each national source document.For the primary data, we analyzed midwives’ self-reported skills and behaviors and their actual performance of those skills and behaviors over the previous 90-day period prior to the interview in each country. Univariate analysis was used to calculate the percentage of midwives who reported having ALL the skills related to each ICM competency, how they obtained those skills, and their performance of skills in the past 90 days. A composite measure summarizing skills listed under each competency sub-category  was also calculated based on the reported skills of the respondents. Furthermore, we performed descriptive statistics and assessed differences in practice by district, facility type, and professional designation, i.e., midwifery and associate midwifery roles. Stata version 16.0 was used for all statistical analyses.The study was approved by the ethical review board in the Office of Human Research Administration at Harvard University (IRB19-1086). Each country also received approval for the study through local institutional ethical review boards. For Argentina, local institutional review boards approved the study . The Ghana Health Service Ethics Review Committee (GHS-ERC022/08/19) approved the study in Ghana, and in India, the local institutional review board Sigma-IRB (IRB Number: 10052/IRB/19-20) approved the study.Informed consent procedures were submitted and approved by all ethical review boards in each setting. Written informed consent was obtained from all participants prior to data collection. Data collectors explained the study purpose and procedures and the voluntary nature of the research. Potential participants were encouraged to ask questions and any concerns were addressed by the research investigators, with emphasis on participant’s ability to withdraw at any time. Electronic informed consent was used in Argentina. Precautions were taken to secure and de-identify data, and data protection procedures. Throughout the data collection process, data entry and analysis, the anonymity and confidentiality of the data was carefully maintained. To reduce the risk of deductive disclosure, data was aggregated in a manner that individual province/district, facility, or participant could not be potentially identified.Argentina has two national standard-setting documents that govern midwifery practice, Ghana has three, and India has four. Agreement between these national regulatory documents and the global standards is presented in Tables The comparison between national scopes of practice for midwives and the ILO classification of occupations for all eight tasks .A total of 1,266 midwives responded to the survey that asked them to report their skills reflected in the ICM Competencies in Category 2 , Category 3 (care during labor and birth), and Category 4 (ongoing care of women and newborns). details the percentage of midwives interviewed who reported possessing the skills and behaviors included in ICM Competencies, Category 2 , Category 3 (intrapartum care 3) and Category 4 (ongoing care for women and newborns). Further detail is available in .Table 4. The percent of midwives from Argentina who reported possessing the skills and behaviors in these subcategories varied, with the highest number reporting they possessed the skills to ‘assess fetal well-being’ (63%) ‘provide anticipatory guidance related to pregnancy, birth, breastfeeding’ (38%). For some ICM skills and behaviors in Category 2, more than half of midwives in Ghana reported possessing them, specifically to ‘assist woman and her family to plan for an appropriate place of birth’ (60%) and ‘promote and support healthy behaviors’ (61%). In India, for all sub-categories in Category 2, respondents reported skills ranged between 7% and 36%.The nine subcategories of competencies included within Category 2 are listed in There are three sub-categories of ICM competencies included in Category 3. The percent of midwives who reported having the skills described in these sub-categories ranged from 7% to 29% in Argentina, 37% to 68% in Ghana, and 5% to 31% in India.Table 4).Within Category 4, there are six sub-categories. The highest percentages (top 3) of midwives in Argentina who reported skills and behaviors included in the ICM competencies for ongoing care for women and newborns ranged from 22–38% in Argentina, 62% to 69% in Ghana and 26% to 41% in India,)  than respondents in secondary or tertiary facilities . However, for Category 3, none of the midwives working at primary care level in Argentina reported having skills included within the subcategory, ‘manage a safe spontaneous vaginal birth and prevent complications’ compared to 19% in secondary level facility and 30% in a tertiary facility. For Category 4 in Argentina, the percentage of midwives reporting that they have the skills within the subcategory necessary to ‘provide postnatal care for the healthy woman’ at primary, secondary and tertiary level were 71%, 19% and 38% respectively.assess fetal wellbeing’ from ICM Category 2. Conversely, 60% of midwives from primary facilities and 49% from secondary facilities in Ghana reported that they had all the skills in the subcategory necessary to ‘provide anticipatory guidance related to pregnancy, birth, breastfeeding, parenthood, and change in the family’. For Category 3, a similar percentage of midwives at primary (38%) and secondary (35%) facilities in Ghana reported possessing the skills to ‘manage a safe spontaneous vaginal birth’. For ICM Category 4, there was minimal variation in the percentage of midwives’ reports between facility levels.In Ghana, there are two levels of facility where midwives work. More midwives from secondary facilities (60%) than from primary facilities (50%) reported that they had the skills within the subcategory ‘‘monitor the progression of labor’ were reported by 16%, 15%, 18% of midwives across primary, secondary, and tertiary levels respectively. For Category 3, the percentage of midwives who reported that they had all necessary skills under the subcategory to ‘provide care to healthy newborn infant’ was 30% at primary level, 33% at secondary level and 26% at tertiary level. For Category 4 under the subcategory ‘provide family planning services’, 49% of midwives at the primary facility level reported they could, compared to 41% of midwives at the secondary level and 31% of midwives at the tertiary level.For Category 2 in India, the percentages of respondents who reported possessing skills matching all the ICM sub-categories were low overall but did not vary greatly across the three facility levels. For example, the skills under the subcategory necessary to This study provides data critical for validating measures to assess the adequacy of the midwifery workforce in three diverse countries. This is, to our knowledge, the first study to examine the adoption of global standards for midwifery scope of practice and competency within national policies and guidelines for the regulation of midwives’ job tasks, skills, and behaviors. Previously published studies , 23 haveThe overall findings of this study suggest a considerable variation in national scopes of practice for midwifery professionals compared to the ILO ISCO-8 across the three study countries. The broadest scope of practice is observed in Ghana and the most restricted is in Argentina. The national law that currently regulates the professional practice of midwives in Argentina dates from 1967 when the role of midwives was limited to merely collaborating with physicians, and thus it authorizes them to provide only partial, fragmented care to women before, during, and after pregnancy and childbirth. The Argentinian federal scope of practice for midwifery professionals covers only two out of eight ILO tasks . The natIn Ghana there was consistent agreement between the National Reproductive Health Policy and Standards and the ILO task list. Ghana’s Free Maternal Health Policy has been in existence since 2008 and there has been notable progress in increasing the number of midwives and other health staff and reducing maternal and newborn mortality . In 2021The skills reported by India’s midwifery workforce overall matched across the ILO ISCO-8 Tasks with some inconsistencies. To address the gaps in providing quality MNH care in India, there has been a move–although still nascent—towards developing a midwifery cadre who can work independently, providing care of women and newborns at midwife-led birth centers, with support from doctors when complications are identified. The Government of India has committed to adding an additional 85,000 midwives , includiIn a multi-country n = 73) review of midwifery education, regulation, and association, less than half of the countries had legislation that recognized midwifery as an independent profession . The inc review oFindings from the three countries in our study show considerable variation of reported skills and behaviors across the three categories of ICM competencies studied. In all three study countries, midwifery scopes of practice mostly aligned with the skills and behaviors for ICM competencies that fall within Category 3 (Care During Labor and Birth). We know, however, that midwives offer more than just care during labor and birth . This fiIn a push to reduce maternal and newborn morbidity and mortality to meet both the United Nations Millennium Development Goals and Sustainable Development Goals there has been much focus over the last two decades on updating health provider skills around “the day of birth”. Numerous development and bilateral donors have prioritized investments supporting in-service training on Emergency Obstetric and Newborn Care in multiple countries, without necessarily aligning such efforts with each country’s policy and health worker regulatory processes . AdoptinA study in Middle East and North African countries indicated that midwives from different nations have non-standardized levels of profisciency, scopes of practice, and education . HoweverIn India—perhaps unsurprisingly, given the lack of an independent cadre of professional midwives—fewer respondents possess all the basic skills for intrapartum care competencies. There are gaps in reported skills in critical areas for detecting, treating, and stabilizing pregnancy related complications. This finding supports a systematic review in India which suggests that lack of competency of midwives is a key barrier to the provision of high-quality midwifery services in India . The ovemanage a safe spontaneous vaginal birth and preventing complications’, where 93% in Argentina, 86% in Ghana and 95% in India reported gaining the skills via this modality. Elsewhere in Ghana, a study found inadequate in-service training and midwives felt they missed opportunities for continuing education as well as having limited knowledge of relevant health policies [Knowledge gained from pre-service theory, coupled with OJT experience is essential to improve the competencies of the midwives at their place of work. There were differences between countries in midwives’ reports of where they acquired the necessary skills and behaviors to align with the ICM competencies. Midwives from Argentina reported acquiring more skills through in-service education and OJT experience–interestingly—even though most respondents from Argentina are university graduates. In Ghana and India midwives reported gaining more skills through pre-service training and OJT experience. OJT experience was high across all three countries for specific subcategories of competencies in Category 3—such as ‘policies , 32. ThiA multi-country study, including Argentina, India, and several African countries, found that midwives in Argentina had more years of labor room experience on average than midwives in other countries, giving them greater confidence in their clinical practice , which i‘assess fetal movements’, ‘provide skin-to-skin contact’ and ‘promote early and exclusive breastfeeding’ over those skills and behaviors that are more complex or comprise numerous, unrelated elements, such as: ‘provide counselling about nutritional supplements such as iron and folic acid, dietary intake, exercise, updating immunizations as needed, modifying risk behaviours, and prevention of sexually transmitted infections, family planning, and methods of contraception’Global standards in the form of the ICM Competencies lay out the core skills and behaviors that constitute competency to perform the midwifery scope of practice and can be used as benchmarks to indicate the adequacy of the midwifery workforce, considering effective coverage and expected quality of care. For this study we used the skills and behaviors part of the ICM Competencies, Categories 2, 3, and 4, as the skills and behaviors are the most objective, observable aspect of these standards. The skills and behaviors listed in some of the ICM core competencies are however very detailed, complex, and diverse. There are 18 subcategories and over 110 components within the three ICM categories assessed. Each component is a complex composite of numerous skills and tasks that are not assigned value or a scoring system and do not obviously contribute to one discrete domain of competency. As the predominant set of globally recognized standards or benchmarks, these competencies are not well constructed from a measurement standpoint. Not surprisingly, midwives in this study more frequently reported possessing skills to match the more easily understood, discrete, and measurable sub-components–such as Our study findings from three countries demonstrate gaps in both midwifery policy and practice. Nevertheless, there is a growing evidence base to demonstrate that when midwives have opportunities to be trained to global standards, licensed and regulated, and working within functional systems and enabling environments, they can provide most essential RMNH services , 5, 14 aFrom a policy perspective, country guidelines can be modified to fully authorize midwives to perform all the recommended tasks outlined by ILO and ICM that are essential for improving MNH outcomes and be supported to do so. From a country program perspective, curriculum development can be tailored to build midwives’ skills and adopt competency-based learning across the whole maternity care continuum. Pre-service and in-service midwifery training programs, and other MNH in-service updates have been developed in many countries, however there is not always a systematic process within human resource departments to ensure all midwives have opportunities to access in-service training or OJT mentoring to improve their skills and behaviors especially at primary and secondary facilities.It appears that where national documents are more closely aligned with ICM competencies such as in Ghana, midwives report more skills and behaviors to match the ICM standards for the three categories. In Argentina, midwives reported higher percentages matching specific antenatal and intrapartum component, suggesting potential to gain competency in other areas if regulation allowed. Overall, in India, midwives reported lower percentages of skills and behaviors matching ICM standards–however many reported higher percentages for specific skills–again indicating that their full potential has yet to be met.“I have all the competencies”). Moreover end-aversion bias  may have influenced participants responses differently, including according to their culture. Finally, the method for data collection across the three study countries was not uniform, due to the global COVID-19 pandemic, thus response bias may have affected the study results.While the study offers important insights into the midwifery scope of practice in each of the study countries, the findings may be interpreted with caution. First, while an extensive search of national documents relevant to midwifery regulations and competencies in each country was undertaken, there is a possibility that some national policy documents were missed. Second, the self-reported skills and behaviors by the midwives in the survey may have been under- or over-reported. Third, the ICM competencies, the “yardstick” used to measure competency may be subject to measurement error, given the complexity of considering all composite skills and behaviors in each sub-category  within national policy and guidelines regulating the practice of midwifery in three countries. Previous studies did not comprehensively compare standards to both ILO and ICM standards , 23. We S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S1 Filess(DOCX)Click here for additional data file.


Polycystic ovary syndrome (PCOS) is among the predominant endocrine disorders of reproductive-aged women. The prevalence of PCOS has been estimated at approximately 6–26%, affecting 105 million people worldwide. This systematic review aimed to synthesize the evidence on the effects of physical activity on reproductive health functions among PCOS women.The systematic review includes randomization-controlled trials (RCTs) on physical exercise and reproductive functions among women with PCOS. Studies in the English language published between January 2010 and December 2022 were identified via PubMed. A combination of medical subject headings in terms of physical activity, exercise, menstrual cycle, hyperandrogenism, reproductive hormone, hirsutism, and PCOS was used.Overall, seven RCTs were included in this systematic review. The studies investigated interventions of physical activity of any intensity and volume and measured reproductive functions and hormonal and menstrual improvement. The inclusion of physical activity alone or in combination with other therapeutic interventions improved reproductive outcomes.The reproductive functions of women with PCOS can be improved with physical activity. Furthermore, physical activity can also reduce infertility, as well as social and psychological stress among women.CRD42020213732. Polycystic ovary syndrome (PCOS) is among the predominant endocrine disorders of reproductive-aged 18–40 years) women . Among r0 years wThe Rotterdam criteria are widely used to diagnose PCOS with the occurrence of any two of the clinical features: oligoovulation/anovulation (O), hyperandrogenism (HA), and polycystic ovaries on ultrasound (PCOM) . Based oFertility problems are commonly manifested among PCOS women. These problems include menstrual disorders, ovulatory dysfunctions, infertility, metabolic syndrome, sarcopenic obesity, emotional distress, and physical problems . The famThe quality of life of women with PCOS can largely be affected, as they are prone to develop psychological problems, low self-esteem, and social isolation . FurtherThe recommendations in the international evidence-based guidelines for the evaluation and treatment of polycystic ovarian syndrome are based on a synthesis of the published evidence, clinical consensus, and experience. Based on how closely the true effect matches the estimated impact, the evidence is graded between extremely strong and low for PCOS assessment and management. One of the evidence-based management recommendations for PCOS is lifestyle intervention, including diet, exercise, and behavioral strategies to reduce weight, central obesity, and insulin resistance .Physical activity reduces the risk of weight gain and can improve reproductive functions along with promoting quality of life among PCOS women . LifestyDespite the health benefits of physical activity/exercise in PCOS, a limited focus has been placed on analysing the independent beneficial effects of exercise on women’s reproductive functions in a systematic way. This systematic review aims to synthesize the positive effects of various exercise regimes and types on reproductive functions among PCOS women of reproductive age. Therefore, it will inform decision-makers about the importance of physical activity/exercise to address reproductive dysfunctions among PCOS women along with pharmaceutical interventions.The systematic review was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA) statement  and the Randomized clinical trial (RCT) studies were selected to analyse the therapeutic interventions of physical activity/exercise in this systematic review to synthesize their effects on the reproductive functions of women with PCOS aged 13 to 45 years. English language RCT studies published in the selected databases between 1 and 2010 and 31 December 2022 were selected in this systematic review. Systematic reviews of randomized controlled trials (RCTs) are considered to be the most reliable sources of information. Despite a recent increase in the number of PCOS-controlled trials published, a systematic review to produce evidence on numerous commonly utilized treatments and approaches to PCOS management used in multiple RCT studies has not been performed.This review article complies with the Ph.D. thesis titled “Association of physical activity and dietary habits with vitamin D and anti-Müllerian hormone among polycystic ovarian syndrome women in Lahore, Pakistan” registered at the Advanced Studies and Research Board (ref # 6067-ACAD) at the Department of Public Health, University of the Punjab, Lahore, Pakistan.RCTs use physical activity or exercise as the primary intervention to measure the relationship between cause and effect with the outcome parameters of reproductive functions (primary), menstrual irregularities, infertility, hirsutism, metabolic characteristics, and obesity (secondary). RCT studies with or without a comparison group using physical activity/exercise as the main intervention along with any other intervention were selected in this study. In the selected studies, the interventional effect should address at least one outcome parameter of reproductive functions for the post-test comparison.Gray literature, unpublished manuscripts, conference proceedings, and publications without primary data were not selected in this systematic review. The original peer-reviewed published articles were chosen rather than the preprints. The terms “physical activity” and “fertility” were selected as the primary reproductive outcomes, and “metabolic syndrome” was selected as the secondary outcome in PCOS women. This search strategy can opt for the database with keywords searched in full text or MeSH terms, as mentioned in Table The keywords indexed in the Medical Subject Headings (MeSH) were deployed using a three-parameter search combination including exercise or physical activity (independent variable) and reproductive functions (dependent variable) and PCOS (population of interest). The research evidence was identified using PubMed. The search engines were almost accurate in finding the required studies when searching with MeSH keywords of exercise, menstrual cycle, hyperandrogenism, reproductive hormone, hirsutism, infertility, and PCOS, as shown in Table The citation manager Mendeley (desktop version 1.19.6) was used to remove duplicated studies from the identified articles. The titles and abstracts of retrieved articles were screened by one reviewer (MB) and then verified by the second reviewer (JS). The reliability of the screened and verified studies was increased by using a predefined screening form based on the eligibility criteria (level 1: screening). The full texts of the screened articles were acquired to extract information on their study design, information of participants, sample size, type of interventions and duration, follow-up period, outcome parameters, and methods used for outcome validations (level 2: selection).The appropriateness of the searched studies to be added in this systematic review was determined by identifying that the outcome measures were in the domain of interest (level 3: eligibility). All discrepancies were resolved with the mutual consensus of the reviewers (level 4: inclusion). A flow diagram related to the information on these different levels of selection was developed based on the PRISMA statements  and is sTwo reviewers on the research team extracted the main findings from the selected articles to be included in the synthesis. Data extraction included information on study participants, intervention, comparison group, primary outcome, and research design (PICOS) to integrate all major findings. All the articles were assessed by one reviewer, while the other reviewer independently appraised 10% of randomly selected articles. All discrepancies in the findings observed by the two reviewers were resolved by mutual consensus.General characteristics of the selected studies, including information on the author(s), year of publication, demographic characteristics, duration, and research design, were also enumerated in the PICOS tables. Study population characteristics, including the source of recruitment, sampling technique, method, age, ethnicity, and proportion of the comparison group, were considered in the data extraction process.Reproductive functions of women with and without PCOS, including their reproductive hormone levels, metabolic characteristics, anthropometric features, and phenotype of PCOS, were extracted. The physical activity level was also considered, and data were extracted to measure the type, level, and effect of physical activity on reproductive functions.The methodological quality of the selected studies was evaluated by using the Cochrane Effective Practice and Organization of Care Risk of Bias Tool  and PRISA total of 334 potentially eligible articles were selected for screening through PubMed. An additional 85 studies were identified through manual searches from other sources, such as Scopus. Predefined screening at level 1 excluded 128 articles, and 291 were selected after duplication was removed, as shown in Fig. At full-text analysis at level 2, 162 articles were excluded from further analysis because they did not meet the eligibility criteria based on their respective study design, information on participants, sample size, type of interventions and duration, follow-up period, outcome parameters, and methods used for outcome validations. Based on the primary and secondary outcome measures, 83 full-text articles were excluded at level 3 screening. A total of 46 articles were found eligible for full-text assessment, and 39 studies were rejected because the studies’ primary outcomes were rather concentrated on metabolic outcomes, weight loss, and quality of life among PCOS women in general and were not focused on sexual function. Among the included studies, seven RCTs were fully analysed to synthesize the evidence in this systematic review, as shown in Table The included studies were analysed using the PICOS model and tabulated to present the reproductive health outcomes of physical activity Table . The stuThe average duration of physical activity/exercise intervention was 15 weeks (range: 6–24 weeks). Most of the interventions were planned for 16 weeks –20. SomeMost of the studies planned aerobic exercises of submaximal heart rate. Continuous and intermittent aerobic training exercise protocols as per the American College of Sports Medicine (ACSM) recommendations were followed . AccordiExercise regimes including continuous aerobic training (CAT) and intermittent aerobic physical training (IAT) were designed for the experimental cohort for 16 weeks . Such trAerobic exercise and endurance exercises also reduce the risk of anxiety and depression (P < 001) . RegularSexual function among PCOS women improved among the experimental group taking CAT and IAT physical activity when measured on the female sexual function index (FSFI) . Lopes eImprovement in hyperandrogenism-related features was also found to be improved by CAT and IAT physical activities . In anotThe beneficial effects of physical activity on PCOS women aged 13–45 years were evaluated in this systematic review. This systematic review synthesizes the effects of regular physical activity of varying volume and intensity on menstrual function and reproductive health among PCOS women. Lifestyle modification, including exercise and healthy dietary patterns, proved to be a beneficial therapy for PCOS women , 27. DesPrimary and secondary outcomes of the selected RCTs vary in their endpoints. Considering these heterogeneous outcomes and their endpoints, this systematic review cannot fully synthesize the results in a homogenous manner. Selected studies mostly addressed reproductive functions , 25, menPhysical exercise can be used as an independent treatment for PCOS women to appraise all PCOS phenotypic characteristics . PossiblAustralian guidelines for the management of PCOS recommended at least 150 min of moderate-level exercise each week . The timInactivity has been associated with obesity, hypertension, peripheral insulin resistance, and dyslipidemia, as is prevalent among PCOS patients, according to the metabolic syndrome model. Women with PCOS need to take a multidisciplinary approach, including exercise . AerobicIn addition to enhancing reproductive and self-esteem in PCOS women, physical activity has positive effects on mental health . It was The PCOS women were found to have depression and anxiety disorders, reduced psychosexual function and self-esteem, and were prone to develop eating problems with binge eating. The suggestion indicates modifying an individual’s habits based on the screening assessment and the frequency of adverse health-related symptoms among PCOS. These interventions should focus on behavioural aspects, change dietary patterns, incorporate exercise and physical activity into daily routines, and create a management strategy to control obesity and weight . A lifesThis systematic review’s results suggested that exercise improves sexual functions and menstrual frequency and balances hormonal actions in PCOS women, especially in reducing hyperandrogenism  and normAdolescent children are living more sedentary lifestyles due to advancements in technology. It is discovered that females in the reproductive age group do not take part in any regular physical activity. This may serve as a precursor to the development of PCOS in young women. The link between an inactive lifestyle and the development of PCOS needs to be further investigated. Future research can further investigate the role of lifestyle modification including regular physical exercise and change in dietary patterns to reduce the prevalence of PCOS and related anomalies including emotional well-being, metabolic syndrome, and self-esteem among women of the reproductive age group.The literature regarding physical activity in patients with PCOS was found to be extremely limited. The effect size of these interventions on reproductive function outcomes was not measured, as it was beyond the scope of this systematic review. The available data were limited to fully concluding the beneficial effects of exercise on reproductive functions.The reproductive functions of women with PCOS can be improved with physical activity and can also reduce infertility and social and psychological stress among these women. The practical implication and dissemination of knowledge of strategies to improve reproductive functions and health outcomes can reduce the inappropriate costs of using health care.