The world of migration is a vast and diverse landscape. The 17 articles in this collection cover every step in the migration process, from origin to destination and beyond, as migrants in a variety of streams – temporary and permanent; labor, family, and refugee; of diverse countries, backgrounds, and aspirations – find help and hindrance, welcome and opposition from a wide swath of nonmigrants and immigration officials. Scholarly topics include self-selection and government-selection, into legal status and residential location; determinants of prejudice; integration and naturalization; children and subsequent descendants of migrants; impacts of law and contexts of reception. The articles traverse theory and empirics, micro and macro matters, qualitative and quantitative approaches, cross-sectional and longitudinal perspectives, single-country and multi-country settings.Soysal and Cebolla-Boado address selectivity in four usually unobserved but here self-described traits – ambition, creativity, independent-mindedness, and risk-taking – among international higher-education students from China in Germany and the United Kingdom, comparing them to nonmigrant higher-education students in China, Germany, and the United Kingdom. Results indicate no systematic differences across these student groups and no gender difference, suggesting global convergence in these traits and a remarkable homogeneity around the world in how university students see themselves.Jacobs examines how skilled migrants navigate legal migration channels in the United States, based on a sample from India holding H-1B temporary work visas, plus smaller subsamples of unsuccessful H-1B applicants and immigration lawyers. The sample includes both direct recruits newly arriving in the United States and H-1B visaholders transitioning in the United States from a student (F-1) or exchange (J-1) visa. Results document the challenges and uncertainties of the visa process, noting how an earlier transition  increases the likelihood of applying for legal permanent residence (LPR), now with more options beyond employment visas , but also how the mismatch between LPR aspirations and the temporary H-1B visa may lead to emigration.Spörlein and Kristen assess educational selectivity among labor migrants from 15 countries in Africa, Latin America, Asia, and Europe who moved to Germany, England, Ireland, the Netherlands, and Spain, together with refugees from Afghanistan, Iraq, and Syria in Germany. Results indicate that there are few selectivity differences between labor and refugee migrants, but these differences vary, with some labor migrant groups scoring the same or lower on selectivity than refugees; moreover, every origin group includes both positively and negatively selected individuals.Haberfeld et al. assess post-migration selectivity in location choices among refugees who arrived in Sweden from nine countries in Africa, Asia, and Europe during 1990–1993, a period when refugees were assigned an initial location but were subsequently free to move. Analysis of register data over an eight-year period indicates that refugees’ educational levels are related to their destination choices, with highly skilled refugees more likely than the less skilled to move to labor markets with more opportunities, and that all relocation choices have positive effects on refugees’ income growth.Jasso develops a framework for analyzing migration restriction regimes, applicable to any migration stream and any country, illustrating it with the United States system for LPR. Restriction may be based on personal criteria and/or numerical ceilings and generates both backlogs and unauthorized migration. The framework can be used to summarize a country’s migration law -- rules for admission, periodization of its immigration history, and policy devices for addressing backlogs and unauthorized migration -- as well as to compile stocks and flows of legal temporaries, LPRs, and naturalized.McAvay and Waldinger analyze naturalization patterns among migrants in France from over 50 countries who are married to a French citizen and thus, under French law, eligible for both standard naturalization and a fast-track naturalization for spouses of French citizens, which has more extensive documentary requirements, especially with respect to demonstrating that the marriage is genuine. Results indicate that while marriage to a French citizen is the single most powerful determinant of naturalization, choice of track is strongly related to the nativity and parentage of the French citizen spouse, with marriage to a French native especially likely to promote marriage-track naturalization, particularly among women.Bohman et al. explore the effect of political discussions with peers during adolescence on prejudice against immigrants in Sweden, using data on two cohorts followed for a five-year period (ages 13 and 16 at the start of the survey). Results show an association between political discussion and prejudice, its strength increasing as the adolescents grow older. Moreover, the effect of political discussions depends on the level of prejudice among peers; political discussion with low-prejudice peers is associated with lower levels of prejudice, but political discussion with high-prejudice peers is not significantly related to attitudes toward immigrants.Mitchell examines how differences in social trust, both within and between countries, influence attitudes about immigrants, using the European Social Surveys of 2002–2016 and, for robustness checks, supplementary data from the European Values and World Values Surveys. Results from longitudinal analyses indicate that countries with higher levels of social trust have more favorable attitudes toward immigrants and that changes in trust over time, albeit small, result in comparably large changes in anti-immigrant attitudes, even when controlling for other social factors.Gorodzeisky and Semyonov analyze opposition to immigration among natives of 20 countries in the 2014 European Social Survey, showing that opposition varies not only across host countries but also across five ethnoreligious migrant groups . Results indicate hierarchical opposition to the five groups, being most extreme toward Muslims and Roma but relatively minor toward immigrants of the same race-ethnicity or toward Jews, as well as varying sources of opposition to immigration .Evans and Kelley analyze prejudice toward outgroups – using a classic measure of social distance rooted in the work of Bogardus that taps objection to members of specific groups “as neighbors” -- among respondents in 100 countries . They find that prejudice and social distance against immigrants, other races, Hindus, Jews, Muslims, and Roma tend to decline with level of socioeconomic development of the host country. They also find that a single latent ethnoreligious prejudice generates prejudice against specific outgroups.Steele and Perkins examine how natives’ perceptions and misperceptions about the size of the noncitizen population affect attitudes toward redistribution and social policies among a sample of residents of New York City – one of the most diverse and ethnically heterogeneous cities in the world -- recruited via Amazon Mechanical Turk. Results indicate that about a quarter of New Yorkers overestimated the relative size of the noncitizen population in their neighborhood, and these respondents were among the least supportive of redistribution and other social policies.Bevelander and Luik assess the employment integration of refugees in Sweden in the first 12 years since arrival, using longitudinal data on three arrival cohorts (1998–2000). Despite differences across the three main refugee groups , results show similar patterns of employment integration; all refugee groups increase their employment probabilities, but from different starting points and at different speeds, some reaching parity during the study period. In particular, women from Bosnia, Eritrea, and Ethiopia have similar or higher employment probabilities than Sweden-born women after between five and eight years in the country.Amit and Chachashvili-Bolotin analyze the mismatch between subjective work perception and actual position in the labor market – the discrepancy between actual integration  and subjective integration (combining satisfaction from job and wage) – in Israel among four immigrant groups  and four native-born groups . A larger fraction of women than of men experienced a positive mismatch, and a smaller fraction of women than of men experienced a negative mismatch; moreover, the largest fractions experiencing a positive mismatch occurred in groups with disadvantaged backgrounds.Kogan and Shen assess life satisfaction among migrants from/to 30 European countries, using data from the 2008–2016 European Social Surveys. Results indicate that immigrants’ assessments of economy, democracy, and quality of public goods  in the host country contribute to life satisfaction, with satisfaction with the economy being the strongest correlate of life satisfaction, particularly among migrants from Turkey and countries of Eastern and Southern Europe.Wilkes and Wu study the complex relations between three kinds of perceived discrimination  and three types of trust  between five groups in Canada . They find that perceived discrimination is more relevant to general and specific trust than to political trust and that perceived discrimination explains more of the trust gap between foreign-born people of color and the native born than between foreign-born whites and the native born.Lubbers and Gijsberts use a four-wave panel to assess change in self-rated health among immigrants from Bulgaria, Poland, Spain, and Turkey who arrived in the Netherlands in 2012 and 2013. Results indicate that lack of Dutch friends, perceived discrimination, cultural distance, and homesickness strongly affect self-rated health; moreover, self-rated health declined over time, although slightly, mostly from “very good” to “good,” and possibly linked to the new immigrants becoming parents in the early years after migration.Sanderson and Kentor assess the relation between migration and development by analyzing migration (im)balances and wage differentials within 22 pairs of countries in the Americas at five decennial points between 1970 and 2010. They find a positive feedback between international migration and cross-national inequalities; wage differentials between countries have a strong effect on migration, especially in contiguous countries, while migration has a smaller effect on wage differentials.The 17 articles open new doors for further inquiry, as migration continues and researchers study its impacts on the well-being of migrants and others at origin and destination.


The COVID-19 pandemic generated a growing interest in and need for evidence-based tools to facilitate the implementation of emergency management strategies within public health practice. Quality improvement (QI) is a key framework and philosophy to guide organizational emergency response efforts; however, the nature and extent to which it has been used in public health settings during the COVID-19 pandemic remains unclear.We conducted a scoping review of literature published January 2020 – February 2021 and focused on the topic of QI at public health agencies during the COVID-19 pandemic. The search was conducted using four bibliographic databases, in addition to a supplementary grey literature search through custom Google search engines and targeted website search methods. Of the 1,878 peer-reviewed articles assessed, 15 records met the inclusion criteria. An additional 11 relevant records were identified during the grey literature search, for a total of 26 records included in the scoping review.Records were organized into five topics: 1) collaborative problem solving and analysis with stakeholders; 2) supporting learning and capacity building in QI; 3) learning from past emergencies; 4) implementing QI methods during COVID-19; and 5) evaluating performance using frameworks/indicators.The literature indicates that QI-oriented activities are occurring at the organizational and program levels to enhance COVID-19 response. To optimize the benefits that QI approaches and methodologies may offer, it is important for public health agencies to focus on both widespread integration of QI as part of an organization’s management philosophy and culture, as well as project level activities at all stages of the emergency management cycle.The online version contains supplementary material available at 10.1186/s12889-022-12631-0. The Coronavirus Disease 2019 (COVID-19) pandemic generated a growing interest in and need for evidence-based tools and techniques to facilitate the implementation of public health emergency management (PHEM) strategies. Quality improvement (QI) is one such approach, and is defined as “the use of deliberate and defined methods in continuous efforts to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes,.” [While QI is a well-established field of study and practice in clinical health care settings, it is still emerging in relation to public health programs, services, policies and research . PreviouThe COVID-19 pandemic elicited renewed interest in the capability and capacity of public health systems to respond to infectious disease emergencies. The objective of this scoping review is to explore literature on applications of QI at both the organization-wide and project level at public health agencies during the pandemic . This scoping review is intended to to inform strategies for implementating QI in pandemic response and recovery by synthesizing information on QI experiences across different contexts and jurisdictions, to enhance effective management strategies for COVID-19 pandemic and future public health emergencies. To achieve the research objective, a scoping review methodology was employed. Scoping reviews are a type of knowledge synthesis which maps existing literature on a new, complex or heterogeneous topic of interest with respect to its volume, nature and characteristics . ScopingThe objective of this review was to explore the current evidence base related to applications of QI at public health agencies during the COVID-19 pandemic, and was guided by two questions: “How have public health agencies used QI during the COVID-19 pandemic?” and “How can QI be used to support public health emergency management?” This review includes QI initiatives undertaken by public health agencies (and other relevant PHEM settings) as well as QI resources applicable to these settings; information on QI initiatives undertaken in patient/clinical care settings  were out of scope. Studies and grey literature on QI initiatives related to clinical treatment for COVID-19, protective measures  and technical studies were also out of scope. Finally, this review did not examine the effectiveness of the QI initiatives or resources.A search of both peer-reviewed and grey literature was conducted between January 2020 and February 2021. Four indexed databases were selected to be comprehensive and inclusive of literature in the biomedical, public health, health science, and global health disciplines: MEDLINE, Ovid Embase, Ovid Global Health, and Scopus. Search strings used for the query were developed by PHO Library Information Specialists (seePeer-reviewed articles were eligible for inclusion based on the following criteria: (1) takes place in a public health-related setting at any level ; and (2) describes emergency management at any stage ; and (3) describes study objectives and/or methods based on QI; and/or (4) uses an established QI approach, tool or technique , or uses qualitative/quantitative indicators and/or metrics to measure performance; and (5) describes implemented, supported or mandated actions. Records were considered ineligible if they were: basic research; epidemiological/clinical studies; medical/patient care research; clinical guidelines/best practices; and/or commentary/editorial/opinion pieces. We did not consider specific study designs, but results had to include study objectives and methods to exclude anecdotal articles. In addition, records that described QI in non-human elements  were excluded. Only English language articles focused on Organisation for Economic Co-operation and Development (OECD) countries published and between January 2020 and February 2021 were included in the search. The language restriction considered limited resources for translation, while the location restriction ensured publications from jurisdictions with similar or comparable public health system structures and contexts to Canada. The date restriction ensured articles were relevant to the COVID-19 pandemic.For the supplementary grey literature search, English language records related to OECD countries and published during the above date range were eligible for inclusion based on the following criteria: (1) published by a governmental health agency at any level ; (2) describes tools, techniques and/or resources for public health or related PHEM settings; and (3) describes tools, techniques and/or resources developed or using QI methodology.The peer-reviewed literature screening process involved two levels. For the first level of screening, titles and abstracts were reviewed by two independent reviewers . The second level of screening involved a full-text review by two reviewers  with any conflicting decisions resolved by a third reviewer (FG). All screening, de-duplication, and reference management was completed using the systematic review software, Covidence . For theData extraction was completed by two reviewers  based on the descriptive  and methodological  characteristics of each record, in addition to key findings. Furthermore, each record was assessed for its QI relevance and emergency management cycle stage(s) discussed . The records were grouped into overarching topics conceived by the research team, representing the nature in which QI has been operationalized during the COVID-19 pandemic.The peer-reviewed literature search returned a total of 1,878 records. After de-duplication and the first level of title and abstract review, 74 were approved for second level screening, of which 15 were eligible after screening based on the inclusion criteria , Canada (n = 3), Europe , Italy (n = 1), United Kingdom , US (n = 11), and multiple/unspecified jurisdiction (n = 4). Records were related to health care (n = 3), laboratory (n = 1), public health , national level (n = 4), international/multi-jurisdictional (n = 1) and health systems settings (n = 8). Moreover, the records identified in this review discussed preparedness (n = 2), preparedness/response (n = 4), response (n = 12), mitigation/preparedness/response (n = 1), and all four stages of the emergency management cycle (n = 1). This review did not find any records related solely to the recovery stage of the emergency management cycle. In addition, several records were related not to emergency management, but rather, overall health system improvement (n = 6). , tools and techniques  and other improvement-related assessments  were discussed. Notably, the majority of grey literature records did not describe assessment of QI initiatives, but rather, provided resources developed for use in public health settings and were not specific to COVID-19.The descriptive summary in Table Collaborative problem-solving and analysis with stakeholders emerged as a key topic in this scoping review with the greatest number of records emerging under this category. Ten (10) records described initiatives to facilitate collaborative problem-solving and analysis with stakeholders to bolster public health emergency response and improve response efforts.Several records highlighted interdependent efforts in working towards a shared goal of emergency preparedness and response. For example, a group from Washington State  used a sResearch from Europe demonstrated that stakeholder engagement in real-time during the COVID-19 response helped to identify and leverage areas of shared knowledge regarding efficient collaboration, improved teamwork based on mutual respect, thus contributing to the development of innovative decision-making methods tailored to the needs of an inter-professional and multi-disciplinary COVID-19 response. Hunger et al.  identifiThe Agency for Healthcare Research and Quality (AHRQ)’s  ACTS COVSixteen 16) records described learning and training in QI, with a focus on improving capacity among individuals involved in the public health response to COVID-19. These included educational resources to support self-directed learning and participation in facilitated activities, such as learning exchanges  records  describeSpecific grey literature results describe QI methods and tools to prepare participants for learning, some were adapted with respect to the management of COVID-19. One example is the Project Public Health Ready program , which hAs seen in the literature, improving access to educational resources and building capacity in QI may represent key actions for public health agencies interested in developing or bolstering their organizational QI strategies.Five (5) records described the use of QI tools and techniques following large-scale health emergencies , H1N1, Zika Virus, etc.). They described recommendations for improvement from previous emergencies, including measures that could be applied to the COVID-19 pandemic. For instance, the World Health Organization (WHO) Although the uptake of IARs and AARs by public health agencies has been encouraged by globally prominent public health agencies, an analysis by Parker  found thProcesses to apply learning from past events was a key area identified in the literature. This encompassed formal improvement-oriented evaluations, such as IARs and AARs, which help teams and organizations identify critical lessons learned and factors contributing to weaknesses which, if addressed, can improve the response to the next emergency.Five (5) records described individual or organizational experiences implementing QI projects or initiatives. The use of QI tools and methods, including process mapping, root cause analysis, and PDSA cycles were found to be effective in supporting the achievement of specific objectives. Aragon et al.  describeDespite substantial strain on public health capacity during COVID-19 pandemic, there is some evidence to suggest QI tools and techniques guided improvements to PHEM and response work during the COVID-19 pandemic. Although large-scale QI projects may be challenging to plan, execute, and evaluate—due to the rapid progression of the COVID-19 pandemic and sizeable human and material resource demands required for response—our review identified several examples of QI applied on a smaller scale .In health care and public health settings, frameworks and indicators can be useful tools to organize and conceptualize common elements across organizations, and to systematically measure and assess areas for improvement. This review identified seven (7) records that applied a framework or set of established indicators to assess public health management of COVID-19. For example, formal frameworks and indicators were used to assess emergency preparedness and/or response at various stages of the COVID-19 pandemic, as well as the performance of selected countries.Some studies used established frameworks and indicators as the basis for evaluating the PHEM response to COVID-19. Curtis et al.  applied 29 similarly used the indicators from the International Health Regulations (IHR) State Party Annual Reporting (SPAR) tool to develop an index that assessed countries’ capacities to prevent, detect, and respond to outbreaks. They found national capacities varied widely, although there is an overall need to increase the strength of emergency preparedness infrastructure and update national plans [Kandel et al.al plans  proposedThe articles identified in this scoping review illustrate examples of public health agencies adapting QI and improvement at the project and organizational levels in response to the COVID-19 pandemic. QI concepts, tools and techniques were applied to a variety of PHEM functions and also at different stages of the emergency management cycle, which provides a useful framework for understanding how public health and emergency management systems intersect to respond to infectious health emergencies . The cycPublic health systems involve a large number of stakeholders  and their structures and functions can vary across jurisdictions. It is this scale, complexity and diversity in functions that renders the task of implementing QI practices in public health settings challenging . FactorsProponents of QI have noted that to optimize the benefits of QI and elicit large-scale or transformational change, permeation of QI throughout an organization is required. Riley et al.  and DuffIn this review, preparedness and learning from past events were common themes, representing an iterative and cyclical process for improvement. IARs, AARs, SWOT analyses, and other improvement-related assessments were found to be useful tools for evaluating public health agency responses, including challenges, opportunities, and key learnings. Despite efforts to document experiences and recommendations from previous emergencies, research indicates this information is not applied to novel emergencies . This haAuthors also described their experiences with implementing a variety of QI tools and techniques during COVID-19. Their findings – while contextually and jurisdictionally specific – may offer valuable lessons for others looking to implement similar methods. QI methodologies range from formal QI tools and techniques implemented at the individual team or project level, to frameworks and methods exist for broader implementation of QI throughout the organization. Notably, few of the records reviewed discussed broader QI frameworks, suggesting that permeation of QI within public health settings is limited or not recorded and disseminated.Frameworks provide common terminology and an organized way to conceptualize information, and performance indicators provide standardized methods through which to measure performance, allowing comparability over time and across different settings. The availability of performance measurement data is a critical component of improvement in public health. Although the metrics and goals of QI in clinical and health care settings may differ from those in public health, these settings face similar data quality-related challenges. For instance, multiple factors hinder efficient data-sharing, data collection is labour-intensive, and lack of standardization in data collection methods hinders comparison across jurisdictions and over time; these challenges are compounded amid the demands of emergency response, creating a challenge in having reliable data available to inform action . Our resThere is applicability and value in implementing QI tools and techniques during rapidly evolving public health emergencies, including the COVID-19 pandemic. Yet, the findings here highlight a breadth of opportunities for the future scope of research and application of QI in PHEM. While the literature for this review spans a relatively short period of time, as the literature expands, future updates could explore experiences and evidence emerging from later waves of the pandemic. Additionally, none of the records addressed QI tools and techniques applied to health equity initiatives during the COVID-19 pandemic – an important goal within public health and PHEM. Application of QI to such functions  will help to support equitable public health measures and PHEM strategies given the disproportionate impact of COVID-19 related to population risk and the social determinants of health, as well as low-/middle-income countries, with deleterious impacts on local and global pandemic trajectories. , 47.This review had a number of limitations. First, due to the rapid nature of the review, additional search methods  were not undertaken; therefore, some relevant records may not have been not included. Second, any internal QI initiatives that were not posted publicly , or available in English, were not included in the review. Third, there is wide variation in the terminology used to refer to QI and improvement. Although our detailed search strategy sought to include the most commonly used terms, any terminology that does not appear in our search strings was excluded from the findings. Finally, the information summarized in this review includes records from a limited timeframe of the COVID-19 pandemic. The findings may change as the COVID-19 pandemic progresses, and as the corresponding literature evolves and expands.This review maps and describes the current evidence on QI strategies used by public health agencies to support key aspects of PHEM and the COVID-19 response. To optimize the benefits of QI methodologies, implementation of QI should focus both at the individual project as well as the organization level, integrated as part of an organizational management philosophy and culture. The examples in the literature provide support for inclusion of QI in public health practice as a systematic and transparent approach for public health agencies to monitor progress and improvements in PHEM to meet population health challenges. Future research describing and exploring QI outcome or process measures relevant to public health settings can be helpful to provide a more in-depth understanding of the mechanisms of organizational change, and may be helpful for informing future PHEM-related policy decisions.Additonal file 1. Appendix A. Search Strings


Diabetes mellitus is a major health problem among people with physical disabilities. Health coaching has been proven to be an effective approach in terms of behavioral changes, patient self-efficacy, adherence to treatment, health service use, and health outcomes. Telehealth systems combined with health coaching have the potential to improve the quality of health care by increasing access to services. Treatment fidelity is particularly important for behavior change studies; however, fidelity protocols are inadequately administered and reported in the literature.The aim of this study is to outline all the intervention fidelity strategies and procedures of a telecoaching intervention—artificial intelligence for diabetes management (AI4DM)—which is a randomized controlled trial to evaluate the feasibility, acceptability, and preliminary efficacy of a telehealth platform in adults with type 2 diabetes and permanent impaired mobility. AI4DM aims to create a web-based disability-inclusive diabetes self-management program. We selected the National Institutes of Health Behavior Change Consortium (NIH BCC) fidelity framework to describe strategies to ensure intervention fidelity in our research.We have developed fidelity strategies based on the five fidelity domains outlined by the NIH BCC—focusing on study design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills. The design of the study is grounded in the social cognitive theory and is intended to ensure that both arms would receive the same amount of attention from the intervention. All providers will receive standardized training to deliver consistent health coaching to the participants. The intervention will be delivered through various controlling and monitoring strategies to reduce differences within and between treatment groups. The content and structure of the study are delivered to ensure comprehension and participation among individuals with low health literacy. By constantly reviewing and monitoring participant progress and protocol adherence, we intend to ensure that participants use cognitive and behavioral skills in real-world settings to engage in health behavior.Enrollment for AI4DM will begin in October 2021 and end in October 2022. The results of this study will be reported in late 2022.Developing and using fidelity protocols in behavior change studies is essential to ensure the internal and external validity of interventions. This study incorporates NIH BCC recommendations into an artificial intelligence embedded telecoaching platform for diabetes management designed for people with physical disabilities. The developed fidelity protocol can provide guidance for other researchers conducting telehealth interventions within behavioral health settings to present more consistent and reproducible research.ClinicalTrials.gov NCT04927377; http://clinicaltrials.gov/ct2/show/NCT04927377.PRR1-10.2196/31695 Although diabetes mellitus (DM) is a significant problem among all populations, people with disabilities are more likely to be affected by DM. According to the 2017 Behavioral Risk Factor Surveillance System report, 23.6% of people with disabilities are diagnosed with diabetes, whereas 9% of people without a disability are diagnosed with diabetes . GlycemiBehavioral weight loss programs, such as the lifestyle interventions used in the Diabetes Prevention Program, have proven successful in DM management . HoweverTo address these deficiencies, we are developing a platform that combines human synchronous telecoaching with mobile health  technologies to promote T2D self-management for people with disabilities. In this artificial intelligence (AI)–assisted, individualized, family-focused, lifestyle modification telehealth intervention (AI for DM [AI4DM]), we use an AI-embedded telecoaching dashboard to promote the fidelity of coaching sessions and reduce the workload required to personalize telecoaching.Fidelity in health behavior change studies is an essential factor in ensuring that the intervention program is delivered as intended . TeleheaThe complexity of research designs, working with diverse populations, and maintaining credibility when testing the feasibility of innovative interventions are common challenges faced by behavior change studies. The methodological challenges in designing, conducting, and reporting health behavior change studies eventually led to the formation of the Treatment Fidelity Workgroup of the National Institutes of Health Behavior Change Consortium (NIH BCC) . In 2004Considering the importance of developing and using treatment fidelity in behavioral change interventions, we aim to describe and report the fidelity protocol for the AI4DM study. AI4DM combines mHealth technologies with telecoaching sessions to create the first-ever web-based diabetes self-management program for people with disabilities. The fidelity protocol was developed to address the five domains of intervention fidelity outlined by the NIH BCC. Considering the complexity of our intervention design, the development and use of the fidelity protocol is essential to document our fidelity measures to present more consistent and reproducible research.This project aims to develop and assess a telehealth framework, AI4DM, paired with inclusive diabetes self-management content. AI4DM is grounded in the social cognitive theory (SCT)  and is dAt the center of AI4DM, there is an AI-embedded coaching dashboard. This dashboard will assist health coaches in offering consistent and personalized health coaching for participants. The AI engine will be connected to a commercial ingredient and recipe database and use a food recommendation engine to offer personalized nutrition tips that take into account a given participant’s recommended diet, the participants’ and caregivers’ cuisine preferences, time and food availability, financial limitations, cooking skills (accessibility), and other preferences and limitations. The AI engine will also feature a rule-based expert system to offer personalized PA recommendations based on the participants’ physical conditions, environmental conditions, and preferences. All data generated by the AI engine will be delivered to the participants and their caregivers after approval and tailoring from health coaches. The delivery of information to participants and caregivers will be enabled through multiple channels—smartphones , conversational agents , and telecoaching phone calls—thereby enhancing accessibility to the information. The design and educational content of mHealth apps will be tailored and inclusive of people with all forms of disabilities. Collectively, these AI-assisted and user-centered design features will reduce the time and effort required by health coaches and promote sustained use of the intervention by participants, eventually enabling self-management.The primary aim of AI4DM is to evaluate the feasibility , acceptability , and preliminary efficacy of AI4DM in adults with type 2 DM (T2DM) and permanent impaired mobility. We will use a randomized controlled pilot study design in which 90 adults with T2DM and permanent impaired mobility will be randomized to the AI4DM intervention arm or an attention control arm. The entire recruitment will be conducted nationally, on the web, through the National Center on Health, Physical Activity, and Disability website, associated social media, and ResearchMatch website. The inclusion criteria were as follows: (1) diagnosis of T2DM; (2) glycated hemoglobin ≥8%; (3) 18 to 65 years of age; (4) living with a permanent physical disability such as a spinal cord injury, spina bifida, multiple sclerosis, or stroke; (5) can speak and read English; and (6) availability of a smartphone. This study was approved by the institutional review board, and all screened participants provided informed consent before enrollment.For the intervention, each participant will be randomly assigned to one of two treatment conditions: (1) AI4DM intervention with telecoaching support and (2) attention control. We planned an active (coach contact) intervention period of 24 weeks (6 months) with 18 coaching calls during that period, followed by a passive period of 24 weeks (6 months) with only technology access to see if self-management behaviors were sustained. study design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills [We have developed methodological strategies to monitor and enhance fidelity based on the NIH BCC Treatment Fidelity recommendations, focusing on t skills . Monitordose of the treatments, and (3) all procedures would address possible setbacks in implementation. On the basis of the Behavior Change Consortium treatment fidelity recommendations, study designs must ensure that (1) the procedures and implementation are congruent with the presented theory and clinical practices, (2) participants receive the equal GoalIntervention will be congruent with presented theory and practiceEqual treatment dose will be given within and across conditionsAddressing implementation setbacksDescription from the National Institutes of Health Behavior Change ConsortiumOperationalize treatment to optimally reflect theoretical roots; precisely define variables most relevant to “active ingredients” of the interventionEnsure equal treatment “dose”  is adequately described and is the same for each subject within and across treatment conditionsAddress possible setbacks in implementation Fidelity monitoring plan for artificial intelligence for diabetes mellitusMonthly review of coaching call checklist and call logsQuarterly review of randomly selected coaching callsQuarterly review of content resource bankTeam meetings to discuss participant progress and protocol adherenceReview of telecoaching platform and its event logReview of adverse event logAI4DM is grounded in the SCT view that self-management is not under the complete control of an individual but rather occurs in the context of a larger social environment involving the individual . Thus, Acourtesy calls are devised to ensure that both groups received the same amount of attention from the telecoach, thereby not influencing or inflating the effect size for future research. Thus, both groups will receive one weekly call for 12 weeks and one biweekly call for the next week. The AI4DM intervention and attention control groups will be exposed to the same data collection measures and protocols.The attention control group will be used to provide an untreated comparison for the AI4DM intervention group and will receive phone calls from the telecoach at the same frequency as the intervention group. These We will collect evidence on reporting and handling constraints of adverse events, serious adverse events, and clinical emergencies, as well as participant experiences, burdens, and compliance during the assessment experience and intervention. Assessment experience will be documented through participant self-reports of time to complete the baseline intake. Intervention experience will be documented by having participants self-report parameters of coaching sessions in participant logs and through an evaluation of staff logs.drift in provider skills, and (4) accommodate provider differences. The project team of the study has the appropriate experience and training needed for the successful completion of all the proposed activities. We have assembled a multidisciplinary team of academic, technical, and programmatic professionals that are uniquely positioned with the necessary technical, disability, diabetes, PA, nutrition, behavior change, content development, and coaching-related skills and knowledge. During the intervention, health coaches will be formally trained in a PA-, nutrition-, or nursing-related health profession and pay special attention to regular blood sugar monitoring, setting nutrition goals, and PA goals in weekly calls (up to 60 minutes). The dashboard in the developed platform will assist health coaches in offering consistent and personalized health coaching for participants. The Behavior Change Consortium recommends four strategies to monitor and improve provider training: (1) standardize training, (2) ensure provider skill acquisition, (3) minimize GoalStandardized trainingEnsure provider skill acquisitionMinimize “drift” in provider skillsAccommodate provider differencesDescription from the National Institutes of Health Behavior Change ConsortiumTraining must be conducted similarly for all providersTrain providers to well-defined performance criteriaEnsure provider skills do not decay over timeEnsure adequate level of training in providers of different skills level, experience, or professional backgroundStrategies used in artificial intelligence for diabetes mellitusThe coaches will receive American Council on Exercise health coaching trainingReview of coaching calls checklists and call logsRecording coaching callsQuarterly review of random selection of callsTeam meetings to discuss participant progress and protocol adherencecontrol for provider differences,reduction of differences within treatment groups,ensure adherence to treatment protocols, and minimize contamination between conditions [Another essential strategy provided by NIH BCC is to ensure that treatment or intervention is delivered as planned. As recommended by NIH BCC, we designed our protocol to address four major goals for fidelity of treatment delivery: nditions ,14  across conditionsEnsure that providers in the same condition are delivering the same interventionEnsure that the treatments are being delivered in the way in which they were conceived with regard to content and doseMinimize contaminationStrategies used in artificial intelligence for diabetes mellitusCoaching call checklists and call logsRandom audit of audio recording of coaching callsReview of randomly selected coaching sessionsHaving different supervisors to evaluate the content and coaching sessionsTeam meetings to discuss participant progress and protocol adherenceReview of telecoaching platform and its event logTo deliver the intervention protocol effectively, we plan to incorporate various strategies, including reporting and monitoring participants’ and health coaches’ complaints, having health coaches working with participants in both arms, audiotaping coaching sessions, and auditing and monitoring of random selection of coaching calls by an expert to evaluate the sessions. Although the platform and REDCap (Research Electronic Data Capture)  will proAI4DM, as a telecoaching platform, uses an artificial engine–embedded telecoaching dashboard to promote the fidelity of coaching sessions and reduce the workload required to personalize telecoaching. The dashboard will assist the coach in effectively preparing for and conducting calls and acting as a proxy for the participants’ self-management activities if needed. While using a scripted intervention protocol and detailed coaching manuals to reduce human error, we will also use standard materials and resources scheduled for each week based on the PRIDE (Partnership to Improve Diabetes Education) toolkit that has 30 comprehensive interactive education modules .courtesy calls will only focus on the general well-being of the participants. Besides the coaching sessions, the platform will involve an abundance of videos, graphical and textual content, and technical features to deliver the intervention effectively. We will maximize the use of short video clips and infographics, paired with appropriate alternate access strategies. Educational content will be provided through the app and reinforced through telecoaching sessions and conversational agents (Amazon Echo). Conducting weekly team meetings to discuss participant progress and protocol adherence and having different supervisors evaluate the content and coaching sessions will also help ensure adequate treatment delivery.All procedures for delivering treatment goals will be standardized according to the group assignment to reduce the differences within treatment groups. For the coaching sessions, health coaches will focus on four domains: healthy eating, exercise, glucose monitoring, and medication adherence. Although the attention control arm will receive phone calls from the telecoach at the same frequency as the intervention group, these In addition to the quarterly audio recording of coaching calls, coaching call checklists and coaching call logs will be used to improve adherence to the intervention protocols. Call logs will include information regarding the calls made, attempted, missed, and voicemails. Scheduled calls and summary notes will also be recorded in these logs. Coaching call checklists are intended to remind health coaches to prepare for scheduled content delivery. The call logs and coaching checklists will be audited monthly. Moreover, a detailed scripted missed call protocol will be provided for health coaches to follow.Upon randomization, participants will be assigned to either the attention control arm or the intervention arm. The coaches will be provided with a scripted protocol for both groups. The coaches will be given standardized training and supplied with the PRIDE manual. The review of recorded phone calls and the trackable progress of the participants on the platform will act as a monitoring step to detect contamination.The success of an intervention depends on its clarity and applicability. Receipt of treatment strategy focuses on the participant’s ability to understand the given content and perform the related behavioral activities during the intervention. The structure of AI4DM was created according to the three goals that NIH BCC suggests: (1) ensure participant comprehension, (2) ensure participant ability to use cognitive skills, and (3) ensure participants’ ability to perform behavioral skills .AI4DM is developed for people with disabilities who are more prone to experiencing low health literacy (LHL) ,23. SimiIn addition, participants will be counseled using techniques drawn from cognitive behavioral therapy . The cogGoalEnsure participant comprehensionEnsure participant ability to use cognitive skillsEnsure participant ability to perform behavioral skillsDescription from the National Institutes of Health Behavior Change ConsortiumEnsure that participants understand the information provided by the interventionMake sure that participants are able to use the cognitive skills taught in the interventionMake sure that participants are able to use behavioral skills taught in the interventionStrategies used in artificial intelligence for diabetes mellitusTarget reading level of fifth grade or below for the contentReview of recorded coaching sessionsReview of participant food, physical activity, medication, and glucose journalsReview of participant log-ins and time spent on platformTeam meetings to discuss participant progress and protocol adherencereal-world settings. To ensure participants’ use of cognitive and behavioral skills, the content for the proposed program will be adapted from a variety of sources. The Diabetes Literacy and Numeracy Education Toolkit [According to NIH BCC, enactment of treatment skills is one of the most challenging aspects of intervention fidelity. It involves applying the proposed theories and protocols to  Toolkit  and the  Toolkit  will forParticipants in the intervention arm would also receive a wireless blood glucose monitor and a Fitbit Flex (Google LLC), which are used for intervention delivery and not for outcome measurement. This program involves an abundance of videos, graphical and textual content, and technical features such as AI-assisted dietary planning and tracking, sensor-based PA tracking, and context-aware recommendations to help participants understand and adopt the related cognitive and behavioral skills. Having access to digital content (texts and videos) and one-to-one interaction with a health coach is expected to improve the cognitive and behavioral performance of the participants. GoalEnsure participant use of cognitive skillsEnsure participant use of behavioral skillsDescription from the National Institutes of Health Behavior Change ConsortiumEnsure that participants actually use the cognitive skills provided in the intervention in appropriate life settingsEnsure that participants actually use the behavioral skills provided in the intervention in appropriate life settingsStrategies used in artificial intelligence for diabetes mellitusReview of participant food, physical activity, medication, and glucose journalsReview of participant log-ins and time spent on platformTeam meetings to discuss participant progress and protocol adherenceReview of coaching notesEnrollment for AI4DM began in August 2021 and will end in August 2022. The results of this study will be reported in late 2022.Treatment fidelity refers to strategies for monitoring and enhancing the consistency and accuracy of an intervention. Reporting treatment fidelity is an essential component to ensure that the intervention is implemented as planned ,27. A beThis study applied treatment fidelity strategies and recommendations from NIH BCC, which includes five fidelity domains . We haveFollowing the NIH BCC framework, we generated detailed protocols regarding the design, training, delivery, receipt, and enactment components for the management and implementation of our program. One of the challenges that we encountered was using different platforms to manage and monitor the fidelity of the intervention. Comprehensive protocols that use both an AI-assisted telecoaching platform and a data management tool, that is, REDCap, to manage and deliver the intervention. To prevent potential setbacks in the implementation of the intervention and increase the applicability of the procedures, we collaborated with our tech team before finalizing our protocols. Thus, we expected no drastic changes in the fidelity processes during the intervention.therapist drift, which can lead to lower treatment engagement. In this phenomenon, health coaches may unintentionally or unknowingly shift from the main topic by making small changes to the administration of the intervention [We have observed extensive preparatory and postwork before and after a call through several of our earlier health coaching–related projects. This often involves reading call notes, search recipes, manually emailing reminders, and follow-up messages. Similarly, some studies have pointed out that variations between coaches are a major limitation for health coaching ,31. All rvention ,32. In tAlthough there is always a threat to fidelity assessment that participants can provide desirable responses to the coaches, having a protocol based on NIH BCC criteria will positively affect the study’s internal or external validity, which will eventually affect the outcomes and interpretation of the results. Consistently monitoring fidelity can also provide valuable insights regarding the implementation of the intervention. Therefore, in this study, we outlined all the intervention fidelity strategies and procedures of the AI4DM project to evaluate its feasibility, acceptability, and preliminary efficacy in adults with T2DM and permanent impaired mobility.


This commentary reviews the current status of compounding pharmacies and underscores outdated and inaccurate information in the clinical opinions and position statements of two prominent societies. There has been limited and outdated guidance from both The American College of Obstetrics and Gynecology (ACOG) and The North American Menopause Society (NAMS) regarding the utilization of bio-identical hormones in women. Prior to the Women’s Health Initiative (WHI), hormone replacement therapy was used to treat the symptoms of menopause and improve the overall quality of life and health of women worldwide. In fact, in a randomized controlled trial, there were improvement in the somatic and psychological complaints affecting post-menopausal women ,2.®  , the indications and utilization of Hormone Replacement Therapy (HRT) have changed dramatically. Many physicians, fearing reported side effects, have stopped prescribing HRT. Moreover, many patients have retreated to the sidelines, feeling that no HRT may be the safer alternative. Time magazine dramatized the outcome further by stating that hormone replacement therapy was “riskier than advertised”  Com“Not only is evidence lacking to support superiority claims of compounded bioidentical hormones over conventional menopausal hormone therapy, but these claims also pose the additional risks of variable purity and potency and lack efficacy and safety data.”In 2017 , the Nor“Compounded hormone therapies are prepared by a compounding pharmacist using a provider’s prescription and may combine multiple hormones , use untested, unapproved combinations or formulations, or be administered in nonstandard (untested) routes such as subdermal implants, pellets, or troches.”“Compounded HT has been prescribed or dosed on the basis of salivary hormone testing; however, salivary testing for HT is considered unreliable because of differences in hormone pharmacokinetics and absorption, diurnal variation, and interindividual and intraindividual variability.”“Prescribers should only consider compounded HT if women cannot tolerate a government-approved therapy for reasons such as allergies to ingredients or for a dose or formulation not currently available in government-approved therapies. With interim guidance on compounding safety and quality control from FDA, quality control of compounded HT may improve.”“Compounded bioidentical HT presents safety concerns such as minimal government regulation and monitoring, overdosing or underdosing, presence of impurities or lack of sterility, lack of scientific efficacy and safety data, and lack of a label outlining risks.”As these are the most updated statements and opinions, they remain outdated and are not accurate in depicting the current state of compounded bio-identical hormone therapy.Just as pharmaceutical manufacturing has evolved and improved over the past decades, the same can be said for compounding. In a world where HRT has been more established for women, the availability of individualized dosing of hormones has relied heavily on compounding pharmacies to achieve products of the greatest need for women’s health. Individualized dosing more precisely addresses the hormone deficiencies of each patient and contributes to greater benefits while simultaneously minimizing risk. This is especially true of testosterone where there are no commercially available products for practitioners to prescribe for women.“Compounding is the creation of an individualized preparation in response to a health care provider’s prescription to create a medication tailored to the specialized needs of an individual patient“, according to the Position Statement (532) published by the ACOG. This definition is both antiquated and incomplete because of The Drug Quality and Security Act in 2013, which added a new section 503B to the FD&C Act . Under sAdditionally, they are required to report serious and unexpected side effects and complications from their products directly to the FDA, which adds a layer of safety on a foregoing basis regarding adverse outcomes that might occur from their products.Healthcare has entered an era of precision medicine. Better stated, we have graduated to individualized healthcare and, as such, women very much want to co-pilot their care. Furthermore, women are trying to feel their best no matter their age. Thus, longevity with vitality matters. They want to avoid many of the diseases suffered by their ancestors such as Alzheimer’s disease, cardiovascular disease, osteoporosis, and breast cancer. The slogan to take hormones in the lowest dose possible for the shortest time possible should be phased out based on newer evidence in the existing literature .Many of the symptoms in both pre-menopause and post-menopause have been successfully treated with bio-identical hormones . These symptoms include hot flashes, night sweats, insomnia, mood disorders, fatigue, joint pains, and many others. The response to these hormones has been reported in multiple citations in the existing literature ,12,13,14The position statement from the North American Menopause Society (NAMS) has focused on the unreliability of salivary testing but has failed to mention the reliability of serum hormone testing, particularly concerning the use of RIA (radioimmunoassay) and HPLC (High-performance liquid chromatography) .® does pose that risk  and Climara® ) and sub-cutaneous hormone pellet therapy with testosterone and estradiol.A more contemporary position statement is needed from both the ACOG and NAMS. Such statements should provide a more accurate depiction of the current state of compounded Bio-identical hormones. These statements should also note that the stringent conditions imposed by the FDA on 503b outsourced pharmacies have improved the purity, potency, and sterility of these products, comparable to that of commercially available hormone products. The question concerning the long-term safety of bio-identical hormones has been answered through years of experience utilizing estradiol patches (e.g., Vivelle


Cannabis sativa L.) grown for cannabidiol (CBD) has spurred a surge of interest in the United States. Cultivar selection and harvest timing are important to produce CBD hemp profitably and avoid economic loss resulting from the tetrahydrocannabinol (THC) concentration in the crop exceeding regulatory limits. Hence there is a need for differentiating CBD hemp cultivars and growth stages to aid in cultivar and genotype selection and optimization of harvest timing. Current methods that rely on visual assessment of plant phenotypes and chemical procedures are limited because of its subjective and destructive nature. In this study, hyperspectral imaging was proposed as a novel, objective, and non-destructive method for differentiating hemp cultivars, growth stages as well as plant organs (leaves and flowers). Five cultivars of CBD hemp were grown greenhouse conditions and leaves and flowers were sampled at five growth stages 2–10 weeks in 2-week intervals after flower initiation and scanned by a benchtop hyperspectral imaging system in the spectral range of 400–1000 nm. The acquired images were subjected to image processing procedures to extract the spectra of hemp samples. The spectral profiles and scatter plots of principal component analysis of the spectral data revealed a certain degree of separation between hemp cultivars, growth stages, and plant organs. Machine learning based on regularized linear discriminant analysis achieved the accuracy of up to 99.6% in differentiating the five hemp cultivars. Plant organ and growth stage need to be factored into model development for hemp cultivar classification. The classification models achieved 100% accuracy in differentiating the five growth stages and two plant organs. This study demonstrates the effectiveness of hyperspectral imaging for differentiating cultivars, growth stages and plant organs of CBD hemp, which is a potentially useful tool for growers and breeders of CBD hemp.As an emerging cash crop, industrial hemp ( Cannabis sativa L.) as marijuana that is mainly used recreationally for its intoxicating properties. In the United States, hemp is legally defined as Cannabis sativa L. that contains no more than 0.3% total tetrahydrocannabinol (THC), the compound that is responsible for getting a person high and more abundant in marijuana. Because of its association with marijuana, commercial production of hemp in the United States has been long restricted until the passage of the 2018 Farm Bill  of the plant organs . Visual inspection is affected by inconsistency and variability associated with the perception of inspectors, which is further complicated by significant biological variations within and among hemp cultivars. Some hemp cultivars may not be visually distinct and readily differentiated from each other. Thus, analytical methods, such as gas/liquid chromatography and mass spectrometry , have beOptical sensing technology, which interrogates biological materials non-destructively, is considered an attractive means for addressing the shortcomings of human inspection and analytical testing. Numerous studies have been conducted on using spectroscopic techniques for cultivar/variety differentiation of plants and agricultural products . RecentlHyperspectral imaging is a power modality for measuring spectral and spatial information of samples simultaneously . CompareGiven the limitations of existing methods using visual assessment and chemical analysis for phenotyping and characterization of hemp plant materials, the objective of this research is therefore to present a proof-of-concept validation of a novel hyperspectral imaging-based approach for non-destructive, fast, and objective differentiation of cultivars, growth stages and plant organs  of CBD hemp. Specifically, in this research we acquired hyperspectral images from freshly harvested leaf and flower materials of five cultivars of CBD hemp at five growth stages using a benchtop hyperspectral reflectance imaging system, developed an image processing pipeline for segmenting the plant parts from background and extracting spectra from sample segments, performed exploratory analysis of spectral features of hemp samples, and built classification models to differentiate the cultivars, growth stages, and plant parts. This study demonstrates the efficacy of hyperspectral imaging technology as a tool to differentiate cultivars, growth stages and plant parts of CBD hemp, which will be beneficial for hemp cultivation and breeding programs.Five CBD hemp cultivars were used in this study, including Cherry Wine (CW), BaOx (BX), First Light 58 (FL58), First Light 70 (FL70), and TJ’s (TJ). These cultivars were chosen as they were used in a complimentary field trial to determine the optimum harvest date, and particularly BX and CW represent the majority of CBD hemp cultivars planted in North Carolina. The hemp plants were grown in a greenhouse, as shown in Hemp harvests took place during September to November of 2020, at 2, 4, 6, 8, and 10 weeks after flower initiation, corresponding to five plant growth stages. At the time of harvest or growth stage, four plants were randomly chosen per cultivar row, corresponding to four replications, and both leaves and flowers, as shown in A portable, benchtop hyperspectral reflectance imaging system  under co2 per pixel for hemp samples), and the number of scanning lines per datacube depended on the actual scanning duration.Image acquisitions were conducted on five harvest occasions as indicated above. The hemp leaves and flowers were imaged separately for individual plants. The software SpectrononPro  was used for controlling the camera and motorized stage during imaging. The acquired hyperspectral datacube consisted of 462 wavelengths over a wavelength range of 400–1000 nm (at a spectra resolution of 1.3 nm), and spatially each scanning line consisted of 1,600 pixels /(Rλ1@+Rλ2@), where, R@λ1 and R@λ1 denote the reflectance images at wavelengths λ1 and λ2 (λ1 > λ2), respectively.The acquired hyperspectral images were processed to segment the reference and hemp samples from the background. Thresholding is a simple and effective technique for image segmentation, provided that the image histogram has well-defined modes corresponding to regions of interests. While a flat, uniformly colored tray  was usedIn this study, the best wavelength pair was determined, as illustrated in The contrast-optimized NBD images enable the segmentation of hemp samples and reference by global thresholding. The histogram of the NBD image, as showed in Furthermore, given a hyperspectral datacube for each scan, mean spectra were extracted for the reference and individual hemp leaves/flower samples, respectively, by averaging the spectra of all the pixels in the corresponding region of interest. Thereafter, ratio spectra were obtained by dividing the spectra of hemp samples by the spectrum of the reference in the same scan, to standardize the spectral responses of the camera, and used for building discriminative models as described below. While morphological or texture features can also be extracted and fused with the mean spectra for modeling tasks, only the latter were used for the modeling tasks and found adequate for yielding high classification accuracies.Machine learning models were developed to differentiate five hemp cultivars, five growth stages (corresponding to five sampling dates) and two plant organs , respectively. For cultivar differentiation, the models were built using the spectra of hemp leaves and flowers, respectively, as well as using the ensemble of hemp leaf and flower samples, at each growth stage. Furthermore, the ensemble of the samples from different stages is also examined for model development. For growth stage differentiation, similarly, classification models were built using hemp leaves and flowers, respectively, for each cultivar. Moreover, models were built for discriminating hemp leaves and flowers for each cultivar at each growth stage. In each modeling scenario, the spectral dataset was randomly partitioned into training and test sets according to a ratio of 3 to 1 , for modRegularized linear discriminant (rLDA) proposed by All the analyses for image preprocessing, feature extraction and model development were performed in Matlab R2020b .The hemp samples cannot be directly distinguished for the five cultivars from the spectral profiles, because of strong overlapping  top; wheThe machine learning models based on rLDA were first developed for differentiating the hemp cultivars using the spectral data of leaf and flower samples separately as well as their combination, at each growth stage (harvest dates). In each scenario, discriminative models were built and tested over 30 replications with random dataset partition for each replication, and the mean overall classification accuracy on test data was calculated and used as the metric of classification performance. may have low concentrations at this stage, which remains to be validated by a further study on chemical analysis of hemp samples. At later growth stages (8–10 weeks after flower initiation), a few hemp plants had minor spider mite (Tetranychus urticae) infestation on the leaves, which could also confound the discrimination of hemp cultivars.In addition to modeling the samples at individual growth stages, the samples collected from different growth stages were also pooled together to build models for cultivar classification. Here, three types of models were built by pooling all the leaf samples, the flower samples and their combination at the five growth stages, resulting in the accuracies of 91.9%, 91.8%, and 82.8%, respectively, as shown in Overall, these classification results demonstrate that hyperspectral imaging coupled with supervised modeling is a viable means for differentiating hemp cultivars with high accuracy, and that the growth stage and plant organ need to be factored in developing cultivar classification models.Cannabis sativa using NIRS combined with support vector machine. Cannabis sativa and achieved near 100% precision based on decision tree modeling. All these findings conceivably verify the prowess of hyperspectral imaging for accurately discriminating plant growth stages and organs (leaf and flower). Moreover, the perfect classification of growth stages can be potentially beneficial for improving the classification of hemp cultivars at varying growth stages by deploying cascade classifiers for classifying both hemp growth stages and cultivars.Furthermore, rLDA models were built for discriminating the five growth stages and plant organs (leaf and flower) for each of the five hemp cultivars. The classification accuracies of 100% with zero standard error in 30 modeling replications  were obtIt is important to point out potential areas for further improvements. Although the standard reference (2” × 2” in size) was scanned along with hemp samples for spectral correction, it was not still sufficient for accounting for the spatial non-uniformity of illumination over the scanning line. It is more desirable to use a larger reference for imaging so that the spectral correction of samples can be performed at a pixel level along the scanning line. An alternative solution is to improve the lighting design to provide uniform illumination over samples. Using two line-light illuminators positioned symmetrically to the camera axis , insteadin-situ scanning of hemp plants under natural light conditions, requiring no sampling of plant parts. Harvesting hemp for maximum CBD yield while avoiding THC exceeding legal thresholds requires quantification of these chemical compounds in plant organs . Investigations are underway to determine the feasibility of using hyperspectral imaging for screening hemp genotypes based on CBD and THC concentrations in plant tissues at different growth stages.The present study only conducted hyperspectral scanning for sampled plant organs  in controlled-light settings. For high-throughput testing and a further validation of the hyperspectral imaging approach, further studies are needed to perform in-situ applications.In this study we propose a new methodology of using hyperspectral imaging for differentiating cultivars, growth stages, and plant organs (leaves and flowers) of CBD hemp. Fresh leaves and flowers of five hemp cultivars, harvested at five growth stages 2–10 weeks after flower initiation, were scanned by a benchtop hyperspectral reflectance imaging system in the wavelength range of 400–1000 nm. An image processing algorithm was developed for segmenting samples from background. The spectral profiles and PC score scatter plots of hemp samples, to a varying degree, revealed the separation among the hemp cultivars, growth stages and plant organs. The rLDA models, using leaf or flower samples at individual growth stages, achieved the classification accuracies of 96.8%-99.6% in the differentiation of hemp cultivars. Pooling leaf and flower samples at all growth stages resulted in deteriorated accuracies compared to modeling samples at individual growth stages. Both growth stages and plant organs need to be factored in model development for hemp cultivar classification. In contrast, in the differentiation of growth stages and plant organs, the rLDA models achieved 100% accuracies consistently. This study shows that hyperspectral imaging can be used for non-destructive and accurate differentiation between hemp cultivars, growth stages and plant organs, and it is a potentially valuable tool for phenotyping, cultivar selection and optimization of harvest timing in CBD hemp production. Extensive research is still needed to develop and deploy hyperspectral imaging technology for field-scale, The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.YL: conceptualization, methodology, data collection, final analysis, writing – original draft preparation, reviewing, and editing. SY: data collection, writing, reviewing, editing, and project administration. EL: data collection, writing, reviewing, and editing. BW: resources, writing, reviewing, and editing. DS: data collection, resources, writing, reviewing, and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Safe and effective rotavirus vaccines (RVs) are needed to reduce the enormous public health burden of rotavirus illness in developing countries. Vaccination is critical for effective control of rotavirus infection since it cannot be prevented with improvements in water and sanitation. The International Centre for Diarrhoeal Disease Research, Bangladesh  has completed several groundbreaking RV trials (Phase I–Phase IV). The safety, immunogenicity, efficacy, and effectiveness of different RVs were evaluated among both urban and rural populations. In this study, we present the results, policy implications, and lessons learned for successful implementation of these trials as well as future directions for rotavirus vaccination in Bangladesh. Almost all infants without vaccination experience at least 1 rotavirus infection by 2 years of age, and approximately 118 000 children under 5 years of age died globally due to rotavirus in 2019 . HoweverThe icddr,b is the world’s largest diarrheal hospital and treats more than 200 000 patients a year. For the last 50 years, its research continues to evaluate low-cost, scalable vaccines against rotavirus, cholera, other enteric and respiratory diseases and different noninterventional public health approaches. It is notable that its development of oral rehydration solution has saved tens of millions of lives and created a profound impact on global health crises. With the support of highly knowledgeable and skilled scientists, clinicians, researchers, nurses, health workers, and auxiliary staff with unparallel experience, icddr,b can undertake various investigations on emerging infectious diseases and new interventions to reduce maternal and neonatal mortality.The icddr,b has conducted several RV trials ranging from Phase I to III and postmarketing evaluation of the vaccines (Phase IV). Three US Food and Drug Administration-licensed rotavirus vaccines were tested and evaluated in the icddr,b trials: tetravalent rhesus rotavirus vaccine , pentavalent rotavirus vaccine , and monovalent rotavirus vaccine  , 5–7. WeThe first rotavirus vaccine trial conducted by icddr,b was a Phase II randomized, double-blinded, placebo-controlled trial to test the safety and immunogenicity of RRV-TV during the period of 1998–1999 in rural Bangladesh. The study showed that RRV-TV was comparably immunogenic (87% seroresponse rate) and safe as other trials conducted in the developing world . The stuThe icddr,b conducted a Phase III clinical study among 2036 infants to assess the safety, immunogenicity, and efficacy of the 3-dose RotaTeq vaccine administered at 6, 10, and 14 weeks of age along with Vietnam and scientists from other institutions who simultaneously conducted trials in 3 sites in Africa . The study showed a significant reduction of severe rotavirus disease by 51% in the first year of life, when children are at the greatest risk of diarrhea-related illness and death. This finding supports expansion of the WHO recommendations to promote the global use of the rotavirus vaccine . Our stuOur experience with rotavirus vaccine trials indicates that that all phases of clinical trials with good clinical practice standards can be conducted maintaining high quality and coverage in urban slums and in rural populations of Bangladesh. For all trials, we were able to enroll a large number of study participants within the timeline and foster high compliance of study-related activities. We conducted these studies in vulnerable slum and rural populations by maintaining a community relationship, which benefitted the study population to a large extent. The rotavirus-effectiveness study provided experience with the vaccine in a “real-world” setting, and valuable lessons were learned on routine vaccine delivery in Bangladesh.am to 5:00 pm and remained open for 24 hours for any emergency services. After office hours, mothers could easily communicate with study medical officers and respective field staff over the phone to ensure necessary treatment of their infants. Standard medical care was provided free of cost, and we referred patients to the nearby hospitals when inpatient services were needed. All these initiatives highly encouraged the community in both the urban slums and rural Bangladesh to take part in our studies over many years.A few challenges were faced in the trials, such as maintaining proper temperature of vaccines in very hot weather and carrying vaccine cold boxes during rainy season with difficult transportation system, but it was managed successfully because of very careful forward planning. There were no unacceptable temperature deviations recorded during vaccine and sample storage or transportation, nor any record of vaccine vial damage. Retention of study participants in a mobile population, particularly in urban areas with migration rates of approximately 25% per year, was hard to achieve. The study clinic provided outpatient services for the study population 7 days a week from 8:30 In 2016, Bangladesh applied to Gavi for support for rotavirus vaccination, and they expected to introduce Rotarix in the routine immunization in 2018 . Gavi-fuWe are optimistic that Bangladesh will hasten the process to introduce the rotavirus vaccine initially approved in principle. We need strong political commitment and approval from different national immunization committees  to ensure that appropriate attention and energy is focused on implementing the country’s rotavirus vaccination plans. Furthermore, the decision to introduce any new vaccines also depends on the different studies conducted by research organizations, particularly on disease burden and cost-effectiveness analysis. Coordination among EPI officials, global and national rotavirus experts, vaccine developers, and concerned people is crucial to explain the intervention to the policymakers to convince them to move forward and take the necessary action. Even after the introduction of the rotavirus vaccine, there can be a shortage of supply; hence, there must be a backup plan for possible alternative products for uninterrupted vaccine supply. A coalition with neighboring India, which contains the developers of 2 recent WHO prequalified rotavirus vaccines (ROTAVAC [Bharat Biotech] and ROTASIIL [Serum Institute of India]), can make the transition easier. Soon after a vaccine is introduced, postvaccination surveillance is important to identify effectiveness, manage postvaccination risk  to understand the impact of vaccination, and undertake postvaccination control measures . The rou


Depression in older adults is associated with loss of functioning and increased mortality. While many factors contribute to depression among this population, activities of daily living (ADL) limitations and cognitive impairment have been identified as key risk factors. However, no study, to our knowledge, has examined the extent to which physical and cognitive limitations independently and jointly contribute to the risk of depression. The current study describes the prevalence and compares the independent and joint associations of these limitations with depression in a nationally representative sample of adults aged 51 and older in the US. Analyses are based on a sample of 17,044 repeated observations on 6,636 unique primary respondents from three waves of pooled data from the Health and Retirement Study. We estimate linear and logistic multivariate regression models investigating the association between ADL limitations , cognitive impairment , and depressive symptoms (8-item CES-D), controlling for a standard set of socioeconomic and health factors. First, we find that 66% of respondents report no limitations, 16% report only cognitive impairment, 11% report only ADL limitations, and 7% report both types of limitations. Multivariate analyses suggest that ADL limitations have a much stronger association with depression compared to cognitive impairment, and this association is robust across alternative specifications. In next steps, we will take advantage of the longitudinal nature of these data to estimate changes in these characteristics over time and within individuals and explore heterogeneity in associations across relevant groups.


A large body of literature exists on trade liberalisation and the ways in which trade agreements can affect food systems. However, the systematic and objective monitoring of these and their impact on national food environments has been limited. Using a case study, this paper undertakes a systematic analysis of how Vanuatu’s obligations under WTO agreements has impacted its food environment.Data collection was guided by the INFORMAS trade monitoring framework’s minimal approach and seven selected indicators outlined in three domains: trade in goods, trade in services and FDI, and policy space. Strong associations between trade liberalisation and imported foods, especially ultra-processed foods were evident in measured indicators as follows: (i) food trade with 32 WTO countries showing high levels of import volumes; (ii) a marked increase in ‘less healthy’ focus food imports namely fatty and other selected meat products, sugar, savoury snacks, ice-cream and edible ices and energy-dense beverages; (iii) actual and bound tariff rates impacting import trends of ice-cream and edible ices, bakery products and confectionary; and in other instances, a sharp increase in import of crisps, snacks and noodles despite tariff rates remaining unchanged from 2008 to 2019; (iv) policies regulating food marketing, composition, labelling and trade in the domestic space with relatively limited safeguard measures; (v) 49 foreign-owned food-related companies involved in food manufacturing and processing and the production of coffee, bakery products, confectionary, food preservatives, fish, local food products and meat, and the manufacturing, processing and packaging of palm oil, coconut oil, cooking oil, water, cordial juice, flavoured juices, soft drinks and alcoholic beverages. These were largely produced for local consumption; (vi) 32 domestic industries engaged in food and beverage production; and (vii) an assessment of WTO provisions relating to domestic policy space and governance showing that the current legal and regulatory environment for food in Vanuatu remains fragmented.The analysis presented in this paper suggest that Vanuatu’s commitments to WTO agreements do play an important role in shaping their food environment and the availability, nutritional quality, and accessibility of foods.The online version contains supplementary material available at 10.1186/s12992-021-00748-7. Food environments globally are dominated by highly accessible and heavily promoted ultra-processed foods –3. Food A wide range of policies shape food environments, including government policies covering food composition, labelling, marketing, availability and price, across a broad range of sectors: health, agriculture, education and trade. Trade policies regarding liberalisation, export promotion, import substitute measures, protection of domestic industries and support for foreign direct investment have also contributed to the increased availability of foods associated with the nutrition transition. Throughout the Pacific region, there is some evidence of a correlation between the introduction of free trade/trade agreements and the increasing availability/consumption of ultra-processed foods high in trans-fat, sugar and salt –11. ThreVanuatu is an archipelago nation in the Melanesian group of the Pacific region with a population of about 300,000 people. Its economy relies primarily on agriculture, with the key crops of kava, copra, coffee and cocoa . DespiteVanuatu NCD Roadmap 2015–2018 calls for national action to reduce premature NCD mortality by 25% by 2025. The four major NCDs, namely cardiovascular disease, diabetes, cancers and chronic respiratory diseases, are now responsible for approximately 60% of all premature deaths in Vanuatu [The Pacific NCD roadmap, developed at the request of Pacific finance and economic ministers in 2014, recommended five key strategies for adoption by Pacific countries in their own NCD country roadmaps to intensify response to the Pacific NCD crisis. In line with the Pacific NCD roadmap , the Van Vanuatu . Vanuatu Vanuatu . The preDespite Vanuatu’s accession to the WTO, and its high burden of obesity and diet-related NCDs, there has been no systematic assessment and monitoring of its food environment and their relationship with Vanuatu’s NCD rates. To address this gap, the aim of this study is to establish baseline information on the volume and types of unhealthy imported foods entering Vanuatu as a result of its WTO trade commitments. This will better inform and guide trade policies and legislations that promote healthy diets.Given the focus of this study on the links between trade and food availability at the national level, the INFORMAS trade monitoring framework and its associated data collection protocol . The scope of the review of the WTO agreements identified general rules that apply to Vanuatu as an LDC (least developed country) member of WTO, and specific commitments were listed as ‘schedules of specific commitments’. These reflect specific tariff concessions for the goods schedule , the specified level of market access and national treatment for the services schedule , and specific services commitments that Vanuatu has given in the context of trade negotiations. Data on these indicators were analysed using Microsoft Excel and compared with changes in Vanuatu’s WTO commitments and domestic regulations in order to shed more light on the impact of trade. There were 32 major WTO trading partner countries exporting food into Vanuatu in 2019. Details of ‘other countries’ trading with Vanuatu were not segregated, so only major partners are reflected. The decision regarding the years to monitor food import volumes was based on the escalation of imports prior to Vanuatu joining WTO in 2012 and the trend of import volumes after the ratification and sign-off on WTO agreements and their implementation phases. Detailed food import volume data were collected from VNSO’s Automated System of Customs Data, which captures and implements all international standards for trade data by specific HS Code categories.Drawing on the four domains of the INFORMAS monitoring framework, in this analysis, the focus was on the minimal monitoring approach in three of the four domains: trade in goods, trade in services and foreign direct investment, and policy space . These food categories excluded variations of products used for pharmaceuticals, animal feeds, live animals, and flower cuttings and seeds not listed as edible. As Fig. –2501. ThFigures ad valorem rates to agricultural and NAMA tariff lines does not, however, prevent LDCs like Vanuatu from negotiating higher rates for sensitive lines, as it does not impose any tariff cap. For instance, Table 4  at an overall average rate of 43.6%. For non-agricultural products, the WTO decision provides two options: acceding LDCs shall bind 95% of their NAMA  lines at an overall average rate of 35%, or they can undertake more comprehensive binding coverage. Vanuatu agreed to a 100% binding coverage of its NAMA tariff lines at an overall average rate of 39.1%. This decision to apply benchmark As part of its WTO obligation, Vanuatu grants MFN (most favoured nation) tariff treatment to all its trading partners. There appears to be sufficient policy space for protecting domestic sectors. Vanuatu also applies preferential tariffs to parties of the MSGTA, The Pacific Island Countries Trade Agreement (PICTA) and, upon ratification, the Pacific Agreement on Closer Economic Relations Plus (PACER Plus). In addition to these, there are two charges affecting food imports, as well as domestic products: VAT and excise duty. VAT of 15% applies to all goods and services unless they are exempt or zero-rated. Imports are VAT exempt if they are valued at VUV 10,000 or less. Until 2017, the VAT rate had been 12.5% but this was increased to support fiscal consolidation. An excise duty applies to items such as alcohol and tobacco products and it is now also applied to sugar-sweetened beverages. In 2015, a specific excise tax was applied to both imported and locally produced sweetened beverages (HS 2022). The tax rate is 50 vt/L, but for imported sweetened beverage products, there is an additional 75% tariff applied  and sweet snacks  remained the same from 2008 to 2019  into Vanuatu over the period between 2008 to 2019 was varied  influence food systems and shape food environments. Globally, food systems have been challenged by population growth, globalisation, urbanisation and climate change and have been altered by agricultural, economic, trade, environmental and international development policies. These create incentives and disincentives which ultimately determine the production of particular types of food. These coupled with rural development, urban planning and transport policies determine the affordability of food and what food reaches which consumers . ConsumeTo better understand the links and impacts of trade on Vanuatu’s food environment, the baseline results presented in this paper suggests a strong association between Vanuatu’s trade liberalisation and the increased availability of the diverse range of imported products: fats and oils, meat and canned fish, processed dairy products, energy-dense beverages, and processed and packaged foods. While liberalisation and commitments under WTO trade agreements have changed the food availability and nutritional quality of Vanuatu’s food environment, there are several important and interesting caveats to note. The main points for discussion in this section focus on a series of liberalisation processes based on Vanuatu’s WTO commitments accompanying the changes in food imports and how these have contributed to shaping Vanuatu’s food environment by increasing less healthy food imports.As a WTO signatory in 2012, Vanuatu agreed to binding all its tariffs. While there has been an influx of less healthy food imports, the relationship is not straightforward. For some food categories, such as ice-cream and edible ices, savoury ready-to-eat snacks and sweet snacks, tariffs have remained unchanged, but the percentage import volumes of these foods has been increasing for a number of years. In the case of soft drink and cordial imports, despite a high applied tariff of 75% on soft drink imports and a 20% tariff on cordial imports remaining unchanged since 2008 at 20%, these imports still recorded an increase from 2016 to 2018. The additional excise duty and VAT applied to some of these food categories are likely to have contributed to the fluctuating trends in total food import volumes of these foods.Many Pacific Island countries, including Vanuatu, have implemented excise taxes as a way to reduce consumer demand for unhealthy choices, but these need to be supported by other, complementary actions. In many instances, with the minimal increases in taxes and the ad hoc implementation of these, the intended impact on consumer behaviours has fallen short. Further to this, recent developments have also shown that the focus of excise tax increases has been on revenue generation rather than changing consumer behaviour and hardly any Pacific Island country (Vanuatu included) dedicates any of the excise tax revenue on targeted unhealthy products to the health sector .To regulate the sale and availability of processed foods and sugar-sweetened beverages in Vanuatu’s food environment, various WTO agreements provide grounds for technical regulations to be prepared, adopted or applied by member states to protect human health and safety. Vanuatu has yet to maximise the general safeguards in line with these agreements and has only imposed import prohibitions on beef imports originating in Europe since the late 1990s for biosecurity reasons. This is in accordance with GATT Article XIII on Non-Discriminatory Administration of Quantitative Restrictions, Article XI, 2(c) on Quantitative Restrictions that allows for “import restrictions on any agricultural or fisheries product, imported in any form, necessary to the enforcement of governmental measures which operate” and pursuant to Vanuatu’s Customs (Prohibited Import) Regulations Order No.115 of 2014. Regarding the Agreement on Preshipment Inspection, Vanuatu does not carry out any preshipment inspection and has no laws, regulations or procedures and criteria in place to put this agreement into force. Moreover, Vanuatu has no intention of doing so as per their schedule of specific commitments. However, to ensure that the quality of goods shipped has complied with quality measures during the production process, it becomes important for countries to opt for pre-shipment inspection. Vanuatu should re-consider this commitment, as pre-shipment inspection can help reduce the risk of receiving poor-quality food products that are non-compliant with Vanuatu’s food related regulations.To ensure fair trade and to protect against the dumping of goods and its trade distortive effects, the WTO Antidumping Agreement allows governments to act against dumping where it is hurting domestic industries or to cope with a sudden surge of foreign goods. While Vanuatu agreed to not applying any anti-dumping, countervailing or safeguard measures until it had implemented appropriate laws consistent with WTO agreements, it now hasdraft anti-dumping regulations under review. It must be cautioned that anti-dumping measures may pressurise the government to restrict the import of better and cheaper imports by calling them dumped commodities. Dumping should not be mistaken and simplified to mean cheap or low-priced imports. Rather it should only be taken up in its legal sense, that is, the export of goods lower than their normal value where the goods are low priced imports only in the relative sense – relative to their normal value.The encouragement of foreign direct investment through Vanuatu’s commitments has also increased the availability of locally produced food preparations and processed foods and ultimately the consumption of these. As presented in Table The study was limited by gaps in available data – the segregation of data by countries exporting into Vanuatu, data relating to tariff rates, FDI investment and monetary data, and calculation of tariff-rate quotas for the identified focus foods. The limited availability of data made it difficult to demonstrate causality, nor could the importance of trade agreement provisions in driving change in nutrition quality and shaping Vanuatu’s food environment be effectively estimated.The analysis presented in this paper suggests that Vanuatu’s commitments to WTO Agreements do play an important role in shaping their food environment by increasing both healthy and less healthy imports. Strong associations between trade liberalisation and imported foods, especially ultra-processed foods were evident in the measured indicators. In terms of total food import volume, Vanuatu’s food trade with 32 WTO countries has contributed to the high levels of food import volumes. This has also seen a marked increase in ‘less healthy’ focus food imports namely fatty and other selected meat products, sugar, savoury snacks, ice-cream and edible ices and energy-dense beverages. Vanuatu’s binding tariffs has impacted import trends of ice-cream and edible ices, bakery products and confectionary. Although for some food categories such as crisps, snacks and noodles, a sharp increase in the importation of these is evident despite tariff rates remaining unchanged from 2008 to 2019. The encouragement of FDI through Vanuatu’s commitments has also increased the availability of locally produced food preparations, processed and ultra-processed foods through its 49 foreign-owned food related companies involved in food manufacturing and processing and the production of coffee, bakery products, confectionary, food preservatives, fish, local food products and meat, and the manufacturing, processing and packaging of palm oil, coconut oil, cooking oil, water, cordial juice, flavoured juices, soft drinks and alcoholic beverages. These were largely produced for local consumption. It has also seen the substantive engagement of 32 domestic industries in food and beverage production.An assessment of WTO provisions relating to domestic policy space and governance in Vanuatu shows that the current legal and regulatory environment for food in Vanuatu remains fragmented. Trade agreements are increasingly including commitments, usually aimed at harmonising national measures affecting traded goods and this potentially constrains domestic policy making . While mAdditional file 1. Tariff rates for selected less healthy focus foods.Additional file 2. Tariff rates for selected healthy focus foodsAdditional file 3. Transnational corporations engaged in the food and beverage sector operating in Vanuatu in 2019.Additional file 4. Domestic industries engaged in the food and beverage sector operating in Vanuatu in 2019.