The spatialities of migrant entrepreneurship have changed dynamically in recent decades. Movements and exchanges transcend national borders more than ever, and transnational migrant entrepreneurship has become a burgeoning field of research. Yet, knowledge is dispersed across disciplines, and an understanding of contemporary spatialities is limited. We review 155 articles published in English, French, German, and Spanish since 2009, thereby providing an overview of existing knowledge on transnational migrant entrepreneurship and suggesting avenues for future research. We identify five current topical areas of research: (1) the business advantages of transnational migrant entrepreneurship, (2) the determinants of becoming a transnational migrant entrepreneur, (3) the transnational networks of migrants, (4) the economic impacts of transnational migrant entrepreneurship on home and host countries, and (5) whether local environments enable or deter entrepreneurial success. Building on our synthesis of the most recent literature, we propose three crucial dimensions which have been under-researched in past and current work, and which address the diversity of geographical locations, spatial connections, and spatial mobilities involved in transnational migrant entrepreneurship. Moreover, we put forward a set of questions for future research which will advance a comprehension of unequal opportunities among transnational migrant entrepreneurs. Rates of business creation and self-employment in migrant communities appear to be higher than the national averages in many countries and play an important role in local economies  the business advantages of transnational migrant entrepreneurship, (2) the determinants of becoming a transnational migrant entrepreneur, (3) the transnational networks of migrants, (4) the economic impacts of transnational migrant entrepreneurship on home and host countries, and (5) whether local environments enable or deter entrepreneurial success. The fifth section discusses future avenues of research, and further develops our proposed dimensions to examine contemporary spatialities of migrant entrepreneurship. The conclusions set the findings in a wider context.2The term “transnational entrepreneur” was first popularised by The multiplicity of places, connections, and mobilities within which transnational business activities occur lead us to rethink the notion of spatiality. In transnational settings the spatial ontology needs to shift “from a static and circumscribed characterization of migrant economies to a more dynamic and flexible one” , 2017.locations and progressively develop meaningful social, economic, political, and symbolic connections by conducting and maintaining diverse mobilities across borders. In this article we attempt to demonstrate how a focus on these spatialities can advance our understanding of transnational migrant entrepreneurship. Thus, we propose to adopt a processual and relational understanding of space, with a focus on the social interactions that (re)produce space over time, as well as the power hierarchies that shape spatial settings and individuals’ options  to include the most recent literature.We selected journal articles on transnational migrant entrepreneurship based on the definition presented in the previous section. To begin with, we researched academic databases and journals using the keywords “transnational”, “migrant”, “entrepreneurship”, and synonyms of these  in English, French, German, and Spanish (see online appendix). We then checked each article to ensure that they actually covered on the topic, which led us to exclude several articles because the transnational dimension of migrant entrepreneurship was not explicitly mentioned. In a third step, we manually reviewed the bibliographies of the selected articles to identify references that the automatic search had missed. We repeated this process with newly selected articles until we could find no further salient references. These steps led us to identify 155 relevant articles (listed in the online appendix) published between 2009 and 2019, and originating from various disciplines . Despite the inclusion of non-anglophone articles, only seven are in French, German, or Spanish, thus highlighting the predominance of English-language publications in the field. Nevertheless, we believe that this corpus allows us to develop an extensive overview of the state of the art. In addition to our main corpus, we also considered a special issue of the We reviewed each publication to identify key definitions of transnational migrant entrepreneurship, research questions, theoretical lenses, regional contexts, methods, results, and research gaps. Our team collaboratively discussed and synthesised this information in an iterative process. We first developed an overview of our knowledge about transnational migrant entrepreneurship. We then applied a content analysis methodology , 2014 to4This section presents an overview of five major topical areas of research—including results and gaps—on transnational migrant entrepreneurship since 2009, highlighting the strengths and limitations of current research: the first focuses on identifying the specific advantages of transnational migrant entrepreneurship and aims to empirically test the extent to which migration experiences can, under certain circumstances, constitute an asset for transnational business-related activities; the second attempts to understand the reasons, determinants, and motivations that lead migrants to engage in transnational businesses; the third analyses the composition of migrants’ personal networks and their potential utility in transnational business-related activities; the fourth assesses the economic impact of transnational entrepreneurs on the places where they conduct business; and finally, the fifth examines the role of local environments in supporting or deterring transnational migrant entrepreneurship.4.1Inspired by The positive conceptualisation of transnational migrant entrepreneurship builds on the notion of “dual embeddedness”, which posits that migrant entrepreneurs have a competitive advantage , 2014, sWhile the literature often implies that dual embeddedness automatically leads to economic success and other promising outcomes, we need to remain sceptical as long as this process is not explained. In practice, authors who stress the added economic value of transnational entrepreneurs tend to select case studies involving highly skilled people in the technology, consulting, and educational sectors , 2018. I4.2Many authors explore the reasons and necessary conditions that lead some migrants to engage in transnational business activities , 2012, sSocial scientists tend to focus more on the determinants of social structure, unpacking the social position of transnational migrant entrepreneurship regarding variables such as education, gender, ethnicity, length of stay, and financial security , 2017. UHowever, a comprehensive examination of the role of spatial mobility in transnational business creation is still lacking. Overall, scholars engage with different determinants of cross-border entrepreneurial activities but pay insufficient attention to the fact that migrants have unequal opportunities to travel and move goods, services, and ideas into transnational spaces. The processes of spatial mobility involved in transnational migrant entrepreneurship should not be taken for granted. Moreover, questions concerning the relationships between (im)mobility, inequality, and space are rarely raised. Examining the interplay between geographical location and social position would enable scholars to reveal the complex spatial nature of the mechanisms that shape transnational migrant entrepreneurship. This focus would cast new light on how entrepreneurs’ options are structured by concrete locations and their connections, and how spatially situated processes of mobility and immobility participate in the (re)production of global social inequalities.4.3Authors in all disciplines have developed a growing interest in how transnational ties and networks impact the performance of migrant entrepreneurs, with particular interest in social contacts between migrants and their countries of origin , diasporic networks , 2019, aFollowing This area of research points towards the interdependence of local and transnational forms of belonging and the relationship between local and transnational socioeconomic integration. We propose that a spatial perspective, which analyses how distant places become connected through the geographically situated activities of entrepreneurs, and emphasises the concrete locations, mobilities, and processes that bring these connections to life, would further advance our understanding of the role of networks in transnational migrant entrepreneurship. It would also enable a closer analysis of the power dynamics that shape the relationships between transnational migrant entrepreneurs and network members. Many studies highlight the importance of private and family networks to transnational entrepreneurs’ business development  idea of “brain circulation”, which describes the positive impacts of transnational entrepreneurial activities on the economies of both home and destination countries . However, authors such as In economic geography and related disciplines, many scholars address the question of how individual migrant entrepreneurs contribute to the development of business clusters and entrepreneurial ecosystems at a local level, asking to what extent and under which conditions they can generate positive dynamics of economic development . Overall, how spatial dependencies are created through the practices of transnational entrepreneurs across the globe and the impact of historical hierarchies between the places involved are topics rarely evoked. Paying closer attention to “the inequality of power and forms of economic domination that characterises the relations between rich and poor countries” , 2002 an4.5Using economic or political science approaches, and inspired by Everett Lee’s theory of migration (1966), most authors distinguish between location-related push and pull factors that may influence a migrant’s engagement in transnational entrepreneurship . Pull factors include positive location-specific elements such as supportive policies, favourable market conditions, or personal networks, whereas push factors refer to obstacles and constraints such as economic crises, competitive pressures, or unemployment. This distinction highlights the fact that transnational entrepreneurship can be a way to balance negative conditions in one location with positive conditions in another. Brzozowski et al. (2014) show, for example, that the home country’s institutional and socio-economic characteristics  play a crucial role in shaping the performance of transnational immigrants’ business activities in the Italian information and communications technology (ICT) sector.“Mixed embeddedness” is another major theoretical framework used to discuss the impact of locations on transnational migrant entrepreneurship. Proposed by Using geographical approaches, other authors examine the territories in which transnational entrepreneurs operate , 2015. SBy emphasising the role of agency and geographical position, these authors propose a powerful research lens through which to examine the experiences and practices of transnational migrant entrepreneurs. However, none of the current conceptual frameworks adequately address the complexity of how different locations provide different types of opportunities for transnational migrant entrepreneurs, and how they are able (or unable) to actively take advantage of such opportunities over space and time.5Our literature review reveals a dynamic field of cross-disciplinary transnational migrant entrepreneurship research. Currently, there appears to be a genuine attempt to shift the focus from a single-location and deficit-based perspective to an opportunity-oriented and transnational approach. This literature addresses important topics for geographers and other scholars interested in spatial dynamics. Yet, geographic contributions on transnational migrant entrepreneurship remain scarce, as seen in Figure 1. the dynamic spatialities of transnational migrant entrepreneurship and the power relations that shape opportunities for different groups of entrepreneurs. We will now discuss these gaps in more detail.Besides the willingness to move beyond simplistic and static conceptualisations of space in the field, there is much potential to develop a more spatially informed understanding of transnational migrant entrepreneurship, which would benefit geography research as well as other disciplines by enabling a greater focus onlocations selected by scholars for empirical work on transnational migrant entrepreneurship is, in most cases, limited to countries of the Global North. This results in most studies focusing on the destination countries of transnational entrepreneurs with migratory trajectories from the Global South to the North. Figure 2 shows that almost 70 % of the articles in our study corpus focus on migrants who move from low-income countries in Asia, Africa, and South America to high-income countries in Europe or North America. This reproduces traditional representations of transnational migrant entrepreneurship as an exclusively South-to-North trajectory and downplays the diversity of current mobilities including South-to-South trajectories. Some scholars expand this view by examining migrants who move from high-income countries to low-income countries , transnational migrant entrepreneurship today is characterised by “multifocality” rather than “bifocality”. By disregarding the diversity of existing connections, authors reproduce a simplistic view of migration that does not correspond to contemporary transnationalism characterised by multisitedness and resulting from onward movements  accurately highlight that most typologies of transnational migrant entrepreneurship are based on motivations and social status but ignore dimensions of inequality such as access to mobility, space, and territory. Opportunities for transnational migrant entrepreneurs to mobilise skills are not context-neutral but depend on how specific markers of social difference  are valued in the locations where they develop business activities. Also, inequalities of power between locations in rich and poor countries, and their impact on transnational migrant entrepreneurship, need further examination. Different countries implement different policies and agendas to attract, promote or discourage transnational migrant entrepreneurship production of social inequalities?How do entrepreneurs use different global locations for business activities and why? How do they transform the locations and shape the entrepreneurial ecosystems in which they operate?Dimension 2: Spatial connectionsWhat kinds of cross-border connections are created, developed, and maintained by transnational migrant entrepreneurs? Between which places and social groups do they build these connections?What connections already exist between spaces and social groups ? How do these relations shape transnational businesses activities?How do transnational entrepreneurs use and transform existing relations, and create new ones? What are the socioeconomic implications of the transnational connections established by transnational entrepreneurs?Dimension 3: Spatial mobilitiesWhat kinds of spatial mobilities are involved in transnational migrant entrepreneurship? How important is spatial mobility for transnational businesses? For whom is it important, and why?Which spatial mobilities are possible for whom, under what conditions, and why? How do transnational migrant entrepreneurs’ capacities to move material and immaterial entities across time and space vary? How do these capacities evolve, and why?How do entrepreneurs’ strategies counteract undesired mobilities or other constraints?To go one step further, we propose some examples of questions for each of the three dimensions put forth in our analysis  to examine contemporary spatialities of migrant entrepreneurship . These questions arise from our critical literature review and build on the main shortcomings of current research, which we identified.6In this article we critically reviewed the literature on transnational migrant entrepreneurship published since 2009. We observed an increasing interest in this topic across a broad range of disciplines. Scholars have intensely studied the business advantages, characteristics, and networks of transnational migrant entrepreneurs as well as their impacts on specific sites (and vice versa). Yet, we observe that the new spatialities of transnational migrant entrepreneurship have not yet received adequate scholarly attention.geographicallocations, spatial connections, and spatial mobilities involved in transnational migrant entrepreneurship. We also advanced the following reflections: first, we argued that a processual and relational approach is necessary to understand how transnational entrepreneurial spaces are dynamically created and maintained through the everyday practices of individuals. Although geographers have so far marginally contributed to the field of transnational migrant entrepreneurship, the “relational turn” in economic geography (To address this gap, we proposed three crucial dimensions for future research which have been under-researched in past and current work, and which address the diversity of eography , 2003 haIn terms of future research, the discussion on how social mobility relates to transnational migrant entrepreneurship is immature but highly promising. Highlighting the role of locations, connections, and mobilities is important, not only to grasp the agency and creative potential of migrants but also to recognise that opportunities and constraints are unequally distributed across social groups and places. We need to advance our understanding of unequal spatialities in transnational migrant entrepreneurship and identify the mechanisms that enable individual and family businesses to move forward economically and socially. This is important not only for research, but also in the development of more inclusive places for migrant entrepreneurs, which could lead to better opportunities for success.Click here for additional data file.


The Ovarian Cancer Epidemiology, Healthcare Access and Disparities study aims to characterize healthcare access (HCA) across five specific dimensions—Availability, Affordability, Accessibility, Accommodation and Acceptability—among Black, Hispanic and White patients with ovarian cancer (OC) to evaluate the impact of HCA on quality of treatment, supportive care and survival, and explore biological mechanisms that may contribute to OC disparities. Currently, there are no validated instruments for empirically measuring all HCA dimensions. To characterize HCA among diverse cancer survivors, there is a need to develop reliable, content-relevant, and comprehensive measures that have cross-cultural applicability. Thus, the goal of the present study was to: (1) develop a comprehensive survey instrument for HCA, guided by the Penchansky and Thomas framework; and (2) evaluate the factor structure, reliability, and psychometric properties of two domains (Accommodation and Acceptability) that are only estimable from patient-reported survey data.Methods: This study reports data from three general methodological approaches: (1) concept elicitation using focus groups with 32 cancer survivors  to inform the development of new HCA survey items; (2) refining the new survey items using cognitive interviews with seven ovarian cancer survivors  and pilot testing with 54 ovarian cancer survivors ; and (3) psychometric evaluation of the Acceptability and Accommodation items among 333 ovarian cancer survivors . Multiple model structures were assessed for each HCA dimension using confirmatory factor analysis methods, and composite reliability was estimated for selected models. Results: In focus group discussions, cancer survivors expressed challenges navigating cancer treatment across multiple HCA domains, with the Acceptability domain  being the most salient across all racial groups. Lack of empathy, compassion, and poor communication overshadowed positive aspects of providers’ specialty, experience, or reputation. Cognitive interviews and pilot testing of new HCA survey items helped to clarify the language of specific items and refine the recruitment and consent process for implementation of the survey. In psychometric evaluation, the Accommodation domain (convenience and organization of services) was best accounted for by a two-factor structure: satisfaction with care and access to support services (comparative fit index (CFI) = 0.99). For the Acceptability domain, all fit indices supported the retention of a five-factor higher-order model (CFI = 0.96). Composite reliability estimates were >0.80 for all latent factors in the two-factor Accommodation model and the higher-order Acceptability model. Conclusions: Empirical evidence supports the utility of standardized measures of Accommodation and Acceptability using self-reported survey items, which will contribute to the better characterization of HCA dimensions among diverse cancer survivors.There are no validated instruments for measuring healthcare access (HCA). This study aimed to develop a cohesive HCA instrument for cancer survivors and evaluate the factor structure, reliability, and psychometric properties of two HCA domains—Acceptability and Accommodation—that require patient-reported survey data.  Several proposed theoretical frameworks have defined the complex nature of healthcare access (HCA) ,2,3, altDespite extensive study, there are currently no validated instruments for empirically measuring all HCA dimensions. While certain dimensions  have established measures ,6,7, othThus, the goal of the present study was to: (1) develop a comprehensive survey instrument for HCA, guided by the Penchansky and Thomas framework; and (2) evaluate the factor structure, reliability, and psychometric properties of two domains (Accommodation and Acceptability) that are only estimable from patient-reported survey data.Participants and Settings: A total of 32  cancer survivors were invited to participate in focus groups to understand their treatment journey and experience accessing care. We partnered with cancer support group organizations for the recruitment of women with a history of any cancer. An introductory letter was sent to each support group organization explaining the study rationale, methodology and requirements and requesting permission to recruit support group members for the study. Interested participants contacted the study team to sign up for focus group sessions. Due to COVID-19 restrictions, focus group discussions were conducted virtually in groups of three to six cancer survivors. Each participant was compensated $25 for their time and effort.Procedures and Data Collection: Focus group sessions were moderated by an experienced facilitator and at least one note-taker, using a structured topic guide  informed the development of new survey items to address gaps in existing HCA measures. Cognitive interviews with seven ovarian cancer survivors recruited from the Duke Cancer Institute  were then conducted via telephone. Participants provided feedback on each item one at a time, and verbal probing was used to determine the ease of understanding of survey instructions, item wording, and content. Feedback was also solicited to assess the frequency of request for clarification and potential time burden. Cognitive interviews were conducted in two rounds; feedback from the first round was used to revise the survey measures before the second round. Results from both rounds of interviews were used to refine the survey for pilot testing. Participants were compensated with a $25 gift card for their time and effort.Pilot Testing: Pilot testing of the entire survey was conducted among 54 ovarian cancer survivors  recruited from the Duke Cancer Institute and the University of Alabama at Birmingham Gynecology Oncology clinics. Surveys were administered by telephone, electronically, or paper versions. Participants were compensated with a $25 gift card for their time and effort. This study was approved by Duke University and the participating hospitals’ Institutional Review Boards (IRB) (Pro00101872). The Duke University IRB served as a reviewing IRB for the University of Alabama at Birmingham study protocol under reliance agreement. All participants included provided informed consent.Participants: Psychometric evaluation of the Accommodation and Acceptability domains was conducted using data from the main ORCHiD study. ORCHiD is a population-based study of ovarian cancer survivors ages 20–75 years at diagnosis recruited from cancer registries in multiple US states . Survivors were recruited into the study approximately 12 months post-diagnosis and invited to complete a survey that used multimodal data collection  of demographic characteristics, socioeconomic status, HCA domains, primary cancer treatment, and post-treatment outcomes. Details regarding study methodology and recruitment have been previously described [escribed . The curStudy Measures: Self-reported items associated with Accommodation included measures related to the following topics: seeing the same doctor repeatedly, convenience of appointment, satisfaction with care and access to support services. The items were newly developed or derived from the Ambulatory Care Experiences Survey (ACES)  or the MPsychometric Analysis: Frequencies and percentages were calculated for binary and categorical variables, and medians and interquartile ranges were calculated for continuous variables. We used confirmatory factor analysis (CFA) for each HCA dimension to determine the factor structure. CFA was used because theory and previous research determined the factor structure of each scale [WLSMV) estimator that provides standard errors and fit indices that are robust to the order-categorical nature of the items and can handle missing data [ch scale . For theing data ,17. To eing data , the Tucing data , and theing data . For eacing data . Composiing data . CFA wasA total of 32 cancer survivors participated in seven focus groups; 63% of participants were Black, 19% were White and 18% were Hispanic/Latinx; all Hispanic survivors participated in the Spanish-speaking focus group. Almost one-third of participants (29%) were diagnosed with cancer within the last five years, and 19% were still in active treatment. Cohort descriptive statistics are presented in Acceptability was the most frequently applied code from the HCA framework, comprising more than 40% of all mentions. Survivors extensively discussed how Acceptability impacted their cancer treatment journey, including the importance of bedside manner, patient–provider communication, and comfort with the provider’s reputation or referral from a trusted source. Approximately 75% of all mentions of Acceptability were positive, describing providers with a gentle tone or caring demeanor, those that provided physical touch as a means of comfort, and those that showed empathy, compassion, and respect for their religious beliefs. When issues related to Acceptability were more critical of members of their care team, these comments tended to focus on issues regarding how a diagnosis was delivered, inadequate personnel bedside manner, and poor provider–patient communication. Participants did not emphasize a provider’s race, gender, or qualifications, and instead, they prioritized the quality of the patient–provider interaction as critical to feeling cared for and as a measure of high-quality care.The second most frequently mentioned dimension was Accommodation, comprising 20% of all mentions. Several cancer survivors described travel over long distances to cancer treatment facilities and the importance of being able to schedule all appointments, treatment, and bloodwork on the same day. Spanish-speaking survivors noted that translation services and/or bilingual providers were key factors in the quality of their treatment journey, acknowledging the significance of a language barrier.Availability was the third most described HCA domain, comprising 14% of all mentions. Ovarian cancer survivors specifically described the availability of gynecologic oncologists as most important for quality treatment, and geographical barriers to gynecologic oncology consultations were identified as a key challenge for this group of survivors.Although mentioned less frequently, for 14% of all mentions, Affordability was an important consideration of HCA. While a majority of the survivors in the focus groups had insurance that covered most of their medical costs, several participants reported anxieties and worry regarding the uncertainties about insurance coverage and the adverse impact of high cancer treatment cost on their family’s finances.Accessibility was described as a challenge to HCA, with 11% of mentions, especially among survivors in rural areas. Many focus group participants lived near their treatment facility and did not have a significant amount of travel time. However, survivors in rural areas described substantial challenges with finding reliable transportation to providers, and those who relied on county-provided transportation options experienced longer travel times as they had to wait until all fellow travelers completed their visits before returning home.Two key emergent codes were identified outside of the a priori specified HCA domains, which were categorized as supports/facilitators and challenges/barriers to treatment. Typically, these represented individual characteristics or access to important resources outside of the healthcare setting that may be modifiable and interact with other dimensions of access. Having access to a strong support system (59% of facilitator mentions) supported recovery and positive experiences during one’s treatment journey. Support derived from participation in cancer-related support groups was mentioned most frequently, with many participants noting the importance of connecting with other women with similar experiences. Participants also noted the importance of having family members for support during their treatment journey, including for emotional and tangible support . The next frequently mentioned code was faith (28% of facilitator mentions)—highlighting the importance of faith and belief in helping survivors persevere along their treatment journey.Focus group participants also noted barriers that negatively impacted recovery experiences. Fear was the most frequently mentioned (46% of barrier mentions), with participants reporting initial fear in seeking diagnosis and care, fear upon learning of a new diagnosis, and the primacy of fear in outdated cancer narratives. Fear was a salient theme for Hispanic participants who described a fear of having personal or familial immigration status revealed to authorities in healthcare settings and reluctance to share personal information on medical forms “even though they are residents.” Mental and emotional awareness was the next most frequently mentioned by survivors (18% of barrier mentions). Survivors noted the impact of diagnosis on their mental health and cognitive abilities. Some mentioned these effects in terms of shock or being in a fog, likely as part of a trauma response to a new diagnosis. Inadequate social support often exacerbated the fear (15% of barrier mentions). Role conflict  also emerged as a key barrier (9% of barrier mentions).Cognitive Interviews: Survivors participating in cognitive interviews generally reported that the survey was easy to understand. Feedback was incorporated into specific survey items, including defining certain terminology  and being more specific in the wording of items .Pilot Testing: After two rounds of cognitive interviews, the survey  was edited for length, clarity, and content, and then pilot tested. The purpose of the pilot testing was to refine recruitment, consent, and data collection processes for the implementation of the survey in the main study population. Feedback was incorporated from interviewers and pilot testing participants to improve recruitment efficiency .A total of 333 women were included in psychometric analysis of Accommodation and Acceptability HCA dimensions. The median age at diagnosis was 60 years (IQR 46–65 years); 81% were non-Hispanic White, 13% were Black/African American, and the remainder of the cohort were of other races, including Asian, Native Hawaiian or Pacific Islander, and Native American or Alaska Native . Missingable to see the same doctor at most appointments did not significantly load on its hypothesized factor alongside the item measuring convenience of scheduling appointments. As the item convenience of scheduling appointments is a similar concept to the latent construct Satisfaction with Care, we hypothesized that the convenience item might better fit alongside those measures, and the measure of seeing the same doctor might instead fit better with measures of Availability or as a stand-alone measure. Therefore, we tested a two-factor model of Accommodation which dropped the item seeing the same doctor and shifted the convenience of scheduling appointments item to load on Satisfaction with Care. This alternative model still showed good fit: CFI = 0.99, RMSEA = 0.03 (r = 0.44), indicating that they measure distinct sub-dimensions of Accommodation. Thus, factor scores were derived for Satisfaction with Care and Access to Support Services based on the two-factor model. The alternative, one-factor model for the Accommodation items had poor fit as measured by the model fit indices compared to the other tested model structures (CFI = 0.78 and RMSEA = 0.10).For the Accommodation dimension, the proposed three-factor model fit statistics indicated a satisfactory fit: CFI = 0.98, RMSEA = 0.03 ; howeverA = 0.03 . The facSharing Information and Cultural Competence factors). Consequently, the higher-order model was retained  and factor scores for Acceptability and its component item groupings were produced based on the multidimensional model. Standardized factor loadings linking each variable to their respective factors are presented in For the Acceptability dimension, model fit indices supported the retention of either: the five-factor first-order model or the five-factor higher-order model . Fit staAccess to support services, it is still acceptable given the high composite reliability [Satisfaction with Care and Access to Support Services) and the factor scores for the higher order Acceptability dimension and its subfactors . The moderate correlations indicate that there may be two distinct sub-dimensions of Accommodation (correlation = 0.44), whereas higher correlations for all sub-dimensions of Acceptability, except the trust dimension, indicate the sub-dimensions are more likely part of same latent construct of Acceptability. Considering the low/moderate correlations observed in the Accommodation dimension, this construct will be analyzed as two sub-dimensions (Satisfaction with Care and Access to Support Services), and Acceptability will be measured using an overall Acceptability score in addition to utilizing factor scores for the individual sub-dimensions of Acceptability.The composite reliability estimates (Ω) were ≥0.80 for the Accommodation sub-dimensions and ≥0.89 for the Acceptability dimension and all sub-dimensions . The higiability . SupplemUnderstanding the role of multiple dimensions of HCA on cancer outcomes may help inform targeted strategies to mitigate racial disparities; however, the lack of standardized and validated measurement instruments has inhibited rigorous research in this area. It is especially critical to measure distinct HCA dimensions that may independently or jointly impact the quality of cancer care and subsequently, survival outcomes. To our knowledge, this is the first study to report the psychometric properties of the Accommodation and Acceptability HCA dimensions, and to center the experience of Black and Hispanic survivors in developing a cohesive HCA instrument. Results from the concept elicitation interviews highlight that all five theoretical HCA dimensions are important in cancer survivors’ treatment journey, although the Acceptability domain  was the most salient for cancer survivors. When Acceptability was high, survivors reported being more trusting and comfortable sharing concerns and fears related to their diagnosis, prognosis, and other concerns related to their physical, mental, and emotional health. These findings indicate that the Acceptability dimension can be utilized as a specific and quantifiable measure of patient-centered, high-quality care.There were racial differences observed in the importance ascribed to certain HCA dimensions by cancer survivors in focus groups. Black and Hispanic survivors were more likely to describe significant challenges with Acceptability, which was consistent with prior studies that have documented that racial minorities are more likely to report a lack of trust in physicians ,25,26, hNotably, these data were collected during the COVID-19 pandemic—a global event that has significantly influenced all aspects of daily life, including access to and receipt of timely healthcare. Changes to cancer care in the U.S. included discontinuing cancer screenings, delaying cancer surgeries, and reducing or delaying treatment to reduce the risk of COVID-19 infection for cancer populations who may be immunocompromised ,43,44. EThe Acceptability and Accommodation domains demonstrated strong psychometric properties, with component patterns having moderate to high item loadings, and importantly, meeting or exceeding established cut points for reliability. The final model structures also demonstrated good model fit, meeting or exceeding values considered as evidence of good fit. The internal reliability estimates for each of the sub-dimensions also indicate that the items within each dimension relate to each other and support the interpretation that the item sets measure similar underlying constructs, and high composite reliability and AVE for both domains indicate the internal consistency of scale items. Although AVE was low for ‘Access to support services’, it is still acceptable given the high composite reliability, as explained by Fornell and Larcker . AdditioSeveral limitations should be noted. Survivors in the focus groups had varying treatment experiences, including differences in cancer stage and time since diagnosis. While this provided us with a range of experiences , we were unable to determine how time since treatment impacted survivors’ perceptions of HCA. Furthermore, survivors who completed treatment many years prior to the focus group may have been vulnerable to recall bias. However, one of the questions assessed by facilitators was “How well do you remember your cancer treatment experience,” and participants noted that their cancer treatment was such a life-altering experience, they were able to remember even the most trivial details. Additionally, as a means of protecting privacy, we did not assign statements to specific individuals, so we do not have quantifiable data on HCA mentions by race. The limitations of the psychometric evaluation include its inclusion of only a few U.S. states and ovarian cancer survivors, limiting the generalizability of results to the broader U.S., to females with other cancer types, and to male cancer survivors. We did not test for other types of validity, and hence, additional testing of the measures is needed to provide more evidence regarding construct validity. However, with an acceptable factor structure and reliability, these multi-item scales are promising instruments to be used in future studies that evaluate the Acceptability and Accommodation dimensions of HCA.In conclusion, cancer survivors’ perceptions of HCA largely aligned with the framework proposed by Penchansky and Thomas, indicating that this framework captures important aspects of access in this population. Psychometric evaluation supports standardized measures of Accommodation and Acceptability using self-reported survey items, which will contribute to the better characterization of HCA dimensions among diverse cancer survivors. Improved rigor in studies examining healthcare access will provide a better understanding of care delivery patterns and disparities in care and will help guide interventions to provide equitable access to timely and quality cancer care.


High levels of occupational physical activity associate to increased risk of cardiovascular disease. However, knowledge regarding the acute effects of different components of the occupational physical activity, such as lifting, on risk factors for cardiovascular disease remains uninvestigated during every day work. Thus, the aim was to investigate the acute effects from exposure to occupational physical activity with and without lifting on heart rate, physical activity and ambulatory blood pressure.A randomized cross-over study among 18 farming workers in Denmark, all working in the stables of pig- producing farms. Workday measurements of heart rate (Actiheart), physical activity (Axivity placed at front thigh and upper back) and ambulatory blood pressure  were collected at a workday with and a workday without occupational lifting. The wash out period between the measurements was 48 hours. Data were processed in the Acti4 software.During workdays with lifting compared to workdays without lifting we observed higher intensity of occupational physical activity , number of steps/workday , standing/walking activities , as well as higher heart rate  and higher ambulatory blood pressures, both systolic  and diastolic . The average burden of the occupational lifting were 2,425 kg/workday and amount of lifts/workday were 239 lifts.This pilot project indicated that occupational lifting are adding strenuousness on top of the general occupational physical activity, and influence blood pressure and heart rate at clinically relevant magnitudes. Disentangling the potential relations between one component of occupational physical activity, such as lifting, and risk for cardiovascular disease is key in the development of initiatives for specific prevention, exposure recommendations and vocational rehabilitation.


Dear Editor,Although scalp involvement is common in patients with pemphigus vulgaris (PV) and pemphigus foliaceus (PF), vegetative scalp lesions have rarely been reported in PV patients.Among a total of 524 PV and PF patients followed up at the bullous disease outpatient clinic, only three (0.6%) developed recalcitrant vegetative and nodular lesions on the scalp Figs  . The deThe first and second patients had a diagnosis of PV presenting with mucocutaneous involvement including scalp . Four yeScalp involvement is reported in up to 60% of pemphigus patients in various series.We think that these scalp lesions which were observed during the disease course may have occurred as a result of a hypertrophic healing process of the recalcitrant pemphigus lesions. Recently, the development of keratotic verrucous plaques on the trunk was reported in a patient with long-lasting PF which was resistant to various therapies, similar to the PV patients.Interestingly, the clinical appearance of the scalp lesions in all three patients were vegetative plaques and nodular lesions mainly localized on the right vertex. The other possible mechanism for the scalp lesions in the present study’s patients may be explained by the “immunocompromised district” concept, proposed by Ruocco et al., which denotes a regional immune dysregulation characterized by either reduction or induction of immunity.In conclusion, the present PV and PF patients had scalp involvement with vegetative plaques and nodular lesions on the vertex, representing a distinct and rare clinical manifestation.None declared.Rifkiye Kucukoglu: Critical literature review; data collection, analysis and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; manuscript critical review; preparation and writing of the manuscript; study conception and planning.Tugba Atci: Critical literature review; data collection, analysis and interpretation; effective participation in research orientation; manuscript critical review; preparation and writing of the manuscript; study conception and planning.Goncagul Babuna-Kobaner: Critical literature review; data collection, analysis and interpretation; effective participation in research orientation; manuscript critical review; preparation and writing of the manuscript; study conception and planning.Nesimi Buyukbabani: Data collection, analysis and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; manuscript critical review; preparation and writing of the manuscript; study conception and planning.None declared.


As of 2022, only 51% of active eligible state employees in Missouri have been screened for colorectal cancer and 67% for breast cancer, despite having state-sponsored health insurance. In fall 2020, the Missouri Department of Health and Senior Services Comprehensive Cancer Program partnered with the Missouri Cancer Consortium to create a strategy to improve cancer screening rates among state employees. The project was designed to include 3 phases: 1) a colorectal cancer education phase, 2) an expanded education phase that included additional cancers, and 3) a proposed intervention phase that will include screening events. In the first phase, in 2020, colorectal cancer educational materials were sent to all state employees. In the second phase, in 2022, educational resources were expanded to include additional cancers and screening tools. In both initiatives, educational materials and information on current screening recommendations were distributed to approximately 40,000 state employees. A database of screening rates was developed to monitor screening rates and challenge state employees to complete screenings. Evidence-informed interventions were implemented with a focus on health equity. We used a regional approach to identify geographic areas with the greatest need. These efforts will support the next phase of the project, which involves planning breast and colorectal cancer screening events. Policy changes will be encouraged to remove systems-level barriers that discourage employees from being screened for cancer. Recommended tools and strategies can be adopted by similar organizations with complex, multitier employee structures. Missouri state employees have lower rates of cancer screening compared with statewide averages, despite having access to state-sponsored health insurance.Our screening improvement program used a strength-based approach to identify existing resources and leverage partnerships to promote collaboration among internal and external partners. We implemented a health education campaign that used print materials, email, videos, and digital media and developed a sustainable and scalable evidence-informed health communications campaign aimed at increasing cancer screening rates among state employees, all of whom have access to health insurance.Results of these efforts have broad implications for public health practice, providing a roadmap for designing and implementing expanded employer-based cancer screening initiatives.The Missouri Comprehensive Cancer Control Program (MCCCP) of the Missouri Department of Health and Senior Services (DHSS) is funded by the Centers for Disease Control and Prevention and provides leadership for the coordination of the state’s comprehensive cancer prevention and control efforts . To achiThe collaboration between MCCCP and the Missouri Cancer Consortium was established, in part, in response to a 2016 study that analyzed the extent to which national comprehensive cancer control programs implemented cancer prevention interventions in the workplace . A compaMissouri has approximately 40,700 full-time employees working in 24 state agencies, representing 0.007% of the total state population. State employees are a heterogenous population, with a median salary of $41,750, age groups spanning 3 generations, residence in both rural and urban regions, diverse racial and ethnic backgrounds, and a wide range of education and socioeconomic levels. All state employees have access to a state-sponsored health insurance plan .In 2020, MCCCP conducted a needs assessment to compare statewide rates of colorectal and breast cancer screening, screening rates among state employees, and screening rate objectives set forth in Healthy People 2020 , which have since been updated in Healthy People 2030 .Healthy People 2030 Objective C-05 is to increase the proportion of women in the US who receive a mammogram, with a goal of 80.5% . Only 67Implementation of the Screening Improvement Project (SIP) began in fall 2020, with an expected completion date of July 2024. The project team selected a strengths-based approach, defined as a process of capitalizing on assets, strengths, and available resources. Thus, the SIP team began by identifying the resources, strengths, and capabilities of MCCCP to leverage existing partnerships through the Missouri Cancer Consortium. This approach allowed the SIP team to build an evidence-informed intervention based on existing team strengths, including an accessible population, an existing infrastructure for communicating health information to state employees, and collaborative partnerships between state programs and MCCCP. The goal of this project is to increase state employee screening rates by tailoring existing educational materials to a diverse audience of state employees with access to state-sponsored insurance. During early project planning meetings with project partners, the key objective of the SIP was defined as changing the behavior of state employees by encouraging them to develop preventive care-seeking behaviors, such as participating in cancer screenings. Expected outcomes include increases in screening rates, knowledge of cancer prevention behaviors, knowledge of how to access care, and awareness of the importance of cancer screenings; increased work productivity; and decreased time off caused by illness. All of this will result in savings in health care costs, improved health behaviors, and, most importantly, decreased mortality.The SIP project was designed to include 3 distinct phases directed toward specific populations. The first phase focused on convening partners, disseminating readily available tools and resources on colorectal cancer prevention and screening to state employees, and monitoring overall screening rates over time. The second phase included expanded distribution of education materials to state employees and the development of statewide media campaigns to educate all Missouri residents on screening. The third phase will focus on implementation of evidence-based interventions among state employees and evaluation of these screening events.SIP partners were assembled from the Missouri Cancer Consortium, which has multiple workgroups consisting of key partners from around the state, as well as DHSS MCCCP representatives. The partners for this project are the American Cancer Society, DHSS Show Me Healthy Women, DHSS Tobacco Prevention and Control, DHSS Wellness Program, Gateway to Hope, the Masonic Cancer Alliance, the Missouri Cancer Consortium Breast Cancer Workgroup, the Missouri Colorectal Cancer Roundtable, the Missouri Department of Mental Health, the University of Missouri–Columbia School of Medicine, the Siteman Cancer Center, and the Washington University School of Medicine.The SIP team comprises a diverse group of individuals with a wide range of experience and expertise in cancer control and evidence-based interventions. The team includes 2 master’s-level social workers with experience in strengths-based approach theory. A gastroenterologist joined the SIP team to provide clinical oversight for the interventions, based on her extensive experience with colorectal cancer screening; she is also the chairperson of the Missouri Colorectal Cancer Roundtable. The SIP team also includes a professor who works as an epidemiologist, specializing in cancer prevention, rural health, and health promotion in underrepresented populations, including sexual and gender minorities; a senior scientist to support SIP’s goals to reduce potential disparities in cancer screening and education in the diverse state employee population; a chief executive officer with a unique understanding and perspective on multisector approaches to complex social challenges, such as health care access; and a cancer partnership expert with experience in clinical quality control and improvement. The team’s combined experience is wide ranging and allows for a strong collaboration and partnership for the implementation of SIP’s various phases.The assembled SIP team began by identifying existing assets and expertise that could support the proposed employee screening efforts. This approach builds on the capacity of the existing environment, promotes systems-level change, and encourages preventive care-seeking behavior among state employees. This multitiered intervention was critical to addressing multilevel barriers that could affect preventive care-seeking behaviors, including individual behaviors and resource alignment. By mobilizing available resources and assets of the health landscape, the employer, and the collaborative community partners, MCCCP and the Missouri Cancer Consortium sought to strategically engage in systems-level change to modify the built environment. Identifying and removing barriers for individuals would increase the likelihood of state employees’ potential for successful navigation of systems and use of existing cancer screening resources.In fall 2020, colorectal cancer screening rate among state employees enrolled in state-sponsored health insurance plans was 16%. The direct mail brochure featured a selection of photographs that reflected our goal of promoting health equity by representing the diverse population of state employees. These brochures included facts about colorectal cancer, how survival rates are improved if the cancer is caught early, an overview of the screening process, recommendations to lower risk, how to find an in-network physician, and sources of additional information. The materials also encouraged employees to ask their physician about being screened earlier on the basis of additional risk factors, such as family history of colorectal cancer.The SIP program distributed an email to state supervisors to encourage support of a systems-level policy change. Specifically, we asked supervisors to consider approving employee requests to use their 1 hour per month allocated time for health-related activities, such as participating in a cancer screening event. A 2018 study of the Centers for Disease Control and Prevention–funded Colorectal Cancer Control Program reported higher screening rates in primary care clinics  with a champion , further illustrating the importance of developing strong messaging across multiple state divisions and identifying champions to encourage screening at each site . To moniIn fall 2021, the prevalence of colorectal cancer screening among state employees enrolled in state-sponsored health insurance plans (50.1%) was 15.1 percentage points less than the prevalence among Missouri population overall (65.2%) . Therefowww.youtube.com/watch?v=YcdFuqTM03Q) and one focused on cancer survivorship (www.youtube.com/watch?v=BypYX20kwVI). Both campaigns were run via television advertisements, Facebook, and Instagram to reach adults aged 25 years or older. We based our decision to use television advertisements on the rationale that advertisements viewed on the largest screen in the home (television) are more likely to reach multiple people in a single household simultaneously. The campaign also included static image messages to be shared on social media, such as an infographic on colorectal cancer .In addition to the original cancer education materials, new materials are being developed for lung, colorectal, breast, and cervical cancer. A general cancer screening guide will also be available to print and display in the facilities of 24 state agencies, on bulletin boards throughout buildings and breakrooms frequented by employees. Because some employees may not have reliable access to email or the internet, this phase also seeks to provide accessible resources to state employees not reached through digital media. The development of expanded print materials began in April 2022, with an expected completion by end of summer 2022. By providing both print and electronic versions, we hope to ensure that all employees have access to these materials.Through implementing these project activities, the SIP team identified several key recommendations to share with other CCCPs (or any employer) seeking to increase cancer screening rates among employees .The strengths-based approach used throughout this project capitalized on resources and capabilities of MCCCP partnerships by building on current evidence-informed interventions and tailoring them to state employees. At least 2 pre-event educational webinars will be advertised to state employees via email announcements in late fall 2022. These webinars will provide information about breast and colorectal cancer and prevention and what to expect when being screened or if receiving an abnormal test result and time for a question-and-answer session. Two physicians will participate on the expert panel, ready to field general medical questions. The first on-site event, scheduled for December 12, 2022, will take place in a centralized location in the state capitol, Jefferson City. Fifteen state agency buildings with 3,185 employees are located within a 5-mile radius of the event site. The Ellis Fischel Cancer Center mammography van, which can accommodate 15 appointments per day, will be on site. Approximately 300 stool FIT kits for home-based colorectal cancer screening will be provided by BJC Healthcare/Siteman Cancer Center. Employees who attend the event will complete a brief survey to determine eligibility for screening, and if they are eligible, they will be given a stool FIT kit to take home to complete. Each FIT kit will include a postage-paid addressed envelope for the patient to easily return their stool sample to the laboratory. Test results will be kept confidential, and the referring physician will review results with the patient. Employees with positive test results will be referred for follow-up colonoscopy evaluation. In addition to state employees, other household members on the same health insurance plan can take advantage of the FIT testing opportunity. Others  who attend the event and ask about receiving a mammogram or colonoscopy will be provided information about resources. SIP has set a goal of distributing educational pieces to at least 300 attendees at this first pilot event. This event model will be adjusted and replicated at additional events throughout the state in 2023.Because state employees have diverse demographic characteristics, the SIP team has engaged with the MCCCP Health Equity Workgroup to discuss strategies for planning these events in other parts of the state to reach a diverse population. Our initial selection of evidence-based interventions includes patient reminders and small media . AddressEvaluation of each of these events — both process evaluation and outcome evaluation — will be completed. The SIP team will meet approximately 2 weeks after each event for a debriefing on such aspects as the pre-event webinars, use of the mammography van, distribution of FIT kits, and volunteers’ feedback. For the quantitative evaluation, we will assess the number of FIT kits returned within 1 month of the event, the proportion of mammogram appointments completed, the number of FIT kits distributed, the number of non–state employees asking for breast or colorectal cancer screening referrals, the approximate number of attendees, and the number of volunteers needed versus available. On the basis of this feedback, we will adjust the logistics of the next event to maximize screening opportunities.Even among state employees with health insurance coverage for routine cancer screening, compliance with cancer screening recommendations fall far short of Healthy People 2030 goals. Collectively, our 3-phase state employee screening project seeks to build on existing resources, strengthen partnerships among organizations and institutions involved in reducing the burden of cancer, and promote preventive care-seeking behavior among state employees. The first 2 phases increased exposure to information about the importance of cancer prevention and screening among state employees and the overall population in Missouri. The capstone events in phase 3, to begin in late 2022, will provide breast and colorectal cancer screening opportunities for state employees. The ultimate success of this 3-phase initiative will be determined by whether cancer screening rates of state employees increase over time. With a state agency providing leadership and a role model, other workplaces have the opportunity to adopt this process with the overarching goal of better health and less cancer burden among Missourians.


Care plans are central to effective care delivery for people with multiple chronic conditions. But existing care plans—which typically are difficult to share across care settings and care team members—poorly serve people with multiple chronic conditions, who often receive care from numerous clinicians in multiple care settings. Comprehensive, shared electronic care (e-care) plans are dynamic electronic tools that facilitate care coordination and address the totality of health and social needs across care contexts. They have emerged as a potential way to improve care for individuals with multiple chronic conditions.To review the landscape of e-care plans and care plan–related initiatives that could allow the creation of a comprehensive, shared e-care plan and inform a joint initiative by the National Institutes of Health and the Agency for Healthcare Research and Quality to develop e-care planning tools for people with multiple chronic conditions.We conducted a scoping review, searching literature from 2015 to June 2020 using Scopus, Clinical Key, and PubMed; we also searched the gray literature. To identify initiatives potentially missing from this search, we interviewed expert informants. Relevant data were then identified and extracted in a structured format for data synthesis and analysis using an expanded typology of care plans adapted to our study context. The extracted data included (1) the perspective of the initiatives; (2) their scope, (3) network, and (4) context; (5) their use of open syntax standards; and (6) their use of open semantic standards.We identified 7 projects for e-care plans and 3 projects for health care data standards. Each project provided critical infrastructure that could be leveraged to promote the vision of a comprehensive, shared e-care plan. All the e-care plan projects supported both broad goals and specific behaviors; 1 project supported a network of professionals across clinical, community, and home-based networks; 4 projects included social determinants of health. Most projects specified an open syntax standard, but only 3 specified open semantic standards.A comprehensive, shared, interoperable e-care plan has the potential to greatly improve the coordination of care for individuals with multiple chronic conditions across multiple care settings. The need for such a plan is heightened in the wake of the ongoing COVID-19 pandemic. While none of the existing care plan projects meet all the criteria for an optimal e-care plan, they all provide critical infrastructure that can be leveraged as we advance toward the vision of a comprehensive, shared e-care plan. However, critical gaps must be addressed in order to achieve this vision. Multiple chronic conditions affect 1 in 3 American adults and 4 in 5 Medicare beneficiaries. It is the most common chronic condition seen in clinical practice, and while there is no standard definition or measure of multiple chronic conditions, it is generally understood to be the co-occurrence of 2 or more chronic mental or physical health conditions. Other impairments or disabilities are also sometimes included in the definition of multiple chronic conditions, as are syndromes such as frailty and social factors such as homelessness. Providing integrated person-centered care to people living with multiple chronic conditions is a major challenge . FragmenCare plans are a central component of effective care delivery for people with multiple chronic conditions and other complex health care needs. Care plans, increasingly required by the Center for Medicare and Medicaid Services (CMS) in its programs, include written, comprehensive, patient-centered longitudinal plans of action that identify a patient’s goals and health needs and the services and support required to meet them.Existing care plans are largely paper based, and when electronic, often designed for a specific care setting or condition. They are often not interoperable and are difficult to share between providers, patients, and caregivers. People with multiple chronic conditions are more likely to have multiple care plans, which, rather than improving care coordination and integration, can instead lead to competing plans and increased fragmentation of care.A comprehensive, shared electronic care (e-care) plan (CSeCP) that is also interoperable is a dynamic electronic tool that employs health information technology to facilitate collaboration between individuals and their clinical teams, with the goal of addressing the totality of their health and social needs across all care settings . IdeallyThe use of CSeCPs has emerged as a potential solution for improving and coordinating the care of individuals with multiple chronic conditions . HoweverTo advance toward a CSeCP, the Agency for Healthcare Research and Quality (AHRQ) and the National Institute for Diabetes and Digestive and Kidney Diseases (NIDDK) are collaborating to build interoperable, open-source, patient-, caregiver-, and clinician-facing e-care plan applications and a Health Level Seven (HL7) FHIR implementation guide to improve care coordination for people with multiple chronic conditions across clinical and community settings. To inform this and other efforts in the field, we conducted a scoping review of past and current e-care plans and care plan–related initiatives, aiming to identify foundational projects and resources that could inform the multiple chronic conditions e-care plan project and other efforts in this space. This paper describes the process and results of our scoping review, as well as the functionality of existing e-care plans and the gaps that need to be addressed in order to advance toward a comprehensive e-care plan.Using the scoping review methodology , we firsOnce an e-care plan project was identified, data were extracted, including (1) the implementation period, (2) project contact information, (3) the project description, (4) the population targeted, (5) fields and domains documented through the e-care plan, (6) standard technology features , (7) current project activity, and (8) project results and outcomes. To determine how the identified e-care plan, including the multiple chronic conditions e-care plan project, contributes to the development of an interoperable CSeCP, we applied a recently developed typology of care plans by Burt and colleagues  that incMost care plans in use today are paper-based and localized or limited to a specific discipline, disease, or care setting. An electronic, interoperable CSeCP has the potential to greatly improve the quality of care for individuals with multiple chronic conditions, who see numerous providers across multiple care settings, and overcome barriers faced by these providers to accessing and sharing person-centered health information across settings. The burden of multiple chronic conditions is increasing in the United States as its population ages, warranting a redoubled focus on care coordination and the interoperable exchange of health information for people with multiple chronic conditions. Greater interoperability across all health care settings may improve health outcomes, increase clinician workflow efficiency, decrease redundant services, minimize searching for clinical information, and reduce health care costs. This need is heightened in the wake of the ongoing COVID-19 pandemic, which has increased the use of virtual care and, given evidence of potential long-term complications among COVID 19 survivors, may result in individuals with underlying chronic conditions carrying a heavy burden of multiple chronic conditions, in addition to creating a new cohort of people with multiple chronic conditions in previously healthy populations.Prior efforts to develop e-care plans ,29,35,36While we anticipate that the multiple chronic conditions e-care plan project will bring us closer to the vision of a CSeCP, much work will be necessary beyond the scope of this project. Key data elements and corresponding value sets and FHIR profiles must be identified and specified for numerous additional chronic conditions. Many data elements known to be important for care—including SDoH—are currently not supported by semantic standards or clinical terminology. While efforts to build these standards are underway , widesprThe purposes of an interoperable shared e-care plan are, first, to improve the quality and outcomes of care delivery by improving communication, coordination, and information sharing across clinical teams, patients, and caregivers. The second purpose is to provide comprehensive data on clinical conditions and management, as well as patient-reported outcomes, social factors, and patient goals and preferences in order to conduct real world research on people living with multiple chronic conditions. Clinical research on the management of different constellations of disease and health service research on the most effective models of care delivery are both needed . FurtherA CSeCP has the potential to greatly improve the quality of care for individuals with multiple chronic conditions who see multiple providers across multiple care settings. Prior efforts to develop e-care plans ,29,35,36


The health crises related to climate change in African countries are predicted to get worse and more prevalent. The response to catastrophic events such as cyclones, flooding and landslides must be rapid and well-coordinated. Slower adverse events such as droughts, heat stress and food insecurity must similarly be anticipated, planned for and resourced. There are lessons to be learnt by the health system following the crisis created by Cyclone Idai in Zimbabwe during March 2019, which required a massive humanitarian response to mitigate the impact of torrential rainfall on lives and livelihoods. Several researchers and organisations documented the emergency response in detail. They reported that the government response was hampered by a lack of preparedness, poor planning, inadequate resource mobilisation and weak coordination. Rural communities did not access the early warning cyclone alerts disseminated through television, print and social media, nor did they appreciate the seriousness of events until it was too late. Primary health care (PHC) teams are familiar and trusted by the communities they serve and have a critical role in raising public awareness and in documenting the evolving impact of climate change, using established health indicators and local narratives. PHC leaders and providers have the knowledge and skills to mediate between government bodies, international agencies, other stakeholders and communities on the predicted impact of climate change on health outcomes, highlighting the vulnerability of disadvantaged and impoverished groups. They are also able to work with community leaders, using indigenous knowledge on weather patterns, to build local engagement in protection plans.This article describes the role health professionals and civil society can play in educating the public on the dangers faced in the near future as a result of climate change and actions that can be taken to become more resilient and to mitigate this impact. Key economic sectors of agriculture, water, energy, forestry, tourism and industry will also be impacted by climate variability.4 The poor, disadvantaged and marginalised are 50% more likely to bear the impact of climate change than non-poor people, with more pushed into poverty as a result of adverse climate events.4Primary care providers (PCPs) have a crucial role in the urgent response needed to address the impact of climate change on communities, especially the most vulnerable and disadvantaged.7 So, when disasters occur, health service leaders and PCPs are often bypassed or marginalised in the arrangements.1 To explore the potential role of primary health care (PHC) in DRM, the case study of the health crisis created by Cyclone Idai in Zimbabwe is briefly presented here.Zimbabwe’s multisectoral and interdisciplinary disaster risk management (DRM) system is led by a National Civil Protection Committee with coordination from the Ministry of Local Government, Public Works and National Housing. This ministry relies heavily on international agencies for funding and implementation of emergency responses.13 At least 270 000 people were affected (129 600 children), with more than 340 dead, 51 000 displaced and many missing in Zimbabwe because of torrential rainfall, severe flooding and mudslides.10 The 1500 km of roads that were damaged prevented access to essential services immediately and for several months following the cyclone.12 The water supply network in Chipinge district was disrupted, leaving more than 30 000 people without access to safe drinking water, who were instead supplied by privately funded water truck deliveries.7 Manicaland health facilities initially recorded 354 cyclone-related hospital admissions, which escalated to 21 952 by May, of whom 64.3% were women.5 Acute respiratory infections, malaria, dysentery and diarrhoea cases were reported by health facilities, with active surveillance conducted for cholera and typhoid.11 Trauma, injuries, multiple fractures and lacerations constituted the main immediate health repercussions, with women, children and the elderly as the most vulnerable. Psychological and post-traumatic stress was reported for health staff working with survivors as well as amongst those who had witnessed or suffered personal loss resulting from the cyclone.9The impact of Cyclone Idai in Manicaland province (Eastern border of Zimbabwe) in March 2019 has been documented in detail because it caused extensive damage to homes, agriculture, roads, bridges, communications, electricity supplies, schools and health centres, together with disruption to livelihoods, food security and loss of life.13 Emergency food supplies were provided to approximately 133 200 individuals.7 At least 300 internally displaced persons were given refuge inside a hotel in one of the affected towns while others were sheltered in tents.8 Casualties were initially treated in trauma units and first aid tents in open fields, then later air-lifted to hospitals for surgical management.13 Volunteers from medical associations travelled from the capital city to the district hospitals to replenish supplies and carry out surgery.13 Health facilities received emergency medical supplies and 11 satellite clinics were established to provide emergency health services. Many of those who needed help had chronic conditions, diabetes, hypertension, asthma and HIV, who had lost their medications along with their homes. People living with HIV usually receive 3-months’ supply at one time so the ones worst affected were those who lost their medication when their homes were destroyed.12 Proactive immunisation against cholera and measles was carried out while counselling centres provided some limited psychosocial, mental health and child protection support at a few clinics in the two districts.10 New boreholes were drilled to resuscitate water sources; water purification tablets and hygiene materials were distributed to reduce the risk of water-borne diseases such as cholera.8 Disaster risk reduction (DRR) training and emergency drills were conducted for district civil protection committees (CPCs), targeting government employees, school teachers and pupils, humanitarian agencies and NGOs.8 Crop seed and farming equipment were provided to resuscitate farming livelihoods, although only a few households received this assistance.8The immediate outpouring of humanitarian support for the two districts most affected was significantly from local civil society groups, non-governmental organisations (NGOs), churches, private individuals and international organisations, providing food relief, clothes, water supplies and medications.8 Local government bodies who were meant to lead the emergency response were unprepared and not visible at the onset of the disaster. Coordination of the various agencies providing humanitarian assistance, civil and social protection was problematic. There were capacity, regulation and policy shortcomings, poor information-sharing, duplication of interventions on the one hand and neglect of essential health needs on the other.6 The tents provided by the United Nations High Commissioner for Refugees (UNHCR) as temporary accommodation were still providing shelter two years later because recovery strategies failed to include permanent housing in that time.8 District CPCs and communities had limited awareness of disaster vulnerability and risks associated with flood hazards so they failed to anticipate the seriousness of the early warning alerts notified through various forms of media , which are not readily accessed by rural communities.8Studies conducted in the aftermath of the cyclone found that the government response was retarded by fragmented disaster planning, inadequate resource mobilisation, inexperienced personnel on the ground and dependence on donor funding, followed by inadequate reconstruction and rehabilitation follow-up measures.8 Primary care providers can contribute not only to rebuilding programmes and primary care services disrupted by adverse climate events such as Cyclone Idai but also in long-term protection efforts. The principles underlying PHC include social determinants of health, including human rights to safe water and sanitation, shelter, food security and access to healthcare, so encompass a range of interventions that underpin the build-back-better approach. This requires a multidisciplinary and intersectoral team approaches utilising the skills of all PHC providers and partners in the health system and the community, especially village health workers and environmental health assistants. Building-back-better would mean PHC working with public health colleagues to improve surveillance of communicable and non-communicable diseases in relation to climate change and monitoring trends with regard to ambient temperature, air pollution, rainfall, drought and seasons. A gap currently in understanding health impact is data linking routine health information with environmental conditions. The PHC role also extends to strengthening communities to be able to protect themselves and be less vulnerable from future adverse climate events.2 Leadership from PHC, including through academic colleges and professional associations, has a major role to play in this through advocacy and coordination, to influence policy and research priorities and to emphasise the urgency and gravity of the climate change and health nexus.15The build-back-better approach to post-disaster recovery presents opportunities to create safer, sustainable and more resilient communities as part of reconstruction and rehabilitation.15 These need to be ongoing, persistent and persuasive and build on the DRR training conducted with the CPCs. Educating communities, for example, about the relationship between deforestation, rainfall, mudslides and soil erosion would be more effective if alternatives to wood and charcoal are made cheaper and easily available. The relationship between household air pollution and childhood respiratory complaints and burns could be explained to motivate the use of alternative cooking fuels.16 These are some multisectoral and community-empowerment PHC-based solutions to climate change-related problems and mitigation efforts. Research has identified that some community members in Zimbabwe study weather patterns, trees and clouds, alongside the behaviour of particular birds and animals, to predict imminent flooding and other adverse climate events. Communities take preventive action (e.g. moving to higher ground or building temporary bridges) because they trust these indigenous knowledge systems.17 Partnering with them as part of the PHC and DRR approaches to climate-related stresses could improve communities’ engagement in actions required to respond to increased ambient temperatures, air pollution, veld fires as well as with early warning alerts for torrential rain and flooding. Primary health care leaders and district CPCs can also work together to ensure minimal disruption and restoration of supply chains to ensure effective responses and adequate preparation for climate change-related emergencies.2Public education and awareness on climate change and health are key PHC team activities.In conclusion, the health sector must negotiate to be more directly involved in decision-making, planning and policy development about the impact of climate change on the health of communities. Primary care providers are well-placed to mediate between government bodies, international agencies, other stakeholders and communities, so they should be recognised as central to leadership, advocacy and public health protection in the climate change and health nexus.


More than 500 million people worldwide live with cardiovascular disease (CVD). Health systems today face fundamental challenges in delivering optimal care due to ageing populations, healthcare workforce constraints, financing, availability and affordability of CVD medicine, and service delivery.Digital health technologies can help address these challenges. They may be a tool to reach Sustainable Development Goal 3.4 and reduce premature mortality from non-communicable diseases (NCDs) by a third by 2030. Yet, a range of fundamental barriers prevents implementation and access to such technologies. Health system governance, health provider, patient and technological factors can prevent or distort their implementation.World Heart Federation (WHF) roadmaps aim to identify essential roadblocks on the pathway to effective prevention, detection, and treatment of CVD. Further, they aim to provide actionable solutions and implementation frameworks for local adaptation. This WHF Roadmap for digital health in cardiology identifies barriers to implementing digital health technologies for CVD and provides recommendations for overcoming them. Cardiovascular disease (CVD) affects more than 500 million people worldwide if you wording needs to be modified . Global 245Digital health technologies, such as electronic decision support tools, telemonitoring, remote monitoring, or mobile health  apps, have the potential to help address health system challenges which limit the achievement of optimal and universal health coverage (UHC). These technologies can contribute to UHC by empowering patients  and provA range of fundamental barriers prevent implementation and access to digital health technologies globally . Health 1820222324252627In 2020, the WHF commissioned a writing group to develop a roadmap on digital health for cardiology. WHF regional Members were invited to nominate an expert to the writing group to ensure that the content of the roadmap has accurate global representation. In addition, experts in digital health with clinical, public health or research backgrounds were selected. The writing group also included representatives from allied health professions and people living with CVD to ensure an inclusive perspective.The roadmap is derived from a synthesis of peer-reviewed evidence on the barriers to and benefits of using digital technologies, an online survey among WHF members and the public and an iterative process of expert consultation involving eight writing committee members and 12 reviewing committee members drawn from the global WHF membership network. The Supplementary Appendix details the methodology of the survey. Inputs from surveys and (patient) experts were supplemented with a narrative evidence synthesis on barriers and solutions for implementing digital health solutions. The Writing Committee identified and selected case studies based on their experience and relevance to the identified barriers and solutions.The primary focus of this roadmap is to identify and provide solutions and tools for commonly faced barriers in the development, implementation and scaling of DHIs for CVDs and their risk factors. Solutions in this roadmap are intended to be practical and are directed at different stakeholders within health systems, including people living with CVD and who might be active in-patient organisations, health care practitioners and policy makers, helping them to come together and drive meaningful change.In 2018, the World Health Organization (WHO) presented a classification of digital health interventions (DHIs) . This taSeveral DHIs have shown potential for CVD management [1833343536373839404142433438394041421833353645464849375140A 2018 systematic review found that mobile  apps can reduce rehospitalisation, improve patient knowledge, quality of life, and psychosocial well-being, and help manage CVD risk factors . ImportaPhysical activity trackers are an example of wearable devices that may be used to support CVD management. A 2019 systematic review (28 RCTs including 3646 participants across nine countries) investigated the effects of wearable activity trackers and found an average increase of 627 daily steps (95% CI 417 to 862 steps) and energy expenditure among the intervention groups compared to controls . The mSTThe EXPERT (Exercise Prescription in Everyday Practice & Rehabilitation Training) Tool is an example of a clinical electronic decision support tool. The European Association for Preventive Cardiology (EAPC) introduced EXPERT as an interactive decision aid enabling healthcare professionals to compare their exercise prescriptions to predetermined patient cases using an algorithm . The rec5158The WHO recommendations on DHIs for health system strengthening laid out several conditions necessary to implement digital health technologies successfully . These iUnfortunately, in reality, many of the ideal conditions for implementing digital health technologies are often not met. The WHO/ITU framework suggests that a national eHealth environment requires good leadership and governance, high-quality legislation and policies, a clear investment and reimbursement strategy, high-quality services and applications, a supporting digital health infrastructure, clear interoperability and data standards and a tech-savvy workforce . BarrierNational governments and policymakers are uniquely responsible for setting universally applicable strategies and standards . More thThe ITU/WHO national eHealth strategy toolkit guides the development of national eHealth strategies . NationaIn the WHF digital health roadmap survey, low (perceived) quality was a moderate to significant barrier to more than 70% of respondents. The WHO reported that only 7% of DHIs in LMICs are properly evaluated . A systeThe WHO has highlighted the importance of robust evaluation and recommends using the mHealth Evidence Reporting and Assessment (mERA) checklist, emphasising quantitative, qualitative, and economic evaluation 71. The UPrivacy concerns and individuals’ willingness to disclose personal medical information are essential barriers to adopting technologies . The lac80Rigorous and transparent regulatory mechanisms and guidance on data security and privacy are essential conduits to enhance trust by patients and clinicians in using digital health technologies 64. An arCurrent policy guidelines in many countries require face-to-face consultation for reimbursement. Therefore, the lack of proper reimbursement of DHIs is a significant barrier to adoption by patients and providers. More than half of survey respondents considered limited reimbursement, prohibitive costs of training staff and patients, and high out-of-pocket patient costs significant barriers. Separate scoping and systematic reviews 8788 on b8789Implementation of DHIs should consider funding mechanisms because they will impact the (cost) evaluation and long-term sustainability. The COVID-19 pandemic has accelerated the need for new funding mechanisms for telehealth solutions, for example, in the United States  and SingCommon issues with DHIs are insufficient assessment of the patients’ and healthcare providers’ actual needs, developing ‘one-off’ interventions without contextualisation within national health systems, and lacking cultural and social adaptations . Lack of16There is a need to focus on unmet population needs and promote thoroughly researched and adequately contextualised technologies. Contextualising DHIs starts by recognising that many are often considered complex interventions . DHIs in100102Limited national and institutional ICT and digital infrastructure are essential barriers to implementing DHIs 106. In 216109DHIs require sufficient and efficient information and communications infrastructure, including software, hardware, internet connectivity, maintenance support, data storage and security. National governments should consider national infrastructure in their eHealth and finance strategy, for which the ITU/WHO guidance is a valuable tool . In addiLack of integration with the existing (ICT) workflow was a moderate to significant barrier for most respondents. These results were in line with published studies and meta-analyses 92. InstiThe Health Data Collaborative Digital Health & Interoperability working group, currently co-chaired by USAID and WHO, has developed several toolkits relevant to developing and implementing national data interoperability standards . Many daDHIs have the potential to empower and educate health workers, reduce their workload and save travelling time . A recen87User-focused design and a solid evidence base regarding effectiveness are vital in enabling clinicians to use digital health technologies . As a ruSimilar to providers, DHIs have the potential to empower and educate patients, reduce their workload and save travelling time. Various patient-level barriers impact DHI adoption and acceptability. Patients with CVD are commonly older and have several comorbidities leading to impaired physical and mental functioning . The dis168288123124123124As is the case for health care workers, digital health technologies require significant investments in patient education. Active involvement of caregivers and assisting patients in using DHIs might improve utilisation . DeploymDHIs can fill critical health system gaps in CVD management and prevention, empower patients, and enable healthcare practitioners to provide higher quality and more efficient care. There is a substantial unmet need for collective action involving patients, healthcare providers, industry members, regulators and reimbursement authorities, and policy makers to identify and help solve context-specific barriers. This roadmap provided potential solutions for frequently encountered obstacles to scaling up digital health solutions to improve the management and prevention of CVD and the support and experience of care for those living with those conditions globally.Empower non-physician healthcare workers through the use of a digital platform .mPower Health is a digital platform designed to deliver integrated, comprehensive, and continuous care to patients through innovative technology-driven tools that support healthcare professionals.In 2010, the Government of India initiated the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) to respond to the challenges related to the high burden of NCDs in India. The mPower Health platform was designed to complement the NPCDCS programme.The mPower Heart works on two core principles: Technology  and task-shifting  .mPower Health’s major capabilities/features are:A mobile app for healthcare providers and a web-based dashboard/server for healthcare administration.Clinical Decision Support System generates ersonalized management plans for patients with hypertension and diabetes by computing complex clinical management algorithms and suggesting the diagnosis, optimal drugs, dosage, warning contra-indications, etc.Computing clinical risk scores to identify high-risk individuals and initiate preventive measures.Maintaining longitudinal health records of the patient and assisting in scheduling follow-up visits based on clinical parameters (avoid unnecessary travel and visits of the patients).Task Shifting: empowering the non-physician workforce to deliver quality care by using technology.Generating lifestyle recommendations tailored to individual patients.Ability to work in offline mode (without internet connectivity).Real-time monitoring and profile visualiser for trending and quick decision making.Piloting of the mPower platform has shown impressive results and significantly impacted clinical outcomes of patients with hypertension and diabetes . Two staThe lack of national guidelines and strategies for the DHI at the time of implementation of the mPower Health and no strategies for long-term investment impacted the uptake and sustainability of mPower Health. As a result, the Government of India recently initiated the Ayushman Bharat Digital Mission (ABDM) which aims to provide the necessary framework and infrastructure . The leaTo integrate data and communication directly between patients and their health care providers.‘It was a nice way of seeing the graph of the cholesterol thing coming down, so that was great–that’s a bonus…visual feedback…I better keep walking, riding, whatever because it’s working.’ [Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) is a consumer-focused, responsive web application that is interactive and integrated with data from the patient’s primary care electronic health record. It was co-designed with consumers, clinicians and software developers and supported CVD risk management and decision-making. CONNECT  includesorking.’ .Patients have electronic access to auto-populated information about their medical conditions and prescribed medicines with links to more detailed information to enhance knowledge. CONNECT also has smartphone and website access to an interactive and personalised CVD risk system where individual patients can use interactive functions and receive visual feedback about the relationships between their risk factors and absolute cardiovascular risk. Interactive goal-setting  based on healthier eating, physical activity, smoking cessation and emotional well-being, and goal achievement tracking with virtual rewards to facilitate and motivate lifestyle changes.CONNECT is integrated with each patient’s primary care electronic record. Progress tracking combines data imported from electronic medical records with patient logs such as blood pressure control and weight management with calendar links for tests such as cholesterol measurement requirements.The intervention was co-designed, validated and beta-tested via a four-phase iterative process that involved consumers, multidisciplinary clinicians, software developers and graphic designers . Through121Deliver emergency care in underserved areas and remote settings.Providing emergency care in rural areas continues to be a global challenge. The pandemic amplified the disparity in the care of underserved populations in the United States, notably the 20% of the people living in rural areas. With the closure of many rural hospitals, the emergency medical response system faced longer response and transport times, delaying hospital-level medical care. The Emory rural Tele-Emergency Medical Services (Tele-EMS) network underwent a significant innovative change with the work of Drs. Monique Smith and Michael Carr and their team bring the clinical understanding of the hospital to the point of emergency contact and automate data communication, allowing earlier patient-focused clinical care in the community . The digIn this programme, an emergency physician provides a video televisit to rural Grady Hospital EMS crews to evaluate and suggest management of initial patient care. Patient data is uploaded to a streaming cloud if specialised care is needed. The receiving facility is notified of the patient’s arrival and the treatment plans that have been started. This allows emergency medical personnel to focus their attention on the patient’s care while the communication is automated.In contrast to usual telemedicine programmes, rural platforms require the ability to work in low bandwidth settings and inside and outside the hospital. After evaluating solutions from multiple companies, Emory chose SWYMED , which aNotably, the platform can integrate into EMS and hospital technology to enable rapid cardiovascular data transmission. In this instance, the product integrated explicitly with Zoll, the X series monitor defibrillator used on Grady ambulances and the Emory electronic medical record.In conclusion, this case underscores the complex human capital, data standardisation, integration, transmission and communications infrastructure needed to achieve scalable and sustainable rural telemedicine. It also highlights the importance of multi-industry collaboration to create meaningful change in rural health by creating new systems for high-quality access to high-quality care.