Telemedicine and remote patient monitoring are rapidly growing fields. This scoping review provides an update on remote patient monitoring for neuropsychiatric disorders from recent publications and upcoming clinical trials.ClinicalTrials.gov and Japanese registries; active or recruiting by March 2021) that assessed wearable devices for remote management and/or monitoring of patients with neuropsychiatric disorders were searched. The review focuses on disorders with ≥3 publications.Publications  and trials , primarily for monitoring motor symptoms and/or preventing falls. Other disorders (3–5 publications each) included epilepsy , sleep disorder , multiple sclerosis , depression , and amyotrophic lateral sclerosis (symptoms). Very few studies focused on newly emerging technologies , and few studies integrated remote symptom monitoring with telemedicine.Currently, development of digital devices for daily symptom monitoring is focused on Parkinson's disease. For the diseases reviewed, studies mostly focused on physical activity rather than psychiatric or nonmotor symptoms. Although the validity and usefulness of many devices are established, models for implementing remote patient monitoring in telehealth settings have not been established.Verification of the clinical effectiveness of digital devices combined with telemedicine is needed to further advance remote patient care for neuropsychiatric disorders. Measurement of disease progression entails both objective measures and subjective clinician- and patient-reported outcomes related to functions, symptoms, and health-related quality of life.9–12Many studies from around the world have assessed the use of telemedicine for neurological and psychiatric disorders,5 For example, because of the subjective nature of clinical assessment and because patients typically present with a complex array of symptoms, continuous objective monitoring of symptoms and adverse events has the potential to provide real-time information that can help guide the timing of drug administration to improve outcomes and help reduce side effects.6 Despite these advances, integration of remote patient monitoring with telemedicine remains a challenge now and into the future.For patients with chronic neurological disorders, most research is focused on physical activity as a measure of symptom deterioration and treatment effectiveness and to predict adverse events.per se. In particular, the review is focused on the most recent trends and opportunities with regard to remote patient monitoring and the identification of studies that integrate remote patient monitoring with delivery of online medical care.In this review, we conducted a comprehensive literature search of publications and upcoming clinical trials on the use of wearable devices for routine patient monitoring in neuropsychiatric disorders. A scoping approach was taken to identify (1) recent publications from the peer-reviewed literature to gain an understanding of the focus of current research and (2) active or actively recruiting clinical trials to anticipate future trends. The objective of our review was to identify the extent to which monitoring and visualization of neuropsychiatric symptoms are being validated and used in conjunction with telehealth in many countries rather than on the development of devices ClinicalTrials.gov (English), the Japan Pharmaceutical Information Center Clinical Trials Information website, the University Hospital Medical Information Network Center Clinical Trials Registry, the Japan Registry of Clinical Trials, and the Japan Medical Association Center for Clinical Trials website. The search strategies and search terms were tailored for each database.This was a scoping review of peer-reviewed publications in PubMed and ICHUSHI and the following online clinical trial databases: S2. As this was a literature review of publicly available information, institutional review board approval was not required. Although we took a methodical approach to the development of literature search, a formal protocol was not prepared for this scoping review.Search terms included Medical Subject Headings (MeSH) for PubMed, MeSH terms converted to thesaurus terms for ICHUSHI, and free-text terms connected by Boolean operators . The search terms and search hierarchy are described in detail in Publications and clinical trials on neurological or psychiatric disorders were included if they assessed wearable, portable, or mountable devices (1) that are intended for at-home monitoring to facilitate disease management or (2) for remote management of patients. Studies that did not provide information on the clinical use of wearable devices or that were only focused on the development of software algorithms for digital devices were excluded.PubMed and ICHUSHI searches were limited to full-text publications with abstracts that were published between January 1, 2010, and February 12, 2021, and included any neurological or psychiatric disorder. Review articles were excluded.ClinicalTrials.gov and Japanese databases) were conducted on March 8, 2021, and were limited to trials that were active or actively recruiting. Searches in each clinical trial database included the neuropsychiatric disorders for which three or more publications had been retrieved from the literature search .Clinical trial searches  use of a wearable, home, or portable device for patient monitoring; (2) patients with a neuropsychiatric disorder; and (3) studies focused on the remote use of wearable devices. Inclusion of each study was confirmed after a manual review of the full text or full record; duplicate publications and clinical trials were excluded manually.Four reviewers conducted the screening. Reviewer 1 sequentially evaluated the titles and abstracts of publications identified by the online literature searches, and then manually assessed the full text of all potential publications against the eligibility criteria. Reviewer 2 screened the full electronic clinical trial records for all trials that were retrieved by the online search against the eligibility criteria. Reviewers 3 and 4 confirmed the eligibility of all publications and clinical trials identified by Reviewers 1 and 2 against eligibility criteria. Any discrepancy was resolved by consensus.Data from each eligible publication and clinical trial were charted into prespecified spreadsheets by Reviewers 1 and 2, respectively, and all chartered data were checked by Reviewers 3 and 4 against the original source. Inconsistencies between the initial data extraction and a reviewer were verified from the original source.For publications, the following data were charted: citation information, title, disease, study location, abstract, objective, study design, patient population, comparators, eligibility criteria, intervention, device name, device overview, time frame, outcomes measured using the digital device, and assessment of telemedicine. For clinical trials, the following data were charted: title, disease, synopsis, objective, study design, target sample size, eligibility criteria, intervention, comparators, primary and secondary outcomes, sponsor, device name, device overview, study location, trial status, trial ID, registration date, start date, primary completion date, and completion date.Data charted from each publication and clinical trial were grouped by neuropsychiatric disease. The numbers of publications and clinical trials that met the eligibility criteria were counted and the dates of publication or trial registration were summarized. For each neuropsychiatric disease, objectives and/or intended uses of the digital device (for publications) or study objectives  were tabulated and summarized. Current trends and future perspectives and the role of telemedicine for each neuropsychiatric disease were tabulated and summarized.ClinicalTrials.gov and 10 from Japanese databases)  and 51 active or actively recruiting clinical trials . There was no publication that assessed the effectiveness of integrating a digital device with telemedicine. One clinical trial17 was designed to assess patient satisfaction with the integration of remote patient monitoring with telemedicine (Supplementary Table S4).There were 11 publications25–27 One study reported on the combined use of electrocardiographic parameters, voice patterns, and kinematics to monitor changes in motor symptoms and cognitive function.22 One study assessed the use of a wearable accelerometer and barometer to predict falls in a home-based setting,23 and one measured muscle contraction and gait frequency to detect freezing of gait in real time.28 In two studies, digital indices comprising multiple parameters were analyzed by statistical methods or machine learning before and after treatment to determine whether changes in these indices could predict response to treatment.27Most devices used indices comprising several motion and joint movement parameters to monitor dyskinesia, tremor, gait impairments, and postural instability.25 Findings from two of these studies showed strong correlation between objective data from a wearable motion capture system and subjective measures of dyskinesia  and tremor , respectively.21 Two publications assessed the ability of patients to tolerate a wearable digital device; patients wore the devices at home for 1 month24 or 1 week.29 In both studies, patients found the body-worn devices to be acceptable and expressed a preference for the devices over manual self-reporting methods such as symptom diaries.Four publications examined the correlation between objective digital indices obtained from a wearable device and subjective clinical assessments.46 The other five studies were designed to assess the use of auditory or tactile cues to facilitate the detection, notification, and prevention of symptoms such as freezing of gait and difficulties with swallowing.45 While most studies were focused on objective measures for detecting specific motor symptoms or events, there appeared to be growing interest in the use of digital devices for remote disease monitoring,33 optimization of drug dosing,18 and disease management.17Of the 19 clinical trials that were active or actively recruiting, 15 were designed to quantify symptoms and/or functions.17 is designed to assess patient satisfaction with a digital platform for online medical consultations, which includes remote symptom monitoring with digital devices, and patient satisfaction with online instructions provided by a pharmacist on drug use and drug delivery. In this study, information on patient-reported motor and nonmotor symptoms will be collected through a digital device worn at home for 8 weeks, and physicians and pharmacists will conduct their examinations and provide instructions online in accordance with routine clinical practice.The Care-For-One observational study47–51 and seven clinical trials52–56 on the development of new wearable or portable electroencephalograms (EEGs) for the monitoring of patients with epilepsy 57 or conventional polysomnography (wrist-worn reflective photoplethysmography).59Of the other publications, one study correlated objective sleep parameters based on wrist-worn actigraphy with patient-reported sleep outcomes62 and three were evaluating the effect of various interventions aimed at improving sleep  using sleep parameters measured by a wearable device.63 One clinical trial was designed to compare sleep activity and patterns measured at home using portable EEG/electrocardiogram (ECG) devices and a wrist accelerometer with conventional inpatient sleep tests .64Of the five clinical trials that were active or actively recruiting, one was designed to evaluate quantification of sleep parameters using a wearable device,65–68 and five clinical trials69–73 on the development of digital devices for remote patient monitoring in multiple sclerosis .66 There was no publication or clinical trial assessing the effectiveness of integrating a digital device with telemedicine.There were four publications66–68 and one assessed correlation between physical activity measured at home using an accelerometer and symptoms of fatigue, mood, pain, and cognitive function.65 One study compared patients' walking ability using a GPS wristwatch with patients' and neurologists' subjective estimates of walking ability,66 and two studies conducted a long-term assessment of step count using a wrist-worn accelerometer and compared the outcomes with step count/activity assessed using actigraphy, manual measurement, and subjective assessment.68Of the four publications retrieved, three correlated objective measures of physical activity measured at home with conventional clinical methods to assess patient disability,73 behavioral programs to improve physical activity and weight,69–71 and cognitive behavioral therapy and drug treatment.72Of the five clinical trials that were active or actively recruiting, all were designed to verify the effect of various interventions for improving symptoms of multiple sclerosis and included an assessment of physical activity measured through accelerometers. Interventions included the effects of diet,74–76 and six clinical trials77–82 on the development of digital devices for remote monitoring of patients with depression  and Hamilton Depression Inventory (HAM-D) in patients with major depressive disorder and the Depression Anxiety Stress Scale-21 items in young adults with psychological distress.Of the three publications retrieved, two aimed to correlate objective measures of physical activity collected remotely with conventional patient-reported scales of depression symptoms.74 This study showed that adherence to the activity tracker decreased over time and that patients preferred to review their recorded symptoms with a clinician. There was no report on the evaluation of mood symptoms using wearable devices.One study compared the preference and adherence of patients with bipolar disorder for self-monitoring of physical activity using a smartphone application versus objective monitoring using a wearable activity tracker.82 and two studies assessed wearable devices to quantify symptoms in response to behavioral therapies.80 Two studies were evaluating behavioral therapy delivered by a smartwatch application,78 and one study was evaluating a group-based lifestyle intervention supported by mobile health technology and social media.81 Of these, one study was designed to include a review of symptoms by a therapist and feedback by the smartwatch application.78Of the six clinical trials that were active or actively recruiting, most were evaluating the effectiveness of behavioral therapies or support systems using various measures that included wearable physical activity or sleep trackers , difficulties initiating or maintaining sleep , or excessive daytime sleepiness . The gold-standard measure for sleep disorders is polysomnography, which requires an overnight stay in a sleep clinic.Because of the need for long-term sleep assessment in patients with sleep disorders, there is growing interest in the use of wearable devices that can provide an accurate and objective measure of sleep quality at home  the literature searches were not systematic and focused on peer-reviewed publications in English and Japanese, and clinical trials from Japan, Europe, the United Kingdom, and the United States only, (2) because the focus was on most recent and future trends, we only included information on those diseases with three or more peer-reviewed publications and we did not include information summarized in other review articles, which may have contributed to selection bias, (3) the quality of the information on each of the clinical trials was limited to what was reported in each database, and (4) unregistered observational studies that may have been ongoing were not identified.4 For patients with chronic neurological diseases who have limited access to specialist care, the use of wearable devices that provide objective information about disease progression and treatment effectiveness is likely to transform the way in which patients and their carers engage with health care systems.The emergence of COVID-19 has thrust telemedicine to the forefront of health systems research and has shown that quality health care can be administered remotely.Current studies suggest that longitudinal measurement of data on a daily basis can provide clinicians and carers with the information needed to optimize and individualize treatment and can potentially enable early detection and/or prevention of acute symptom deterioration or adverse events. Once telemedicine with remote patient monitoring is implemented, patients and caregivers are likely to experience reductions in the burden associated with treatment of chronic neurological and neurodegenerative diseases and improvements in quality of life.However, evidence that digital devices can be integrated successfully into telehealth settings or lead to improved outcomes for patients with neuropsychiatric disorders who require long-term, home-based care is limited. Because the potential benefits of telemedicine to patients, carers, and societies are substantial, further research is needed to advance the use of new technologies for remote patient monitoring and health care delivery.Data sharing is not applicable to this article as no datasets were generated or analyzed during this study.


The application of innovative technologies, and in particular of wearable devices, can potentially transform the field of antenatal care with the aim of improving maternal and new-born health through a personalized approach. The present study undertakes a scoping review to systematically map the literature about the use wearable sensors in the research of foetal and pregnancy outcomes. Online databases were used to identify papers published between 2000–2022, from which we selected 30 studies: 9 on foetal outcomes and 21 on maternal outcomes. Included studies focused primarily on the use of wearable devices for monitoring foetal vital signs  and maternal activity during pregnancy . There were many studies that focused on development and/or validation of wearable devices, even if often they included a limited number of pregnant women without pregnancy complications. Although their findings support the potential adoption of wearable devices for both antenatal care and research, there is still insufficient evidence to design effective interventions. Therefore, high quality research is needed to determine which and how wearable devices could support antenatal care. High-quality antenatal care is crucial to ensure maternal and neonatal health, along with providing evidence-based information and education on healthcare to expectant women. Although most pregnancies are uneventful, high-quality antenatal care is needed to provide timely prevention and to manage the minority that have complications . A signiThe application of innovative technologies, and in particular of wearable devices, can potentially transform the field of antenatal care with the aim of improving maternal and new-born health. This research field, however, is in continuous expansion and requires a constant updating on newest devices, research pitfalls, and potential perspectives. Although several systematic reviews exist about the role of mobile health in antenatal care ,9,10, noThe protocol for the current scoping review was drafted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist . To idenTwo authors (AM and MB) independently selected the studies and charted the data, using a standardized data abstraction tool designed for this scoping review. The tool captured the relevant information on article characteristics , study characteristics , detailed information on wearable device , and the main findings achieved. Any disagreements were resolved through discussion between the two authors or further adjudication by a third author (AA).Studies were grouped by the type of outcome considered , and summarized describing the type of setting, populations and study designs for each group, along with the wearable devices used and broad findings.After duplicates were removed, a total of 1244 articles were identified from literature databases. Based on screening of titles and the abstracts, 1119 were excluded while 125 full-text articles were retrieved and assessed for eligibility. Of these, 95 were excluded for the following reasons: 3 described the development or improvement of wearable devices without application on human participants; 5 were qualitative interview surveys on opinions and perceptions toward wearable devices; 53 used sensors that were not wearable; 1 did not analyse foetal and maternal parameters characteristics; 25 were conducted before or after pregnancy; 8 commentaries, reviews or systematic reviews. The remaining 30 studies were considered eligible for this scoping review  and thein = 4), followed by USA (n = 3), Australia and UK . The vast majority of studies aimed at validating new wearable devices or systems for the collection of foetal parameters (n = 5), or at comparing different methods for data processing (n = 1). The remaining articles pertained to one case-control study and two prospective multicentre studies. Study populations ranged from 3 to 147 pregnant women at different weeks of gestation. The study by Yuan and colleagues, instead, used a maternal abdominal signal generator developed to simulate the abdominal surface signal of a pregnant woman [Nine studies described the application of wearable sensors to collect information about foetal parameters ,18,19,20n = 3) or a combination of accelerometer and acoustic sensors (n = 1). The opportunity of detecting foetal movement through non-invasive sensor systems, in fact, has received a lot of attention for the research of foetal growth and development. However, recovering foetal movement signals from a continuous, low-amplitude, and heavily contaminated background is a challenging task, which requires advanced signal processing techniques to differentiate foetal movements from contaminating artefacts. To solve this issue, Liang and colleagues proposed a four-stage system that integrated foetal movement signal pre-processing, maternal artifact signal pre-identification, signal identification and classification [Nearly half of studies detected foetal movements using accelerometer sensors  or a device combining electrical and acoustic sensors (n = 1). In fact, the monitoring of changes in heart sounds, heart rate, and electrocardiogram (ECG) is useful to track foetal growth and for early detection of foetal congenital heart disease and distress. Yuan and colleagues proposed a foetal ECG monitoring device to detect maternal abdominal ECG signals, from which to extract foetal ECG signals and heart rate [Three studies monitored foetal heart rate through devices that were based on different sets of electrodes  and Finland (n = 3). Other countries with only one study included: Australia, Bangladesh, Brazil, China, Israel, Japan, Perú, Singapore, and Taiwan. Six studies aimed at evaluating and/or validating wearable devices for the collection of maternal information: two case studies; two validation studies; and two feasibility studies. A total of seven observational prospective studies were conducted with the purpose of assessing the feasibility of using wearable devices during pregnancy and/or evaluating the relationships between maternal parameters, activities, and pregnancy outcomes. Three articles reported on randomized controlled trials, in which the efficacy of wearable-based interventions was evaluated. There were also two articles, one describing a semi-experimental study and the other describing a field trial. The remaining articles pertained to three protocols for planned prospective studies or randomized controlled trials, which evaluated the relationships between maternal activities and pregnancy outcomes. The majority of devices used in studies described above were wristband trackers of health parameters or activities (n = 16 studies), followed by finger-based health trackers (n = 2), body-conforming flexible wearable sensors (n = 2), and a system based on three chest, limb, and abdominal sensors (n = 1). Monitored information was varied and included maternal parameters  and activities  during pregnancy. In the following sections, we present findings by grouping studies that used wearable sensors to exclusively monitor health parameters or maternal activities, and those that instead simultaneously collected both pieces of information.Twenty-one studies described the application of wearable sensors to collect information about maternal parameters and activities during pregnancy ,39,40,41n = 2), body-conforming flexible devices (n = 2), or a sensory system based on three sensors (n = 1). To our knowledge, the first example dated from 2005, when Maggioni and colleagues used an automated wearable device to monitor the circadian rhythm of maternal blood pressure during the third trimester. In particular, the authors found that a high variation in diastolic blood pressure was associated with intrauterine growth retardation [Five studies monitored a set of maternal parameters, in particular cardiovascular parameters and other clinical data, using wristband health trackers  surveys, and machine learning models . Their rSeven studies reported on the validity and feasibility of wearable devices used to monitor maternal activities during pregnancy, as well as on findings obtained through their application. All these studies were conducted using different types of wristband activity trackers. Kominiarek and colleagues conducted a study to assess the feasibility of a wristband activity tracker to measure objective physical activity among women in early pregnancy. Interestingly, objective measures of physical activity did not differ significantly from those collected through validated questionnaires. Moreover, pregnant women were greatly motivated to wear the device and reported high satisfaction with its use . EhrlichWearable devices can also be useful to assess sleep quality during pregnancy. Accordingly, Galea and colleagues conducted a pilot study to evaluate the feasibility of objectively assessing sleep quality and the physical activity of pregnant women in a low-resource setting . In spitAs well as collecting data, wearable devices may be used to design interventions aimed at improving the behaviour of pregnant women. Kawajiri and colleagues employed a semi-experimental approach to evaluate the effects of an intervention against behaviour which was based on in-person advice, automatic alerts from wearable devices, and self-monitoring of sedentary behaviours . In geneClinical parameters and lifestyle data should be collected simultaneously in order to identify factors that contribute to adverse pregnancy outcomes and to hypothesize future interventions for pregnant women. Accordingly, six studies reported on the validity, feasibility, and perspectives of using wearable devices for the simultaneous monitoring of maternal health parameters and activities during pregnancy. In general, the devices described in this section were designed to monitor data on maternal parameters , physical activity , and sleep patterns . Controversies, however, existed principally around the feasibility of applying them in studies involving pregnant women. For instance, Nulty and colleagues explored the validity and acceptability of a commercially available activity tracker in pregnant and non-pregnant women . PrelimiAn alternative to wristband activity trackers has recently been tested on a few subjects, e.g., a finger-based activity tracker which was less invasive. This device is able to monitor resting heart rate and variability, sleep, and physical activity. In their first study, Jimah and colleagues reported significant correlations between objective and self-reported measures by analysing a pregnant woman at 33 weeks of gestation . In a laFor the sake of completeness, the current scoping review included three protocols of already planned studies. The protocol proposed by Cai and colleagues regarded a prospective study which will use a wristband activity tracker to evaluate the association of physical activity level with gestational diabetes mellitus and hypertension . Souza aIn this scoping review, we have identified 27 primary studies and 3 protocols describing research using wearable devices to assess foetal and pregnancy outcomes. Except for one, these studies were published between 2018 and 2022, revealing how this field of research is relatively new and undergoing rapid and continual evolution. At its current stage, the research has focused primarily on the use of wearable devices for monitoring foetal vital signs  and maternal activity during pregnancy .In the first instance, included studies clearly demonstrated that non-invasive sensors, usually placed on the mother’s abdomen, are capable of detecting foetal heart rate and movements ,17,19,20For the second domain of application, selected studies reported on wearable devices used to collect maternal parameters and activities during pregnancy, and to investigate their association with maternal and neonatal health ,39,40,41This problem was also present in studies using wearable devices to monitor maternal activities during pregnancy, such as physical activity and sleep patterns. There was a general decreasing trend in participants’ compliance throughout the entire periconceptional period. In fact, compliance was higher before pregnancy , then deOverall, our findings clearly support and advocate the potential adoption of wearable devices for both antenatal care and research. However, our scoping review also indicates a paucity of research on specific pregnancy outcomes, as demonstrated by the limited number of studies on women with a complicated pregnancy. Likewise, only some interventions have proved effective in promoting adequate behaviours and the health of pregnant women. Effectiveness could be improved by increasing the compliance of participants with wearing the devices. Due to these considerations, improvements in the technical performance and structural design of wearable sensors, as well as adequate data processing, remain necessary ,6. This Some limitations should be considered when discussing our findings. The scope of our review covered a wide range of research conducted using wearable sensors during pregnancy. Moreover, we cannot exclude the existence of relevant studies, which were indexed in other databases . Accordingly, future systematic reviews should be encouraged to learn more about pitfalls and perspectives of using wearable devices in the antenatal care. Although there were many studies included that focused on wearable device development and/or validation, the evidence was generally obtained from studies involving a limited number of pregnant women, often without pregnancy complications. Moreover, there were few randomized controlled trials evaluating the effectiveness of wearable-based interventions.Our scoping review identifies gaps in the literature and perspectives of wearable devices which may guide future research. Although promising and feasible, these technologies only partly address the needs of antenatal care in their current form. There is still insufficient evidence to describe the experience of pregnant women and to design effective interventions. Therefore, high quality research is needed to determine which and how wearable devices could support antenatal care.


Future research should consider the intersection between multiple SDOH to better understand their combined impact on engagement in PA or exercise among PLWH.Physical activity (PA) and exercise are an effective rehabilitation strategy to improve health outcomes among people living with HIV (PLWH). However, engagement in exercise among PLWH can vary. Our aim was to characterize the literature on the role of social determinants of health (SDOH) on engagement in PA or exercise among adults living with HIV. We conducted a scoping review using the Arksey and O’Malley Framework. We searched databases between 1996 and 2021. We included articles that examined PA or exercise among adults with HIV and addressed at least one SDOH from the Public Health Agency of Canada Framework. We extracted data from included articles onto a data extraction charting form, and collated results using content analytical techniques. Of the 11,060 citations, we included 41 articles, with 35 studies involving primary data collection 23 (66%) quantitative, 8 (23%) qualitative, and four (11%) mixed methods. Of the 14,835 participants, 6398 (43%) were women. Gender ( In Canada, approximately 62,050 people were living with HIV (PLWH) in 2018, with an incidence of 2242 new cases . As indiPhysical activity (PA) and exercise are an effective rehabilitation strategy for addressing disability and improving health outcomes among PLWH . PA is dThe World Health Organization (WHO) recommends, adults aged 18–64 year, including those with chronic conditions or disability, should undertake at least 150–300 min of moderate-intensity aerobic PA, or at least 75–150 min of vigorous-intensity aerobic PA, or an equivalent combination of moderate-intensity and vigorous-intensity activity throughout the week with at least 2 days of muscle strengthening activities to obtain benefits of engaging in PA and exercise . For oldThe role of social determinants of health (SDOH) on engagement in PA and exercise among PLWH is emerging. Social determinants of health (SDOH) are defined as conditions with which people are born, grow, live, work and age, that shape their level of power, income, and other determinants of life . These dWe conducted a scoping review to investigate what is known and not known about SDOH and engagement in PA or exercise among adults (ages 18 and over) living with HIV.Conceptual Foundation: We used the Public Health Agency of Canada (PHAC) SDOH framework as a conceptual foundation for our review. This framework encompasses 12 determinants: income and social status, employment and working conditions, education and literacy, childhood experiences, physical environments, social supports and coping skills, healthy behaviours, access to health services, biology and genetic endowment, gender, culture, and race/racism   . In a sy = 0.91] . In a syTo our knowledge, this is the first scoping review that examined the nature and extent of evidence on the relationship between SDOH and engagement in PA or exercise among adults living with HIV. Our findings indicate that gender was the most common SDOH among included articles, followed by social support and coping skills, and income and social status. Most included articles (76%) explored the relationship between SDOH and PA or exercise in PLWH as a primary aim, whereas the rest of the articles (24%) reported SDOH as a secondary aim. Among the 23 quantitative studies, the majority (78%) used a cross-sectional design that prevented establishing a causal relationship between the SDOH of interest and engagement in PA or exercise. Eight qualitative studies highlighted socio-environmental factors as barriers and facilitators of PA or exercise, with financial cost, social support, cultural context, and physical environment  as the most common SDOH influencing engagement in PA or exercise among PLWH.Despite the explicit focus of articles examining relationships between different SDOH and PA or exercise among PLWH, none of the articles used a SDOH framework to inform their analytical approach. In addition, a large number of studies examined only a single SDOH ,64,65,66Results from individual studies in this scoping review suggest that women living with HIV engage in less PA compared to men living with HIV. Only one study reported higher PA among women , whereasOur review suggests no association between unhealthy behaviours such as smoking and alcohol use with engagement in PA. Smoking and alcohol consumption are not considered as healthy behaviors because of their adverse impacts on physical and mental health ,75. InteOur findings suggest that stigma associated with culture and race/racism were underrepresented in the literature, with only 12% and 15% of included studies addressing these SDOH, respectively. While one systematic review was inconclusive regarding the relationship between race and PA , authorsThis review identified gaps in the literature related to SDOH and engagement in PA or exercise among HIV. Definitions of PA and exercise varied significantly across the studies. None of the included studies adopted a SDOH framework as the theoretical basis for their work. Additionally, authors used a variety of self-reported questionnaires and objective measures of PA and exercise. Considering the diversity in PA definition and assessments, and benefits and limitations of objective versus self-report of PA, researchers should consider the inclusion of an operational definition of PA or exercise in future work and provide a rationale for the selection of the PA or exercise assessment tools. Similarly, authors examining SDOH should better define the determinant(s) of interest and the research context. Clearly defined PA, exercise and SDOH variables using a conceptual framework to guide the analytical work and standardized and validated outcome measures should improve the interpretation of evidence in this field and foster standardized approaches in future research. Furthermore, the majority of studies were cross-sectional in nature making it difficult to identify the causal relationship between SDOH and PA or exericse. Future longitudinal or cohort studies among PLWH, may help to further understand the strength and direction of the relationships and whether PA or exercise is a moderator or mediator of health outcomes among PLWH. Another major gap in the evidence is the absence of research on the impacts of the intersection between multiple SDOH on PA and exercise. Finally, many studies included small sample sizes with unclear transferability to the broader HIV population, highlighting the need for a richer understanding of the collective influence that a combination of SDOHs have on engaging in PA or exercise among PLWH.Other research has explored the relationship between SDOH and physical activity or exercise among other chronic illness populations. This body of work has also documented that the ability for individuals to engage in exercise is affected by cost, health status and disability . Social Strengths of this scoping review includes our rigorous adherence to well-established scoping review methodology ,25,27, oThis scoping review characterized the evidence examining the role of SDOH on PA or exercise among PLWH. Gender was the most commonly reported SDOH in the literature with the majority of studies addressing only one SDOH. Results from individual studies suggest that social support is a facilitator, and financial constraints and costs are a barrier to engagement in PA or exercise among PLWH. Results of this review may help to inform clinicians, researchers, and policy makers to better understand the role of SDOH as potential barriers or facilitators while promoting or evaluating PA or exercise with PLWH. Future research should consider the intersection between different determinants to better understand the combined impact of different determinants on engagement in PA or exercise.


Clinical teaching practice of nurse educators is important in the development of clinical competence of undergraduate nursing students, but it is often not done according to best practice standards. This study aimed to summarise the best clinical teaching practices of nurse educators teaching undergraduate nursing programmes. An integrative literature review was conducted according to Whittemore and Knafl’s adapted stages. A systematic search of electronic databases, including EBSCOhost and ScienceDirect, for applicable papers from January 2001 to June 2021, was followed by a manual search. The review resulted in selection of 67 papers, and critical appraisal had been completed by two independent reviewers using relevant critical appraisal tools. Papers that were selected revealed six main themes, with sub-themes, outlining best practices for clinical teaching, namely: (1) planning for clinical teaching practice: self-preparation and planning for clinical placement; (2) facilitation of students’ clinical learning: orientation of students, planning for clinical teaching and the clinical teaching process; (3) evaluation of students’ clinical skills: reflection by the nursing student and feedback; (4) modelling professional clinical teaching practice: emotional intelligence, self-evaluation, role modelling and continuous professional development; (5) work-based assessment in the clinical environment: clinical assessment process and clinical assessment tools and (6) clinical teaching in the simulation laboratory. The six identified best practices could assist nurse educators to provide comprehensive clinical teaching.The review’s results can be used in the development of a best practice guideline for clinical teaching. This guideline will aid nurse educators in achieving best clinical teaching practices. Clinical education of undergraduate nurses remains an integral part of the nursing curriculum and forms the foundation for bridging the theory-practice gap ; Education Resources Information Centre (ERIC); Medical Literature Analysis & Retrieval System Online (MEDLINE); E-Journals; Health Sources: Nursing/Academic edition; Master File Premier; Teacher Reference Centre as well as ScienceDirect. Subsequently, a manual search of grey literature (unpublished papers) using Google Scholar and Google Search engines, as well as citation searching through reference lists, was conducted.clinical teaching practice* AND clinical educat* OR nurse educ* OR clinical teach* OR mentor* OR preceptor* AND undergraduate*.The following key words were used to search for literature from databases: Both research papers and non-research papers, such as opinion papers, and clinical practice guidelines reporting on the clinical teaching practices of nurse educators, including clinical teachers, mentors, preceptors and clinical educators, teaching undergraduate nursing programmes were included. Inclusion was limited to papers in English as this was the language the researcher was proficient in and dated between January 2001 and June 2021 to obtain sufficient evidence.Papers that were included related to aspects of clinical teaching, namely: planning for clinical teaching practice, facilitation of nursing students’ clinical learning, evaluation of students’ clinical skills assessment, modelling professional clinical teaching, work-based assessment in the clinical environment and clinical teaching in the simulation laboratory.The following papers were excluded: papers which were not relevant to the research study, such as those pertaining to clinical teaching practices by non-nursing educators , teaching of theory, clinical teaching in postgraduate programmes and other health programmes, duplicated papers, papers written in other languages and those possibly relevant papers that could not be obtained.After titles and abstracts were read and selected for inclusion, based on the inclusion and exclusion criteria by both authors independently, full-texts were obtained for possible relevant literature. Full-texts were read and selected based on the inclusion and exclusion criteria. The search and selection process is reflected in As reflected in Various critical appraisal tools were used to assess the rigour of the papers extracted in view of the heterogeneity thereof. These tools included Johns Hopkins’ tools for mixed methods and literature reviews; the Joanna Briggs Institute for interpretive studies; the Assessment of Multiple Systematic Reviews (AMSTAR) tool and Critical Appraisal Skills Programme (CASP) for integrative review, qualitative and quantitative studies. The non-research papers were assessed using the Joanna Briggs Institute for the Narrative, Opinion and Text Assessment critical appraisal tool (NOTARI), and the guideline was assessed using the Rapid Best Practice Guideline appraisal tool from Melnyk and Fineout-Overholt :518.The methodological quality of all the papers extracted was assessed using the US Preventive Services Task Force USPSTF  Guide toIn order to enhance rigour of the integrative literature review process, the critical appraisal of data was performed by the first author and an independent reviewer. Research papers were included if they were considered to be of good or medium rigour according to the various quality appraisal instruments. Research papers generally had to comply with more than half of the following criteria: the aim is clearly stated, the research design is appropriate; sampling, data collection and data analysis are clearly described; findings, recommendations and limitations were clearly stated and ethical issues were considered. Similarly, non-research papers were included if they complied with more than half of the following criteria: whether the opinion of the author(s) was based on scientific evidence or evidence was based on the opinions of more than one individual, who are preferably experts on the topic; the conclusions and recommendations are provided, including potential biases and whether results can be applied and are relevant to clinical practice. The two reviewers discussed this process, and, when consensus was reached, the final selection of papers was made. Four of the 71 papers that were appraised were excluded owing to weak methodological rigour. A total of 67 papers were included for data extraction.Data analysis included the data extraction and synthesis. Data  were extracted by the first author from the 67 papers using the data extraction tool adapted from Russell , in aligThis review was part of a doctoral study (ethics number: H15-HEA-NUR-008) that formulated the best practice guideline for clinical teaching at a public college of nursing. Consent to conduct the research was not obtained as this study had human participants.n = 67) papers were included. Of these, one was Randomised Control Trial, thirteen (13) were non-experimental interpretive studies, five (5) were literature reviews, thirty-two (32) were single descriptive or qualitative studies and fifteen (15) were non-research opinion papers of experts and reports of expert committees.Sixty-seven (n = 11), the United States of America (n = 10), Australia (n = 9), the United Kingdom (n = 8), Ireland (n = 7), Iran (n = 5), Sweden (n = 4), Brazil (n = 2) and South Africa (n = 2). One paper was included from each of the following countries: Belgium, Finland, Israel, Japan, Malawi, Pakistan, Palestine, Scotland and Turkey. Based on the thematic analysis of the extracted data, six themes emerged from the data, namely: planning for clinical teaching practice; facilitation of students’ clinical placements; evaluation of students’ clinical skills; modelling professional clinical teaching; work-based assessment in the clinical environment and clinical teaching in the simulation laboratory. The results of thematic analysis are discussed in the following subsection.Papers reported research conducted in Canada . However, the sharing of responsibilities by these nurse educators, coupled with a heavy workload, limited the effectiveness of the clinical teaching role formal self-assessment) by nurse educators of knowledge, skills and performance ; direct observation ; Objective Structured Clinical Examination ; interviews ; reflective journal  and rating scale  (Kpodo Various authors refer to the e) Kpodo :4;.Clinical teaching in the simulation laboratory was supported by eight papers. Simulation is a technique that can be used to replace real experiences with guided experiences that replicate substantial aspects of the real world in a fully interactive manner. Simulation has been used primarily in undergraduate nursing programmes to teach nursing skills in view of its safety and ability to afford nursing students the opportunity to practise skills until they achieve competency level. Simulation complements traditional education with actual patients and enables nursing students to learn in ways that eliminate risks to patients, thus providing them with opportunities to develop and explore problem-solving skills, clinical skills and critical thinking skills Berragan :3475.The six themes that emerged from this integrative review reflected that clinical teaching is a process, including various aspects.planning for clinical teaching practice – it was found that the nurse educator should prioritise self-preparation and planning for clinical placement. Self-preparation is about identifying own knowledge gaps and engaging in in-service education on a continuous basis. The areas that should be strengthened are clinical teaching and assessment methods, leadership and reflective thinking (Duffy & Watson By examining the first theme – facilitation of nursing students’ clinical placements – focused on implementation of the clinical teaching process. This theme was supported by the majority of papers reviewed. A well-structured clinical teaching programme was found to be necessary. A well-structured clinical programme would be evident in the resources provided to nursing students to utilise during their clinical exposure (Luhanga The second theme –  Luhanga :132. Fur Luhanga .The situation in the clinical sites should be monitored on a continuous basis in order to enhance the quality of clinical education (Farzi et al. Nurse educators must play a supportive role and be actively involved in clinical teaching in order to be familiar with what is happening in the clinical setting. They should be able to implement appropriate clinical teaching models in order for students to receive clinical teaching that is relevant and aligned with their learning objectives and level of teaching received (Leonard et al. The traditional facilitation model as one of the four clinical teaching models highlighted in the included papers is often regarded as the ‘gold’ standard Luhanga :125. Howevaluation of students’ clinical assessment skills – related to the interaction between the nurse educator and nursing student, with the focus on reflection by the student and feedback by the nurse educator. This was confirmed by Karimi et al. (The third theme – i et al. :5195 whoi et al. :667.modelling professional clinical practice – highlights the four characteristics of professional clinical practice that are interconnected. These are emotional intelligence, self-evaluation, role modelling and continuous professional development. Emotional intelligence enables the clinical teacher to pursue self-evaluation (Muthathi et al. The fourth theme – The process of role modelling attracts mutual interaction of clinical educators and nursing students. It enhances humanistic and professional growth. Humanistic growth is ensured through intellectual, spiritual and emotional development. A competent clinical teacher utilises role modelling to council, guide and promote students’ competency (Nouri et al. work-based assessment in the clinical environment – highlights the importance of clinical assessment in development of nursing students as competent professional nurses. Work-based assessment is an integral part of clinical teaching. It provides the students with an opportunity to develop critical thinking and problem-solving skills whilst taking care of patients. Hence, it is referred to as an authentic assessment (Almalkawi The fifth theme – linical teaching in the simulation laboratory – highlights the fact that simulation-based learning is vital for undergraduate nursing education, particularly in a context fuelled by the shortage of clinical faculty and diminishing the number of clinical sites (Aebersold The sixth theme – cThe weakness of an integrative literature review is that both research, such as randomised controlled trials, quantitative, qualitative, mixed methods as well as non-research papers, such as editorials and opinion papers, are included. Non-research papers are often regarded a lower level of evidence according to various hierarchies of evidence (Murad et al. This review aimed to summarise the best clinical teaching practices of nurse educators, teaching undergraduate nursing programmes. The evidence obtained from this review points to the existence of various practices with regard to clinical teaching. More clinical trials need to be conducted on clinical teaching practices and in resource-constrained settings.


Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the “primary effects” of AMR. Previous estimates of the burden of AMR have largely ignored the potential “secondary effects,” such as changes in surgical care pathways due to AMR, such as different infection prevention procedures or reduced access to surgical procedures altogether, with literature providing limited quantifications of this potential burden. Former conceptual models and approaches for quantifying such impacts are available, though they are often high-level and difficult to utilize in practice. We therefore expand on this earlier work to incorporate heterogeneity in antimicrobial usage, AMR, and causative organisms, providing a detailed decision-tree-Markov-hybrid conceptual model to estimate the burden of AMR on surgery patients. We collate available data sources in England and describe how routinely collected data could be used to parameterise such a model, providing a useful repository of data systems for future health economic evaluations. The wealth of national-level data available for England provides a case study in describing how current surveillance and administrative data capture systems could be used in the estimation of transition probability and cost parameters. However, it is recommended that such data are utilized in combination with expert opinion (for scope and scenario definitions) to robustly estimate both the primary and secondary effects of AMR over time. Though we focus on England, this discussion is useful in other settings with established and/or developing infectious diseases surveillance systems that feed into AMR National Action Plans. Surgical site infections (SSIs) place a substantial burden on healthcare systems . SSIs, kAntimicrobials have allowed us to develop safe patient-care pathways that would previously have put patients at a high risk of SSIs, by the integration of protocols of antibiotic prophylaxis into these pathways. Consequently, the threat of antimicrobial resistance (AMR) goes beyond a reduction of treatment effectiveness for acute infections. Increased AMR reduces the effectiveness, and therefore benefits, of the antimicrobial prophylaxis currently protecting patients from potential infections. For example, increasing the risk of SSIs for those undergoing surgery , 5. AMR a priori,” and secondary for purposes other than those stated as primary  . SecondaA previous review suggests the use of prospective, matched cohort studies to estimate the burden of SSIs by infection type . HoweverLinkage of hospital patient data to primary care data see  could alGiven the median age of elective-surgery patients covered within the national surveillance reports ranges from ~50 to 85 years old , long-teThe cost-of-illness impact, from the NHS (payer and provider) perspective, of surgery, SSIs and drug-resistant infections can be estimated using the aforementioned linked surveillance-administrative datasets to estimate length of stay and/or “Health Resource Group” (HRG) impact , 19. If For AMR and SSI burden estimation from a societal perspective, utilizing standard methods , the use of labor activity and earnings to estimate lost wages through illness and death is needed, and is available see  27). Ho. Ho27). As well as monetary costs, policy/AMR-scenario impact on population utility, is an important outcome, necessary for cost-utility analyses utilized by national policy makers . Such ouIn terms of data access, although all the patient-based data sources outlined in In the future there may be an increased ease of secondary use of the data sources outlined in Based on both (i) the existing AMR and SSI literature, and (ii) the data available described above, we propose a state-transition model estimating the primary and secondary effects of AMR, incorporating decision-trees outlining treatment strategies and Markov models outlining potential health states .For the primary effects, i.e., the direct burden of increased AMR in patients who get surgery and develop SSIs, these pathways can be parameterised with the secondary use of surveillance, administrative and economic data available in England. If outcome data are available at the patient level across hospital stays, statistical models can be utilized to estimate transitions along the patient pathways, adjusting for patient, provider, and socioeconomic characteristics. There are methods available to account for potential sources of bias when dealing with healthcare-associated infections, such as time varying confounding, and other complexities that may occur regardless of study design, such as competing events , 31, 32.Yi and Xp,t in Across the prophylaxis pathway depicted in Inclusion of primary care pathways, in terms of direct effects of AMR on post-surgery patients could be parameterised through linkage of patient data across primary and secondary care settings. Health states presented can have utility values, hospital costs and societal costs attached from Patient Reported Outcome Measure, National Cost Collection and Office for National Statistics datasets, respectively, as discussed in the above section , 34, 35.In a situation of the datasets described in the above section not being accessible at the patient-level, given their coverage they can still be useful in quantifying probabilities of acquiring SSIs. As an example, for hip replacement surgery is under the mandatory surveillance for SSIs, under which 60% undertook continuous surveillance for 2019/20, SSIS reports the incidence of SSI from surveilled hip surgery patients, and the distribution of causative microbes across these SSIs . Such reAs England has access to longitudinal microbiology data, trends can be determined using these data. Examples of such techniques include simple linear regression or random-walk models, whilst more complex transmission and forecasting modeling methods including seasonality and non-linearity can also be utilized . These tCandida auris)  . For thiWe first highlight that there are three potential ways for AMR to impact surgery patients including increasing SSI risk, treatment failure risk and risk of operations being unavailable altogether. Highlighted literature indicates that secondary effects could play a substantial role in the burden of AMR in the future, with estimates for lessening antimicrobial effectiveness including an additional 6,300 deaths per year in the USA and a loss of 2% of world Gross Domestic Product, across different scenarios , 42. HowThe scope for the secondary use of health data in establishing SSI and AMR burden for parameterising transition probabilities, costs and mortality for associated infections occurring in a health system is large. The retrospective use of such data may allow for reduced research burden in parameterising our proposed conceptual model. Even national-level, aggregated data can be used in estimating transition probabilities if data are externally valid. This, in turn, highlights another benefit to SSI surveillance, which already has been shown to reduce SSI rates themselves through benchmarking and outlier identification functions . The secEarlier published studies have highlighted the need for standardized SSI surveillance protocols such as defined follow up length and data entry methods . Our revHowever, even with access to current data, data completeness needs to be reviewed. Taking completeness to be in terms of documentation  , about 8Only a few infection types, mainly bacteraemia and notifiable infections, are listed as mandatory surveillance within relevant data capture systems, and as such the epidemiological data for other pathogens could be biased. However, such data has been routinely used to present AMR data at the national level in England  and a 20Though PROMs data are theoretically available for certain patients, it is only available for certain surgeries (hip and knee replacement) . MoreoveRegarding the HRG and excess length of stay unit costing, England is currently undergoing the NHS England and NHS Improvement's Costing Transformation Programme. This was piloted in 2016 and had annual stages of increased implementation subsequently. Therefore, currently such data come with potential data quality issues given these are the first few years of the new Patient-Level Information and Costing system, though this bias should decrease over time if systems and processes remain unchanged .Even with complete and secure data systems in place, this review deduces that the secondary use of health data cannot be used solely to parameterise a secondary effects model for AMR and SSIs. Prospective trials of SSI prevention measures, patient and public elicitation for utility values, alongside expert elicitation studies for “post-antibiotic” scenario understanding are needed. A 2019 literature review calls for more evidence from primary studies on the intervention effectiveness of different SSI prevention techniques . Such daAdditionally, the model currently depicts a simplified picture of “prophylaxis” vs. “no prophylaxis” comparison of surgical management pathways, as in addition to antimicrobial prophylaxis, there are several interventions to prevent SSIs, such as using sterile gowns or changing surgical instruments prior to wound closure , many ofWhile here we do not make specific recommendations related to the general health economic approach of quantifying our conceptual model, general guidelines are available elsewhere for health economic modeling , 57, theThough we have currently focused on the secondary use of health data in the NHS, the findings are applicable to settings where similar datasets are available. A 2018 review found 56 healthcare-associated infection and AMR surveillance systems from 20 countries within Europe, with 32 SSI surveillance systems included . This inIn conclusion, AMR is a complex phenomenon which has the potential to alter health outcomes for patients who contract drug resistant SSIs and change surgery patient pathways due to secondary effects. Though the secondary use of health data, in the English setting, has the potential to parameterise models quantifying the former, it falls short of being able to quantify the latter in isolation. However, such data can be combined with expert elicitation to parameterise a health state transition model that incorporates primary and secondary impacts of AMR on surgery patients over time. With growing SSI and AMR surveillance systems globally, alongside expert elicitation and investigations into potential future epidemiological scenarios, we can begin to understand the potential secondary effects of AMR through the application of the proposed conceptual model in other settings, and therefore understand how to deal with this phenomenon more efficiently.NN and SE reviewed the literature, reviewed the datasets, constructed the conceptual model diagram, and wrote the initial drafts of the manuscript. JR managed the project and contributed to study design. JR and RA secured funding for the project. KP, RT, TL, BM-P, and GK provided technical guidance on data and methods and/or literature cited. All authors aided in drafting the manuscript and approved the submitted manuscript.The research was funded by the National Institute for Health Research Health Protection Research Units (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London (grant number HPRU-2012–10047 funding NN's time and with NN subsequently holding an honorary contract through HPRU-200876) and the University of Oxford (grant number HPRU-2012-10041), all in partnership with Public Health England (PHE) [now United Kingdom Health Security Agency (UKHSA)]. GK was supported by a fellowship from the UK Medical Research Council (MR/P014658/1).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.The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health, or the United Kingdom Health Security Agency .


Effectively preventing and controlling zoonotic diseases requires a One Health approach that involves collaboration across sectors responsible for human health, animal health (both domestic and wildlife), and the environment, as well as other partners. Here we describe the Generalizable One Health Framework (GOHF), a five-step framework that provides structure for using a One Health approach in zoonotic disease programs being implemented at the local, sub-national, national, regional, or international level. Part of the framework is a toolkit that compiles existing resources and presents them following a stepwise schematic, allowing users to identify relevant resources as they are required. Coupled with recommendations for implementing a One Health approach for zoonotic disease prevention and control in technical domains including laboratory, surveillance, preparedness and response, this framework can mobilize One Health and thereby enhance and guide capacity building to combat zoonotic disease threats at the human–animal–environment interface. Applying a One Health approach to optimize zoonotic disease prevention and control programs can save lives by improving efficient use of resources  and the quality and timeliness of healthcare delivery8. Despite increasing awareness of the One Health approach, lack of communication and coordination between human health, animal health, and environment sectors can still hinder implementation. Internationally, the Tripartite organizations, namely the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), and World Health Organization (WHO), have exemplified using a multisectoral, One Health approach through mandated inter-agency collaboration9, and endorsement of One Health to facilitate sustained collaboration for zoonotic disease control at the local, subnational, national, regional, and international level through the guide, “Taking a Multisectoral, One Health Approach: A Tripartite Guide to Addressing Zoonotic Diseases in Countries” (hereafter the Tripartite Zoonoses Guide or TZG)10.One Health is a collaborative, multisectoral, and transdisciplinary approach—working at the local, national, regional and global levels—with the goal of achieving optimal health outcomes that recognize the interconnection between people, animals, plants, and their shared environment. In recent decades, the One Health approach has gained traction in combatting health issues at the human–animal–environment interface. Zoonotic diseases, infectious agents shared between animals and people, are a formidable challenge in One Health. Evolving conditions at the human–animal–environment interface due to factors like climate change, land use change  and increasing travel and trade have directly and indirectly affected the emergence and reemergence of zoonotic diseases10. OH-MCMs can create a way to coordinate all One Health activities across all relevant sectors10. While One Health systems such as OH-MCMs are not necessarily specific to zoonotic diseases, they may directly oversee zoonotic disease programs, or indirectly bolster associated One Health coordination. The TZG primarily provides guidance for a systems-based One Health approach, while providing examples from specific programs. While One Health systems-based approaches are an effective method of building sustainable coordination and collaboration across sectors10, initiating coordination through a zoonotic disease-specific program  presented here provides recommendations for how to use a One Health approach to improve multisectoral collaboration and thereby enhance the prevention and control of zoonotic diseases. The GOHF includes a visualization Fig.  that preFinally, since effective action should involve application of the GOHF to all aspects of a zoonotic disease-specific program, we describe how the GOHF can be applied across several technical domains, specifically laboratory, surveillance, joint outbreak response, prevention and control, preparedness, communication, and government and policy Fig. .The GOHF was developed by subject matter experts in One Health, zoonotic diseases, public health, and animal health at U.S. Centers for Disease Control and Prevention (CDC), and FAO. This framework was developed by combining successful existing and idealized processes for implementing zoonotic disease programming globally, leveraging subject-matter experts in anthrax, brucellosis, rabies, Rift Valley fever, and zoonotic influenza to provide example. Resources included in the Supplementary Tables are not an exhaustive list of all resources available; expert opinion, accessibility of the resource, and frequency of use were used to identify the most relevant resources available.8. Given these and similar advantages, an initial stage in developing One Health systems for zoonotic disease-specific programs involves exploring context-specific benefits, required modifications to current operations, and the level of interest and commitment expressed by stakeholders  between participating stakeholders can assist in establishing accountability and facilitating steady progress. Finally, to ensure that relevant stakeholders remain engaged as programs are expanded, combined, or re-organized, the process of identifying and including appropriate stakeholders should be routinely revisited.Early in system or program development, stakeholders from all relevant One Health sectors  as well as other relevant fields  must be identified13. To address the prioritization needs of countries, regions and other localities, the CDC developed the One Health Zoonotic Disease Prioritization process  and pandemic (H1N1) influenza in 2004 and 2009, respectively. Growing partnerships around influenza created opportunities and demonstrated successes that promoted further collaboration, ultimately leading to a cabinet-endorsed resolution where One Health was a core principle, and formation of a Thai Coordinating Unit for One Health22. Published articles from Kenya19 and Egypt20 also chronicle the path to institutionalizing One Health within government and provide examples for establishing sustainable support. At minimum, government support for One Health systems and programs should include dedicated domestic resources  and political will to initiate and sustain action23. For those advocating for increased governmental investment in One Health, one way to establish support is by demonstrating clear benefits of proposed activities at a reasonable cost, which can be accomplished through cost effectiveness analysis  and society  in the case of brucellosis32, rabies33, and salmonellosis34  compares to various scenarios of investment in control and elimination can both only improve the probability of program success and facilitate program endorsement by stakeholders and government. For zoonotic diseases, economic evaluations or decision analyses that account for all stakeholders are necessary to establish the societal cost of the disease as well as the benefits of prevention and control10. Strategic plans are often long-term (5–10 year), forward-looking documents that should be drafted and endorsed with equal input by all relevant sectors, and include a shared vision with achievable goals and objectives35. Several strategic planning resources exist to assist countries with developing One Health strategic plans, although there are also many countries that develop successful plans independently38. Some zoonotic diseases have specific strategic planning resources, such as the Rabies Practical Workplan, a component of the SARE which translates pending activities into actionable work plans  may be integrated into international initiatives, such as the NAPHS  activities that are required to achieve a mission. They outline the roles and responsibilities of all partners, and identify the resources needed to implement outlined activitiesOfficials that are preparing to implement developed plans should have an in-depth understanding of the tasks associated with building their One Health system or zoonotic disease-specific program. At this stage, costing the program identifies how available resources  will be allocated. This information can assist with devising a strategy to obtain missing resources, such as launching advocacy plans, soliciting resources from private industry, or seeking non-traditional partners including the military, universities, or ministries not directly associated with health . Exploring whether programming fits under the mandates of international agencies or forming regional partnerships to garner international assistance may also be worthwhile depending on current or future global priorities. Ideally, sufficient resources to carry programs through to completion should be identified prior to implementation of each phase, as this can help avoid premature program terminations.41. More sophisticated smartphone technology has spurred comprehensive surveillance, data collection, and prevention applications. For example, the WVS Data Collection app  smartphone app expedites detection of wildlife and livestock zoonotic diseases. In 2017, the KABS reported cattle mortalities that ultimately identified anthrax that triggered a One Health investigation that assessed people, animals and contaminated environments44. Smartphone technology is now also being used for laboratory diagnostics. For example, a smartphone-based system for detecting H5N1 avian influenza in clinical patient samples has a two-folder higher detectability than traditional fluorescent strip readers, making it a sensitive and portable system for field-based diagnostics45.Budgeted and financed plans allow One Health systems or zoonotic disease-specific programs to begin implementation. While this phase largely involves the progressive roll-out of programs resources exist to smooth or improve program implementation. Technological innovations including software and web platforms, mobile phones, tablets, and applications or “apps” are powerful resources being used to implement surveillance, prevention, control and preparedness activities. For example, in the United States, text-based monitoring has also been used to improve detection of illnesses caused by novel influenza A viruses46.Whether implementation mechanisms are conventional or innovative, the ultimate goal at this stage is to implement an effective system that minimizes resources while reaching intended outcomes, including reductions in human and animal morbidity and mortality48. While evaluating the multi-faceted nature of a One Health system or zoonotic disease-specific program can be complex, a framework for monitoring and evaluation of One Health systems can provide evidence to support decision-making. Recent efforts have used common frameworks for monitoring and evaluation of One Health systems, but additional work is still needed to develop a standardized approach to monitor and evaluate One Health systems  can facilitate data sharing between relevant One Health sectors. Collecting common, standardized data elements ensures that data from different sectors can be linked and analyzed together Fig. –S5. Coor70. Further, evidence in epidemic-prone zoonotic diseases like influenza A viruses showed that animal vaccination prevented human outbreaks and perhaps also pandemics in China, where administration of a bivalent poultry vaccine eliminated human cases of H7N972. Finally, for zoonotic pathogens with environmental stages, programs that reduce both animal and human exposure to contaminated environments can be more effective than single-sector disease measures73. While prevention and control plans may be specific to the zoonotic disease and the epidemiologic situation, these examples illustrate that taking a multisectoral, One Health approach to prevention and control can reduce the burden of disease while optimizing program resources.While it seems evident that prevention and control programs that reduce the burden of disease in animal populations would correspondingly reduce the risk of human infection and disease (and vice versa), published records are limited to a few salient examples. For rabies, previous research has established that vaccination coverage of 70% or higher in dog populations can reduce the frequency of human dog-bite injuries, usage of post-exposure prophylaxis, and human rabies cases75. More generally, preparedness efforts that strengthen One Health coordination in laboratory, surveillance, and workforce (described in other sections) can benefit both routine and emergency activities.A great deal of activity within the realm of emergency preparedness has focused on pandemic preparedness for emerging infectious diseases. Preparedness planning using a One Health approach involves participation, engagement and readiness from all relevant sectors through all stages of preparedness planning 79, the In-Service Applied Veterinary Epidemiology Training Programme (ISAVET)80, and the One Health Workforce project81. Through hands-on training, the cadre of health practitioners created through these and other One Health programs can amplify One Health-based training and curriculum messaging, are more likely to meet previously defined One Health Core Competencies82, and demonstrate improved ability to collaboratively respond to threats at the human–animal–environment interface83. Still needed are programs which include environmental health practitioners, incorporate curriculum on the role of climate and the environment on One Health issues, and formalize processes on when and how to engage environment sectors.A number of international training frameworks highlight the need for training and education programs that use a One Health approach to equip the labor force with the skills necessary to combat zoonotic diseases (Supplementary Table 74. To this end, both the JEE and PVS Pathway (see Supplementary Table 62. Kenya is one such country that has published on its road to One Health institutionalization, and therefore provides an example of how governments may shift from sector-specific units or task forces to overarching governance through One Health systems84.Ensuring that the benefits of a One Health approach to zoonotic disease management are recognized by policy and decision makers can improve program success and sustainability. Institutionalizing One Health in governance is one means of establishing sustained support for programs that implement a One Health approachThis manuscript provides a framework for building capacity around zoonotic diseases using a One Health approach in a range of settings Fig. . Users oSupplementary Figures.Supplementary Tables.


The aim of this study was to examine whether inadequate prenatal care affect the risk of severe maternal morbidity in teenage pregnancies.We included 23,202 delivery cases among adolescent mothers aged between 13 and 19 years old with ≥ 37 weeks' gestational age. Data were derived from the National Health Insurance Service National Delivery Cohort in Korea between 2003 and 2018. We used a generalized estimating equation model while adjusting for numerous covariates to determine the adjusted relative risk (RR) associated with severe maternal morbidity. The main outcome measures were severe maternal morbidity and the Kessner Adequacy of Prenatal Care Index.Severe maternal morbidity occurred in 723 (3.1%) of the 23,202 investigated delivery cases. The risk of severe maternal morbidity was 1.8-fold higher among adolescent mothers who had received inadequate prenatal care  and 1.6-fold higher among those who had received intermediate prenatal care  compared to those with adequate prenatal care. Synergistic effects of inadequate prenatal care and maternal comorbidities affected severe maternal morbidity.This study confirmed that inadequate prenatal care is associated with increased risk of severe maternal morbidity among pregnant teenagers. Notably, maternal comorbidity and inadequate prenatal care produced synergistic effects on severe maternal morbidity. Public health policy makers should focus on the development and implementation of programs to ensure that adequate prenatal care and financial/healthcare support is provided to teenage mothers during their pregnancies. According to the World Health Organization, ~21 million teenage pregnancies occur each year, of which ~50% are unintended . In low-SMM is defined as “an unintended outcome of the process of labor and delivery that results in significant short- or long-term consequences to a woman's health” . IncreasInadequate PNC has been associated with increased risk of SMM and prophylactic interventions responsible for increasing delivery medical costs in South Korea . While rFurthermore, among studies targeting adolescent pregnancies and infant/maternal clinical health outcomes after adjusting for PNC, few have suggested a direct association between PNC and SMM among teenage mothers , 14, andData from this population-based cohort study were retrieved from the National Health Information Database (NHID) between 2003 and 2013 and included data for utilization of healthcare, health screening, sociodemographic characteristics, and mortality for the whole South Korean population. These data were provided by the National Health Insurance Service (NHIS) which is the single insurer covering all Koreans . The NHIInternational Classification of Diseases, 10th Revision (ICD-10), length of stay, treatment costs, services received) and prescription. records   . The hea dosage) .The NHIS delivery cohort were extracted using the NHID claims database, which included data on all delivery cases in South Korea. We defined diagnosis and procedure codes for pregnancies by women aged between 13 and 19 years, who were hospitalized for delivery purposes and were enrolled for at least 280 days before childbirth through up to 6 weeks following childbirth between January 1, 2003 and November 19, 2018. Childbirth was identified as any inpatient hospital admission record including a pregnancy-related diagnosis  or proceSMM was defined according to SMM indicators and the possession of at least one of the 21 previously established ICD-10 diagnosis and procedure codes during the delivery hospitalization, using an algorithm developed by the Centers for Disease Control and Prevention . The oriWe identified adequacy of prenatal care according to the Kessner Adequacy of Prenatal Care Index (KAPCI) . To meetWe selected covariates based on previous literature as follows: maternal socioeconomic characteristics included maternal age , household income level (quintile), type of insurance , residential area , and employment status (employed and unemployed). Clinical variables included mode of delivery , parity , twin birth status (singleton and twin birth), and maternal comorbidities  using Howell's study  and 95% confidence intervals (CI) using a Poisson regression model with a robust error variance adjusted for all covariates. The Poisson regression model was generated for combined effect between adequacy of prenatal care and maternal comorbidities on SMM and evaluated for interactions. All statistical analyses were performed using SAS 9.4 . The level of significance was set at We also examined the combined effects of prenatal care and maternal comorbidities with SMM, as shown in This nationwide population-based cohort study revealed that within a 16-year observational period, teenage mothers who had received inadequate prenatal care and those with maternal comorbidities may have increased risk of SMM compared to their counterparts. Interestingly, our findings also confirmed that inadequate prenatal care and maternal comorbidities could synergistically affect the risk of SMM among teenage mothers.To our knowledge, this was the first study to examine the effects of PNC and SMM in teenage pregnancies; hence, the available evidence does not suffice for accurate comparisons. However, in a South Korean epidemiologic study of general pregnancy outcomes and prenatal care utilization among teenagers and adult women, 14.4% of teenage mothers reported to never having received PNC, which was in line with our findings  .Similar to most studies focusing on the maternal age effect and its association with maternal complications, our study also found that teenage mothers are at greater risk of complications such as IUGR, preterm birth , anemia,While immaturity of the uterine or cervical blood supply in teenage mothers have been found to raise the risk of subclinical infection and prostaglandin production resulting in increased risk of preterm delivery , our invSeveral studies have highlighted the importance of prenatal care in reducing the risk of adverse maternal and neonatal outcomes. Many studies have proven the relationship between prenatal care and prevention of adverse maternal health outcomes such as eclampsia and puerperal infection , severe Through our results, we inferred that limited access to prenatal care and lack of prevention and treatment interventions for adverse health conditions during adolescent pregnancy will also result in increased risk of eclampsia, puerperal endometritis, and systematic infection . Here, iIn particular, in South Korea, the entire population is covered by the National Health Insurance; hence, access to healthcare utilization could be adequate; however, emotional barriers to visit the obstetricians, and related mental illnesses such as depression may make it difficult for teenage mothers to receive PNC. A recent study, in high-income countries, demonstrated that over half of young women have experienced a mental disorder before becoming a parent , and tha≤ 15 years has gradually decreased until recently; ~0.17% reduction in total pregnancies was observed from 2015 to 2020 . Furthermore, as this database did not include gestational age, we could not control for this factor. However, we attempted to calculate the prediction of gestational age from the childbirth date to confirm the adequacy of prenatal care. Second, in order to calculate gestational age more precisely, we excluded teenage mothers who had preterm birth. In fact, preterm birth is a well-known risk factor of adverse maternal health outcomes, especially of teenage mothers. However, this database has diagnosis codes for preterm birth (childbirth <37 weeks) but there is no information on the exact gestational age, which might reflect a significantly different health status for both the mother and fetus during under 37 weeks; therefore, we excluded preterm birth teenage mother to ensure homogeneity. Another limitation is the heterogeneity of the study population. In this study, teenage pregnancy was defined as pregnancy in girls aged 13–19 years, but the study population had different characteristics, such as physical maturity, socioeconomic status, or marital status. Therefore, further research should determine whether each age group has a different effect on the relationship between comorbidity and prenatal care with regard to SMM.Nevertheless, this study has several strengths. First, to our knowledge, this was the first study of teenage pregnancy on SMM using large population-based long-term cohort study. Most of previous studies included adolescent and adults  , 43; howOur study confirmed that inadequate prenatal care may be associated with increased risk of SMM among pregnant teenagers. Notably, maternal comorbidities and inadequate prenatal care produced synergistic effects on SMM. Therefore, public health policy makers should focus on the development and implementation of programs to ensure adequate prenatal care and support financial accessibility of healthcare to improve the health of teenage mothers.https://nhiss.nhis.or.kr/bd/ab/bdaba000eng.do.The datasets presented in this article are not readily available because the data were obtained from the database of the National Health Insurance Sharing Service. The authors are not eligible to duplicate and disseminate the database. Requests to access the datasets should be directed to This study design was reviewed and approved by the Institutional Review Board of Eulji University (No. EU21-005). Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.JN and SO: conceptualization and writing-original draft. JN: data curation. SO and E-CP: validation. JN: resources and supervision. All authors: investigation, methodology, writing, reviewing, and editing. All authors contributed to the article and approved the submitted version.The authors disclosed receipt of the following financial support for the research, authorship and/or publication or this article: This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (2020R1C1C1013668).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.


Governments and health authorities must invest more in primary health care (PHC). This is increasingly urgent to assure service continuity throughout and beyond the pandemic , 2. The Mass vaccination in 2021 demanded proactive involvement across sectors, especially PHC, public health (PH), community services and the third sector [Governments have not followed a “Vaccine-plus” approach failing to use all preventive measures available . MandateThe avalanche of patients with less severe COVID-19 is shifting care progressively from hospitals to PHC, but without plans in place to strengthen investment and reallocate staffing, as happened in hospitals during earlier waves. As society reopens while case rates remain high, PHC and community services remain fragile . The DelIt is essential to learn from experiences in countries such as Canada after the shock of SARS in 2003, which identified the need for better coordination and integration of PH services with health care structures, particularly PHC. PHC services have also recognised opportunities for permanent and beneficial change brought about by the pandemic, especially digital technologies .As we strengthen PHC, public and community health, we must build more sustainable, approaches, increasing protection of our local and global eco-system and environment, following the “One Health” philosophy . We have(1) Understand and act on the principle that preparedness and response begins with communities, PH, and PHC services.(2) Assume a multi-disciplinary approach to creating and disseminating new knowledge and understanding, responding to challenges posed by the pandemic: prevention, awareness, diagnosis, treatment, recovery. Health and science literacy, modern tools and communication must be within reach of all.(3) Ensure that the core COVID-19 approach is coordinated by pivoting investment towards PHC, interconnected with PH services, clarifying this does not mean hospitals withdraw from providing needed care.(4) Sustainably strengthen PHC with necessary human, financial and technological means, with investment levels reflecting community need.(5) Invest in universal community and homecare services, meeting need and reducing hospital and PHC centre presentations.(6) Address the need to support children’s health in the community, including school nursing and assure health services complement PHC.(7) Review availability of occupational health services, seeking to grow these to meet workforce health care needs.(8) Invest in community development and voluntary services to support preventive efforts tackling inequalities, support vulnerable people and address needs caused by the pandemic(9) Create funded plans for strengthening PHC, including mental health care and community services, enhancing support for people with chronic conditions, ensuring better longitudinal and coordinated care and minimising the risk of unconnected or non-integrated hospital services and managing increases in multimorbidity arising as a direct consequence of long COVID.(10) Build sustainable, less wasteful approaches giving attention to animal health, eco-system and environment protection, following the “One Health” approach.ASPHER believes that health administrations, local and national governments should:. We must invest in local PH and PHC and communities to extract us from this pandemic and provide better health for the future.The end of the pandemic is not determined by the pronouncements of politicians or journalists. We will not be free of the virus, until everyone is free . All intwww.aspher.org.The Association of Schools of Public Health in the European Region (ASPHER) is the key independent European organisation dedicated to improving and protecting the public health by strengthening education and training of public health professionals for both practice and research. ASPHER is responsible and liable for all contents of ASPHER statements. ASPHER statements are approved by an Editor-in-Chief but not externally peer reviewed.