Advancements in assisted reproductive technologies (ART) and policy development have enabled more people to have biologically related children in Canada. However, as ART continues to focus on infertility and low fertility of heterosexual couples, ART access and research has been uneven towards meeting the reproductive needs of lesbian, gay, bisexual, transgender, queer, two-spirit, intersex, and asexual (LGBTQ2SIA +) people. Furthermore, experiences of reproduction are impacted by intersectional lived realities of race, gender, sexuality, and class. This commentary utilizes a reproductive justice (RJ) framework to consider reproductive access for LGBTQ2SIA + Black, Indigenous, and people of colour (BIPOC), while simultaneously engaging through a critical lens RJ has on ART. An RJ framework considers the constitutive elements of reproductive capacity and decision making that are not often at the forefront of reproductive health discussions. Additionally, this commentary discusses reproductive rights violations and reproductive violence such as coerced and forced sterilizations that have and are currently occurring in Canada. This article considers systems of access and structures of regulation that seek to control the reproductive capacities of marginalized communities, while empowering accessibility and upholding white supremacy and heteronormativity. In thinking through research and access in ART, who are ART users and whose reproduction is centered in research and access in Canada?A reproductive justice framework is urgently needed to address inequities of sexual and reproductive health access in Canada. Evidence indicates a significant increase in the use of assisted reproductive technologies (ART) in Canada over the past two decades , 2. ThesTo address complex issues in ART access and research, it is necessary to utilize a framework that centers complexity and lived realities constituting reproductive capacity and decision making outside of predominant white heteronormative standards. Adopting a reproductive justice framework offers a more nuanced approach to address sexual and reproductive health inequities among Black, Indigenous and people of colour (BIPOC) with intersectional lived experiences in Canada. Further, in order to meaningfully engage and advocate for the implementation and use of a reproductive justice framework within sexual and reproductive health research (SRHR) and ART, historical and present injustices of reproductive violence must be acknowledged and addressed.Rooted in Black feminist thought, critical race theory, and critical feminist theory –9, reproRJ highlights an original intersectional lens on integrative, rather than additive, impacts of racism, sexism, misogyny, transphobia, homophobia, and classism in reproductive politics . As a prIn applying an RJ framework there needs to be awareness of critiques and cautions that RJ has made in relation to ART. This includes a history of eugenics and reproductive control using ART , 19, 20,By engaging with critiques of ART, we can better understand constitutive elements of reproductive capacity and access. It is a call to consider historical and ongoing conditions of racial violence and reproductive control of racialized people’s bodies. Black and women of colour feminists have aptly written about reproduction and regulation of Black, Indigenous, and people of colour’s bodies as central to intersectional oppression and health inequities, concealed into the ordinary present and unacknowledged past , 20, 27.However, reproductive violence is not just a thing of the past in Canada. Legislated and non-legislated coerced sterilizations were and are currently used as a form of mass birth control for Black, Indigenous, and people of colour, as well as LGBTQ2SIA+ people , 31–35. Currently, the majority of ART is privatized with access being a highly stratified and stratifying process –42. If ASociotechnical innovation of reproductive access and ART research have been uneven with respect to meeting the unique reproductive needs of LGBTQ2SIA+ people. ART was initially designed to provide “infertile/low fertility” heterosexual married couples with options to conceive children –55. ThisRegulation of ART and funding for fertility are under provincial jurisdiction in Canada . CurrentOverall, fertility clinic data in Canada is voluntarily reported and stored through the Canadian Assisted Reproductive Technologies Register . As clinIn contrast to the Canadian context, fertility clinics in the US performing ART are required to report data to the Centers for Disease Control and Prevention through the Society for Assisted Reproductive Technology Clinic Outcome Reporting System . Using tPresent research on reproductive technologies and fertility clinics predominantly centers on white, cisgender, heterosexual couples with socioeconomic privilege. In addition, the rare research study exploring LGBTQ2SIA+ participants’ experiences with reproductive access have included primarily white, cisgender lesbian and bisexual women with relatively high levels of education and income , 69, 70.An RJ approach to ART includes understanding and dismantling structures that seek to control the reproductive capacities of marginalized communities, while empowering accessibility and upholding white supremacy and heteronormativity. Implementing RJ in ART access and research would include asking questions like who gets access to ART? What are present and historical conditions of ART that impact access? What socio-political factors impact reproductive access? Is the right to parent children in safe and healthy environments supported ? AdditioBeyond data collection on socio-demographics, the lived realities of reproductive capacity and decision making among BIPOC LGBTQ2SIA+ communities should be considered in research, clinical work, and policy development. Experiences of integrative social locations including race, class, gender, sexuality, family structure, and access to health care  are consAs a family formation process, ART brings interconnections of sexuality, gender, race, socioeconomic status, family structure, and access to healthcare into play. Applying RJ as an approach to ART for BIPOC LGBTQ2SIA+ communities and other users necessitates attention towards complex constitutive elements that impact reproductive capacities and decisions that are not often at the forefront of reproductive health discussions. As a foundational framework, reproductive justice can advance our understandings and attempts to reduce sexual and reproductive health inequities among BIPOC (and) LGBTQ2SIA + communities in Canada.


Patient experience is a key measure widely used to evaluate quality of healthcare, yet there is little discussion about it in China using national survey data. This study aimed to explore rural and urban differences in patient experience in China.Data regarding this study were drawn from Chinese General Social Survey (CGSS) 2015, with a sample size of 9604. Patient experience was measured by the evaluation on healthcare services. Coarsened exact matching (CEM) method was used to balance covariates between the rural and urban respondents. Three thousand three hundred seventy-two participants finally comprised the matched cohort, including 1592 rural residents and 1780 urban residents. Rural and urban differences in patient experience were tested by ordinary least-squares regression and ordered logistic regression.The mean (SD) score of patient experience for rural and urban residents was 72.35(17.32) and 69.45(17.00), respectively. Urban residents reported worse patient experience than rural counterparts . Older  and healthier  rural residents living in western area  with higher social status , evaluation on adequacy , distribution  and accessibility  of healthcare resources had better patient experience. In addition, urban peers with lower education  and higher family economic status  reported better patient experience.Differences in patient experience for rural and urban residents were observed in this study. It is necessary to not only encourage residents to form a habit of seeking healthcare services in local primary healthcare institutions first and then go to large hospitals in urban areas when necessary, but also endeavor to reduce the disparity of healthcare resources between rural and urban areas by improving quality and capacity of rural healthcare institutions and primary healthcare system of China.The online version contains supplementary material available at 10.1186/s12913-021-06328-0. Feedback of equipment, environment and services from healthcare users, is of vital importance to quality assessment and healthcare services improvement . As a crGlobally there is an increasing trend towards research on patient experience. The growing focus on patient experience reflects the fact of broader emphases and actions on patient-centered healthcare delivery . The meaPatient experience is a multi-dimensional construct encompassing numerous elements of healthcare. It can be measured by either patient report (what happened to patient) or patient evaluation (how patients rate) items, including the process of an appointment, waiting time, cleanliness of environment, efficiency of apparatus, communication with doctors and nurses, responsiveness and interactions with medical staffs and receptionists, and so on . Albeit Rural and urban disparities were embodied in various aspects. Compared with their urban counterparts, rural residents are more likely to be unemployed with lower level of education and income , 21, andOn the concept of theory of Andersen’s Behavioral Model of Health Services Use –37, patiA key issue arises from the described background: there is little discussion about patient experience differences between comparable rural and urban residents in China by using a national survey data under the theory of Andersen’s Behavioral Model of Health Services Use. The focus of current study was rural and urban differences in patient experience in China, and the objectives were: 1) to explore the association between place of residence and patient experience; 2) to examine the factors affecting patient experience for rural and urban residents, respectively.Based on the theory of Andersen’s Behavioral Model of Health Services Use, an individual’s utilization of healthcare service is a behavior of his/her need for such healthcare service, a predisposition to use them and factors that enable them to be utilized . GeneralData of this study were drawn from Chinese General Social Survey (CGSS) 2015, a national, representative and all-around survey first conducted in 2003 by Renmin University of China (RUC) and Hong Kong University of Science and Technology. CGSS can be considered as the Chinese counterpart of the General Social Survey (GSS) in the US . A multiAs a primary outcome variable, patient experience, regarded as feedback of healthcare utilization, was measured by healthcare services evaluation with following question: “What score will you give to healthcare services (0–100)?” In addition, during the analysis, the 0–100 values were further divided into five ordered levels: very bad , bad , fair , good , very good , coding from 1 to 5. Ordered classification was used to better depict participants’ subjective perception, since Chinese are accustomed to assessing the quality by dividing centesimal system into such levels.Based on the concept of Andersen’s Behavioral Model of Health Services Use, the evaluation on healthcare services could be explained by independent variables as follows: 1) predisposing factors: age, gender, education, marital status, social status, place of residence and region; 2) enabling factors: personal income, family economic status, medical insurance, the evaluation on adequacy, distribution and accessibility of healthcare resources; 3) need factors: self-rated health status. Social status was measured by the following question: “What level/layer do you think you are in society?”, with an answer from value 1 to 10 and higher value indicating higher social class. Thus, the key independent variable was place of residence classified by sample type . Control variables included age , gender , education , marital status , social status , and region , personal income , family economic status , medical insurance , the evaluation on adequacy , distribution  and accessibility of healthcare resources , self-rated health status . For further information about the definitions/codes of variables, please check the supplementary files Table .1 is employed, of which size depends on the data set and the selected covariates. L1 ranges from 0 to 1, where 0 and 1 means perfect global balance and maximal imbalance respectively, and larger value represents larger imbalance between two groups. A good matching usually brings a substantial reduction in L1 [CEM is a matching method of the class Monotonic Imbalance Bounding (MIB), which shows the basic advantage over other matching methods that reducing imbalance in the empirical distribution in one covariate won’t affect any other covariates chosen for balancing . Furtheron in L1 . In our Chi-square test for categorical variables and one-way ANOVA for continuous variables were used to examine whether the rural-urban difference was statistically significant or not. Ordered logistic regression for ordinal categorical outcome and ordinary least-squares regression for numerical outcome were applied to examine the association between place of residence and patient experience in the matched cohort, and to explore factors affecting the patient experience for rural and urban residents in the unmatched cohort with sample weights. In matched data, all analyses were conducted incorporating matched weights. Potential confounders were controlled in multivariate analysis. All analyses were performed by using Stata software . All statistical tests were two sided with a significance threshold of 0.05.1 statistic before and after CEM was reported in Table 1 was reduced from 0.771 to 6.504e-16 and all matched variables after CEM were also close to zero. The results indicated that the rural and the urban became more comparable and balanced after matching process.Figure Patient experience and basic characteristics of rural and urban residents before and after matching were presented in Table Table Table The present study explored the relationship between place of residence and patient experience by using national survey data, based on which, further examined the factors affecting patient experience for rural and urban residents, respectively. Our findings revealed that: 1) urban residents had worse patient experience than rural residents; 2) Older and healthier residents living in western area with higher social status, evaluation on adequacy, distribution and accessibility of healthcare resources had better patient experience; 3) in addition, urban residents with lower education and higher family economic status had better patient experience.In line with previous study , we founIt was found that older and healthier residents tended to have better patient experience, consistent with other studies , 56. PotIn addition, our finding that indicated urban individuals with high education level was associated with poor patient experience is in line with previous study , mainly Our study supplements and improves the existing literatures on patient experience in the context of urban-rural dual structure in China from the perspective of residents. To the best of our knowledge, the key advantage of this study was a nationwide survey to explore the association between place of residence and patient experience with CEM application to balance the rural and urban two comparison groups. However, the findings should be interpreted with caution to some extent because of the following several limitations. First of all, there was a sample loss during preprocessing the data with CEM, which might make some estimates lack precision and affect the representativeness of demographics distribution. Secondly, due to the lack information of healthcare institutions respondents visited , the characteristics of hospitals that might influence patient experience couldn’t be well controlled when comparing patient experiences for rural and urban residents. Thus, it needs to be further examined in future studies. Thirdly, since data on multidimensional measures of patient experience were unavailable, such as waiting/consultation time, communication and interaction with doctors and nurses, and hospital environment, the patient experience bias might exist in our study. Fourthly, considering the targeted people in this study were residents instead of outpatients or inpatients, the results might be less accurate in measuring patient experience compared to patients investigated after their encounters with physicians.As found in this study, patient experience differences did exist in rural and urban residents in China. Rural residents had better patient experience than their urban counterparts. Older and healthier residents living in western area with higher social status, evaluation on adequacy, distribution and accessibility of healthcare resources were associated with better patient experience. In addition, urban residents with lower education and higher family economic status reported better patient experience. It is essential to not only encourage residents to form a habit of seeking healthcare services in local primary healthcare institutions first and then go to large hospitals in urban areas when necessary, but also abridge the disparity of healthcare resources between rural and urban areas by improving the quality and capacity of rural healthcare institutions and primary healthcare system of China.Additional file 1.


Malawi depends on Lake Malawi outflows into the Shire River for its water, energy and food (WEF) security. We explore future WEF security risks under the combined impacts of climate change and ambitious development pathways for water use expansion. We drive a bespoke water resources model developed with stakeholder inputs, with 29 bias-corrected climate model projections, alongside stakeholder elicited development pathways, and examine impacts on stakeholder-elicited WEF sector performance metrics. Using scenario analysis, we stress-test the system, explore uncertainties, assess trade-offs between satisfying WEF metrics, and explore whether planned regulation of outflows could help satisfy metrics. While uncertainty from potential future rainfall change generates a wide range of outcomes (including no lake outflow and higher frequency of major downstream floods), we find that potential irrigation expansion in the Lake Malawi catchments could enhance the risk of very low lake levels and risk to Shire River hydropower and irrigation infrastructure performance. Improved regulation of lake outflows through the upgraded barrage does offer some risk mitigation, but trade-offs emerge between lake level management and downstream WEF sector requirements. These results highlight the need to balance Malawi's socio-economic development ambitions across sectors and within a lake-river system, alongside enhanced climate resilience.This article is part of the theme issue 'Developing resilient energy systems'. The WEFAcross Africa, mainstreaming climate resilient development into on-going planning and policy making is vitally important . MainstrDecision-making under uncertainty (DMUU) approaches have applicability in WEF nexus decision contexts  because In this paper, we explore the interactions between development pathways and climate change uncertainty, for a least developed country (LDC) context in Africa; Malawi. We focus on the transboundary Lake Malawi Shire River Basin (LMSRB) that supports greater than 90% of Malawi's hydropower and irrigation, water supply for its growing population, and environmental flows for an important biodiverse wetland, the Elephant Marsh, before the Shire River joins the Zambezi River. We use a Water Evaluation And Planning (WEAP) model developed with inputs and insights from multi-sectoral stakeholders  to analy (1)How might existing irrigation expansion plans, and potential future expansion and intensification of irrigation in the Lake Malawi catchment, affect downstream Shire River hydropower, irrigation and environmental flow requirements? (2)To what extent can regulating lake outflows help manage risks to stakeholder-identified hydropower and irrigation infrastructure, and environmental flow requirements in the Shire River, under uncertain changes in climate and upstream water use?Specifically, this paper focuses on the following research questions:In §2, we elaborate on the decision context from a WEF nexus perspective within the LMSRB. In §3, we detail the methods, including stakeholder engagement, modelling approach and scenario framework. Results are presented in §4 and §5 discusses the results followed by brief conclusions from the study.. 2a), has played a major role in the country's development to date, and is a crucial component of current and future plans for economic development. Malawi's development plans involve extensive irrigation and hydropower expansion ostensibly to address food insecurity and low access to electricity (approx. 9% of the population), among other objectives [The LMSRB dominates Malawi's physical geography a, has pljectives . Infrastjectives ,15 and ejectives  recent ijectives ). WEF sejectives ), and gia). Lake Malawi outflows sustain dry season Shire River flows, which since 1966 have been used for hydropower generation from the Nkula (1966), Tedzani (1973) and Kapichira (2000) hydropower plants (HPPs). Together their approximately 0.35 GW total installed capacity accounts for approximately 94% of electricity generation capacity of Malawi [Opsaridium microcephalum)) [Africa's third largest lake, Lake Malawi, overflows into the 410 km long Shire River, and together they form the LMSRB, the last major sub-basin of the Zambezi River Basin a. Lake Mf Malawi . Currentb). The Kamuzu Barrage (built in 1965) enabled some regulation of outflows and management of lake levels; however, observations (starting in the early twentieth century), historical documents and paleoclimate evidence indicate that climate variability can cause lake levels to fall below the Lake Malawi Outflow Threshold (LMOT) of approximately 471.5 masl [c).Lake Malawi levels depend on runoff contribution from the mountainous regions around Lake Malawi that lie in Malawi, Tanzania and Mozambique, with lake inflow contributions of approximately 55%, approximately 41 and approximately 4%, respectively b. The Ka1.5 masl . A multic). The Kamuzu barrage was upgraded in 2018 to enable automated control of its release gates, using real-time rainfall and runoff data at key locations, primarily to optimize outflows for Shire River hydropower generation and irrigation requirements, but also for better management of lake levels. Before the upgrade, records of river flows and releases (and their underlying decisions) are very sparse, making it difficult to determine the precise influence of the barrage on fluctuations in lake level and outflows. However, it is possible to reconstruct lake levels confidently and Shire River outflows to a reasonable level [During wetter periods high lake levels pose flood risk to lakeshore and downstream Shire regions, such as those experienced in 1979–1980, when lake levels reached record highs. Extreme floods in the Lower Shire River due to high rainfall over the lower catchment  have also caused major socio-economic disruption . High spfigure 1le level . Revisedd). Decision makers have to balance potentially conflicting priorities between the interconnected Lake Malawi catchment and the Shire River Basin. Regulating lake levels within an acceptable range in a way that avoids no-outflow conditions and lakeshore flooding is important and this requirement has to be balanced against meeting Shire River Basin requirements for hydropower, irrigation and the environment.Four key WEF sector priorities capture the complex decision-making context in the LMSRB d. Decisi. 3 (a)The stakeholder engagement process comprised of stakeholder identification, initial personal interactions and sequential meetings with multi-sector stakeholders over a four-year period (2015–2019). Identification of participants was made through initial contacts within our project consortium. Other potential participants were identified by asking existing contacts to recommend a wide range of relevant individuals to engage with the study. We sought technical staff directly involved with water resources management, hydropower generation, agriculture, irrigation, domestic water supply, the environment and sectoral planners. Initial personal interactions helped introduce research objectives, and explain that the research approach involves both modelling/analysis and engagement with the aim of enhancing its value to stakeholders. We held three focused group discussions with representatives from the Departments of Irrigation, Surface Water and Agriculture Extension Services within the Ministry of Agriculture, Irrigation and Water Development (MoAIWD), the Department of National Parks and Wildlife, Electricity Supply Corporation of Malawi Ltd, the Shire River Basin Management Programme, and operators of the Kamuzu Barrage. These expert discussion forums aimed to facilitate a shared understanding of the system such that its main characteristics could be incorporated in the modelling, analytical framework and performance analysis. In the forums, stakeholders shared information and insights to help develop an initial conceptual water resources model, refine the resulting WEAP model, and discuss the analytical approach among private sector stakeholders, hydropower companies were engaged in the discussion forums, while we engaged the largest irrigation water user, Illovo Sugar Malawi, through personal visits. Stakeholders provided details regarding the infrastructure, including its operation, key performance needs and system vulnerabilities (cf.  for detahttp://amma2050.ipsl.upmc.fr/CMIP5_AFRICA/) and have been used in previous studies [For this paper, we elicited stakeholder perceptions on uncertainties relating to drivers of future water availability and demand change, key characteristics and likelihood of hydropower and irrigation development plans in Malawi, and what were considered to be important performance metrics for WEF sectors and the environment in the Shire River Basin. We also asked about availability and details of water management options . Stakeho studies ,18,24. T (b)et al. [In this study, we use a Water Evaluation and Planning (WEAP) model developed for the LMSRB by Bhave et al. . This moSix metrics are identified (using stakeholder prioritization) to represent the four main decision-relevant outcomes in terms of risk to infrastructure performance . The met (1)Baseline : This scenario uses observed climate for the period 1971–2000, historical water use and upgraded Kamuzu Barrage and operation rules. We choose this 30-year period because it includes incidences of high (1979–1980) and low lake levels (1995–2000), which helps capture the recent observed climatic variability. Although during the 1971–2000 period, the barrage and operation rules were actually different, we use the upgraded barrage and rules to allow direct comparison of impacts with simulations under future climate change and development pathways . (2)Climate change with SEP: This scenario combination represents the period 2021–2050, with 29 climate change projections, SEP related water demand changes, and upgraded Kamuzu Barrage operation (§4.a). (3)Climate change with IP: Represents the period 2021–2050, with 29 climate change projections, IP related water demand changes, and upgraded Kamuzu Barrage operation (§4.a). (4)et al. [Climate Change with Old Barrage : This scenario for the period 2021–2050 uses climate change projections, historical water use and historical barrage operations. This combination is the same as presented in Bhave et al.  and is uWe use four scenario combinations as part of the scenario framework, which are described below.. 4 (a)The pathways represent two realizations of future changes in water demand associated with different assumptions about irrigation expansion. The SEP includes hydropower and irrigation plans , which ahttp://sagcot.co.tz/) investment blueprint. It envisages rapidly expanding irrigation in the Ludewa Cluster from approximately 8000 ha in 2020, to approximately 23 000 ha in 2025 and to approximately 37 000 ha by 2030 [The IP addresses stakeholder concerns about additional expansion of irrigation upstream in the Tanzanian part of Lake Malawi's catchment. It comprises upper estimates of irrigation expansion in Malawi and Tanzania, coupled with reduction of irrigation return flows, much greater than the stakeholders expected, as a stress-test of the system . Three p by 2030 . In Mala (b)We present results for five decision metrics with the scenario combinations ‘Climate Change with SEP’ and ‘Climate Change with IP’ compared with performance metrics under the Baseline scenario. Future risk profiles are derived from the suite of 29 GCM projections . The widIn the Baseline scenario, the lake level performance metrics are always met, i.e. the lake levels are never higher than 476 masl or lower than 471.5 masl. We find that the satisfaction of the Shire River performance metrics In this section, we explore how potential future changes could affect Shire River hydropower generation and floods in the lower Shire River. For hydropower, we analyse hydropower generation as a percentage of the total installed capacity at that time, while for the Shire River floods we use the flooding metric  are not observed, suggesting that the improved barrage operation rules are useful in reducing the risk of downstream floods under historical climatic and water use conditions. For future scenarios  model that has a number of assumptions owing to the complexity of the LMSRB and data sparsity. To improve the understanding of the system and support operational management and risk assessments in the basin, better and extensive monitoring of lake inflows and outflows and documentation of barrage management priorities is necessary. It is important to be clear about the assumptions and values inherent to any analysis of uncertainty, risk, water resources allocation priorities, and performance metrics. A key uncertainty here is the historical and potential future changes in lake rainfall-evaporation balance . Better The government targets used here for irrigation and infrastructure expansion (SEP and IP) are towards the higher end of current targets, given the rate of development in the past and experience elsewhere in sub-Saharan Africa . As suchWe show that a recent upgrading of the Kamuzu barrage and its operation rules has benefits, particularly in reducing lakeshore flooding risk. Under baseline climate conditions, the barrage satisfies LMSRB performance metrics for most of the time. At the river basin level, our analysis highlights important interdependencies; upstream, downstream and cross-sector. We obtain a wide range of results for the future, reflecting the deep uncertainty in climate model projections and different sensitivities of the performance metrics. While in some projections lake levels rise, causing increases in the risk of lakeshore flooding, for many projections lake levels fall below the LMOT for significant periods of time, leading to no-outflow conditions. Analysing the implications of low lake levels on maintenance of the barrage and hydropower infrastructure was not within the scope of this study, but could be an important issue worth exploring in terms of contingency planning and infrastructure management. Downstream of the lake, there is a decline in the satisfaction of Shire River performance metrics compared to the baseline. Of particular concern are very dry climate projections under which lake levels fall below the LMOT, when the barrage is no longer useful. These conditions would lead to a failure of the system, severely limiting the ability to satisfy hydropower and environmental flow metrics. Enhanced agricultural water demand and agricultural intensification in the Climate Change with IP scenario reduces Lake Malawi inflows and results in slightly lower lake levels than for the Climate Change with SEP scenario, and hence a marginally lower risk of lakeshore flooding. The four climate model projections with the highest rainfall cause the Lower Shire River to be flooded for between 5 and 20 per cent of the time, which is much more than under baseline conditions. Extreme rainfall in southern Malawi can lead to Shire River flooding, such as seen in 2015 and 2019, and potential future co-occurrence of high lake levels and high rainfall in the Shire River Basin would lead to very severe flooding in the lower Shire.The uncertainty created by having many different projections of rainfall can be a challenge to decision-making, yet, the full climate risk profile is important for advising policy makers and guiding further research . The mosThe study highlights how a single infrastructure, the Kamuzu Barrage, is of critical importance for the welfare of a large region. While the model-based simulations take into account the changed barrage operation rules, human intervention in barrage operation (e.g. to increase hydropower generation) could significantly affect how different performance metrics are or are not satisfied. Contingency plans might consider modified and adaptive barrage operating procedures and water allocation under both drier and wetter conditions and development of multi-agency drought and flood management plans for single and multi-year events. This would involve sequences of decision points across years, with increasingly stringent restrictions on releases after successive years of drought. Such plans would require careful analysis of climate variability at timescales ranging from sub-seasonal to multi-decadal, to identify trigger points for decisions and explore trade-offs between sectors and stakeholders.The cost of completing and maintaining hydropower dams can exceed their benefits and alternatives or complementary options, such as solar, thermal or wind power, which can be expanded incrementally, are rapidly becoming more cost-competitive. This calls for more thinking around the different energy sources that are available to address development aspirations articulated in Malawi's Vision 2063 document ,18 among


The Great CTSA Team Science Contest (GTSC) was developed to discover how Clinical and Translational Science Award (CTSA) hubs promote and support team science . The purSecondary qualitative analysis of the GTSC data addressed the following research questions, which defined the top-level coding: (1) What CTSA component sponsored it? (2) Who was the team doing the work? (3) Who were the intended beneficiaries? (4) What was the intended outcome? (5) What strategies did they use? (6) What translational science (TS) stage was addressed? (7) How do they align with the NCATS team science strategic goals? (8) How do the CTSA’s team science efforts align with the National Academies Research Council (NRC) recommendations for enhancing the effectiveness of team science?The GTSC received 170 submissions from 45 unique CTSA hubs. Qualitative analysis revealed a great variety of team science strategies for virtually all team science stakeholders. In addition to strategies to promote team science, results show successful examples that focus on outcomes and illustrate ways of measuring success.The GTSC shows that the CTSA consortium is involved in an extremely diverse array of team science activities, which align well with both the NRC recommendations for enhancing the effectiveness of team science and the NCATS strategic goals for team science. Future research should evaluate the efficacy of team science strategies. The scope of team science strategies across the Clinical and Translational Science Award (CTSA) consortium is extremely diverse, but they have not been fully characterized or evaluated for effectiveness. Many CTSA hubs are engaged in promoting team science, however, there is no single definition of what constitutes “team science.” The increasing complexity of Clinical and Translational Science (CTS) problems has prompted large investments in team science initiatives –9. The NThe complexities of science along with rapid technological advances have created the necessity for scientific collaborations between researchers with complementary expertise. The demand for collaborations has outpaced the development of institutional support, policies, funding opportunities, and team science culture. These gaps gave rise to the Science of Team Science (SciTS), a field of study designed to address the value of team science and develop strategies for facilitating, engaging in, leading, and supporting scientific teams . The Sci1 for the GTSC Instructions and Qualtrics Survey). Here, we conducted a secondary qualitative analysis of the GTSC dataset using a set of research questions to guide the analysis: (1) What CTSA component sponsored the team science activity? (2) Who was the team conducting the team science work? (3) Who were the intended beneficiaries? (4) What was the intended outcome? (5) What method did they use? (6) What translational science (TS) stage was addressed? (7) How do they align with the NCATS team science strategic goals? (8) How do the CTSA’s team science efforts align with the National Academies Research Council (NRC) recommendations for enhancing the effectiveness of team science? Thus, the purpose of this study was to conduct a qualitative analysis of how hubs were engaging in team science and to demonstrate the great breadth of consortium team science activities. In addition, this analysis sought to classify the submissions into meaningful categories as a resource for hubs interested in expanding team science initiatives. This study aims to advance our understanding of the diversity of CTSA team science initiatives including the intended recipients, strategies used, intended outcomes, and metrics for measuring success. Since the GTSC asked for strategies for enhancing team science, the results are discussed in the context of the how well they address the National Research Council’s recommendations for enhancing the effectiveness of team science [The GTSC was developed in the NCATS Workgroup on Institutional Readiness for Team Science to collect stories describing how CTSA hubs promote and support team science . The con science .after completion of the contest to mine the contest results for meaningful information about team science. Thus, several submissions do not specify sufficient data to answer the research questions and are classified as “Not explicitly specified.” The GTSC was developed in 2018 by the NCATS Workgroup on Institutional Readiness for Team Science to collect stories describing the ways hubs were promoting and supporting team science across the CTSA consortium. The original contest purpose, rules, and winners are listed on the CLIC website [2 [This paper represents a secondary analysis of an existing data source: The GTSC dataset. The research questions addressed here were developed  website . The fulbsite [2 .3. All 170 submissions were coded independently by the 3 authors. Where there was disagreement, the final coding assignment was made where two out of the three coders agreed. Many submissions could be coded to more than one subcategory, which more accurately represents the overlapping multidisciplinary nature of team science. When this occurred, the primary team science strategy was used to categorize the submission.The major research questions were used to organize the top-level coding categories, and inductive processes were used to develop the subcategories, such as the types of team science interventions or the beneficiary of the intervention. Subcategories were verified with more coding examples and similar subcategories were combined (e.g. trainees and students). The goal was to develop a meaningful framework to understand what strategies are being used to advance team science across the CTSA consortium. The qualitative data analysis coding structure with definitions is listed in Appendix The research questions were developed using two main criteria: (1) What CTSA hubs would find useful in terms of methods/strategies, intended beneficiaries, intended outcomes, and metrics for measuring effectiveness and (2) To answer the question: How well does team science across the CTSA consortium, as found in the GTSC dataset, address the NRC recommendations for enhancing the effectiveness of team science and the NCATS strategic goals?This analysis addressed the following research questions: (1) What CTSA component sponsored the team science activity? (2) Who was the team conducting the team science work? (3) Who were the intended beneficiaries? (4) What was the intended outcome? (5) What team science strategy did they use? (6) What TS stage was addressed? (7) How do the findings align with the NCATS team science strategic goals? (8) How do the CTSA’s team science efforts align with the NRC recommendations for enhancing the effectiveness of team science? The analysis also examined both the short-term outcomes for the participants  as well as the mid- and long-term outcomes to assess team science success.The first two research questions focused on who conducted the work. First, each submission was coded by labeling which CTSA component conducted the work using the components from the 2018 CTSA Funding Opportunity Announcement  (Table 1The intended beneficiaries for the submissions included the following groups (case numbers in parentheses): team scientists (119), the community (21), patients (6), and students (24) Table . Team scThe intended outcome of the GTSC submissions fell into four major subcategories, as shown in Table The subcategory of team science skills and process was very broad. The primary goal or intended outcomes included the following areas from most to least (number of submissions in parentheses): 1. Training in team science competencies (24); 2. Training in communication skills (9); 3. Providing pilot funding or specific awards to promote existing team science (4); 4. Training undergraduates, graduates, and postdoctoral students in team science (7); 5. Developing a team charter or engaging in team building (5); 6. Leadership or mentorship training (5); and 7. Training in technology ventures or entrepreneurship (3). Each area is described below with specific examples.Training in team science competencies covered 24 evidence-based competencies involving the 7 dimensions of leadership, communication styles and adjusting for different styles, and workshops on leading multidisciplinary teams. For some hubs, the outcome was better team science leadership, whereas others were developing every aspect of researchers’ teams. Some innovative programs were designed to promote team science leadership skills in underrepresented postdoctoral fellows. Importantly, team science competencies were not just for leaders, but some focused on training the research staff to help the entire team function more efficiently.Training in communication was prominently represented and took many forms, such as workshops designed to promote smoother team functioning or end-of-meeting debriefs to clarify the meeting outcomes and next steps. A more complex workshop involved faculty and community members together focusing on public understanding of science and dissemination of results. Communication training included community members, researchers, trainees/students, and clinicians.Providing pilot funding and special awards for promising teams is a frequently used strategy to promote team science. Sometimes a new funding mechanism incentivized the formation of a multidisciplinary team with researchers or community members with common interests. To promote community research on real-world problems, some pilot programs created community member review committees for input into pilot funding decisions. To promote entrepreneurs’ ideas getting into the real world, experts in dissemination and implementation collaborated on business/marketing plans to move the ideas forward as commercial ventures.Training undergraduate, graduate, and postdoctoral students improves the team science pipeline. Several student training programs taught team science competencies, methods, team building, entrepreneurial skills, real-world observations, and analysis of teams. Student training often encompassed longer-term sessions with a week-long residential boot camp or a semester-long course. Several student-focused trainings put students onto existing collaborative teams where they engaged in real-world problem-solving.Team building and developing team charters are important aspects of the team science process which detail many aspects of team function including direction, roles, and how team members should interact. Team charters were regularly mentioned by participants as one of the most useful outcomes of training. Other team building outcomes included improved distance collaboration and building multidisciplinary teams following facilitated brainstorming sessions. Some team building provided a facilitated residential event to create research proposals to address a grand challenge.Leadership or mentorship training was one component of multifaceted programs that also addressed innovation, adaptation, project management, and communication. Training varied from 2-hour workshops to 12-month programs and several leadership programs are actively evaluating their outcomes.Developing technology or entrepreneurial skills focused on developing technological solutions for specific unmet healthcare needs. Others supported increasing awareness of entrepreneurial activity and the potential to commercialize ideas, reinforcing the practice of team science for health science innovation.A key component to getting the community involved in TS was engaging community members in determining the specific needs of the community. There were two subcategories of team science submissions that involved the community: (1) Partnering with community members by making them part of a community advisory board, a stakeholder panel, or providing direct advice to researchers on the conception, design, and execution of the study in community settings (26); (2) Providing targeted funding opportunities that address community health needs and incentivize researchers to include community members on the team (3).Fostering new multidisciplinary collaborations, an outcome in 33 submissions, included bringing together researchers from different disciplines to brainstorm solutions to a specific challenge. Strategies for creating collaborations included: (1) Hosting one-time events focused on a particular health problem to foster collaboration between multidisciplinary researchers; (2) Matchmaking among researchers from different disciplines using social network analysis, speed networking or, for example, paring physicians who needed medical devices with design engineers; (3) Creating ongoing formal research networks; (4) Providing unique grant mechanisms to foster multidisciplinary research and incentivize new collaborations; (5) Connecting CTSA structures, such as the TIN, with community organizations; (6) Creating formal coursework to train researchers how to create and maintain multidisciplinary collaborations; (7) Creating programs to train researchers to be entrepreneurs.Multidisciplinary development of new informatics or biostatistical tools was a unique type of submission (6). These were collaborations between bioinformatics researchers, computational biologists, or biostatisticians who were developing devices or apps to solve specific problems. They included: (1) Medical apps to manage chronic conditions; (2) Informatics solutions for data discovery such as finding collaborators, biomarkers or developing algorithms; (3) Developing repositories to link data to patients’ electronic health records; (4) Medical device development or improvement (5) Using videogames to train healthcare students; (6) Programs to train informatics students or emergency healthcare professions to work in multidisciplinary teams.Workforce development with research personnel included training health equity researchers, health system leaders, and community health workers in programs that integrate transdisciplinary research, community activation, education, and policy translation (6). Other programs trained research coordinators or managers. Collaborative educational programs enhanced the skills of healthcare students to interact with a community partner on a healthcare challenge.Expanding capacity to conduct TS consisted of developing new systems or relationships to increase TS (10). Examples include new partnerships with scientific journals, developing new MS programs in data science across multiple departments using a shared governance model, and connecting regional health systems to the TIN to facilitate community-based trials.Changing promotion and tenure (P&T) policies for team science was in only three submissions. One story helped chairs understand what it takes for researchers to get P&T as a team scientist. Another submission involved extensive studies of the faculty, chairs, leadership, and the institutional climate to understand the attitudes and barriers to changing team science P&T policies. Finally, a team science symposium was held on ways to advance team science.There were many submissions that described a specific successful example of multidisciplinary collaborative teams doing disease-specific or wellness interventions. These covered areas of wellness/prevention, chronic disease, cardiovascular disease, mental/behavioral health, addiction, genetics, infectious disease, reducing health disparities, cancer, and others. These generally did not detail a specific intended outcome and are not described in greater detail. If an example described a team science intervention with an intended outcome, then it was moved to the relevant intended outcome category.Evaluation of team science strategies can reveal more effective methods for producing productive teams. Table There were two types of submissions: (1) Team science research, interventions, or resources (133) and (2) Unique examples of successful teams (37). The first category revealed several types of team science interventions including team science training programs 61), the development of new teams (43), community collaboration with teams (20), and other team science methods that did not fit into the previous categories (9). Table 1, the deTeam science research, intervention, or resource covered team science training and research activities, including leadership training for K-scholars and trainees, symposia to discuss best practices, and collaborative research. To foster new teams, submitters organized symposia and workshops around specific topics of interest to bring researchers together to develop ideas for new proposals. Funding opportunities developed for multidisciplinary teams took the form of awards honoring specific scientists and competitive award offerings.Unique examples of team science were stories of a specific successful research team. They were coded as an “example” if they did not describe using a strategy to promote team science.The submissions were categorized by assigning them to a specific TS phase to determine if most of the team science is addressing research occurring early in the TS spectrum or later in the applying discoveries to public health . A breakSupporting the CTSA program, NCATS has made team science a strategic goal with four objectives: (1) Engage patients, community members, and nonprofit organizations in the translational process; (2) Share resources through collaborative research with other NIH Institutes and Centers; (3) Form innovative collaborations with multidisciplinary scientists at other institutions; (4) Develop new collaborative structures with the private sector. Table We examined the data to understand how they aligned with the second objective of NCATS, that is, sharing resources and expertise across the federal government through collaborative research with other NIH institutes and Centers. Six cases demonstrated collaboration with other NIH Institutes and Centers such as the National Heart, Lung, and Blood Institute (NHLBI), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Endowment for the Arts (NEA), or the National Library of Medicine (NLM). These were multidisciplinary collaborations conducting clinical trials for heart disease and testing a solution for sepsis and acute respiratory distress syndrome. The cases also represented the creation of a multicenter community-based trial in pediatrics, work integrating biomedical datasets in an effort to accelerate translational research, providing a mechanism for investigators to share data and training to improve perspective-taking skills in trainees.Regarding the NCATS third objective of multi-institutional collaborations, several multidisciplinary submissions involved multistate and multi-CTSA hub consortia around pressing health problems like the opioid crisis, obesity, and biomarkers for autism. Several consortia formed to transform clinical research with efforts such as improving the e-consent process, expanding research into primary care practices, streamlining study start-up, and helping regional healthcare systems use the TIN. Other multi-hub efforts sought to provide a grand challenge and develop teams over a week of intensive training or to network KL2 and TL1 trainees from across multiple hubs.Relating to the final NCATS team science objective of developing collaborative structures with the private sector, most of the submissions that involved the private sector concerned helping programs to scale inventions to help develop commercial health products or public health interventions. Other private sector collaborations involved getting industry members to join partnerships around major health challenges  or getting input into potential start-up companies.The value of this qualitative analysis of the GTSC dataset is the examination of the breadth of team science across the consortium. What the individual submissions lacked in detail, they made up for in the breadth of interventions, the diversity of beneficiaries, and the broad multidisciplinary involvement.Two kinds of submissions dominated the GTSC: strategies for promoting team science, but many lacked evidence of efficacy versus examples of team science that often lacked clear team science strategies, but provided examples of successful outcomes. The outcomes included short-term evaluation metrics such as increased leadership self-efficacy, greater confidence in conducting clinical research, and greater understanding of the value of multidisciplinary research. This led to midterm behavior changes by teams such as increased efficiency, writing grants, publications, and patent applications, and developing novel apps/digital tools. Finally, several long-term outcomes were attributed to the team science strategies, including improving health access for underserved populations, expanding capacity for special populations in clinical trials, policy changes, and expanding programs to other hubs.Team science represents the ability for teams to effectively collaborate but also, the ability to integrate knowledge from diverse perspectives. Successfully involving the community in research is one transdisciplinary challenge in team science. To partner effectively with community members involves engaging in research that is both meaningful to the community and focused on community priorities. Many GTSC submissions describe such collaborations including community interventions and improvements in public health. Several submissions were focused on joint university–community research programs to improve public- and clinical/mental-health. Other team science initiatives provided training to team scientists and community members, involving them in creating funding mechanisms for TS, reviewing project proposals, and providing venues and activities for scientists and community members to meet and develop project ideas.Integrating knowledge from individuals who have different perspectives is another vital aspect of engaging in successful transdisciplinary team science which involves fostering knowledge sharing and optimizing the use of appropriate collaboration technologies . As techThere is ample evidence that the CTSA consortium is addressing the team science objectives set forth by NCATS . ObjectiThe GTSC dataset provides appropriate evidence that the CTSA consortium is addressing the team science recommendations made by the National Research Council (NRC) in 2015 . Here, wConcerning geographically dispersed teams, the NRC recommends providing activities to develop shared vocabularies and work routines, train team members to use proven collaboration technologies, and develop criteria to give credit for team-based work . Many ofRegarding public and private funders, the NRC recommends reducing the barriers to team science by encouraging new collaborative models, providing informational resources, and removing disincentives to participate in team science while including collaboration plans and how they will promote knowledge integration between disciplines. Finally, they propose studying the effectiveness of team science and facilitating access to research and personnel data . Many GTPertaining to researchers, the NRC recommends improved methods to match participants with project needs to enhance team effectiveness, professional and leadership development for team science, and collaboration with universities to develop new principles and remove barriers that discourage team science. Several submissions promoted matchmaking among scientists from different disciplines around research needs in basic science, healthcare, and public health. Likewise, many of the submissions involved professional development covering team science competencies. The final recommendation, to evaluate how criteria for allocating credit for team science are working was not addressed by the GTSC submissions. This may be due to the fact that although most CTSA hubs have some policies expressing the value of team science, there is significant variability across the consortium and within-institution variability as to how the policies are carried out . Most huIn connection with universities and other scientific organizations as well as the scientific community, the NRC recommends fostering positive team processes to enhance effectiveness, create and evaluate leadership development opportunities and remove barriers that discourage young faculty who are interested in team science from joining teams. The GTSC received many examples of positive team processes from training in team competencies to fostering good communication and strong leadership. The final barrier preventing systemic adoption of team science may involve diverging from the current funding system that rewards the investigator-initiated grants to provide additional incentives for team-based science . In summary, both the NCATS team science objectives and most of the NRC recommendations for team science are being addressed in the GTSC dataset. There is one notable exception: evaluating how criteria for allocating credit for team science are working was not addressed. This area warrants further research.Strengths of this study include the robust CTSA consortium participation of 45/64 (70%) hubs and the large and extremely diverse dataset of submissions to the GTSC, which enabled the demonstration of the great heterogeneity in the consortium interventions to enhance team science. The contest provided more team science efforts than would other methods such as expert opinions, focus groups, or surveys. The resulting dataset and qualitative analysis provide hubs with a large reservoir of information so that they can focus on the team science strategies and outcomes that interest them. These strategies show the great breadth of innovation, particularly in interventions that involve the community or industry in team science. Besides many traditional team science trainings, there were several submissions that encompassed both an intervention, such as a scientific retreat, and a successful example of team science. Although the GTSC did not request examples of innovative and successful team science, several were submitted that demonstrated involvement of researchers who are not typically associated with team science.Subdividing submissions according to the 2018 NCATS FOA categories assumed that a particular CTSA component was the driver of the team science story. This was not the case in many submissions that either did not specify what component was doing the work or involved many collaborating CTSA components and/or institutional promotion of team science. This is a positive finding which suggests team science has permeated so many aspects of the CTSA infrastructure that it has become intrinsic to the fabric of a CTSA hub and is no longer an activity performed by a single core.For limitations, this study is a secondary analysis of an existing dataset. The GTSC dataset is not a random sample nor is it representative of all team science, and not all cases in the dataset were equally informative. The GTSC was designed to be an easy, low-effort contest so that more hubs would respond to the survey. Considering potential survey fatigue, the GTSC designers had to make a choice between getting fewer entries that were more detailed versus getting more responses that were very brief. They opted for the latter to demonstrate the breadth of team science. Additionally, some entrants submitted a specific example of a successful team rather than strategies for encouraging better team science, suggesting perhaps a lack of understanding about the purpose of the GTSC. Thus, some lack of clarity in describing interventions was due to the 150-word limit, which meant the submissions lacked significant detail on the process, the key stakeholders, or the evaluation outcomes. An additional limitation is a difficulty in teasing out distinct categories when there is significant complexity between the causal networks required to move from early TS training to measuring TS improvements to more productive research and publications to health-related benefits.There are many challenges for defining team science outcome metrics, as well as institutional policies that could thwart well-meaning efforts including P&T criteria, indirect cost allocation policies, team science incentives, and the availability of collaborative organizational structures. It is more feasible to evaluate the knowledge, attitudes, and beliefs about team science functioning. It is much more challenging to evaluate downstream evidence that teams are functioning better or having real impacts. Only a few submissions described evaluating their team science strategies to encourage team approaches, reduce barriers to team science or improve team functioning. None of the submissions examined how credit for team contributions was allocated, which poses a significant challenge that deserves more attention in future studies. Only one submission described using control and experimental groups, emphasizing how difficult such approaches can be. Although some of the team science examples did not provide team science strategies, they did provide some more distal team science outcomes. These included changes in health policy, expanding the team science program beyond the hub, better health, screening, and access for underserved populations, and increased efficiency.2 and contact those hubs to learn from their experiences to get assistance in their team science expansion. Future research should focus on evaluating the efficacy of team science strategies.In conclusion, analysis of the GTSC dataset shows that the CTSA consortium is involved in an extremely diverse array of team science activities, which are appropriately addressing most of the team science recommendations made in 2015 by the NRC and the NCATS team science objectives. The strategies in this paper provide a resource for CTSA hubs seeking to expand their team science endeavors. To use this information, hubs would match their team science goal with our research questions. For example, if a hub wants to expand team science to include the community. Three of the research questions deal with the community as beneficiaries (Q3 and Table


Redressing the maldistribution of the health workforce in regional, rural, and remote geographical areas is a global issue and crucial to improving the accessibility of primary health care and specialist services. Geographical classification systems are important as they provide an objective and quantifiable measure of access and can have direct policy relevance, yet they are not always consistently applied in rural health research. It is unclear how research focusing on the graduate health workforce in Australia has described, measured, and analyzed place of practice. To examine approaches used, this review systematically scopes Australian rural studies focusing on dentistry, medicine, nursing, and allied health graduates that have included place of practice as an outcome measure. The Joanna Brigg’s Institute Scoping Review Methodology was used to guide the review. Database searches retrieved 1130 unique citations, which were screened, resulting in 62 studies for inclusion. Included studies were observational, with most focusing on the practice locations of medical graduates and predicators of rural practice. Variations in the use of geographical classification approaches to define rurality were identified and included the use of systems that no longer have policy relevance, as well as adaptations of existing systems that make future comparisons between studies challenging. It is recommended that research examining the geographical distribution of the rural health workforce use uniform definitions of rurality that are aligned with current government policy. Improving the accessibility of health care services for populations residing in regional, rural, and remote geographical areas is a global issue . It is wThere is a substantial body of literature examining issues mediating the recruitment and retention of the rural and remote health workforce, with a large proportion of this literature from Australia, Canada, and the United States ,10. In AThe importance of using geographical classification systems in research to inform policy and the allocation of resources and understand rural health disparities has been supported by scholars ,15. ThisThe purpose of this review was to scope the literature for objective approaches used to examine the place of practice of dentistry, medical, nursing, and allied health graduates in rurally focused research undertaken in Australia. This is important in understanding how place of practice following graduation is objectively measured, to identify opportunities to improve the consistency of geographical reporting between studies  and consThe research question for this scoping review was as follows:How is place of practice of graduates described, measured, and analyzed in rural research studies focusing on dentistry, medical, nursing, and allied health graduates in Australia?[1]Scope Australian rural studies focusing on dental, medical, nursing, and allied health graduates that have included graduate place of practice as an outcome measure and examine objective approaches to analysis; and[2]Examine reported findings and implications of studies, including alignment of approaches used to objectively measure place of practice with relevant state-wide and national policies.The review objectives were to:This systematic scoping review examined approaches to describing, measuring, and analyzing place of practice in rural research studies focused on dentistry, medical, nursing, and allied health graduates. The Joanna Briggs Institute’s (JBI) scoping review methodology was used to guide the review . Search The JBI three-step search process guided the development of the search strategy . This inDatabases searched included Ovid MEDLINE, CINAHL (EBSCOhost), PsycInfo (EBSCOhost), and Embase (Elsevier). Google Scholar was also searched to capture any additional studies. A search for grey literature was not undertaken due to the inclusion specifying only peer-reviewed research. Database searches were completed on 3 September 2021.Literature was screened according to the inclusion and exclusion criteria shown in Citations were imported into Covidence  for screening. Titles and abstracts were screened independently by at least two reviewers, with conflicts resolved through discussion with a third reviewer. Full text review and data extraction was then undertaken. For articles reviewed at full text screening not meeting the inclusion criteria, reasons for exclusion were provided . ReferenOf the 103 citations eligible for full text screening, 62 studies met the inclusion criteria. No additional citations were identified through a review of the reference lists of included studies and reasons for exclusions are shown in n = 44, 71%), nearly a quarter cross-sectional , and the remainder mixed methods  with an embedded cohort study design. The majority of studies tracked medical graduate outcomes . Studies of other professions  were limited to dentistry (n = 4), physiotherapy (n = 1), optometry (n = 1), pharmacy (n = 1), nursing (n = 1), multiple allied health professions (n = 1), and nursing and multiple allied health professions (n = 2). Most studies focused on graduates from a single university   with a small number of collaborative studies undertaken by more than one university (n = 3). Of other studies, five had a national focus and three had a statewide focus.A summary of included studies included is provided in n = 38, 70%) with repeated surveys and/or data linkage  data). Nearly a quarter were cross-sectional studies involving surveys, university and/or AHPRA data , and the remaining three (6%) studies utilized a mixed methods design with an embedded cohort study. Most studies were undertaken within only one jurisdiction, including Western Australia , Queensland  , New South Wales , South Australia , Tasmania , and the Australian Capital Territory (ACT) . Two studies (4%) were conducted in two or more Australian states/territories.Of the university studies, most employed a cohort approach (l cohort ), Victorhttps://www.yellowpages.com.au/) accessed on 20 September 2021). However, a diverse range of approaches was used to analyze and describe place of practice. Most studies reported using an established geographical classification system to analyze and describe place of practice  and to provide an objective measure of rurality or provided information around an alternative approach used to define rurality or analyze/describe place of practice  [n = 6, 10%). One study used both the Accessibility/Remoteness Index of Australia (ARIA) and Socio-Economic Indexes for Areas (SEIFA) to analyze and describe practice locations [Similar methods were used to collect place of practice data ), which included either self-reporting via survey (undertaken over the phone or online), or data linkage methods using AHPRA data, and/or other open access online sources  , or otheocations . Two stuocations ,30, whilocations ,32.n = 32). In order of frequency, the other classification systems used were MMM (n = 13), RRMA system (n = 6), ASGS-RA (n = 4), and the Accessibility/Remoteness Index of Australia (ARIA) (n = 1). Two studies used both ASGC-RA and MMM to analyze and describe place of practice [practice ,30.Four studies used an alternative approach to define rural, one used population sizes to classify geographical areas but did not cite an established classification system . AnotherApproaches to distinguishing rural from metropolitan practice varied between studies, and generally involved merging geographical classifications into broader categories. Studies using the RRMA usually classified RRMA1-2 as metropolitan and RRMA3-5 as rural, although two studies classified RRMA 3-7 as rural. Twenty-two of the 32 studies using the ASGC-RA classification dichotomized rural or non-metropolitan as RA2-5 and metropolitan or urban as RA1, while a single study dichotomized RA1-3 as non-remote and RA4-5 as remote . Two of Although there were variations in the approaches used to analyze and describe place of practice, and define rural practice, similarities in findings and implications were evident across the included studies. These are synthesized below according to profession.There were four studies with a focus on the practice locations of graduate dentists  with varying approaches to analyzing and describing place of practice. A retrospective cohort study, from a single university, found that 51% of dentistry graduates practiced in high socioeconomic areas and areas that were classified as highly accessible using the ARIA classification system, while fewer than 12% were practicing in low socioeconomic areas . AnotherOf 51 studies examining the place of practice of medical graduates, 40 were either cohort studies, longitudinal cohort studies, or mixed methods studies with an embedded cohort study. Of these studies, different models of rural clinical placements and training were supported. This included the value of longitudinal integrated clerkships (LIC) in rural areas as a strategy to recruit graduates to rural areas , with grOther predicators of rural practice identified in cohort studies of medical graduates included: rural preference prior to medical school or rural practice intention ,51,58; bStudies identified a range of challenges related to classifying the geographical distribution of medical workforce, which were as follows: uptake of rural internships by domestic graduates being insufficient to meet rural workforce demands ; movemenOf the 11 cross-sectional studies examining the place of practice of medical graduates, studies broadly described the location of graduates and proportion of graduates practicing in rural areas with the use of an established geographical classification system ,64,74,86Three studies examined the practice locations of nursing graduates, two of which also included allied health graduates. In the study that examined nursing graduates only, a higher proportion of graduate nurses who had studied in a rural-based program were practicing in rural locations compared to those who did not study in a rural-based program . Of the n = 1), physiotherapy (n = 1), optometry (n = 1), and multiple allied health disciplines (n = 1), two studies identified rural background as a predictor of graduate rural practice [Of the remaining four studies that focused on allied health professions, which were pharmacy  study that is compiling a multi-institutional, multidisciplinary, longitudinal database to address this need . In AustAlthough there is a need for improved consistency and more collaborative research between universities to examine the graduate health workforce, there is value in adopting more localized approaches. For example, using area level geographical data to examining the practice locations of health graduates, across all states of Australia. This is particularly useful for determining the effectiveness of clinical training delivered in rural areas in meeting the demands of the local health workforce. Such an approach was used by Wolley et al. who analyzed the proportion of graduates practicing within the university geographical footprint to examine how the university was contributing to the medical workforce supply in the region . This apDue to the review question and defined scope of this review, only peer-reviewed studies were included. The potential for publication bias is a limitation of this review due to the exclusion of grey literature studies, including health workforce evaluation reports. Including health reports and graduate data (unpublished) may have helped to highlight more consistent use of classification systems and data collection methods, particularly within states; however, the aim of this review was to investigate peer reviewed literature. Furthermore, given the particular nature of the geographical classification systems investigated, the focus of the review was limited to the Australian context, as per the review question and objectives. Future research could also examine international approaches to measuring, analyzing, and describing place of practice in graduate health workforce research in other high-income countries that also have a maldistribution of the health workforce, such as Canada and the United States. This would serve to expand the range of geographical classification systems and allow international comparisons. Additionally, this study focused on how published studies described, measured, and analyzed place of practice in the context of standardized geographical systems. Therefore, we did not analyze the broader historical context of place of practice or social interactions that influence the distribution of health workers. These are important priorities for future research focus in rural health workforce research.Variations in the use of geographical classification systems and definitions of rurality are evident in the literature. It is recommended that future research examining the geographical distribution of the rural health workforce use definitions of rurality that are aligned with current government policy and to facilitate longitudinal graduate tracking. Consideration should also be given to the use of local area level geographical analysis to examine more closely the relationship between training programs and the actual practice location of graduates. While there is a large volume of literature relating to medical graduates, further research is required into the place of practice of dentistry, nursing, and allied health graduates in Australia, as rural health services and communities experience critical workforce deficiencies across these disciplines. In addition, to better inform health workforce planning and education strategies, there is a need for coordinated efforts between universities, health service providers and governments to develop the evidence-base around the health workforce in both metropolitan and non-metropolitan areas.


This review paper examines the extent of employer, worker, and labour union concerns to occupational health hazard exposure, as a function of previously reported and investigated complaints. Consequently, an online literature search was conducted, encompassing publicly available reports resulting from investigations, regulatory inspection, and enforcement activities conducted by relevant government structures from South Africa, the United Kingdom, and the United States. Of the three countries’ government structures, the United States’ exposure investigative activities conducted by the National Institute for Occupational Safety and Health returned literature search results aligned to the study design, in the form of health hazard evaluation reports reposited on its online database. The main initiators of investigated exposure cases were employers, workers, and unions at 86% of the analysed health hazard evaluation reports conducted between 2000 and 2020. In the synthesised literature, concerns to exposure from chemical and physical hazards were substantiated by occupational hygiene measurement outcomes confirming excessive exposures above regulated health and safety standards in general. Recommendations to abate the confirmed excessive exposures were made in all cases, highlighting the scientific value of occupational hygiene measurements as a basis for exposure control, informing risk and hazard perception. Conclusively, all stakeholders at the workplace should have adequate risk perception to trigger abatement measures. Current occupational health and safety (OHS) legislation, in South Africa (SA), the United Kingdom (UK), and the United States (U.S.), makes provision for the reporting of complaints from exposure to occupational hazards by various stakeholders. The legislation was designed to ensure that working conditions encountered by workers employed in the various sectors is safe and healthy, as possible ,2,3,4,5.Given that workers are in close proximity to occupational hazards, OHS legislation also places responsibility on them to report dangerous conditions to various stakeholders. This worker activism, provided for in the OHS legislation, can increase the effectiveness of legislation, which can translate to safety at work ,8,9. On Worldwide, OHS legislation also provides for workers to refuse dangerous work ,15,16. TThe current review paper focused on the micro analysis of reports, where available, indicating stakeholder concerns in regard exposure to occupational health hazards. Lack of concern and inadequate risk perception by affected stakeholders in the management of identified occupational health hazards can result in adverse health impacts, especially on workers. In the U.S., the National Institute for Occupational Safety and Health (NIOSH) investigates workplace health hazards as well as offers technical and consultative assistance to various stakeholders through the discharge of legal authority given under the Occupational Safety and Health Act of 1970 (Section 20(a)(6)) . In the This aforementioned scholarly review paper, part of a postgraduate study with the Tshwane University of Technology; ethical clearance: FCRE 2020/10/015 (FCPS 02) (SCI), investigates stakeholder concerns to occupational health hazard exposure as a function of reported and investigated exposure concerns.The management of occupational health hazards follows from a hazard identification and risk assessment . How theAn online search on databases of regulatory inspectorates from SA (Department of Employment and Labour), UK (HSE), and the U.S. (OSHA), recording stakeholder concerns or investigation requests to occupational health hazards was conducted as a first phase of the literature search. However, information in these inspectorates’ online databases including annual reports detailing conducted inspections were generic, complex (in the case of OSHA), and scant on the details set out as important search criteria adopted in this study. Thusly, these databases were excluded in the final adopted search strategy.The second phase of the literature search focused on databases of supplementary and legal bodies to the inspectorates. Consequently, the final adopted database search only focused on the National Institute of Occupational Safety and Health (NIOSH) Health Hazard Evaluations (HHEs) reports as they yielded results matching the adopted search criteria for this review paper. The HHE report database provides a repository of all completed NIOSH-led workplace investigations, a topic of concern for this current study. As of March 2021, the repository had 3614 HHE reports dating back to 1972, covering all sectors. This study however targeted HHEs conducted over two decades spanning from the year 2000 to 2020, conducted within the manufacturing sector. As per the database repository structure, the literature search was refined to include “All States/OSHA Regions”, “Manufacturing”, “all industry subcategories”, and “all health effects”.Reports considered in the final synthesis were those published in English. Other criteria used in the inclusion and exclusion criteria are shown in In general, the synthesised literature suggests that NIOSH is discharging its designated legal duties given under the Occupational Safety and Health Act 1970 , and Codn = 87(42%)); employees at (n = 59(28.5%)); and unions at (n = 32(15.5%)) were the chief initiators of workplace investigations for the period from 2000 to 2020, which when combined, contributed 86% of the investigations. The agency also offered technical and consultative assistance over the period to other government agencies or departments with investigated cases at (n = 10(4.9%)). Investigations conducted as part of state programmes at (n = 3(1.4%)) were also discharge during the period. Joint requests by different stakeholders were also recorded during the period. Workers are empowered by OHS legislation to request investigations following concerns of exposure to occupational health hazards [t n = 325.5%) wer5.5% wernn = 872%); empl hazards , as is tOf the investigated and quantified chemical hazards, diacetyl levels from the popcorn manufacturing industry exceeded the NIOSH recommended exposure level in almost all cases. Whereas noise exposures above the regulated exposure limits were noted in almost all investigated and quantified physical hazards. The measured noise levels exceeded both the NIOSH recommended exposure level as well as the OSHA permissible exposure level. Additionally, exposure to heat stress was also prevalent in the included investigations.The workplaces at which these investigations were conducted were enabled to abate hazards, in most instances, highlighting the positive impact of these investigative activities. Actions taken to abate identified hazards serve as evidentiary proof of employers fulfilling their legal responsibility of providing safe and healthy workplaces.The moderate volume of requested investigations may also be an acceptance of a declining influence of governmental institutions in OHS matters . AdminisIn support of worker-initiated requests for investigations, Smith  expoundsFrom a global point of view, there is a need for the continual up keeping of occupational hygiene exposure data sets for some of the identified hazards as well as better OHS regulatory policies. In the case of exposure data sets, these become valuable during occupational exposure assessment initiatives and indicates that workers are indeed exposed . With reThis therefore implies that companies should thus attach great value in collecting exposure data as part of demonstrating legal compliance, for instituting and checking the efficacy of implemented preventive measures . RegrettWorkers’ risk perception leading to formal complaints to responsible government institutions relating to occupational health hazard exposure is shown in Workers perceive and interpret hazards differently based on gender, duration of employment and prevailing safety climate. A hazard may be perceived as trivial and hidden by one worker, whilst the same hazard is perceived as obvious and emerging by another ,256. WitThe evident disparity in risk perception also extends to new workers into a job compared to experienced workers in the same job ,260,261.Arezes and Miguel , FlemingAlthough workers are empowered by health and safety laws to receive information related to workplace hazards , the infThe law also affords workers the right to refuse dangerous work, however, the action of refusing dangerous work will not in itself result in the improvement of workplace conditions . The rigEmployers carry the unquestionable bulk of the responsibility of providing healthy and safe workplaces ,276, andFor the purpose of clarity regarding this matter, employer concern to occupational hazards and risks are also shown in Occupational hygienists in particular, play a proactive role in influencing risk perception by employers and subsequent establishment of occupational health programmes . Bian anOther legally recognised stakeholders with vested interest in occupational hazards include labour unions and Health and Safety Representatives, acting as worker voices ,2,4. In In so far as labour union involvement in workplace health and safety, Jacques  posited In criticism directed towards labour unions, Brown  argued tThese mandatory exposure limits have been developed to protect workers and to provide for workplace regulation of the various occupational hazards ,299,300.Due to differences in the OHS legislative arrangements and reporting methods between that from U.S., SA, and the UK, no comparisons could be deduced about aspects discussed in this paper. The discussions and conclusions made in this review paper are reflective of the state of OHS affairs in the U.S. on the relevant topics. The inference of the volume of conducted HHE investigations was solely based on numerical counts in the absence of records indicating the number of requested investigations over the covered period. The authors also acknowledge the intensive and time-consuming nature of conducting occupational hygiene measurements, investigations and actual reporting, which further complicates the issue. The statement on the justification of complaints was solely based on exposure data derived through occupational hygiene measurement techniques, and excluded biological exposure indices and questionnaire as complementary data collection tools which also used during these investigations, due to their inherent complexities. Additionally, statements on compliance to exposure limits considered the worst case scenario  for each quantified occupational hazard. The discussion and conclusions made in this review paper are made against these methodological constraints.The role of OHS specialists, including occupational hygienists, remains little understood in industry. Occupational hygiene, as a specialised profession, is not limited to workplace monitoring and report writing, but is legally empowered to propose effective preventive measures for the advancement of worker health . The effThe synthesised literature covering two decades from the year 2000 indicated that employers, workers, and unions, combined at 86%, were the main initiators of conducted exposure investigations. These stakeholders initiated the exposure investigations through the discharge of legal duties afforded by prevailing occupational health and safety laws, which promotes active participation in the management of issues of concern. The investigated exposure concerns related to both chemical and physical hazard types, for which exposure limits currently exist in the main, and all quantifiable through occupational hygiene techniques. The quantification of prevailing exposure levels to these occupational health hazards forms the basis for making judgements on the extent of workplace exposure and justification of exposure concerns. In spite of prevailing exposure limits and current legal arrangements of exposure investigations workers are still negatively impacted by workplace exposure from identified occupational health hazards. The implementation of preventive measures for protection against hazards is however influenced by risk perception and concern among workers, employers and national labour unions, reflected as complaints forwarded to relevant government institutions. Workers with a lack of concern to risks and hazards will not seek or pressure the employer to implement remedial actions, report the infraction to regulatory inspectorates for further investigation nor adequately use and follow provided protective measures. To promote a culture of prevention at the workplace, changes in behaviour and attitudes of workers towards hazards is needed . SimilarThat employees continue to be exposed to exposure levels above exposure limits amidst technological advancements in manufacturing processes highlights the need for renewed calls of making institution of occupational hygiene programs mandatory for all workplaces. This review paper also highlighted the continuing importance of the contemporary need and importance of occupational hygiene exposure measurements as a basis for informing risk and hazard perception amongst concerned stakeholders.Further studies incorporating activities performed by labour inspectorates to those discussed in this current study will shed more light into the subject matter highlighted hereunder.