For the past several decades, a relative potency approach has been used to estimate the human health risks from exposure to polycyclic aromatic hydrocarbon (PAH) mixtures. Risk estimates are derived using potency equivalence factors , based on the ratio of selected PAHs to benzo[a]pyrene (BaP), expressed qualitatively by orders of magnitude. To quantify PEFs for 18 selected carcinogenic PAHs, a systematic approach with a priori and dose response criteria was developed, building on draft work by the US EPA in 2010 and its review by US EPA Science Advisory Board (SAB) in 2011. An exhaustive search for carcinogenicity studies that included both target PAHs and BaP with environmentally relevant exposure routes found only 48 animal bioassay datasets (mostly pre-1992 based on skin painting). Only eight datasets provided adequate low-response data, and of these only four datasets were appropriate for modeling to estimate PEFs; only benzo[b]fluoranthene and cyclopentapyrene had a PEF that could be quantified. Thus, current knowledge of PAH carcinogenicity is insufficient to support quantitative PEFs for PAH mixtures. This highlights the long-acknowledged need for an interdisciplinary approach to estimate risks from PAH mixtures. Use of alternative and short-term toxicity testing methods, improved mixture characterization, understanding the fate and bioavailability of PAH mixtures, and understanding exposure route-related differences in carcinogenicity are discussed as ways to improve the understanding of the risks of PAHs. Polycyclic aromatic hydrocarbons (PAHs) are a ubiquitous group of complex hydrocarbons and are commonly found in the environment as mixtures (rather than single PAHs). Petrogenic PAHs are naturally present in coal and crude oil, and remain within refined coal, coal tar, coal-tar pitch, and petroleum products. Pyrogenic PAHs are formed as the result of incomplete combustion, and are therefore found in soot/smoke, diesel particulate matter, and some foods cooked at high temperature.The International Agency for Research on Cancer (IARC) has found unsubstituted PAHs and certain PAH mixtures to be either carcinogenic Group 1), probably carcinogenic (Group 2A) or possibly carcinogenic (Group 2B) to humans, based on human and/or experimental animal data. For example, occupational oral, dermal, and inhalation exposure to PAH mixtures formed in industrial processes, such as coal gasification, coke production, coal tar distillation, and paving and roofing with coal tar pitch, are considered carcinogenic to humans pyrene (BaP). The carcinogenic potency of PAH mixtures is characterized by multiplying the concentrations of select PAHs in environmental media by the relevant PEFs and summing the resulting values. Many of the currently available PEFs were derived based on the professional judgement of an expert panel following semi-quantitative evaluation of the carcinogenicity data   PAH workIn 2010, the US EPA’s Integrated Risk Information System (IRIS) Program released a draft report evaluating the relative potency approach for PAH mixtures . The EPAIn their review of the US EPA draft report, the US EPA SAB  agreed wThe purpose of this analysis was to build on the premise of the draft 2010 US EPA report, while addressing only a targeted subset of 18 suspected high-potency carcinogenic PAHs and one alkylated carcinogenic PAH. The PAHs evaluated were those that are typically found in soil or sediment at contaminated sites and for which Canada  had prevA conceptual model illustrating our process for selection of candidate PAHs, literature searching, screening and quality assessment of studies, dose–response modeling, and PEF derivation is provided in The initial analysis focused on eight target carcinogenic PAHs for which Canadian PEF values are currently available, and on the comparator chemical BaP . SubsequPotential candidates for PEF evaluation included the 10 PAHs listed in Abbreviations for the target PAHs used throughout this paper can be found in The primary search criterion for our study was that the experimental design include concurrent testing of the target PAH and the comparator PAH using a physiological route of exposure, as recommended in the draft US EPA  documentFor the initial analyses, we utilized the results of the US EPA  literatuBased on the SAB  recommenWithin a particular scientific paper, each dose–response experiment was counted as an individual study, such that some papers contained more than one target PAH/BaP study see . CompletThe SAB  recommenThe first of these a priori criteria addressed the quantification of tumors. The SAB noted carcinogenicity data could include assessment of the incidence of either total or malignant tumors  and/or tumor multiplicity (number of tumors per mouse or per mouse in a specific organ). In the absence of adequate dose–response data for tumor multiplicity, the SAB recommended that only tumor incidence data be used to calculate final PEFs. The SAB also noted that tumor multiplicity and incidence data should not be averaged together. Based on these recommendations, we included only studies with tumor incidence data for both BaP and a target PAH.Our second a priori selection criterion based on the SAB  review cStudies that met the a priori inclusion criteria were further evaluated to determine whether they also met the additional “dose–response criteria” to allow calculation of PEFs .The SAB  specificThe SAB expressed a preference for calculating overall PEFs only if PEFs were available from more than one experimental dataset. The SAB  also sughttps://www.epa.gov/bmds accessed on 25 July 2022). Bayesian model averaging (BMA) was applied to all “unrestricted” dichotomous models. The use of multiple models allowed us to evaluate whether the inclusion of additional models would allow fitting of all datasets, including datasets that were not successfully fitted in the draft IRIS report ). A BMR of 10% extra risk (or 0.1) is standard when modeling dichotomous data [10 was used to calculate the PEF, rather than the lower confidence limit of the BMD10 (BMDL10), since determining the ratio of BMDLs may be problematic if the studies have different sample sizes [The PEF is defined as the ratio of the potency of the target PAH to the potency of the comparator PAH (BaP). The potency can be expressed as the slope of the dose–response curve  that met the a priori criteria  addresseIn terms of data quality, there was little consistency regarding protocols and dosing approaches across the publications, with a few exceptions. All studies were conducted using female mice from a variety of strains. Except for one experiment using oral exposure , all weAcetone was the most common solvent/vehicle for the PAHs. One study used benzene , which mWe noted that only four of 49 dermal experiments stated that mice were cohoused  of the 48 experimental datasets that met the a priori criteria also met the dose–response criteria , and allMore than half (54%) of the datasets that failed to meet the dose–response criteria included only a single dose of both the target PAH and BaP . AnotherMost of the experiments failing to meet our dose–response criteria did so due to a very high tumor response (>50%) at the single or lowest (in multi-dose studies) tested dose of BaP . Of 24 sOnly eight experimental datasets from four publications assessing five target PAHs  met our dose–response criteria : five ofThe four datasets selected for dose–response modeling shared many of the limitations described above regarding data quality. In particular, purity information for the test agent was lacking for some studies, and there was often no indication that measures were taken to avoid ingestion of dermally applied test material by grooming behavior of the mice. In addition, there was little consistency in many of the experimental parameters .This study used a systematic approach to develop quantitative PEFs for a select number of carcinogenic PAHs, building upon preliminary work by the US EPA  while alAll selected experiments used female mice, and all except one were based on dermal application of PAHs. In some selected studies, mice were co-housed. No dermal studies reported limiting either self-grooming or community grooming among mice. Consequently, a portion of the dermal dose may have been ingested by these animals.Most PAH studies were completed prior to the availability of modern test methods and, consequently, there was no standard protocol to evaluate relative potency in the context of exposure duration, single versus multiple doses, frequency of dosing, age and strain of mice, selection of promotor chemical, etc. Given these limitations, it was not possible to determine how these variables may have affected the calculated relative potency. Most publications tested only a single dose of both the target PAH and BaP. Unfortunately, the methodology in publications meeting the a priori criteria was not consistently documented and most did not meet the dose–response criteria , particularly for the common comparator, BaP.The studies meeting the a priori criteria included both I/P and complete carcinogenicity studies. The US EPA  comparedAll PEFs in the current study were based on skin-painting experiments in mice, with most using acetone as the solvent. Unfortunately, potential effects of solvents on absorption, metabolism, and resulting tumor response of the target PAHs and BaP are largely unknown and/or not readily quantifiable. Kontir et al.  found alAbsence of datasets meeting our quantitative dose–response criteria for a particular PAH does not necessarily mean that qualitative potency data were lacking. For example, nine DBalP dermal carcinogenicity datasets from six publications that met the a priori criteria were identified , and somAs listed in In summary, the confidence in, and overall utility of, the derived PEFs are limited by numerous uncertainties and overall poor quality of the datasets, the small number of PAHs for which PEFs can be derived, and the overall lack of PEFs for PAHs routinely included in environmental risk assessments.TMMouse gavaged for 28 days with one of seven different PAHs, the induced tissue-specific perturbations of signaling pathways related to carcinogenesis were distinct from those produced by BaP. Tilton et al. [The first key assumption of the PEF approach was that all PAHs act in a manner toxicologically similar to BaP . While tn et al.  providedn et al. ,45. Gayln et al.  noted thThe second key assumption of the US EPA’s  relativeIn summary, data regarding the key assumptions of PEFs for assessing carcinogenic risk of PAHs in complex mixtures do not support the contentions that they function through a common mechanism of action. Indeed, several recent studies demonstrate that PAHs can act through unique mechanisms potentially contributing to cancer outcomes in a non-additive manner.Polycyclic aromatic compounds (PACs) are a large class of contaminants and include unsubstituted polycyclic aromatic hydrocarbons (PAHs) that only contain carbon and hydrogen, alkylated derivatives of PAHs , and heterocyclic aromatic compounds . In the 1970s, 16 unsubstituted PAHs were identified by the US EPA as priority pollutants, and these pollutants in turn played an exceptional large role in the development of analytical methods ,75, and Combustion-generated PAH particles are not only composed of unsubstituted PAHs, but also include polar PAHs that include HMW PAHs, alkylated PAHs, and PAHs compounds containing heteroatoms  and other substituted PACs such as amino-PAHs, cyano-PAHs, etc. ,76,77,78Based on the above considerations, characterization of PAH mixtures in their original and weathered forms, along with improved understanding, monitoring, and mapping of the fate of PAHs, will enable prioritization of the PAH mixtures most relevant to human health.While some airborne or soil particulates may contain desorbable PAHs, non-polar PAHs can become irreversibly sequestered in carbon over time, and measurement of the total, rather than the bioaccessible/bioavailable PAH content in surface soils and sediments may lead to overestimation of potential exposure and risk ,87.In vitro bioaccessibility assays are often used as surrogate measures of bioavailability, but for hydrophobic contaminants, reported correlations between in vitro bioaccessibility and in vivo bioavailability have generally been poor . Due to 2.5 (particulate matter with diameter less than 2.5 microns or µm) and adverse effects arising from exposure to particulate-associated PAHs have yet to be investigated [Most studies of PAH bioavailability have focused on oral, and to a much lesser extent, dermal routes of exposure. Despite the greater exposure of humans to PAHs adsorbed to or contained within airborne particulate PAHs, the relationships between PAH bioaccessibility in PMstigated .The limitations of current PAH mixture toxicity and the PEF approach, and the need for additional and more potent PAH indicator compounds is well recognized . RichterAlternative high-throughput in vitro or in silico testing methods may allow for more rapid characterization of PAHs and PAH mixtures than is currently possible using in vivo assays, and can reduce or eliminate the use of laboratory animals  in support of risk assessments of PAH mixtures.One such area of active research is analysis of “omics” data from sub-chronic or short-term studies (e.g. ); howeveAlternative testing approaches are unlikely to identify all potential key events and their relationships to PAH toxicity or to divergence in cancer outcomes between exposure routes . Instead, such approaches could focus on key elements of the toxicokinetics  and of the molecular initiating events (MIEs) and selected downstream events in a quantitative adverse outcome pathway. For example, although genotoxicity, DNA adducts, and AhR binding are not strong predictors of PAH carcinogenicity, a combination of these three endpoints might be predictive of comparative toxicity. Recently, Price et al.  proposedDespite the known limitations of the PEF approach, it remains practical as a qualitative screening tool, and for exposure scenarios where the source and the composition of the PAH mixture have not been fully characterized.Nonetheless, the key assumptions underlying PAH PEF derivations lack supporting data. The thinking that PAHs function through a common mechanism of action and in an additive manner has been challenged by recent studies demonstrating carcinogenic PAHs can act through multiple interacting mechanisms and that PAHs considered non-carcinogenic may nonetheless contribute to carcinogenesis. These limitations are particularly problematic for complex mixtures such as coal tar and creosote.The analyses in the current paper showed that data suitable for calculating PEFs were almost wholly limited to those obtained from dermal exposure assays, and long-term oral or inhalation cancer studies are lacking for most individual PAH compounds other than BaP. In addition, no human epidemiological studies specifically addressing cancer risks resulting from oral exposure to PAHs were located; oral and dermal exposures in the available occupational studies were likely confounded by additional inhalation exposure. The abundance of rodent dermal PAH exposure studies may reflect the ease of administration compared to the oral or inhalation routes. However, dermal and oral bioavailability of PAHs may differ , and apparent potency may vary depending on the solvent/vehicle used.However, completion of multiple new animal studies meeting the study selection criteria recommended by the SAB  to derivFinally, this analyses also demonstrated that there are currently insufficient data to develop new high-quality quantitative PEFs to replace the semi-quantitative PEFs currently available. Recently published reviews and experimental studies support future replacement of the PEF approach with an interdisciplinary mixtures approach. This shift will require improving our understanding of the fate and transport of selected PAH mixtures, deriving additional bioavailability data, expanding chemical analytical capabilities, and incorporating 21st century risk assessment methodologies (including in vitro and in silico techniques). In the interim, associated uncertainties must be explicitly addressed when relative potency is used for human health risk assessment of PAH-contaminated media.


In the last 20 years, substantial improvements have been made in stroke recanalization treatment. Good outcomes after modern reperfusion treatment require the rapid and accurate identification of stroke patients. Several stroke rating scales are available or have been proposed for the early recognition of stroke and the evaluation of stroke severity and outcome. This review aims to provide an overview of commonly used stroke scales in emergency and clinical settings. The most commonly used scale in a prehospital setting for stroke recognition is the Face, Arms, Speech, Time (FAST) test. Among many prehospital stroke scales, the Los Angeles Prehospital Stroke Screen has the highest sensitivity and specificity for confirming stroke diagnosis. The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for the evaluation of stroke patients in hospital settings and research, and it has two variants: the shortened NIHSS for Emergency Medical Service and the modified NIHSS. The evaluation of comatose patients usually involves assessment with the Glasgow Coma Scale, which is very useful in patients with hemorrhagic stroke or traumatic brain injury. In patients with subarachnoid hemorrhage, the outcome is usually accessed with the Hunt and Hess scale. A commonly used tool for stroke outcome evaluation in clinical/hospital settings and research is the modified Rankin scale. The tools for disability evaluation are the Barthel Index and Functional Independence Measure. Stroke is associated with high rates of disability and mortality worldwide . DespiteThis review aims to provide an overview of commonly used stroke scales in emergency, clinical prehospital and hospital settings, and research.There are several stroke screening scales that have been created for stroke recognition within the population. The most commonly used tool is the Face, Arms, Speech, Time (FAST) test, especially in emergency settings . DespiteFor stroke mimics, there is the Recognition of Stroke in the Emergency Room (ROSIER) scale, which has proved to be better than the FAST, CPSS, and LAPSS scales ,19. AnotThe National Institutes of Health Stroke Scale (NIHSS) is a broadly adopted stroke impairment and severity scale in hospital settings . It consHowever, the NIHSS has some limitations: (1) it does not evaluate the cranial nerves in detail; (2) it underestimates the severity of disease in patients with brainstem or cerebellar infarction; (3) some discrete neurological deficits might be missed; (4) it does not accurately reflect the stroke severity of each cerebral hemisphere; (5) the least reliable score is present in patients with cognitive dysfunction; (6) some clinical changes in repeated examinations might not be shown as changes on the scale; and (7) an abnormality on the NIHSS does not support or refute a stroke diagnosis ,30,31,32Despite the standard full version of the NIHSS, there are other versions designed for an emergency setting, the most promising of which are: (1) the modified NIHSS and (2) the shortened NIHSS-EMS ,33,34,35Other popular stroke scales that assess stroke severity are: (1) the Canadian Neurological Scale, (2) the European Stroke Scale, and (3) the Scandinavian Stroke Scale . The scoThe evaluation of comatose patients usually involves assessment with the Glasgow Coma Score (GCS), which is very useful in hemorrhagic stroke or traumatic brain injury patients . The GCSThe assessment of patients with subarachnoid hemorrhage (SAH) includes the use of several scales in daily clinical practice. The most commonly used scale is the Hunt and Hess scale for patients with confirmed subarachnoid hemorrhage . The iniThe two most popular disability scales are the Barthel Index (BI) and Functional Independence Measure (FIM) . The BI In our opinion, the utilization of some rating scales should become routine practice for the evaluation of patients with stroke. Training for more demanding scales is necessary to reduce inter-rater variability and to increase reliability . Some trUnfortunately, the currently available scales have limitations regarding recognizing some signs and symptoms, mostly related to posterior circulation strokes . In addiOur review only includes commonly used scales in routine clinical work and research. The major limitation of the review is that we are not able to include all available scales, especially for specific neurological deficits, which are only listed. Therefore, the caveat is that we do not present the result of a systematic review and meta-analysis, which would provide a more detailed and objective analysis of stroke scales.Stroke rating scales are useful tools in everyday clinical practice and research. Despite their limitations, specific scales are used either as stroke recognition tools or as a quantification tool for measuring severity, disability, outcome, or other aspects of stroke. The currently preferred scales are: (1) FAST, for prehospital settings and stroke recognition by the public, and (2) the NIHSS and mRS for clinical in-hospital evaluation and research purposes.


Over-the-counter (OTC) medications are frequently used to self-care for nonspecific ovarian cancer symptoms prior to diagnosis. Monitoring such purchases may provide an opportunity for earlier diagnosis.The aim of the Cancer Loyalty Card Study (CLOCS) was to investigate purchases of OTC pain and indigestion medications prior to ovarian cancer diagnosis in women with and without ovarian cancer in the United Kingdom using loyalty card data.An observational case-control study was performed comparing purchases of OTC pain and indigestion medications prior to diagnosis in women with (n=153) and without (n=120) ovarian cancer using loyalty card data from two UK-based high street retailers. Monthly purchases of pain and indigestion medications for cases and controls were compared using the Fisher exact test, conditional logistic regression, and receiver operating characteristic (ROC) curve analysis.Pain and indigestion medication purchases were increased among cases 8 months before diagnosis, with maximum discrimination between cases and controls 8 months before diagnosis . An increase in indigestion medication purchases was detected up to 9 months before diagnosis . The ROC analysis for indigestion medication purchases showed a maximum area under the curve (AUC) at 13 months before diagnosis , which further improved when stratified to late-stage ovarian cancer .There is a difference in purchases of pain and indigestion medications among women with and without ovarian cancer up to 8 months before diagnosis. Facilitating earlier presentation among those who self-care for symptoms using this novel data source could improve ovarian cancer patients’ options for treatment and improve survival.ClinicalTrials.gov NCT03994653; https://clinicaltrials.gov/ct2/show/NCT03994653 Ovarian cancer is the eighth most common cancer in females worldwide and is the sixth most common cause of cancer-related death in females in the United Kingdom ,2. ThereA proof-of-concept study conducted in 2019 concluded that there may be an increase in purchases of pain and indigestion medications 10-12 months before ovarian cancer diagnosis to treat symptoms , althougThe CLOCS case-control study design and protocol have been described previously . EligiblPatients were recruited from 12 NHS clinic sites in England, Wales, and Scotland from November 1, 2019, to January 31, 2022. Participants without ovarian cancer were recruited indirectly through an online experiment that investigated the effects of an animated decision aid on willingness to take part in the CLOCS in July 2020 (unpublished), and directly through paid social media advertisements using Meta (formerly known as Facebook), a test recruitment email from one of the participating retailers, word of mouth, and the advocate network VOICE  from SepAfter obtaining explicit consent, up to 6 years of loyalty card purchase history, starting from the date of recruitment, was requested from two high street retailers, hereafter referred to as high street retailer 1 (HSR1) and high street retailer 2 (HSR2), for eligible participants using the name and number on their loyalty card(s). One of the participating retailers offers a supply of health and beauty items, while the other stocks a wider range of health, beauty, and grocery items, thereby providing CLOCS with a variety of purchases related to the participants’ intentions to shop at either retailer. If these details matched the retailers’ records, then the participant purchase history was transferred to the CLOCS team. If the details did not match, then the purchase history was not shared, and the participant was recontacted up to two times to clarify their details. Once clarified, the participant’s card history was requested once again as described previously .The CLOCS team included two ovarian cancer patient advocates who were involved in the project from the inception of the idea to study design, ethical approval applications, and development of recruitment strategies throughout the CLOCS. We presented two public-facing seminars to engage with the wider audience about the CLOCS in December 2020 and March 2021 during Ovarian Cancer Awareness month. Furthermore, we held three annual scientific meetings inviting academics, patient representatives, and participating high street retailers.Participants completed a short questionnaire about ovarian cancer risk factors, including ethnicity, marital status, BMI, age at menarche, menopausal status, age at menopause, parity, breastfeeding, hysterectomy, tubal ligation, cancer history, endometriosis, aspirin use, oral contraceptive (OC) use, hormone replacement therapy (HRT) use, family history of ovarian and breast cancers, vaping, and cigarette smoking. The questionnaire also requested information about the symptoms experienced (if any) and number of visits to the general practitioner (GP) in the year before participating in the study for controls or leading up to cancer referral or diagnosis for cases.BRCA1 and BRCA2 mutation status, and any surgical outcomes for cases were provided by the clinical team at their respective recruitment sites.In addition, participants were asked about which food and pharmacy stores they shop at regularly, at which stores they own a loyalty card, frequency of use of those loyalty cards, and where they heard about the study (for controls only). The questionnaire was amended to include a question about the number of people in their household. To gain a better understanding of the impact of COVID-19 on purchase history patterns and ovarian cancer diagnosis delays, the questionnaire was amended to include a question about whether participants had been diagnosed with COVID-19 . The date of diagnosis, type, stage, grade, Unconditional logistic regression was used to calculate the risk of ovarian cancer among CLOCS participants, first using an unadjusted model and then with adjustment for age, OC use (ever/never), menopausal status , and HRT use (ever/never).vim) package in R. Participants were grouped into low-, medium-, or high-risk score groups using cut-off points based on tertiles of the risk score among controls.An ovarian cancer risk score was calculated for all participants stratified by age (<50 years and ≥50 years) using an additive model described previously . The risFor purchase history analyses, two controls were matched with each case according to age (continuous) and which HSR loyalty card they had , with replacement. The analysis was focused on the period of 24 months prior to diagnosis for cases to maximize the amount of purchase history data available from participants and to detect a difference in purchases between cases and controls up to 10 months before diagnosis, according to the prior power calculations . Owing tFor statistical analysis, purchases for each individual were summed on a sliding 3-month window to smooth the signal and to represent a pattern of individual purchase behavior for cases and controls comparing all purchases to the purchase of both pain and indigestion medication bought together. The Fisher exact test was used to calculate the ORs, 95% CIs, and significance of enrichment at each month prior to diagnosis.A conditional logistic regression model was used to investigate the association between purchase of medications that treat pain and indigestion over the 24-month period as well as pain and indigestion medication purchases separately, where the medication purchase was the exposure and ovarian cancer diagnosis was the outcome.A receiver operating characteristic (ROC) analysis was performed for purchases of pain and indigestion medications separately at each month prior to diagnosis for cases and the latest 24 months available for controls. For cases, the ROC analysis was repeated and stratified by stage at diagnosis, where stages 1 and 2 were grouped together and considered the early stage and stages 3 and 4 were considered the late stage.Sensitivity analyses were performed to assess the impact of several factors on purchase behaviors among CLOCS participants. First, conditional logistic regression was used to assess the association between ovarian cancer diagnosis and purchases of pain and indigestion medications before and after the COVID-19 pandemic (before and after March 2020). Second, to account for seasonal purchase behaviors , the conditional logistic regression model was repeated with adjustment for seasons. Finally, to investigate whether the number of members in a household affects the association between ovarian cancer and purchases, the model was run with adjustment for the number of members in the household and OC use.Further sensitivity analyses related to ovarian cancer symptom behaviors were performed using the same conditional logistic regression model with adjustment for whether participants reportedly attended the GP in the 12 months prior to diagnosis for cases and prior to participation for controls, as well as with adjustment for whether participants reported experiencing nonspecific ovarian cancer symptoms.All statistical analyses were conducted in the ISO27001-certified Secure Enclave environment at Imperial College London using R (version 4.1.2).The CLOCS was reviewed and approved by the North West-Greater Manchester South Research Ethics Committee (19/NW/0427). Explicit consent for the research team to request loyalty card data from participating retailers and to take part in the study was given from all participants.As of January 31, 2022, 182 cases and 441 controls consented to take part in the CLOCS. As shown in the CONSORT diagram in The characteristics of CLOCS participants are shown in Ovarian cancer risk and risk scores among participants are shown in Table S2 and Table S3, respectively, of Purchase histories were requested for 178 cases and 160 controls from HSR1 and HSR2, as described in The average cumulative number of purchases of pain and indigestion medications together are shown in As shown in Restricting the analysis to only participants who purchased any pain medication over the 24-month period, 98 cases and 206 controls remained. The ROC analysis for pain medication purchases alone , excludiAmong those who only purchased any indigestion medication over the 24-month period, 63 cases and 112 controls remained. The ROC analysis for indigestion medication purchases alone  also shoAdjusting for purchase behaviors before and after the COIVD-19 pandemic, different seasons, number of household members, and OC use showed little to no effect on the association of purchases with ovarian cancer over 24 months before diagnosis . However, this age difference was accounted for in all analyses either through age adjustment or matching on age.This study highlights the significant timeframe (9 to 19 months prior to diagnosis) in the patient interval in cancer diagnosis for when individuals who have yet to receive an ovarian cancer diagnosis and may have been reacting to the bodily changes and caring for their symptoms using OTC medications to maintain their health status. In the landscape of cancer epidemiology and symptom presentation research ,6, this Likewise, this study only reported the temporal associations between OTC purchases and ovarian cancer diagnosis, and future data analyses will include understanding the characteristics of changing patterns of purchases, as well as combining other purchase categories that are not linked to symptom management using unbiased machine-learning approaches. Future analysis may also consider the association between OTC purchases and other diseases with similar symptoms, such as gastrointestinal diseases. With growing literature on utilizing other data sources in health research, transactional data have already been used to evaluate dietary patterns, and such analysis is considered to be a tool that can supplement our understanding of people’s dietary behaviors ,20. SimiTo date, the CLOCS has identified an increase in purchases of OTC pain and indigestion medications among ovarian cancer patients before diagnosis compared with those of women without ovarian cancer. Further studies with larger numbers of ovarian cancer patients, diagnosed at different stages, and more participating retailers are needed to verify these findings, which can lead to the future development of an alert system for individuals to seek medical attention for the symptoms they are experiencing sooner than they might otherwise.


The unnecessary flaring of natural gas impacts public and environmental health, contributes to climate change and wastes fuel resources. Though reducing flaring is an emergent global environmental governance priority, progress has been slow. We assess gas flaring policy in the critical case of Nigeria through multi-level governance (MLG) structure. Our analysis assesses policy coherence  and divergence (creating tension and undermining progress) amongst sectors and institutional structures across the supranational, federal, state and local government scales. A combined dataset of documents, stakeholder interviews and expert surveys is analysed using Qualitative Document Analysis (QDA) and content analysis. We identify the principal actors involved, examine the extent of gas flaring awareness and policy coherence across multiple sectors/policy domains, and assess progress towards Nigeria’s national intended contribution and national policy on climate change mitigation. We find that policy coherence around gas flaring, including efforts towards climate change mitigation, has been slowed by political partisanship, poor governance, lack of regulatory compliance, and policy conflict between environmental protection and economic development priorities. Nigeria urgently requires inclusive involvement of stakeholder voices across multiple sectors and scales of local/regional government, the strengthening of federal institutions, a revaluation of economic aspirations through revenue diversification, and leadership that can temper the power of International Oil Companies (IOCs) to exploit the complexity of the MLG structure. These actions would help the government in improving environmental justice outcomes for flaring-affected communities.The online version contains supplementary material available at 10.1007/s44177-023-00045-5. Though ostensibly gas a matter of routine fossil fuel operations, flaring often occurs due to a lack of economic, regulatory or technical barriers to developing gas markets and gas infrastructure or when it is not feasible to reinject associated gas back into the reservoir  was formally recognised in 2018 following the Paris Agreement and global commitments to keep warming levels below 1.5 °C UNFCCC . The topThis paper considers the gas flaring policy in Nigeria. Nigeria is a critical case for such analysis because the continued operation of the oil and gas industry is central to the country’s economic and social development strategy. Nigeria is the largest oil-producing country in Africa, with 37.0 billion barrels of proven crude oil and an even greater 190.4 trillion cubic feet (Tcf) of proven natural gas reserves. Fossil fuels account for > 80% of government revenues, 95% of export receipts, and 90% of foreign exchange earnings  during 2010–2020 , which was explicitly designed to implement the government’s policy objectives to eliminate gas flaring, the Federal Government policy position appears to abate gas flaring whilst the Petroleum Industry Bill (PIB) provides legal, governance, regulatory and fiscal frameworks for the Nigerian petroleum industry, the development of host communities and for related matters Amaza . At the Despite escalating policy commitments, flaring activity, particularly across the Niger Delta region, remains high  and policy coherence frameworks to explore how the relationships between different actor perspectives and institutional and policy frameworks operate across different policy sectors in Nigeria. Our research objectives are to:Our analysis provides insight into environmental governance best practices, through an assessment of policy coherence and implementation across multiple sectors and scales of governance, with recommendations for environmental policy globally.Multi-level governance (MLG), multi-tiered governance, polycentric governance and fragmented governance are concepts variably used to describe changes to national, international and supranational regimes Validate through interview and survey data collected from stakeholders within the sector.Our four-stage Qualitative Document Analysis (QDA) approach was used to undertake a horizontal-level policy coherence analysis. We follow a four-step QDA model  2013 document.Step 2. Select and Obtain the Relevant DocumentsSectoral government policy documents were obtained through an internet search, combining the search terms “gas flaring policies and/or regulations” and/or “Nigeria policy documents” with subject headings “Nigeria gas flaring, and/or NDP and/or INDC, and/or climate change”. The corpus was restricted to English language publications. Relevant government websites displayed during the initial search were further searched to locate specific sector policies. Table Step 3: Qualitative Document AnalysisSystematic policy coherence analysis of the selected sectoral policy documents was performed across sectors. Documents were analysed using content analysis , direct content analysis assessed the level of coherence of each policy document using the keywords to locate the sentence or paragraph where they were used within each policy document. This involved thorough reading of each document to ascertain the specific background context and insight into the government’s strategies, particularly how these keywords were prioritised within the strategic plans. Keywords were then grouped and re-organised into themes based on relationships focussing on climate change policy strategies and INDC plans, facilitating cross-comparison.The third stage 3c) involved checking for coherence using keywords. The number of times each of the keywords was mentioned formed the first part of assessing awareness regarding gas flaring. Each mention of the various gas flaring and venting-related concepts was assessed according to how they were used in the paragraph. Scores were applied to the level of coherence, ranging from 0 (no coherence) to 3 (high coherence) for each policy document concerning awareness of each of the nine gas flaring concepts and the extent of relevant strategies using a categorisation matrix (e.g. Elo and Kyngäs c involveThe keywords were then used to search each policy document to assess how and to what extent they described the same issue. Average coherence scores were generated for the various documents.The fourth stage (3d) considered the level of coherence between sectors. This involved careful review of each document to identify when each of the other sectors was either explicitly mentioned or implicitly considered by averaging the two values ascribed to each policy document as calculated in stage three.Step 4. Validation and Finalisation Through Qualitative Interview and Survey ResponsesValidation and finalisation (steps 3 and 4 of the QDA) comprised stakeholder interviews with actors involved in gas flaring, including climate change mitigation and adaptation action in Nigeria. Attempts were made to schedule interviews with the five federal institutions responsible for gas flaring management in Nigeria, but tight political controls meant participation was consistently declined. Furthermore, 30 individuals, employees of these federal ministries, institutions and agencies who were contacted declined our invitation due to “instruction from the top” not to participate. Consequently, seven experts  were interviewed, whilst an industry experts survey targeted people with a PhD in oil and gas and related fields and policy experts.We employed purposive sampling to identify experts for the survey and utilised a snowball sampling technique to recruit the other experts. We contacted 59 experts through e-mail, and 23 replied and completed the survey. Interview and survey respondents’ roles or connections with their organisations were anonymised. NVivo software was utilised in coding and analysing the validation data according to sectoral themes.First, we present key findings from our literature analysis of Nigeria’s MLG system pertaining to oil and gas governance. Second, we show the extent of gas flaring awareness and policy coherence across the policies of different sectors, and finally, we examine the implications for progress towards Nigeria’s INDC and NPCC.Following independence from British colonial rule in 1960, Nigeria began operating as a Federal Government system. The Nigeria constitution of 1999, as amended, provides the basis for all laws and legislation at the highest level. Nigeria currently has 36 states, a federal capital territory (FCT) and 774 local government areas as a federation. States are not autonomous but depend on federal allocation and the 13% derivation from oil and gas producing states  and Federal Ministry of Environment (FMEnv) are responsible for managing gas flaring and other environmental issues through parastatal organisations that wield indirect political authority (namely: the Department of Petroleum Resources (DPR), Nigerian National Petroleum Corporation (NNPC) and the National Environmental Standards and Regulations Enforcement Agency (NESREA)) Fig. . These fThe first statutory agency established to regulate the petroleum industry was the DPR. In 1971, the Nigerian National Oil Corporation (NNOC) was established to manage the commercial and operational activities in the oil industry, whilst DPR under the Federal Ministry of Mines and Power exercised statutory guidance and industry control. The DPR was adapted into the Ministry of Petroleum and Energy in 1975 and later renamed the MPR. In 1977, the MPR and the NNOC were consolidated to create the NNPC. However, the petroleum inspectorate was still an integral component of the NNPC and was mandated to regulate the petroleum industry. The MPR was re-established in 1985, whilst the petroleum inspectorate remained within the NNPC. The NNPC was re-organised in 1988, and the petroleum inspectorate was moved to the MPR as the technical division and renamed the DPR DPR .The MPR is the main federal executive organ responsible for articulating and implementing petroleum resources policies, maintaining standards, monitoring quality and quantity and regulating industry practices. The minister has discretionary powers to grant flaring. The DPR and the NNPC are parastatals under the MPR. Through the MPR, the DPR is responsible for overseeing all the activities of all companies engaged in oil and gas production. It ensures and facilitates compliance with the applicable laws and regulations, including enforcement of safety and environmental regulations, and advises the government and relevant agencies on technical and policy issues MPR .The Federal Ministry of Environment (FMEnv) was established in 1999 to protect and improve Nigeria's water, forest, land and air by formulating, coordinating and implementing environmental policies and programmes, prescribing standards, and formulating and enforcing environmental regulations and laws. NESREA and the National Oil Spill Detection and Response Agency (NOSDRA) are parastatals under the FMEnv. NESREA was established by the NESREA Act of 2007 and empowered to enforce all environmental laws, guidelines, policies, standards and regulations and ensure compliance with international treaties, conventions, protocols and environmental agreements MPR .I have described the oil companies in Nigeria as a country within a country. The oil companies are high key players in the politics of Nigeria and the economy of Nigeria. The oil companies do work together with the Federal Government .International Oil Companies (IOCs) and organisations such as the United Nations Framework Convention on Climate Change (UNFCCC), World Bank, GGFR and OPEC are also involved in gas flaring management. However, power is unevenly distributed across the governance system. Though several different parastatal organisations are involved in shaping the overall gas flaring management structure in Nigeria, political power still follows the conventional top-down quasi-federal structure. Analysis of the expert survey data indicated that 45% of those surveyed considered that the IOCs weaken policy implementation due to their influence on government policies to help them align with their business goals, whilst the 36% who agreed that the IOCs strengthen policy implementation was mainly working in technical fields (engineering) and employees of the IOCs. The remainder considered the influence of the IOCs has a neutral influence on gas flaring policy implementation. Interviewees underscored these findings. One respondent stated:If you tell Shell to stop flaring today, then there is no need to produce oil then. The oil companies know that Nigeria’s government is not ready to stop gas flaring (NGO representative 4).A second respondent noted that:The first factor that shapes the Nigerian MLG structure is the amended 1999 Constitution. The Nigerian governance structure operates within a Type II MLG system, and its structure has created loopholes, overlapping policy domains, fragmentation, and enclaving (“a country within a country”) whereby extractive industries operate in a self-governing manner outside of national regulatory jurisdiction .The fact that these agencies exist does not necessarily mean that they are effective. DPR is controlled at the federal level. Individuals who own oil wells and oil companies mostly are not from the region" .The second factor that shapes MLG is legislative change. The Federal Government has introduced various plans for new laws on gas flaring. At the federal level, all the hydrocarbon legislation .There is hardly any involvement, and it is the lack of involvement that has led us to where we are today, the agitation, the activism in the region to complain about gas flaring to complain about, about injustice .Validating the complex and fragmented Type II MLG system Fig.  with uncWe further asked survey respondents how well they consider policy goals and stakeholder preferences fit together. Again, 45% said that the policy goals and preferences do not fit together, 20% considered that they do fit and 35% were undecided.There have been different governments. This one comes in, changes policies, and even within the same government, you have a somersault in policies. We have not had any strategic push to develop a plan .The third factor shaping MLG and, subsequently, policy coherence and implementation is the administrative structures Figs.  and 2. SThe government concentrates power in Abuja, very far away from where solutions need to be. Until we diversify and see the need for other economic sectors to boost our economy, the people of the Niger Delta region or where the oil is being extracted from will become the sacrificial lamb (NGO representative 4).The Federal Government also exercises strict political control over ministries/institutions and parastatal agencies located in the political centre in Abuja. However, the physical distance (Abuja and the Niger Delta region is approximately 550 km apart) creates a political geography whereby the federal capital territory positions the Niger Delta region as a sacrifice zone to meet other national policy goals de Souza . As an iTable To eliminate the flaring of associated gas by 2008” , NPCC (1.75) and INDC (1.75). However, the highest possible score was 3, indicating that the level of coherence concerning gas flaring in sectoral policies is between limited and partial coherence Table . Expert “End gas flaring and address environmental issues”. The same measure was found in the National Energy Policy  than the environment. From what I see on the ground, economic derivatives or benefits weigh higher in the ranking of government interest than how the people feel. Hence, the Federal Government refused to sign the Petroleum Bill, and they kept shifting the goalpost (NGO representative 3).Despite climate change mitigation being mentioned once and recognised in general statements in the National Gas Policy , there wlicy NEP , which sDespite detailing the policy relevance of climate change and several specific mitigation strategies in the INDC, NPCC and NAP-SLCPs, it is unclear how such strategies can be achieved in practice within the entrenched fossil capitalist economic model in Nigeria. Climate change concepts in policy documentation may, therefore, be used to secure international climate finance funding rather than reflecting a desire for serious economic transformation. For example, the INDC  stated tThis study shows that the main actors involved in Nigeria’s MLG system pertaining to oil and gas governance operate under a fragmented Type II MLG structure with unclear leadership in the various authorities concerned within a tightly controlled and top-down quasi-federal governance regime. The lack of political will to end gas flaring ; the rights of contractors under Production Sharing Contracts (PSC) with the NNPC joint ventures; the exclusion of benefits for some critical stakeholders with the largest investments (the oil companies) from the NGFCP programme; and the huge investments required to develop new infrastructure for flare gas collection and supply Amaza . AlthougExperiences drawn from a global overview of regulatory practices on gas flaring and venting with relevant lessons and conclusion from international experience and best practices on flaring reduction could prove informative Below is the link to the electronic supplementary material.


Objectives: Effective public policy to prevent falls among independent community-dwelling older adults is needed to address this global public health issue. This paper aimed to identify gaps and opportunities for improvement of future policies to increase their likelihood of success.Methods: A systematic scoping review was conducted to identify policies published between 2005–2020. Policy quality was assessed using a novel framework and content criteria adapted from the World Health Organization’s guideline for Developing policies to prevent injuries and violence and the New Zealand Government’s Policy Quality Framework.Results: A total of 107 articles were identified from 14 countries. Content evaluation of 25 policies revealed that only 54% of policies met the WHO criteria, and only 59% of policies met the NZ criteria. Areas for improvement included quantified objectives, prioritised interventions, budget, ministerial approval, and monitoring and evaluation.Conclusion: The findings suggest deficiencies in a substantial number of policies may contribute to a disconnect between policy intent and implementation. A clear and evidence-based model falls prevention policy is warranted to enhance future government efforts to reduce the global burden of falls. Falls among older adults living independently in the community are associated with thousands of fatalities and injuries around the world, and are recognised as a persistent and growing public health issue by the World Health Organization (WHO) , 2 and tEffective government policy is needed to achieve FPC objectives, to inform political decision making for successful implementation of interventions, and to support a systems-approach to falls prevention , 20–22. Policy formulation comprises a process of discrete steps involving problem identification, agenda setting, adoption, implementation and evaluation , 26. ThiWhile the quality of public policies ultimately lies in their successful implementation –40, qualGiven the importance of robust policy analysis in facilitating effective FPC, this paper aims to map and describe international public policy related to FPC and to identify gaps, strengths, weaknesses and opportunities for improvement of future FPC policy to increase the likelihood of their success.A two-phased approach was adopted to address the objectives of the study, described below.This phase used a systematic scoping review methodology –54 to adPublicly available literature on policies related to FPC published between 2005–2020 was identified in a primary search using two sources including 1) bibliographic databases and grey literature repositories, and 2) a desktop search of the websites of the World Health Organization and relevant government and health ministries  and Google. Bibliographic databases included MEDLINE (Ovid Interface); PUBMED (Ovid Interface); EMBASE (Ovid Interface); Cochrane Library (Ovid Interface); Global Health (Ovid Interface); SCOPUS; Web of Science; CINAHL; ProQuest (including ProQuest Policy File Index and PAIS Index); Open Access Theses and Dissertations (OATD). Grey literature repositories included Research Professional, ResearchGate, OpenGrey, GreyLit, InformIT, and SafetyLit platforms. A secondary search was conducted using a snowball method –57 of chThis search adopted a broad and inclusive definition of “public policy” that included policies authored or enacted by systems of government for the population they serve , 27, 58.An inclusive syntax of search terms was used . The indPublished and grey literature was selected using inclusion and exclusion eligibility criteria  and the 4,155 articles were identified  , FollowiRelevant data was extracted from the included 107 articles and imported into a Microsoft Excel (2019) spreadsheet. The chart was iteratively refined as data were extracted, and as secondary search articles were found. Data of interest included broad characteristics of author, year of publication, type of publication, search source, name of policy, country of origin, jurisdiction of policy, type of policy document, policy framing, and evidence of evaluation. These characteristics were collated and descriptive statistics applied.In addition to identifying and mapping policy documents, a content evaluation was undertaken to assess the quality of policies and address the research question “What are the strengths and weaknesses of existing FPC policies?”n = 25) were selected for further content evaluation using our novel framework. Other documents such as legislation and regulations, guidelines and information resources, policy-research and evaluation articles, and those not written in English were excluded. For the national and state policies that had multiple iterations, only the most recent published policy version was included.From the 107 identified articles, a sub-set of FPC public policies, strategic plans, action plans and position statements  worksheets were developed to allow two reviewers (AN and KT) to independently read the selected 25 policy documents and record categorical scores  for the presence or absence of text in the documents that met each of the pre-defined criteria. IRR scores were generated. Discrepancies were discussed with a third reviewer (JO).Quantitative and qualitative analyses of policy content were undertaken. The proportion of policies that met each of the criteria were summed and expressed as percentages. Percentage scores of the two reviewers were averaged and aggregate percentages for the 20 criteria for the evaluated 25 policies were generated. In addition, reviewer observations were thematically assessed. Excel radar charts were generated to illustrate the policy relationships with the criteria.n = 47), followed by Australia (n = 26), and Canada (n = 14). Additional articles were identified from the UK (n = 4), New Zealand (n = 3), China (n = 3), Singapore (n = 1), Switzerland (n = 1), Netherlands (n = 1), European Region (n = 5), and included two global-oriented WHO reports. The majority of articles (72%) were descriptive reviews and research commentaries  and the remaining articles (28%) related to policy evaluations (14 from bibliographic databases and 16 from grey literature).A total of 107 articles were selected for inclusion in the review. Assessment of their broad characteristics revealed that the majority of articles originated from the USA , Canada (n = 6), China (n = 3), European region (n = 3), Netherlands (n = 1), New Zealand (n = 3), Singapore (n = 1), UK  (n = 4), and USA (n = 13). Of these policies, the majority (75%) were national, 19% were from state government jurisdictions, and 6% were multi-national in the European region. Policy authors included national or state government health ministries or agencies, government-funded national advisory organisations  in the USA) or multi-agency consortia  in Canada and the Prevention of Falls Network for Dissemination (ProFouND) and EuroSafe in Europe).The policies included strategic plans and action/implementation plans, position statements, and other policy documents such as legislation, guidelines and information resources for consumers, practitioners and organisations in the community and government grant funding program. Twenty four of the policies (51%) were single-issue policies specifically for falls prevention, whereas the other 23 policies (49%) were multi-issue policies that included falls prevention in their remit. All of the multi-issue policies were from the health sector, and related to injury prevention, healthy ageing, health promotion or public health, and none were from the aged care sector.The results of our content evaluation of the selected 25 FPC policy documents are presented in The findings of the content evaluation for both the WHO and New Zealand criteria are further visually illustrated using Excel radar charts . OverallWe have identified numerous policies from around the world indicating considerable effort by multiple governments to tackle falls-related morbidity and mortality. Our review provides an international policy map that has previously only been commented on for individual countries at one time , 71–73. Falls prevention in the community setting appears to have been a priority in many countries at some point, however, whether it is still a priority is unclear. We found several FPC-related policy iterations in Canada, USA, Scotland and Australia’s state of New South Wales, which may suggest these jurisdictions have had continued political attention on the issue of falls. However, some policies were expired , which may imply that FPC may have lost status as a priority public health issue. Our evidence does not provide enough information to know the trajectory of published policies, so it is difficult to ascertain if the expired policies have ceased or simply lapsed, or been modified to take a different approach. We suggest the latter may be more likely as we found some evidence of embedding falls prevention in more recent multi-issue public health policies . USA and New Zealand had concurrent single-issue falls policies and embedded policies. Stand-alone falls prevention policies are by nature focused and more “niche” public health policies, and could be vulnerable to changing agendas of elected governments , hence eSome of the common deficiencies found in policy content suggest that FPC policies may be too broad in scope, lack important detail and therefore open to misinterpretation, confusion and delay in action , 79. SpeOnly half of falls policies reported inclusion of consumer consultation during development which may imply that older people as citizens and direct beneficiaries of the policies are not always front and centre of ministerial decisions and the preventable human cost of falls is not mitigated by ministers whom have power to enable system change , 87. SimOnly 42% of the policies articulated formal approval by a government minister or ministry, and only 3 policies (12%) identified risks and mitigations of potential positive or negative consequences of the policy. We highlight that attention to funding was shown by only 12% of policies specifying or implying a budget to finance the policy, limiting the allocation of resources . FPC polThese lost opportunities may contribute to a disconnect between policy intent and implementation . It is pMany policies appear to have been designed with little capacity to be evaluated. Only half of the policies we assessed met the content criteria of having a dedicated monitoring and evaluation mechanism to evaluate implementation and effectiveness in achieving objectives in place, and outcome measures were rarely clearly specified. This may suggest that some governments do not have well-developed falls surveillance information systems in place –96 and/oThe strength of this scoping review is that it is the first study to identify and examine the content of a considerable number and variety of international policies governing FPC at national and state jurisdictional levels, hence it fills an important gap in public health policy addressing the health, safety and wellbeing of community-dwelling older people. Our retrospective content evaluation of FPC reveal how intertwined policy content is, and where there is scope to enhance the comprehensiveness of policy documents in ways that are likely to increase the impact of these policies. Future use of evidence-based policy development checklists and criteria is encouraged, particularly to strengthen policies during development and to review them when in evaluation stage.A limitation of this scoping review is its reliance on published government policy documents in the English language, hence our findings may not be generalisable to all countries, particularly those low to middle income countries. Our search strategy made considerable effort to comprehensively and systematically identify relevant policy documents with at least an English-language abstract, and Google Translator was used for policies with non-English full text, such as policies for China and the Netherlands. Some governments may not have published their policies, or may have outsourced them to non-government organisations, so they may have been missed by the search strategy we employed. To the best of our knowledge, the identified policy documents from a large range of countries is the most comprehensive collection to date and will provide a good starting point for further research.This review excluded government policy authored by local/provincial government jurisdictions and for falls prevention directed at non-community setting older people, i.e., those in primary/acute/hospital settings and residential aged care/nursing home settings, so it is possible that our quality assessment of this group of policies might reveal different results. The policies reviewed in this study were high-level national and state jurisdictional documents and due to the nature of their content may have lacked the details we were assessing, hence affecting the results. Although the content criteria were adapted from internationally recommended policy development guidelines they were limited and open to interpretation and our low-moderate inter-rater reliability (IRR) scores reflected the reviewers’ differing levels of knowledge and familiarity with the topics of falls prevention, public policy, as well as the guidelines. While we assessed whether recommended criteria were stated in the policy documents, it is also important to acknowledge that published policy documents might not reflect the totality of the policy process .Finally, we note that although this review focused on good quality policy content, the quality of policy is ultimately determined by its effective implementation and impact , 41, 101This scoping review has shown, encouragingly, that governments around the world are actively pursuing the prevention of falls in community settings by developing a variety of national and state-level public policies. Benchmarking policy content using broad internationally recommended criteria for policy development revealed several content deficiencies in FPC policies which may contribute to a disconnect between policy intent and implementation. While application of these criteria may assist policy makers to improve future falls prevention policies, there is a need for a more focused, clear and evidence-based model policy for falls prevention among community-dwelling older people to enhance future government efforts.


While social connectedness and engagement are key aspects of well-being over the life course, sexual and gender minority (SGM) older adults are found to experience elevated risks of social isolation and limited social connectivity, which have been linked to loneliness. Social isolation and loneliness have been significant health concerns, increasing risk of premature death, cognitive decline, and poor health and well-being, yet SGM older adults are resilient populations. To address the strengths and challenges found in evidence-based intervention development, it is critical to understand how they have managed to build and maintain their social resources and reduce social isolation and loneliness. To this end, this symposium will analyze and incorporate the results using data from both Aging with Pride: National Health, Aging and Sexuality/Gender Study (NHAS), the first longitudinal study of SGM older adults in the United States and Innovations in Empowerment and Action (IDEA) Café, the first clinical trial pilot study addressing social isolation among SGM older adults living with dementia. Dr. Kim and colleagues with present a factor analysis suggesting a multi-dimensional construct of social resources unique to SGM older adults. Dr. Fredriksen Goldsen and colleagues will identify sexual and gender diverse older adults at heightened risk of loneliness and examine risk and protective factors. Dr. Emlet and colleagues will present findings from a pilot study, IDEA Café, designed to enhance social connectedness, physical functioning, and quality of life among socially isolated SGM older adults with cognitive impairment.