Vulnerability to malnutrition is very high with low-income women and their children in rural Balochistan with contributing factors including lack of awareness about proper nutrition, low literacy, scarcity of vegetables and fruit, and low purchasing power of households. The Food and Agriculture Organization’s kitchen garden program provides resources to improve nutrition and health knowledge and promote healthy eating practices. The objective of this study was to assess nutrition and health awareness, knowledge, attitudes, behavioural intentions/behaviours (AKAB) of women who attended the kitchen garden program and trainings.A community based cross-sectional survey (N = 209) using a two-stage cluster sampling method was used to select households with survey participants being mothers with children under five years of age. A pretested questionnaire was administered via face-to-face surveys by trained enumerators in two districts of Balochistan province of Pakistan. Nutrition and health AKAB were constructed indices. Chi-square tests compared statistical differences in AKAB by women attending against a control group who did not-attend kitchen garden interventions. Binary logistic regression analyses were performed to assess kitchen garden program outcomes against key AKAB indicators, while adjusting for covariates.Significant differences (p<0.001) were identified between intervention and control groups with women attending kitchen garden being more aware of the components of kitchen garden (65.8% vs 36.8%), and more knowledgeable about causes of illnesses caused by poor nutrition including, iron deficiency anemia, pregnancy, and unborn child health complications, compared to women not attending kitchen gardens program. Logistic regression analysis identified women attending kitchen gardens also had higher odds of being more knowledgeable , having improved attitudes , and behavioural intentions/behaviours  towards improved nutrition and health.Substantial opportunities exist for achieving improved nutrition and health outcomes with vulnerable groups in Balochistan, through greater participation in kitchen gardens behavioural change programs and interventions. As part of scaling-up efforts, academically rigorous project evaluations should be institutionalized for continuous improvement of nutrition programs to address micronutrient deficiencies in rural communities. Food insecurity leading to malnutrition is a growing problem for individuals and communities which lack consistent access to a sufficient quantity and quality of food, with this issue gaining attention from donors and governments, particularly in low -and middle-income countries (LMICs) . The undPakistan’s economy is agricultural based and more than 65% of the Pakistan’s population depends on agriculture for its livelihood . Many diUnderstanding how deeply connected the food and agriculture sector is to underlying causes of malnutrition, various agricultural tools can be used to improve the health and nutrition of people afflicted with malnutrition. Fortification is one tool that is currently being employed to address malnutrition among resource poor families in the developing world. However, poor technology, lack of economic capacity and lack of regulations and food laws are some cited barriers that are not conducive in creating an enabling environment for fortification ., Thus, There is increasing recognition that the problem of malnutrition is multi-faceted and requires actions with a greater focus on poverty alleviation, improvement of mother’s health literacy, including community-based education and targeted nutritional interventions. Emerging evidence from South Asia and elsewhere demonstrates a potential for nutrition sensitive agricultural interventions to improve nutritional outcomes . KitchenThe Food and Agriculture Organization (FAO) of the United Nations, together with the Department of Agriculture and Cooperatives of the Government of Balochistan piloted an “Integrated Kitchen Gardens” program in Balochistan province in 2015. The project’s primary aim is to provide opportunities to low income rural community women to engage in economic activities and eventually improve food security and nutrition for their families. A secondary objective of the program is to increase the nutritional status of women and children under the age of five years through kitchen garden and nutrition education. FAO has established vegetable kitchen gardens in 6 districts in South West Balochistan.: Chaghai, Kech, Kharan, Nushki, Panjgur, and Washuk. Adopting a Farmer Field School (FFS) approach on the establishment and operation of these gardens FAO equips women with knowledge and skills to maintain their own gardens back home in their districts. Kitchen garden interventions have been shown to be instrumental in increasing rural production and consumption of vegetables and fruits and to enhance the nutritional status of mothers and children in the rural villages in many countries ,20. HoweAs the global community and national governments seek to end hunger and poverty under the Sustainable Development Goals Agenda 1&2, it is important to gain an improved understanding of whether and how nutrition sensitive agriculture interventions can generate nutritional impacts in food insecure areas . Thus, tThe present study was conducted among the rural Pakistani women with children under five years of age, to assess their AKAB towards nutrition and health. The study was conducted between April-August 2019 following the completion of the integrated kitchen garden training and interventions. The majority of the population in Balochistan is located in rural areas and principal livelihood activities include agriculture and livestock production. Households in remote areas are spaced well apart with the province experiencing arid weather patterns and a semi-arid land with mostly dry climate, while the soils are still conducive to cultivation [N = 209) was conducted among participants in the study area using a two-stage cluster sampling method. The study used two stage cluster sampling technique. In the first stage, segmentation of the two district villages (Nushki and Kharan) from 6 FAO intervention districts in South-West Balochistan namely, Chaghai, Kech, Kharan, Nushki, Panjgur, and Washuk was done. In the second stage, sample selection involved randomly assigning twenty villages in the two districts from 10 Union Councils in Nushki district, and 7 Union Councils in Kharan district, being selected as the study sites. Union councils are the smallest administrative units in Pakistan. Within the randomly selected villages from each district, every fourth household was targeted until the required sample was attained from each district. In cases where participants were not available within the selected household, the adjacent household was visited. One female from each of the households was selected for the face-to-face survey.A community based cross-sectional survey  survey conducted in Pakistan  using thThe Kitchen Gardens Program was funded by AusAID and the FAO and ran from 2015–2020 . InitialThe kitchen garden training component focused on training women and some men farmers. A total of 350 community kitchen gardens were established in six districts in South West Balochistan including Chagai, Kech, Kharan, Nushki, Panjgur, and Washuk districts. Women from these districts were recruited to the Farmer Field Schools (FFS) to learn new gardening concepts for the establishment of community kitchen garden. This included experimenting with different planting times, seed varieties, reticulation systems, fertilizer, pest management, solar drying incubators, and planting techniques. Supporting interventions included strengthening of value chains and livelihoods systems and connecting farmers with markets for collective marketing of commodities such as onions, goats, sheep, poultry, wool and dates and to enhance the overall enabling environment. The kitchen garden program evaluation commenced within 4 weeks following completion of the final trainings.The survey questionnaire assessed: (i) Socio-demographic background of participants and household information; (ii) Awareness was a key initial measure, based on participant recall of nutrition and health messages from community-based campaign materials/announcements, trainings or interpersonal communication (IPC) messages on nutrition and health delivered through health/community workers or other influencers; (iii) Knowledge, attitudes and behavioural intentions/behaviours towards nutrition and health; and (iv) Sources of information and preferred communication channels for nutrition health literacy. The questionnaire development process included insights from a literature review, formative research inputs, multi-stakeholder meetings with the project implementers, and piloting the questionnaire to identify any potential issues or areas for improvement before its finalization for data collection. Cronbach’s alpha coefficients were used to assess the questionnaire’s reliability and internal consistency for attitudes and behavioral dimensions measured through 5- point Likert scales while questions on knowledge constructs were measured through dichotomous binary scales. Cronbach’s alpha coefficient values ranging from 0 to 1 and a scoring above 0.7 are generally regarded as acceptable. The questionnaire was developed in English and then translated into Urdu. Following pre-testing with local respondents, the Urdu version of the questionnaire was revised and back translated into English to assure equivalence of items and scales was maintained .‘Awareness’, regarding nutrition and health was assessed by women’s ability to correctly recall messages unprompted and also following prompting of the range of SBCC interventions. All participants were asked to recall any announcements or messages from community-based campaign materials/announcements, trainings, IPC messages on nutrition and health delivered through health/community workers or other influencers. Firstly, participants were asked to spontaneously recall and describe any community-based communication campaigns messages received in the previous six months. All those who recalled any nutrition and health message were recorded as “unprompted recall”. Next, all respondents were shown images from the trainings and messages disseminated through community and IPC channels and were asked if they recalled the messages. All those who recalled any messages from the prompt cards and in addition were able to recall message components were defined as having “prompted recall”. Respondents identified as being aware either through unprompted or prompted recall were designated as Program Aware vs. those who did not recall any message were designated as Program Unaware.‘Knowledge’ indicators contained seven dichotomous items on good diet and nutrition, the risks of malnutrition for women and children, causes and prevention of iron deficiency anemia (IDA). The Cronbach’s alpha score for the knowledge domain (0.712) reflected an adequate internal consistency.‘Attitudes’ towards nutrition and health, and kitchen garden programs included 5-point Likert scales examining personal and child risk to malnutrition, attitudes toward food diversity and developing their own kitchen garden, attending the kitchen garden trainings, introducing healthy food options and vegetables and attitudes toward improving food security. ‘Behavioural intentions’ towards nutrition and health were also measured using 5-point Likert scales. Reported behavioural intentions were assessed using: 1) dietary diversity (2) seeking information and advice for nutrition issues and kitchen gardening. The Cronbach’s alpha coefficient for the attitude domain was 0.936 and behavioral domain was 0.823 respectively. With these domains demonstrating good internal consistency. ‘Socio-demographics’ included information on participant age and number of children, educational status, monthly family income, home status, available water sources, decision making authority over food in the household, and preferred sources of health information.The quantitative survey questionnaire was administered by 14 trained enumerators under the guidance of 2 research assistants supervised by the study researchers. The survey team was identified from members of local communities, familiar with the area and local languages. Prior to data collection, a one-day training session was conducted which included briefing on the project and its objectives. The training ensured that fieldworkers understood the protocols for employing and recording item probes and that all items were clearly understood. Finally, mock interviews and pilot testing of the survey instrument were conducted, and adjustments made prior to going into the field. All participants were required to give their verbal consent prior to completing the survey.Demographic and baseline characteristics were summarized using frequency and percentages for categorical variables and means and standard deviations for quantitative variables. Socio-demographic characteristics and key outcome variables of participants were compared between the two groups (intervention group vs control group) using paired t-test for continuous variables and Chi-square test for categorical variables. Results were reported as p-values and significant criteria were set at 95%*, 99%** and 99.9%*** confidence levels. All analyses were carried out using software SPSS version 21.Strict ethical standards were maintained during the design, fieldwork implementation and analyses of the study design in line with recommended approaches for studies conducted with vulnerable populations in LMIC settings . ApprovaA comparison of socio-demographic characteristics between women attending the kitchen garden program (n = 114) and women not attending kitchen garden program (n = 95) identified differences between groups . Out of Respondents’ preferences on the choice of preferred communication channels for nutrition and health related messages they would receive were also examined in order to provide insights into how health messages could be more effectively targeted to vulnerable populations. The most preferred channels of communication on nutrition and health were through IPC channels including NGO staff ; particularly FAO field workers, and other social referents , while Social media was also preferred by 33% (n = 69) see .aware compared to those who did not attend the kitchen garden program trainings . Similarly results on knowledge indicators also identified significant differences between women attending kitchen garden and women not attending kitchen garden, with attendees more knowledgeable about the lack of nutrient rich foods and nutrient deficiencies causing: serious illness , Iron deficiency/Anemia in mother and children , and pregnant women and unborn child health complications  with 69.3% of respondents with kitchen garden replied correctly that delivery complications are caused by being undernourished . However, there was a gap in participants’ knowledge regarding the mental health consequences and maternal and infant mortality due to poor nutrition.The results (represented in p<0.001), I eat a variety of vegetables every day (p = 0.003), and health seeking behaviours: If I have any questions about food, nutrition and health issues, I’m able to get information and advice from local sources , while one item on fruit consumption identified no significant differences (p = 0.195). , improve dietary diversity (p<0.001), reduce the amount of meat in the family diet (p<0.001), learn more about improving food and nutrition security (p<0.001), and the health impact of food and nutrition (p<0.001). Additionally, significant differences were identified with kitchen garden participants over those not attending kitchen garden on attitudinal indicators (p<0.001), with high mean scores identified across all indicators by intervention group participants (4.03±0.74–4.62±0.74). Findings for behavioural indicators identified significant differences between kitchen garden intervention and control groups with regard to items: We eat vegetables every day ( 0.195). .aware  compared to women who did not attend the kitchen garden program. The association remained significant following adjusting for sources of information, the only significant explanatory variable in the model1 . Similarly, univariate analysis (model 0) identified that women attending kitchen garden were more likely to have higher knowledge, positive attitudes, behavioural intentions and towards nutrition and health ,  and  respectively. The association remained significant in model 1,  and  for knowledge, attitudes, and behavioural intentions/behaviours respectively  indicated that women who attended kitchen garden were more likely to be Programectively .This study provides important insights into the impact of the kitchen garden program on the AKAB of women in rural Balochistan. Recall of and knowledge about nutrition and health were found to be significantly greater among women who attended the kitchen garden program versus those who did not. The findings also identified that households already engaged in kitchen gardening are also more likely to produce and consume nutrient rich foods and have more knowledge about nutrition and health within the households. Similar findings were also observed in rural India and Tanzania where successful implementation of kitchen garden programs and trainings demonstrated greater knowledge among householders attending the interventions ,28. HencSignificant differences in awareness towards nutrition and health aspects were found in women attending kitchen garden compared to women not attending kitchen garden. Moreover, the kitchen garden interventions were more profound for critical behavioural determinants such as behavioural intentions and reported behaviours toward growing their own food and attending trainings on gardening. This emphasizes the potential for improved attitudes, competencies, and skills toward establishing kitchen gardens by vulnerable women who recalled the kitchen garden program interventions. Further, it was found that the majority of both the intervention and control groups were in agreement with regard to the importance of growing their own food and had a stronger preference for IPC channels of communication for the acquisition of knowledge and skills on developing kitchen garden and improving nutrition and health outcomes. Also the findings from this study confirm the need for nutrition specific approaches that address the immediate causes of malnutrition ,31. Thisaware and programunaware participant segments which were approaches applied to a TB advocacy, communication and social mobilization (ACSM) post intervention study also conducted in Pakistan [Another observation was that households attending kitchen garden consumption of vegetables and fruits also increased. They consumed more green leafy, vitamin A rich vegetables, compared to the control group with the same socioeconomic backgrounds, living in the same districts. Moreover, consumption of vegetable and fruit was found to be higher than meat intake among the majority of the women attending kitchen garden. Their intake supported daily recommendations of 2 fruits and 5 vegetables . The posPakistan . Thus, oThe application of SBCC impact assessment AKAB indicators, combined with nutritional data collection, provides a broader range of program performance indicators for continuous improvement of kitchen garden interventions including learnings on how different audience segments may respond to the program activities and their preferred channels of nutrition and health communication. The SBCC approaches also identified where participants reside on behaviour change continuum, identifying measures of cognition (awareness) of the health problem, knowledge, motivation, skills and competencies which may ultimately lead to maintenance and advocacy for the kitchen garden program’s desired behavioural objectives. Findings demonstrate that improvements in all key indicators are possible within a relatively short time period of 3 months of the pilot program. Lessons learned include the need to further refine indicators and evaluation methodologies to account for the resource constrained settings in which the programs are implemented and the need to institutionalize monitoring, evaluation, learning and adaptation (MELA) as a core component in strategies to address malnutrition and food insecurity.Future study approaches could focus more on critical issues in identifying what has been termed the “dose/response relationship” of SBCC. This may lead to a better understanding of the impact of SBCC on participants who may have had only one level of message exposure compared to those who may have recalled multiple messages and interventions, in order to identify the optimal number of contacts needed in order to attain significant impact on the targeted behaviors . AdditioLimitations of our study included resource constraints, geographic isolation, insecurity, and distances to households. These limitations restricted the duration of the fieldwork and sample sizes to a smaller number of households, which restricted case numbers for some statistical tests and additional segmentation analyses. Limitations are also acknowledged in the case/control approach given true randomization of the intervention/experimental and control group was not feasible in the resource constrained and insecure settings, coupled with the potential for control group participants being exposed to and recalling mass media SBCC components. However, the study approach adopted shows promise for similar post-intervention surveys of nutrition sensitive interventions implemented in challenging environments. Other possible limitations include selection bias in unobservable characteristics, and social-desirability bias in the face to face interviews, as women may have over reported their consumption of healthy food and underreported less healthy foods. However, the enumerators were trained to carefully explain the study purpose prior to data collection, and participants assured about confidentiality and anonymity, which may have reduced the potential of biases.It is also important to consider the possible influence of other health nutrition campaigns that were going concurrently in the community. Nonetheless the participants exposed to FAO, kitchen garden trainings and campaign messages had higher scores on measures of concern towards health and nutrition, suggesting that there is a real effect of the kitchen garden program. As future kitchen garden campaign rolls out on a larger scale, a fuller examination of their impact on awareness, knowledge, and additional elements such as attitudes, and behaviors are required, using longitudinal study designs. Last, it is possible that participants who were more concerned about nutrition were also more attentive to the issue, and thus more likely to correctly recall the SBCC messages, following prompting.The evaluation of the kitchen garden pilot program holds great promise for supporting nutrition and health improvements and uplifting the scale of nutrition sensitive interventions. The findings from the kitchen garden pilot program have demonstrated the potential to achieve measurable behavioral impact through the utilization of behaviours centered approaches, while acknowledging the behavioural determinants which may impact on change within complex cultural environments. Additionally, the study method provides a novel, resource efficient and academically rigorous approach to the evaluation of evidence based, agro-biodiversity interventions to reduce food insecurity, an issue which will require greater investment in coming years. Given that malnutrition and food insecurity are global challenges that are affecting a growing number of communities across the world, the evaluation findings can contribute to collective efforts in addressing these challenges by offering evidence on the effectiveness of specific strategies like kitchen garden programs supported by nutrition sensitive SBCC interventions.It is acknowledged that kitchen garden interventions require considerable resources such as time and funding to build trust and engagement toward establishing gardens, particularly in conservative and isolated rural communities like those encountered with this pilot program. Further evaluation studies, including pre- and post-intervention designs could be considered to better detect changes over time, and required adaptation as the program evolves. Findings may support the government, the FAO and other stakeholders in Balochistan to further develop evidence-based, longitudinal studies to assess the impact of nutrition sensitive intervention programs and policies. The impact evaluation of a kitchen garden program in rural Pakistan has the potential to contribute valuable insights to the broader global discourse on nutrition, food security, and sustainable agricultural practices. Its findings can inform decision-making, inspire innovations, and foster collaboration among stakeholders worldwide to address common challenges. Recommendations for further program improvement include important questions of sustainability, scale-up, program barriers and opportunities, and return on investment with kitchen garden program expansion.S1 Data(XLSX)Click here for additional data file.


Universal health coverage (UHC) is an emerging priority of health systems worldwide and central to Sustainable Development Goal 3 (target 3.8). Critical to the achievement of UHC, is quality of care. However, current evidence suggests that quality of care is suboptimal, particularly in low- and middle-income countries. The primary objective of this scoping review was to summarize the existing conceptual and empirical literature on quality of care within the context of UHC and identify knowledge gaps.We conducted a scoping review using the Arksey and O’Malley framework and further elaborated by Levac et al. and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews reporting guidelines. We systematically searched MEDLINE, EMBASE, CINAHL-Plus, PAIS Index, ProQuest and PsycINFO for reviews published between 1 January 1995 and 27 September 2021. Reviews were eligible for inclusion if the article had a central focus on UHC and discussed quality of care. We did not apply any country-based restrictions. All screening, data extraction and analyses were completed by two reviewers.Of the 4128 database results, we included 45 studies that met the eligibility criteria, spanning multiple geographic regions. We synthesized and analysed our findings according to Kruk et al.’s conceptual framework for high-quality systems, including foundations, processes of care and quality impacts. Discussions of governance in relation to quality of care were discussed in a high number of studies. Studies that explored the efficiency of health systems and services were also highly represented in the included reviews. In contrast, we found that limited information was reported on health outcomes in relation to quality of care within the context of UHC. In addition, there was a global lack of evidence on measures of quality of care related to UHC, particularly country-specific measures and measures related to equity.There is growing evidence on the relationship between quality of care and UHC, especially related to the governance and efficiency of healthcare services and systems. However, several knowledge gaps remain, particularly related to monitoring and evaluation, including of equity. Further research, evaluation and monitoring frameworks are required to strengthen the existing evidence base to improve UHC. According to the World Health Organization, universal health coverage (UHC) is achieved when ‘all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’ . UHC hasWhile there is growing evidence linking UHC to different health, economic and social outcomes, recent estimates suggest that about 800 million people globally still do not have access to full financial coverage of essential health services, including but not limited to high-income countries . The WHOCurrent evidence suggests that quality of care is suboptimal, particularly in low- and middle-income countries (LMICs) . While tAs such, efforts to achieve UHC focused solely on expanding access to care are insufficient. Achieving UHC will require a more deliberate focus on quality of care across its various dimensions including effectiveness, safety, people-centredness, timeliness, equity, integration of care and efficiency . HoweverThe primary objective of this scoping review is to synthesize and analyse the existing conceptual and empirical literature on quality of care within the context of UHC. The secondary objective is to identify knowledge gaps on quality of care within the context of advancing UHC and highlight areas for further inquiry.We conducted a scoping review using the five-stage scoping review framework proposed by Arksey and O’Malley  and furtTo synthesize the existing knowledge on quality of care within the context of UHC, we focused on retrieving and analysing relevant reviews (as opposed to primary research studies). Bennett et al.  applied We developed the search strategy in consultation with a research librarian with expertise in public health and health systems. After finalizing our search in MEDLINE (Ovid) through an iterative process involving pilot tests, we completed a systematic search of MEDLINE (Ovid), EMBASE (Ovid), CINAHL-Plus (EBSCO), PAIS Index, ProQuest and PsycINFO (Ovid) for articles published from 1 January 1995 to 27 September 2021. The date cut-off of 1995 was selected to capture articles published during the period leading up to the adoption of the MDGs. We applied adapted search filters from the InterTASC Information Specialists’ Subgroup Search Filter Resource for each database .Our searches combined terms related to the concepts of 1) UHC  and (2) quality of care and its seven dimensions . Our search strategy is available in Appendix A. Figure  UHC (e.gwww.covidence.org) for deduplication and screening.Results from database searches were managed through Covidence (Two reviewers (BY&AK) independently assessed studies against the eligibility criteria in two phases: (1) titles and abstracts and (2) full-text articles. A pilot test of the title and abstract screening was completed for approximately the first 100 search results. The two reviewers discussed disagreements to revise eligibility criteria as required. Any disagreements were resolved via consensus and in consultation with senior co-authors.BY & AK independently completed data extraction for the first 10 articles using a standardized form. Following the pilot, the full data extraction was completed by the two reviewers in parallel. We extracted data on key study characteristics and according to each domain and subcomponent identified in Kruk et al.’s  frameworWe synthesized the results through both a descriptive summary and a qualitative, narrative synthesis. We anchored our narrative synthesis in Kruk et al.’s  conceptuThey define three key domains of a high-quality health system, which they argue should be at the core of implementing and advancing UHC: foundations, processes of care and quality impacts. Foundations refer to the context and resources required to lead a high-quality health system. Processes of care include competent care and systems, relating to evidence-based effective care and health systems’ ability to respond to patient needs. Quality impacts include both patient and provider-reported health outcomes and client confidence in the health system, as well as economic benefits such as a reduction of resource waste and financial risk protection. The Kruk et al.  frameworAs our scoping review examines the existing literature on quality of care within the context of UHC and identifies knowledge gaps, Kruk et al.’s  frameworWe organized the results from our narrative synthesis according to each component of the framework , addressing equity as a cross-cutting theme across these components. Table n = 18), 35.6% were systematic reviews (n = 16), while 20.0% were scoping reviews (n = 9), and 4.4% were overviews of systematic reviews (n = 2). Of the 45 reviews, 28 covered multiple WHO regions (62.2%). This included reviews with a broad global focus, reviews focused on LMICs, ‘developing’ or ‘developed’ countries, as well as reviews with an explicit focus on more than one of six WHO regions. Regarding the dimensions of quality of care, equity was the most well represented, examined by 40 of the studies (88.9%). Integration of care and safety were the least represented across the studies, each examined by 11 of the reviews (24.4%). We did not formally appraise the quality of studies included in our review, which is not required for a scoping review given its overarching aim to map the scope and size of the available literature on a given topic.The database searches yielded 4128 results after deduplication. Following screening, 45 articles that met eligibility criteria were included in the review. The search results are shown in Appendix A and a summary of each article is presented in Table The included studies highlighted varying definitions of UHC and quality of care. A common definition of UHC was that all people who require any essential healthcare services, including but not limited to promotion, prevention and treatment, are able to access services without financial stress –20. One Definitions of quality of care also varied. One study distinguished between service quality  and technical quality  . AnotherBelow, we synthesize findings from the studies according to the components of Kruk et al.’s  conceptuA common theme across the literature was health system governance at local, regional and national scales, and its relationship to quality of care within the context of UHC. Naher et al.  identifiThe literature suggests that poor governance is a common issue across health systems, and is both a cause and indicator of poor-quality care. Causes and forms of poor governance include weak supervision of, and inadequate incentives and remuneration for healthcare providers; lack of transparency and accountability in decision-making; and insufficient financial capacity; in addition to fragmented regulations and policies. Poor governance has also been found to result in low patient trust and confidence in the health system, wasted resources and poor patient outcomes , 40, 44.Interventions to improve governance described by the reviewed literature include decentralization, social accountability mechanisms, such as social audits, and policy reforms to strengthen provider incentives and service integration , 47, 53.Six studies identified measures and/or measurement instruments to assess quality of care or its various dimensions within the context of UHC , 42, 51.Several studies also identified critical health workforce shortages and inequities in the distribution of appropriately qualified staff between urban and rural areas as significant constraints to the provision of high-quality, equitable care within the context of UHC, particularly in LMIC contexts –50, 53. Evidence from the reviewed studies suggests that poor provider competence across a range of health services remains an ongoing issue, particularly in LMICs, posing a considerable barrier to the provision of timely, safe and effective quality of care , 47, 49.Within health systems seeking to provide UHC, significant inequities remain in both LMICs and HICs regarding the quality of care received by different populations. Vulnerable populations, who are more likely to receive care from lower-level health facilities, such as health centres, are disproportionately impacted by incompetent care and systems, having already constrained access to care , fewer oFour studies described organizational factors influencing provider competence, including performance appraisal, continuing education, incentives, and remuneration and payment mechanisms , 40, 46.Regarding incentives to improve motivation and quality of care delivery, Yip et al.  suggesteWait times, a core component of quality of care, were noted as ongoing concerns in HICs and LMICs , 55, 56.Several studies described the relationship between positive user experience and people-centred care, which focuses on the needs and preferences of populations served while engaging them in shaping health policies and services. In addition, people centredness has been linked to improved mental and physical health, and reduced health inequities among other outcomes , 35, 57.One study presented a people-centred care partnership model intended to support the work of advanced practice nurses in sustaining UHC, identifying nine attributes of people centredness including mutual trust and shared decision-making .Several studies also discussed strategies aimed at increasing patient/community voice and engagement and the people centredness of health systems. These strategies included citizenship endorsement groups in Mexico  and vari(i)Regarding programmes intended to improve the quality of care, a community health extension programme in Ethiopia was associated with increased perinatal survival and decreased prevalence of communicable diseases. Though resource constraints such as inadequate medical supplies and limited supervision of health extension workers were noted as challenges, a key success factor included strong community engagement .(ii)Another six studies examined health outcomes in relation to health insurance schemes or health system reforms –48, 55. (iii)Studies also compared patient outcomes in relation to private versus public sector healthcare provision , 56, 58.(iv)Finally, two studies examined integrated models of care and their relationship to health outcomes , 54. AccA few of the reviewed articles reported on empirical studies that analyzed patient and population health outcomes in relation to quality of care in the context of UHC. Where reported, these outcomes were discussed in reference to (i) specific programmes intended to improve quality of care and advance UHC, (ii) the impacts of health insurance schemes or health system reforms, (iii) private versus public sector provision of healthcare and/or (iv) the effects of specific service delivery models.Reports of poor perceived quality of care and low patient satisfaction as barriers to healthcare uptake and enrollment in health insurance schemes were common across the reviewed studies , 55, 56.Several studies also discussed the effects of health system reforms and different service delivery models on patient satisfaction and trust in healthcare systems , 54, 57.Twenty-seven studies addressed the efficiency of healthcare systems and services, which the review by Morgan et al., defined as ‘the extent to which resources are used effectively or are wasted’ , p. 608.Additionally, some studies compared the efficiency of public and private sector healthcare provision, reporting mixed results , 58, 61.In LMICs, the private sector has been linked to increased service costs related to overprescribing and use of unnecessary and expensive procedures . HoweverSubstantial evidence gaps that were identified in the reviewed literature are grouped thematically below. Themes are ordered by how frequently they were discussed by the reviewed studies.Several studies identified the need for additional research to inform the development, selection and use of monitoring and evaluation frameworks and measures to assess quality of care and equity in relation to UHC in various geographic contexts at multiple levels of the health system, including facility and institutional levels , 39, 42.Researchers noted the need for more conclusive evidence comparing the efficiency and effectiveness of public and private health sector provision, and the role of the private sector in contributing to UHC , 57, 62.The reviewed literature identified a lack of evidence regarding the impacts of different financial and insurance schemes on quality-of-care delivery and patient outcomes, particularly for vulnerable groups including women-headed households, children with special needs and migrants , 55, 62.Studies identified the need for more robust evidence related to the effects of integrated service delivery models on access to quality care, as well as patient and population health outcomes , 52, 54.Finally, researchers called for additional evidence regarding the mechanisms and contextual factors such as societal stigma that influence the effectiveness of interventions related to quality of care in the context of UHC , 37, 55.This scoping review aimed to characterize the existing conceptual and empirical literature on quality of care within the context of UHC. As noted in our results, in the reviewed literature, quality of care was often ill defined or defined inconsistently. A lack of conceptual clarity compromises the development of a robust evidence base able to inform the design and implementation of effective quality-related policies and interventions.The 45 articles we reviewed for our study reveal a heterogeneous body of literature when compared with Kruk et al.’s quality of care framework. While some framework components including governance and the efficiency of healthcare services and systems were highly represented in the included literature, others were less represented such as physical and technological resources and tools, and patient and population health outcomes.We also noted in the reviewed literature a lack of clarity regarding how the studies distinguished between private sector involvement in financing and/or delivery of care. This lack of clarity limits our understanding of the implications of private sector engagement for the quality of care and the achievement of UHC in various geographical contexts. Research is required to provide greater clarity of the role and impacts of private sector involvement in financing and/or delivery of health services, to help inform countries’ decision-making regarding private sector engagement. In addition, further research is needed regarding the interactions between the public and private sector and their effects on the sustainability of UHC. For example, studies have noted a concern that the availability of concierge services can create downstream implications for people who cannot afford private insurance, such as an imbalance in resource distribution .Overall, the identified evidence gaps pointed to the need to build a stronger evidence base about what works, for whom, and under what contextual circumstances, and with what effects on equity to improve quality of care in LMICs and HICs. This includes a need for further evidence on the effects of integrated service delivery models, as well as how regulation can be used to create a public–private healthcare mix promoting high-quality and equitable care. The literature further highlighted the urgent need for additional research to inform the creation of robust monitoring and evaluation frameworks prioritizing equity that could support improvements to quality of care. This includes further research to help support the inclusion and use of disaggregated data, such as by wealth, sex and ethnicity to monitor and inform efforts to increase equity in access, utilization and outcomes for vulnerable populations. Beyond the above-noted research priorities, we also recommend additional research comparing quality related outcomes before and after UHC implementation, and how they intersect with health equity.Strengths of our scoping review include the use of a broad search methodology and validated search filters in consultation with an expert librarian, and the use of a conceptual framework to guide analysis of findings. Further, our search was not constrained based on country of origin. In our search of the literature, we did not find other published reviews of similar scope about quality of care within the context of UHC.The primary limitation of our review is the small number of included studies that met our eligibility criteria. This highlights that quality-related research in UHC remains an emerging field. In addition, many of the included studies were narrative reviews, which may not have captured the full breadth of the literature. Another limitation of our review is that we included only English-language studies. Future reviews should attempt to search and synthesize evidence in additional languages to provide more global relevance. Further, the conceptual framework we applied to the analysis of findings does not consider various factors that render health systems more fragile such as pandemics, disasters and conflicts, which may compromise the quality of care and realization of UHC. As our study did not include search terms for specific vulnerable populations such as Indigenous or racialized groups, there is also need for future research related to LMICs and communities experiencing marginalization and discrimination within HICs.In addition, there may be limited applicability of findings across studies to different geographic regions. Finally, due to the heterogeneity and qualitative nature of the included studies, meta-analysis and synthesis beyond thematic analysis were not feasible.This review summarized the existence of available evidence on quality of care within the context of UHC, identifying strategies aimed at improving quality of care as well as diverse knowledge gaps. Further research, evaluation and monitoring frameworks including those that attend to equity are required to strengthen the existing evidence base.


Objectives: The central sterile supply department (CSSD) is responsible for sterilization processes, and instruments are then stored in a clean room until use. Environmental controls, such as temperature, and relative humidity, are important in preventing the spread of infection during the sterilization process and during storage of medical devices. Data regarding temperature and relative humidity readings in the operating room, and whether instruments remain covered for the duration of the operation, are difficult to obtain. For easy access to relative temperature and humidity data covering all operational intervals, a rapid and convenient notification system was designed using a software application to send temperature and humidity information to the ThingSpeak website. We identified abnormal values for temperature and relative humidity and submitted revisions for all operating periods to facilitate monitoring of the refrigeration system. Methods: We implemented 3 programs: (1) DHT11 humidity and temperature sensor; (2) NodeMCU ESP8266; and (3) Program Arduino IDE. Results: The ESP8266 board connected using WIFI SUTH Mobile, and the DHT11 displayed temperature and humidity. The temperature and humidity data were sent to the website every 10 minutes. When an alarm occurred, it triggered immediate notification via the software application. Conclusions: We designed a temperature and humidity alert system using DHT11. Environmental control was possible using ESP8266, and alerts were triggered in the software application when an anomaly occurred. Data were uploaded to ThingSpeak every 10 minutes. The triple system actually sends alerts through the application and records data every 10 minutes. This system can measure environmental conditions in real time.


The 2013-2014 approvals of new direct-acting antiviral (DAA) therapies for hepatitis C virus (HCV) infection have engendered a paradigm shift in HCV treatment and management, offering the potential for a cure at a population level. The availability of the highly effective and relatively safe DAAs prompted revisions to guidance recommendations based on new clinical trial evidence. In the context of this paradigm shift and considerations of the costs associated with the new DAAs, managed care professionals face new questions and challenges regarding HCV treatment and management approaches. To address the continuing education needs of this group, PRIME Education, Inc. (PRIME) conducted a symposium on HCV at the 27th Annual Meeting Expo of the Academy of Managed Care Pharmacy. Moderated by Michael R. Stinchon, Jr., RPh, the program panel featured 2 internationally recognized leaders in hepatitis C treatment and research: Norah Terrault, MD, MPH, and Alex Monto, MD.To summarize the educational symposium presentations and discussions.This article is organized by key questions that the panelists and attendees raised for discussion during the 2-hour symposium. The questions addressed methods for assessing liver fibrosis; comprehensive patient assessment to inform treatment decisions; the influence of viral load on decisions about treatment duration; the role of ribavirin in optimizing treatment efficacy; unmet treatment needs for patients with HCV genotype 3 or advanced liver disease; and managed care strategies for patient education, adherence promotion, and care coordination. In answering attendee questions on these issues, the expert panelists presented established evidence, and recognizing limitations to current evidence and guidance recommendations, they discussed applications of clinical judgment and offered their views and practices regarding individualized care for patients with HCV.In response to questions about the utility of noninvasive methods for assessing liver fibrosis, the expert panel presented a comparative overview of the methodology, accuracy, risks, limitations, and costs of noninvasive tests and liver biopsy. Discussion highlighted the strengths of noninvasive methods for diagnosing advanced disease and cirrhosis and the methods’ limitations that pose barriers to ensuring that patients receive necessary antiviral therapy. Based on guidance recommendations, treatment should be prioritized in patients with advanced fibrosis or cirrhosis (Metavir score F3 to F4). While acknowledging the importance of this recommendation, the symposium panelists also argued that making effective decisions about whom, and when, to treat requires a more comprehensive clinical approach to patient assessment and adjusting recommended priorities according to individual patient considerations. This approach involves evaluating outcomes such as extrahepatic complications, including those affecting quality of life, functional status, and work productivity. In response to questions regarding decisions about DAA therapy duration based on viral load, the panel engaged the audience in thinking critically about evidence-based cutoff values and natural fluctuations of HCV RNA concentrations. Discussions centered on the importance of clinical judgment to ensure that the treatment duration promotes the highest efficacy and avoids risks of relapse. The panel responded to several audience questions about the role of ribavirin in new DAA regimens. Evidence-based presentations and discussions focused on patient-specific factors that must be considered to inform effective decisions about adding ribavirin. The panel took a similar approach to answering questions about emerging challenges and the difficult-to-treat populations of patients with HCV genotype 3 or advanced liver disease. The symposium concluded with presentation of, and discussion on, managed care strategies for educating patients about appropriate HCV medication use, improving adherence, and coordinating care provided by the interprofessional team.The availability of new DAAs for HCV raises new questions and challenges for managed care professionals, especially regarding prioritizing patients for immediate therapy as well as treatment and management approaches that account for the needs of individual patients and subpopulations. The educational symposium summarized in this article directly addressed key questions and challenges through presentations of evidence, guidance recommendations, and interactive discussions on the views and practices of international leaders in HCV treatment and research.


Theory of Mind (ToM) is defined as the cognitive ability that infers other’s mental states .The interest in the study of ToM distinguishing its affective and cognitive components has been growing. Its study in psychopathology has been evolved from its original studies in autism spectrum disorders (ASD), schizophrenia (SCZ) and, borderline personality disorder (BPD), to other mental disorders like major depressive disorder (MDD), bipolar disorder (BP), anorexia nervosa (AN) and social anxiety disorder (SAD).1) review the most commonly used instruments for ToM assessment; 2) to compile the evidence on ToM deficits across mental disorders. For both objectives, target disorders are previously mentioned.The search was carried out on the PubMed, PsycInfo and Scopus databases, using the terms “Theory of mind”, “Mentalization” and the previously mentioned mental disorders and pertinent thesaurus. Articles in English, published since 2010 were considered. A 2-step strategy  was followed to select articles of interest.Reading the Mind in the Eyes  and Movie for the Assessment of Social Cognition  were the most commonly used tasks to assess ToM. Regarding mental disorders, studies showed deficits in cognitive and affective ToM skills in ASD, SCZ, BPD, MDD and BP. Hypomentalization was mainly observed in ASD and MDD, while BPD and SCZ were featured by errors associated with hypermentalization. Studies in AN and SAD are scarce, but they mainly highlight a cognitive ToM deficit, with hypomentalization in AN and hypermentalization in ASD. In all of them, depressive symptomatology seems to be a critical moderator of ToM performance.Although ToM impairments are well described for some mental disorders, more research is needed to reach solid conclusions for others. The use of different and heterogeneous ToM assessment instruments can strongly influence the results of studies. The study of ToM is essential to gain a better understanding of the diseases and to develop effective treatments targeting specific ToM deficits.None Declared


A bibliometric analysis of current research, hotspots, and development trends was used to develop an overall framework of mechanisms of alpine grassland degradation on the Qinghai-Tibet Plateau. This investigation includes data from 1,330 articles on alpine grassland degradation on the Qinghai-Tibet Plateau, acquired from the Chinese Science Citation Database (CSCD) and Web of Science Core Collection (WOS). Research was divided into three themes: spatial scope and management of typical grassland degradation problems, dynamic mechanisms of grassland degradation and effects of ecological engineering, and grassland degradation risk based on remote sensing technology. The results of the analysis showed that the research can be summarized into three aspects: typical grassland degradation identification, dynamic mechanism analysis of grassland degradation, and grassland ecosystem stability strategy. The main findings can summarized, as follows: (1) Ecological analyses using the river source as a typical region defined the formation of “black soil beach” type degraded grasslands in the region, and promoted the ecological environment management and protection of the alpine grassland by discussing the causes of regional ecological environment changes; (2) Dynamic mechanism analyses of climate change and characteristics analyses of grassland vegetation-soil degradation revealed that alpine grassland degradation is the result of multiple main factors; and (3) Risk prediction methods for grassland degradation, methods of grassland management and sustainable countermeasures for agriculture and animal husbandry development, and the development of a comprehensive index of influencing factors on grassland degradation all indicate that selecting the right grassland restoration measures is the key to grassland restoration. Remote sensing monitoring and high-throughput sequencing technology should be used in future research on grassland ecosystems. In addition, multiscale, multidimensional, and multidisciplinary systematic research methods and long-term series data mining could help identify the characteristics and causes of alpine grassland system degradation. These findings can help identify a more effective coordination of landscape, water, lake, field, forest, grass, and sand management for the prevention of alpine grassland degradation. The Qinghai-Tibet Plateau is a unique geographical region with the highest altitude in the world . The plaBecause of continuing grassland degradation on the Qinghai-Tibet Plateau since the 1980s, many studies have been conducted on the causes of this degradation. Climate warming, population increases, grazing pressure, and rodent damage are the key factors leading to grassland degradation . As a coMany studies have examined the degradation of alpine grasslands on the Qinghai-Tibet Plateau, primarily focusing on the composition and structure of degraded grasslands, including species diversity, biomass, ecological vegetation characteristics, community succession, and soil properties . Field qThis investigation includes data collected from 1,330 articles about alpine grassland degradation on the Qinghai-Tibet Plateau published between 1990 and 2022, acquired from the Chinese Science Citation Database (CSCD) and Web of Science Core Collection (WOS). Advanced search methods were used (keywords included: Qinghai-Tibet Plateau OR Tibetan Plateau OR Sanjiangyuan AND Alpine meadow OR Alpine grassland OR Alpine steppe OR Black soil beach AND Degradation OR Deterioration OR Decline). The document type was set to “Article, Proceedings, Papers, Reviews.”Both Citespace 5.7. R2 and Vosviewer 1.6.17 visual analysis software were used to conduct a quantitative analysis of the research on alpine grassland degradation on the Qinghai-Tibet Plateau. Excel 2022 and Origin 2022b software were used for data collation, and for the statistical analyses conducted on the number of published articles, institutions, and authors, and for summarizing keywords. The goal was to analyze international research frontiers and hotspots.A review of the literature found there were 1,330 articles on alpine grassland degradation on the Qinghai-Tibet Plateau published before 2022, including 965 articles found in the Web of Science (WOS) Core Collection and 365 articles found in the China Science Citation Database CSCD; .Early research primarily investigated typical phenomena and management of grassland degradation using field studies. In the 1980s, “black soil beaches” increased sharply, indicating serious grassland degradation in river headwaters . In the In summary, grassland degradation is a complex process of change, and the clearest changes in the early part of this process are the dramatic increase in black soil beaches and the changes observed in grassland vegetation. Most studies on alpine grassland degradation are time series analyses, outlining changes in grass characteristic indexes to identify the degree of grassland degradation. Synthesizing the results of these studies, grassland degradation is mainly manifested in the decline of grassland productivity, biodiversity, soil quality, and ecosystem service function. In recent years, with the implementation of the protection and construction project of the ecological security barrier on the Qinghai-Tibetan Plateau, the degradation of alpine grassland has slowed and the ecology of the grasslands have started to recover through the adoption of restoration measures corresponding to the degree of degradation.Keyword emergence refers to a rapid increase in the frequency of a keyword in a certain period of time, reflecting a research hotspot or new research trend in that period of time. CiteSpace software can extract emergent words from a large number of literature subject words, show the emergence and continuation of relevant research in certain years, characterize the development trend of research hotspots, and reflect the evolution of the research landscape over time . AnalyziIn the CSCD database, the keywords “ecological environment” and the research area “river source area” had appeared already prior to the years included in this study, indicating that these were the focus of early research. In 2000, the keyword “ecological environment” appeared, and the research on alpine grassland degradation at this stage focused on evolution and trends in the ecological environment and the causes of regional ecological environment changes , which e“Soil properties” and “biomass” are the longest lasting research hotspot areas, continuing to be hotspot words even today, as they are a comprehensive reflection of soil physical and chemical properties and biological attributes that can reveal the most sensitive indicators of soil condition dynamics. Emergence words in the WOS database were concentrated from 2003 to 2022 , indicatIn summary, the study of alpine grassland degradation on the Qinghai-Tibetan Plateau has been a gradual evolutionary process. Researchers have sought to identify and analyze the factors and characteristics of degraded grassland from different perspectives and at different times. This study aimed to expand and deepen the response analysis of grassland degradation between various parts of the grassland ecosystem based on an analysis of the keywords, research directions, and publication dates of the relevant articles. This review was more systematic than previous studies.Keywords provide an overall summary of the topic of an article and indicate the core research topics. Thus, research hotspots can be identified through an analysis of keywords . The keyThe Qinghai-Tibet Plateau is a unique ecogeographic region characterized by abnormally changing climate and harsh natural conditions that accelerate grassland degradation . The effLivestock grazing affects grassland stability, resilience, and productivity through livestock trampling, foraging, and defecation. Over time, trampling affects a wide range of grassland components and can have lasting effects. Trampling helps keep grasslands healthy but excessive trampling can also lead to the degradation of these grasslands . Cattle Overgrazing and climate change are important drivers of alpine grassland degradation in the Tibetan Plateau . ClimateThus, the degradation of alpine grasslands is the result of interactions between multiple factors, with temperature and precipitation being the primary climatic factors, small herbivorous mammals the main wildlife factor, and livestock overgrazing being the main factor of human activity .The degradation of alpine grassland on the Tibetan Plateau is the result of the joint action of anthropogenic and natural factors, and long-term overgrazing, rodent damage, and climate change have accelerated this degradation . A clustIn terms of degradation characteristics, the first phase of research focused on the diagnosis of ecological problems in the source area of the river, which was manifested in the serious degradation of alpine grassland with large areas of the surface exposed, changes in soil structure, and a large loss of soil nutrients, stunting vegetation growth and leading to a variety of ecological problems. In the early stage of research on alpine grassland degradation, Different influencing factors lead to different degrees of grassland degradation. Selecting the right grassland restoration measures is the key to effective grassland restoration. Under mild and moderate degradation, measures such as rodent and insect pest control, fencing and sealing, rotational grazing, fertilizer application, and poisonous weed control should be adopted, while effective grassland restoration strategies, such as artificial intervention to re-establish grassland vegetation or cut through the turf, are needed for moderately and severely degraded grasslands . Among tIn terms of research methodology, measured data and modeling assessments are still the main tools used in grassland degradation research, with a variety of remote sensing data sources and different interpretation methods being used, combined with ground observations and field surveys to improve the accuracy and reliability of plant phenological period models . With thThe degradation and succession process of alpine grasslands on the Tibetan Plateau is closely related to the fragile ecological environment of this area, as well as climate change and human activity. These grassland ecosystems have produced different responses from various parts of the ecosystems when faced with external stresses. Future research should explore the various vegetation and soil change characteristics manifested in the grassland degradation process and study and formulate the criteria for using remote sensing to evaluate grassland degradation at the regional scale based on these vegetation and soil characteristics. Although remote sensing can quickly and objectively assess the current status of grass growth, it is currently impossible to exclude information such as increased vegetation cover and grass productivity caused by poisonous weeds. Therefore, applying grass productivity or vegetation cover indicators to the quantitative characterization of vegetation communities is necessary to obtain accurate information on grassland degradation. Future research should also focus on: integrating the influencing factors of grassland degradation into a comprehensive index, using spatial analysis techniques and ecological risk assessment to measure the potential risk of alpine grassland degradation caused by human activities and extreme climate changes and evaluate the main sources of risk, exploring and predicting the formation mechanism of ecological risks and mitigating the losses brought about by those sources of risk. Research scales in this research area continue to broaden from local to regional and global, with expanding spatial scales of research, and lengthened time scales.This article introduces a general framework of the hotspots and development trends in research on alpine grassland degradation on the Qinghai-Tibet Plateau. Research on alpine grassland degradation was divided into three themes: revealing typical degraded grasslands, analyzing the dynamic mechanisms of degraded grasslands, and studying degradation risk based on remote sensing monitoring and ecological models. In earlier research, a sharp increase in the area of “black soil beaches” was found in river source areas, revealing the characteristics of grassland degradation. In recent years, studies have focused on the responses of each part of the alpine grassland ecosystems, identifying climate change as the main factor of influence on the decrease in productivity of grassland vegetation communities. Community structure degradation and declines in both soil water-holding capacity and nutrient levels in grasslands have also been investigated.Although major research hotspots and their evolution were identified, more in-depth information is still needed about each hotspot. Therefore, the following future research priorities are recommended: (1) characterize the relationships between soil microorganisms and vegetation with the help of remote sensing monitoring technology and high-throughput sequencing technology and develop remote sensing identification technology for grass species to improve the precision of identifying affected alpine grassland ecosystem processes; (2) examine changes in alpine grassland ecosystems based on long-term data mining to better understand the characteristics and causes of alpine grassland degradation and establish bridges between grassland ecosystems and the socioeconomic system; and (3) use a system perspective to understand the key mechanisms of multi-type process coupling, multi-factor regulation, and multi-scale effects on the relationships between the socioeconomic system and grassland ecosystems. This summary of current research progress and hotspots provide a reference for future research on alpine grassland degradation on the Qinghai-Tibet Plateau.10.7717/peerj.16210/supp-1Supplemental Information 1X-axis) and number of publications (Y-axis). Orange is the Chinese Science Citation Database, and blue is the Web of Science Core Collection. As shown in Figure 1.Year of publication (Click here for additional data file.10.7717/peerj.16210/supp-2Supplemental Information 2According to the keywords set in this study, the Chinese Science Citation Database was searched as a partial data source for this study, and table 2 and figure 2 were plotted.Click here for additional data file.10.7717/peerj.16210/supp-3Supplemental Information 3According to the keywords set in this study, the Web of Science Core Collection was searched as a partial data source for this study, and table 2 and figure 2 were plotted.Click here for additional data file.


Because of their direct relations to the process of health and disease throughout life, physical activity and sedentary behavior emerge as priorities in the global public health agenda ,2. If thThe available evidence supports the understanding that a lack of physical activity and substantial periods of sedentary behavior is associated with an increased risk of cardiovascular disease, cancer, and premature mortality ,5. Non-cThe COVID-19 pandemic decreased physical activity and increased sedentary behavior . Most peIJERPH Special Issue, “Stand Up For Yourself! Tackling Sedentary Behavior Through Exercise and Lifestyle Change”, invites researchers worldwide to share evidence and discuss the main determinants and strategies of interventions from an interdisciplinary perspective.Physical activity and sedentary behavior are multidetermined and require complex approaches and efforts for confrontation ,9. Thus,


Increased uptake of essential fatty acids during pregnancy through seafood and supplementation has been shown to positively correlate with gestational age and increased infant birth weight. We aimed to evaluate the effect of maternal dietary intake of essential fatty acids, supplementation on gestational period and infant birth weight.A literature search with the help of various databases such as PubMed, Google Scholar, Web of Science and Scopus was conducted.Original research articles and intervention-based studies, which involve an association between dietary intake and supplementation of essential fatty acids during full-term pregnancy on human infant birth outcomes and published from 2011 to 2021, were included.In total, there were 21 intervention-based studies, including full-term pregnant women with or without existing comorbidities, which compared essential fatty acids in the form of dietary sources and supplementation with dietary counseling and with or without placebo. The intervention trials included in this review were conducted in developed and developing countries. Half of the pregnant women who enrolled in the study had comorbidities such as diabetes and hypertension, which might increase their risk of adverse maternal and infant birth outcomes. Most of the studies included in the review have reported a positive association between improvised dietary and supplementation intake of essential fatty acids with increased length of gestation, infant birth weight and other parameters such as head circumference, infant birth length and growth velocity.Positive correlations were found between increased consumption of essential fatty acids in food sources and supplements with improvised infant birth weight and gestational period. Birth weight is a crucial predictor of the health trajectory of an infant. Inadequate food intake or lack of a balanced diet during pregnancy can cause a birth weight of less than 2.5 kg, indicating low birth weight (LBW) and preterm birth. Preterm delivery is the primary cause of infant death and is linked to a higher risk of several detrimental health effects in childhood and adulthood . Even inEvery cell in our body requires essential fatty acids, which serve as precursors of eicosanoids and are physiologically active chemicals that help in cell division and proliferation. Docosahexaenoic acid (DHA), primarily present in oily fish, is essential for early human development because it enhances visual, intellectual and kinesthetic development . Foods hAdditionally, consuming seafood, which is high in essential fatty acids, may boost birth weight in two ways: by increasing the ratio of physiologically active prostacyclins to thromboxanes, lowering the viscosity of blood, and also by aiding in the rapid growth of the fetus and prolonging the length of the gestation period . A transAn intervention-based Cochrane review was conducted using the databases PubMed, Google Scholar, Web of Science and Scopus. The Cochrane handbook for systematic reviews of interventions was used as the guide (2008). In the present review, articles that were published in the English language between the time period 2011 and 2021 were selected. The keywords used in the literature search were ‘essential fatty acids and infant birth weight’, ‘maternal fatty acid intake’, ‘maternal nutrition’, ‘pregnancy and DHA’, ‘gestational length’, ‘omega-3 fatty acids’, ‘omega-6 fatty acids’, ‘fish oil supplementation’, ‘arachidonic acid’, ‘essential fatty acids’, ‘prolonged gestation’, ‘fetal growth’, ‘birth outcomes’, ‘gestational age’, ‘nutrition’ and ‘essential fatty acids’. Boolean expressions indicating ‘OR’ and ‘AND’ were used while completing the literature search. The generated lists of publications were manually reviewed to identify studies that addressed the objectives of the present investigation and to classify the papers according to their associations with the consumption of essential fatty acids during pregnancy and childbirth weight. The present review follows PRISMA guidelines, which are usually used in systematic reviews that evaluate healthcare interventions and present review involves mixed method with qualitative and quantitative research methods. For relevant information for some items, such as dietary interventions and supplementation of essential fatty acids which have already appeared in a publicly accessible review protocol, referring to the protocol was deemed sufficient. Alternatively, detailed descriptions of the methods used, or additional results, were reported. Selection of papers was based on considering all the study characteristics used to determine a study's eligibility for inclusion in the review, that is, components described in the PICO framework or one of its variants, and other characteristics, such as eligible study design for example dietary interventions of essential fatty acids during pregnancy, setting of the intervention and minimum duration of follow-up period, were considered.The published reports mentioning the study population as full-term gestation period in pregnant women aged 17 to 40 years with or without existing comorbidities were included in the present review. The study population includes participants from all over the world. Original research articles that correlate intake from food sources and supplementation of essential fatty acids during full-term pregnancy with infant birth outcomes in human studies were considered. The uptake of essential fatty acids during pregnancy can influence the composition of breast milk, which eventually affects infant development. Hence, research articles stating the related mechanisms were also included. The eligibility and intervention-based studies and placebo and active control interventions with actual intervention group studies were also considered. Studies were excluded if they were animal studies, systematic reviews and an overview of reviews based on exclusion criteria. The title of each chosen published report was carefully checked to avoid duplication of articles.Furthermore, the abstracts from the selected research articles were also thoroughly read and evaluated to determine their relevance to our topic. The articles were chosen based on their abstracts. Then the full text of the articles was examined. This thorough scrutiny checks for eligibility included 21 intervention-based articles in this review.The following data were obtained from the selected published reports: stage of pregnancy, existing comorbidities, place/country of the study, sample size, age of the participant (years), dietary sources of EFA, type and dosage of the supplement, supplementation strategy, association with gestational length and infant birth weight.The relationship between maternal dietary essential fatty acid intake with infant birth and gestational duration.The effect of essential fatty acid supplementation during pregnancy on the birth weight of infants.The impact of dietary consumption of essential fatty acids and their supplementation during pregnancy influence newborn birth weight.The main aim of this review article is to determine the associations between dietary intake and supplementation of essential fatty acids during full-term pregnancy and infant birth weight, gestational length and other parameters such as infant birth length, head and neck circumference, and cognitive development. The articles were divided into the following sub-domains to help understand how essential fatty acid consumed during pregnancy relates to infant birth weight:Searches in databases included 66,900 references. The literature search of Scopus 1309), Pubmed (2357), Google Scholar  and Web of Science (6740) from 2011 to 2021 and additional 21 records from other sources were retrieved. From the reference list, 500 records were screened according to the inclusion and exclusion criteria, out of which 40 records were excluded, and 21 studies were included . Out of 21 selected research articles, there were 11 randomised controlled trials, 3 observational studies, 5 cohort studies, 1 clinical report and 1 cross-sectional study. 09, PubmeDHA has been found to help maintain the fluidity of membrane channels, regulate ion channels to enable synaptic transmission and serve as a substrate for binding to membrane receptors, all of which help to promote neurodevelopment . As therSeveral intervention-based studies suggest a relation between maternal essential fatty acid intake, gestational length and infant birth outcomes. Omega-3 fatty acids have been shown to improve the lipid bilayer membrane's fluidity and receptor-induced activity. Essential fatty acids could boost the growth of the fetus by increasing placental blood flow and lowering blood viscosity with the help of omega-3 fatty acid metabolites like prostacyclin and thromboxane. The study by Mani et al.,  highlighp < 0.05). The findings of Niinivirta et al. [Additionally, a correlation between dietary fat intake during pregnancy and infant newborn weight highlights the importance of essential fatty acids in the growth and development of the fetus. This correlation shows that for every gram of fat consumed, the infant's mean weight, height, and head circumference increase by 3.92 g, 0.013 cm and 0.008 cm, respectively . Severala et al.  emphasiza et al. .Most of the studies have reported positive associations with increased essential fatty acid intake and increased infant birth weight as these studies have considered dietary interventions, which includes essential fatty acid-rich sources in common. Women enrolled for these interventions have not reported any existing comorbidities, and few papers have shown positive relations with increased gestational length. One of the studies showed negative association, as the with an additional intake of 10 g of total fat intake was associated with lower birth weight; however, specific types of fat ingested was not considered.Studies on the effects of prenatal supplements, particularly larger dosages of omega-3 fatty acids of up to 600–800 mg/day, have shown promising benefits in improving gestational age and better childbirth outcomes. Increased birth weight was seen in the Western population due to increased uptake of omega-3 fatty acids supplements. In a randomised controlled study, a double-blinded placebo control group, 400 mg of algal supplementation was given throughout the pregnancy. The primary outcome obtained was associated with increased birth weight, birth length, and head circumference. The secondary outcome obtained was an increased length of gestation . A similSeveral studies, where interventions were randomised controlled trials, which included sources either from marine algae or fish oil capsules that contained substantial high amounts of essential fatty acids ranging from 10% to 70% of total fat consumed in the form of a capsule regularly throughout gestation period, have shown increased birth weight and lower incidences of preterm birth. One of the studies did not show any association, as the supplementation was introduced in the second trimester, and the source of supplement was purely from DHA excluding other essential fatty acids. Multiple factors such as intervention throughout the pregnancy, family support, stress levels and gestational length were not considered.Besides the dietary sources of essential fatty acids, supplementation is essential in increasing an infant's birth weight, psychomotor skills and gestational age. Dietary supplementation is essential when a person finds it challenging to meet prescribed macronutrient intake through diet alone or dislikes a particular food. Preterm and LBW infants are usually born with neurodevelopmental problems due to a lack or inadequate supply of essential fatty acids in the diet of pregnant women; conversely, supplementation of omega-3 and 6 fatty acids is required for maintaining the optimal fatty acid status of the mother and newborn infant . Based oIncreased intake of essential fatty acids helps extend the gestational age and weight of the infant at birth by lowering the chances of LBW infants and helps maintain the flow of fatty acids in the blood circulation . TriacylThe investigation by Lee et al.  stated tFurthermore, higher omega-3 fatty acids and omega-6 fatty acids were linked to shortened gestation length in over obese pregnant women. Phang et al.  investigOne of the major parameters to be considered is the initiation of dietary intervention and the supplementation during pregnancy, which have been reported in previous studies, wherein initiation in first and third trimester is crucial for birth weight of the infant. The regions where seafoods are less consumed, which are rich in essential fatty acids, are more prone to lower birth weight, reported especially in Indian studies. The lowest tertile of EPA intake and risk of LBW in the third trimester showed a similar significant connection. These patterns were also present in the first trimester, and throughout all trimesters, there was no appreciable difference in the relationship's slopes between birth weight and logarithmically transformed fish intake. Gestational weight was not given much importance in previous observational studies; however, increased gestational length has been shown to be associated with increased birth weight and with significant intake of essential fatty acids along with supplementation throughout the pregnancy, and quality and dosage plays a major role in development of fetal growth.It is widely known that unfavourable conditions during pregnancy will lead to malformation in fetal development and can lead to abnormal birth weight and preterm birth. This review emphasizes studies reporting positive correlations between maternal fatty acid uptake, improvised birth weight and gestational length. However, the mechanisms underlying the importance of these predetermined consequences are still poorly understood. Some studies have reported a negative correlation between increased uptake of essential fatty acids and decreased infant birth weight. This may be because the studies were carried out during certain selected periods throughout the pregnancy. More intervention-based studies involving nutrition education should emphasize the need for essential fatty acid uptake during pregnancy. At the same time, some of the studies with longer follow-up periods have reported no association with birth weight as nutrient values were calculated by the software for sub-components based on the database linking the composition of food items, which might not be precise or comprehensive, and a combination of dietary assessments with reduced bias can be made while conducting further studies. Therefore, to further establish the ideal intake of essential fatty acids and their components for long-term maternal and infant birth outcomes, it is crucial to take into account both the absolute content of essential fatty acids, the dosage of its components and the ratio of omega-6 fatty acids to omega-3 fatty acids in experimental investigations.


As anaesthesiologists face increasing clinical demands and a limited and competitive funding environment for academic work, the sustainability of academic anaesthesiologists has never been more tenuous. Yet, the speciality needs academic anaesthesiologists in many roles, extending beyond routine clinical duties. Anaesthesiologist educators, researchers, and administrators are required not only to train future generations but also to lead innovation and expansion of anaesthesiology and related specialities, all to improve patient care. This group of early career researchers with geographically distinct training and practice backgrounds aim to highlight the diversity in clinical and academic training and career development pathways for anaesthesiologists globally. Although multiple routes to success exist, one common thread is the need for consistent support of strong mentors and sponsors. Moreover, to address inequitable opportunities, we emphasise the need for diversity and inclusivity through global collaboration and exchange that aims to improve access to research training and participation. We are optimistic that by focusing on these fundamental principles, we can help build a more resilient and sustainable future for academic anaesthesiologists around the world. Although research, teaching, and administration constitute the core of academic anaesthesiology, the proportion of time dedicated to these activities varies across countries, regions, and institutions. Broadly speaking, academic anaesthesiologists are clinicians whose expertise and efforts contribute to the development and expansion of the speciality beyond the provision of routine medical care. Depending on the setting and individual career goals, the focus of an academic anaesthesiologist may be a combination of investigator- or industry-initiated scientific research, supervision of clinical and research training, development of quality improvement programmes, institutional leadership, and policymaking. Achieving eventual success in academia requires the willingness to persevere through setbacks and rejection, which is best fostered through lifelong mentorship and sponsorship. Despite recent initiatives from professional societies and various stakeholders to recognise and develop structured support for academic career development, the road to academic success can appear to be a journey into the unknown, with large differences prevailing between geographic regions see . Here, wThe UK medical education system involves 5 yr of undergraduate medical education (or 4 yr for graduates), followed by 2 yr of foundation training to achieve General Medical Council registration . Anaesth,,Formal research training is not required for full certification in anaesthesiology; during the undergraduate years, interested individuals can complete an intercalated Master's degree programme or formal MB/PhD programme . Up to 6 months near the end of postgraduate training can be used to gain experience in research, quality improvement, or medical education. Informal clinical research experience can be gained throughout training by participating in collaboratives such as the Sprint National Anaesthesia projectsIndividuals interested in postgraduate research training have formally funded research opportunities, but these vary within the UK; a majority are in England through the Integrated Clinical Academic Pathway. This programme operates in parallel with the standard clinical training programmes and requires a separate competitive application for each training stage. The National Institute for Health and Care Research (NIHR) academic foundation programme funds 3–6 months of academic time over the 2-yr foundation training.The final stage of the integrated clinical and academic pathway is a 4-yr NIHR Academic Clinical Lectureship post, which funds both clinical training and academic time of up to 50%. During the lectureship, trainees complete clinical training and develop proposals for postdoctoral research training fellowships of 3–7 yr duration, after which they would become senior independent extramurally funded researchers with a substantive university appointment. In other cases, clinicians with higher degrees can be supported by dual hospital and university contracts.In the USA, training in clinical anaesthesiology requires a minimum of 12 yr after secondary school graduation. This consists of 4 yr of undergraduate education and 4 yr of medical school to obtain an MD. Many medical schools offer combined MD/PhD programmes with a duration of 6–8 yr.Several bridge funding options after residency provide protected academic time and additional research training needed for development of independent investigators. These include National Institutes of Health (NIH) T32 programmes at select institutions, NIH K series grants or individual mentored research training grants, and grants from private foundations such as the Foundation for Anesthesia Education and Research (FAER) and the International Anesthesia Research Society (IARS). Intended for physicians without prior formal research training, NIH T32 programmes provide 2–3 yr of substantial protected research time (80%) and are currently available in 16 anaesthesiology departments in the USA.Academic medical centres in the USA recognise fundamental differences in daily responsibilities and academic productivity between clinical faculty and those with heavier research designations. As a result, many utilise a different system of promotion and tenure for clinical faculty, broadly organised into separate tracks for primary clinicians and administrators, clinician educators, and researchers including clinician-scientists engaged in collaborative or investigator-initiated research. Such systems encourage faculty to focus on specific professional competencies  and recognise that an individual's contributions to academic medicine extend beyond the traditional paradigm of extramurally funded, investigator-initiated basic science research.Medical schools in continental Europe traditionally offered a 6-yr undergraduate medical degreeBJA Foundation-ESAIC Grants for early career developmentMost medical research in Europe is conducted in state or municipal universities, which are largely financed through political channels that are independent of individual projects.The last two decades have brought a shift in medical school training in Australia and New Zealand from an exclusively 6-yr undergraduate course to a combined undergraduate and postgraduate pathway with 4- or 5-yr options . This haCompletion of training in anaesthesiology takes a minimum of 7 yr after medical school: 2 yr of general hospital experience followed by 5 yr of anaesthesiology training. The Australian and New Zealand College of Anaesthetists (ANZCA) training program includes seven core domains, and one of these termed the ‘scholar role’ requires skill development in reviewing and critically appraising the literature, clinical audit, and teaching others.Further discretionary research training  can be undertaken before, during, or after anaesthesiology training. There is currently no dedicated academic anaesthesiology training pathway that integrates a research qualification with anaesthesiology training. Although additional research training is not mandated, it is increasingly difficult to secure competitive grant funding without a higher degree.,The ANZCA Clinical Trials Network (CTN) supports investigator-initiated and -led multicentre trials in the domains of anaesthesiology, pain, and perioperative medicine.The remuneration of anaesthetists in Australia and New Zealand is commonly through the performance of clinical anaesthesiology. Most university academic appointments are honorary or are minimally paid compared with the income earned through clinical anaesthesiology. Therefore, academic anaesthesiologists including those with a university appointment typically maintain a substantial clinical caseload. A survey of anaesthesiologists across Australia and New Zealand found that the characteristics associated with anaesthesiologists intending to undertake research in the future included having research qualifications or planning to obtain research training, previous research involvement, and obtaining their fellowship in the last 5 yr.The ANZCA has a foundation that annually provides seed funding to ANZCA fellows and trainees in Australia and New Zealand. These grants are typically aimed at pilot and feasibility work to underpin a larger competitive grant application. The ANZCA foundation has specific emerging investigator grants to support early career researchers. The National Health and Medical Research Council (NHMRC) is Australia's primary research funding body, and the Health Research Council (HRC) serves this role in New Zealand. From 2013 to 2022, anaesthesiology research received only $38.7 million  in NHMRC funding from a total funding allocation of $2.9 billion  for clinical medicine and scientific research and $3.4 billion  for basic science research. Anaesthesiology research funding in New Zealand through the HRC has been similarly low with a total spend of less than $1 million  over the last 5 yr representing 0.15% of the total research budget allocation. In 2021, anaesthetists comprised 6.8% of the medical specialist workforce in AustraliaExchange programs can be an effective way for academic anaesthesiologists to gain knowledge and experience, broaden their perspectives, expand their networks, overcome local limitations in training and experience, and bring new expertise back to their institution and country. Researchers, particularly those from Europe, frequently spend a year or more participating in research projects abroad. However, the organisational and regulatory differences between countries are common barriers. Moving abroad for research is contingent on the availability of a sponsor, visas and work permits, funding, and personal circumstances. Additionally, those planning to perform clinical work abroad  can require additional examinations, certifications, or further clinical training. As a result, opportunities to participate are less feasible for potential trainees with fewer personal resources, working in low-income countries, and/or with personal caregiving responsibilities. Given the enormous professional advantages offered by international exchange programs, systems are needed to address barriers to access and make opportunities for exchange more equitable across regions and countries.mentorship, collaboration, and digitisation.Several major global challenges remain in academic anaesthesiology. These include barriers to accessing research opportunities, lack of incentives, lack of funding, and lack of diversity. We have identified several broadly applicable opportunities to overcome some of these barriers, including ,The report on a National Strategy for Academic Anaesthesia in 2005 highlighted the severe crisis in academic anaesthesiology that was occurring in the UK at the time,In a 2016 survey of 2000 physicians in the UK, difficulties in applying for and receiving protected time and funding was cited as the most important barrier to conducting research.Although self-sustainability in academia is the goal, funding sources remain limited, competitive, and heterogeneous. Additionally, academic anaesthesiologists typically require several additional years of specific research training; lower salaries during prolonged training periods significantly disincentivise this career path. The disincentive can be amplified for individuals with debt, and those with financially dependent family members or caregiving responsibilities at home.48Universities, irrespective of whether they are privately or publicly funded, rely on prestige to retain and attract income. This prestige can take many forms, including endowment, scientific impact, citation metrics, and, importantly, funding attracted, in a feed-forward cycle. Research institutions seeking high-impact science require large upfront and ongoing investments in research infrastructure. Much of the contemporary funding landscape is outsourced, competitive, results-oriented and, by extension, merit-oriented. To attain results and merit, junior researchers require considerable institutional investment to reach academic independence and self-sufficiency. From an economic perspective, funding of junior investigators is uncertain and carries risk, which is a direct disincentive to investing in resources required to support early careers.Despite the role of anaesthesiologists as innovators and drivers of technological advancement,,Diverse teams in healthcare are associated with clinical excellence,Despite increasing parity among students and recent graduates, faculty researchers are less likely to be members of underrepresented groups,Most advocacy groups and societies are committed to achieving gender equity and actively report on this issue ; US Agency for Healthcare Research and Quality (K12 HS026372-04 to EAV). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.