Health economic assessments are used to determine whether the resources needed to generate net benefit from a screening programme, driven by multiple complex benefits and harms, are justifiable. We systematically identified the benefits and harms incorporated within economic assessments evaluating antenatal and newborn screening programmes.For this systematic review and thematic analysis, we searched the published and grey literature from January 2000 to January 2021. Studies that included an economic evaluation of an antenatal or newborn screening programme in an OECD country were eligible. We identified benefits and harms using an integrative descriptive analysis, and illustrated a thematic framework. .The searches identified 52,244 articles and reports and 336  were included. Eighty-six subthemes grouped into seven themes were identified: 1) diagnosis of screened for condition, 2) life years and health status adjustments, 3) treatment, 4) long-term costs, 5) overdiagnosis, 6) pregnancy loss, and 7) spillover effects on family members. Diagnosis of screened for condition , life-years and health status adjustments  and treatment  accounted for most of the benefits and harms evaluating antenatal screening. The same themes accounted for most of the benefits and harms included in studies assessing newborn screening. Overdiagnosis and spillover effects tended to be ignored.Our proposed framework can be used to guide the development of future health economic assessments evaluating antenatal and newborn screening programmes, to prevent exclusion of important potential benefits and harms. •Health economic assessments are used to determine value for money of antenatal and newborn screening programmes.•Systematic review conducted to identify benefits and harms adopted in health economic assessments.•There is no consistency in the adoption of benefits and harms of screening programmes in these studies.•A thematic framework is proposed to assist researchers with the identification of benefits and harms. MEP: Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Visualisation, Writing – original draft, Writing – review & editing, MY: Formal analysis, Investigation, Methodology, Writing – review & editing, ST-P: Conceptualization, Formal analysis, Funding acquisition, Writing – review & editing, SR: Methodology, Writing – review & editing, NR: Resources, Writing – review & editing. AW: Writing – review & editing. LH: Conceptualization, Funding acquisition, Writing – review & editing, FB: Conceptualization, Funding acquisition, Writing – review & editing. AMcN: Writing – review & editing. JF: Conceptualization, Funding acquisition, Writing – review & editing, BT: Conceptualization, Funding acquisition, Methodology, Writing – review & editing, SO: Conceptualization, Funding acquisition, Methodology, Writing – review & editing, A-MS: Conceptualization, Funding acquisition, Writing – review & editing, JSO: Project administration, Resources, Writing – review & editing, SP: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing, OR-A: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Visualisation, Writing – original draft, Writing – review & editing1Antenatal and newborn screening programmes can facilitate earlier detection and diagnosis of health conditions, enabling timely care and treatment for pregnant women and their newborns. A successful screening programme maximises benefits and minimises harms to all the relevant stakeholders affected by screening . AntenatAntenatal and newborn screening programmes are associated with many benefits and harms. Harms of screening associated with false positive and false negative results include unnecessary additional resources to conduct further investigations, adverse psychological and physical effects and legal claims, as well as decreased trust and confidence in the health care system . In antePopulation screening programmes are evaluated by national screening committees using independent evidence-based recommendations relevant to the jurisdiction that may adopt the programme. The United Kingdom National Screening Committee (UK NSC) and the United States Preventive Services Task Force (USPSTF) are examples of screening committees using such approaches. The recommendation to adopt a screening programme on a national scale is based on the premise that the benefits associated with screening outweigh the harms once implemented. In the UK, for instance, the UK NSC requires evidence of these benefits and harms, and data demonstrating that the screening programme represents value for money. The latter is determined using a health economic assessment confirming that the additional costs of implementing a screening programme are justified by the additional benefits achieved. Decision-analytic based economic assessments can account for the abovementioned benefits and harms through outcome measures , model inputs and the structure of the decision-problem . There iIn this study, we report the first systematic review of the benefits and harms of antenatal and newborn screening adopted by different types of health economic assessments in the published and grey literature.22.1We used the PRISMA 2020 checklist  when rep2.2The PICOS  framework was used to develop the study eligibility criteria  and applhttps://www.crd.york.ac.uk/CRDWeb/), EconLit (Proquest)[1969-present], Science Citation Index, Social Science Citation Index and Conference Proceedings Citation Index – Science (Web of Science Core Collection)[1945-present], CINAHL (EBSCOHost)[1982-present] and PsycINFO (OvidSP)[1806-present]. SCOPUS (Elsevier) was used to run forward and backward citation searches once relevant studies were identified. The academic electronic database search was supplemented by manual reference searching of bibliographies, contacts with experts in the field and author searching. Only studies assessing screening programmes in at least one of the Organization for Economic Co-operation and Development (OECD) countries were included. A full search of the published literature was conducted on January 22, 2021 (The published literature was searched using the following electronic bibliographic databases: Medline (OvidSP)[1946-present], Embase (OvidSP)[1974-present], NHS Economic Evaluation Database A section that contained items from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist , modifie2)de novo as we could not find any previous examples in the published literature. A description of the consequences as reported by authors by screening test outcome  and source  was captured and categorised as either a benefit or a harm. We also recorded the stage of the disease pathway at which the screening test was administered and the phase(s) of the screening programme using categorisations from recent guidance  was assessed using the CHEERS checklist . The iteWe used the information captured in the bespoke form to create a framework of benefits and harms adopted by health economic assessments using a process of grouping themes into categories derived from information extracted about consequences in the bespoke form . An inteThe funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.33.1We identified 52,244 articles and reports from the searches of the published and grey literature. Among the 16,052 records that were sought for retrieval based on identification of records via other methods (i.e. grey literature), 7464 records were non-English (46.5%). Thirty-nine studies of the non-English records were assessed for eligibility with five subsequently included in the data extraction phase. A total of 336 records (310 articles and 26 reports) were included in the systematic review. One HTA report included two separate economic evaluations that were separated into two different reports, resulting in 337 outputs. Study selection and reasons for exclusion as well as data extraction of the ancillary form are summarised in the PRISMA diagram . The lisThe characteristics of screening programmes and populations in the included articles and reports are summarised in The medical conditions investigated are summarised in The methodological characteristics of the health economic assessments are summarised in Reporting quality assessed using the CHEERS checklist was heterogeneous among the 264 full length articles and reports . An abridged version of the thematic framework with a description of each theme and key examples is presented in The benefits and harms incorporated within health economic assessments are presented in 4To our knowledge, this review is the first of its kind focusing on the adoption of benefits and harms by health economic assessments of antenatal and newborn screening programmes. Previous work has focused on the identification of methodological challenges and the development of good practice guidelines in the conduct of health economic assessments . HoweverWe found clear evidence that decision-analytic models represent the main vehicle for the conduct of these studies, unsurprisingly given the nature of the evidence synthesis needed. Almost half of the articles and reports used standard health economic measures of QALYs or DALYs to measure the health benefits of the screening programmes. Lifetime horizons are important to understand the costs and consequences of these screening programmes in the long run, but such an approach was adopted by less than half of the studies. Current lack of long-term data to inform this aspect of economic evaluations partly explains this result , but it Our thematic analysis summarised a wide range of benefits and harms adopted by these studies and summarised them into seven core themes. There is no consistency on the selection of benefits and harms across and within conditions suggesting that additional guidance is needed in this field. In general, articles and reports assessing antenatal and newborn screening programmes have considered benefits and harms that reflect the processes of identifying a condition in their health economic assessments. This includes, for example, cases correctly identified or missed or the number of unnecessary tests due to false positives. This result is not surprising because benefits and harms associated with the diagnosis of screened for conditions provide the first line of clinical evidence about these programmes and are of key interest to screening organisations. Around half of the articles and reports evaluating newborn screening programmes across all conditions did not consider benefits and harms associated with life years and health status adjustments. Our review also found that benefits and harms identified as important by screening agencies and international health organisations, including overdiagnosis and spillover effects on family members, have rarely been adopted by these economic evaluations . In the Authors did not generally refer to “benefits” and “harms” when describing the utilities and dis-utilities included in their evaluations. In addition, what constitutes a benefit or harm depends on the perspective of the particular stakeholder involved in the decision-making. For instance, a reduction in the number of infants born with a condition through pregnancy termination may be seen by some as a societal benefit in economic terms, due to health care savings and reduced societal comorbidity. However, this may well be considered a devastating harm for families who value living with an infant with a condition. Therefore, we had to extract and interpret detailed information about the consequences included in the studies and reports for the thematic analysis from a neutral ethical perspective when categorising benefits and harms together into unique themes. It is worthwhile noting that the terms benefits and harms are commonly used by national screening committees to communicate their decisions about implementation of these programmes . We hopeA key strength of this review includes the focus on a comprehensive set of antenatal and newborn screening programmes across OECD countries. We did not restrict our searches to English-only records to avoid language bias, and did not restrict our searches to the published literature only in order to avoid publication bias. We have also identified a thematic framework of benefits and harms that can act as a starting point for researchers when considering the benefits and harms to be included in their analyses in the future. However, this study has its limitations. We did not dual extract data as currently recommended  due to tIn conclusion, we have conducted the first systematic review identifying the benefits and harms incorporated into economic evaluations of antenatal and newborn screening programmes. We found that many of these studies did not adhere to the most recent guidance on the conduct of economic evaluations and that many benefits and harms considered important by screening agencies, including overdiagnosis, are often overlooked . Our wor10.13039/501100000272National Institute for Health Research (UK): 10.13039/501100000664Health Technology Assessment Programme (NIHR127489).SP receives support as a UK National Institute for Health Research (NIHR) Senior Investigator (NF-SI-0616-10103) and from the UK NIHR Applied Research Collaboration Oxford and Thames Valley. ST-P is supported by an NIHR Career Development Fellowship (CDF-2016-09-018). LH is based at the Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge. THIS Institute is supported by the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK.This project was funded by the The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Health Technology Assessment Programme, NIHR, NHS, or the Department of Health.Study data are available on request to the corresponding author.OR-A, JF, BT and FB are members of the Foetal, Maternal and Child Health (FMCH) reference group of the UK National Screening Committee (UK NSC). ST-P is a member of the UK NSC Adult Reference Group. JF and AMS are members of the UK NSC. The remaining authors declare that they have no competing financial interests or personal relationshipts that could have appeared to influence the work reported in this paper.


A health services research organization in Toronto, Ontario, Canada conducts population-based research to improve the health of Canadians in seven main areas: (1) cancer, (2) cardiovascular disease, (3) chronic disease and pharmacology, (4) health system planning and evaluation, (5) kidney, dialysis and transplantation, (6) mental health and addictions, and (7) primary care and population health. The Information Management (IM) team within the Data Quality and Information Management (DQIM) department at our non-profit organization is an integral component for upholding privacy and confidentiality policies and procedures while facilitating quality research using different types of data such as health administrative, third-party, primary data collection, and electronic medical records (EMR).The IM team is responsible for receiving data, encoding direct personal identifiers, screening for unnecessary identifiers, performing probabilistic data linkage when necessary, importing the data to the Research Analytics Environment (a client/server Linux-based system), and destroying the data according to the terms stipulated in the executed data sharing agreement. The purpose of the presentation is to detail the above steps of processing data to protect individuals' identities yet preserve the usefulness of carrying out research. The presentation will include aspects from importing data into SAS to storage and encoding of personal identifiers to probabilistic data linkage, which involves maximizing linkage with other datasets at the organization. Linking data at the organization involves the encryption or encoding of health card numbers to "Key Numbers".The processing practices used at the organization comply with Canadian privacy laws such as the Personal Health Information Protection Act (PHIPA) as well as organizational policies and Research Ethics Board approvals. The approaches used to conceal individual identities yet allow linkage to various data sources can be modelled by other health agencies, ministries, and non-health related organizations that work with sensitive data but face challenges in maintaining both privacy and research quality. Our organization strives to make processing as efficient as possible and create maximum linkability to the various data sources in house while upholding privacy and confidentiality.


Natural products are an essential aspect of global human health. Integration of contemporary technologies based on the Fourth Industrial Revolution (4IR) and the Quintuple Helix is needed to discover additional metabolites to be developed sustainably for the broad and unmet range of human healthcare needs. Natural products and their derivatives have remained a reliable source of new pharmaceutical agents in the past 30 years . For theThe core premise of the Quintuple Helix initiative towards the Sustainable Development Goals is local and international collaboration between governments, academia and industry to focus and enhance research and product development, followed by integrated knowledge accumulation, culminating in overarching social ecology and focused on population needs . This isthe fundamental aspect of discovery programs and requires high quality, intensity, reliability and consistency from all the participants and their programs for success. Such efforts are underpinned by negotiated agreements for intellectual property rights (IPR) sharing locally and at the sample source, providing compensation strategies for access to resources and publication authorship arrangements for the group.Collaboration is Sustainability in drug discovery is not a choice. It is the contemporary wisdom that will allow future generations to thrive. Promoting sustainable philosophies and practices, including resource acquisition and experimentation, through ecopharmacognosy  is therein silico metabolite prognostications, robotic processing of extracts, network pharmacology and the human interpretation of AI-generated outcomes is a critical element of contemporary integrated discovery programs.Integration of the seven contemporary technologies relating to natural products based on the Fourth Industrial Revolution (4IR) embrace the utilization of large data sets for artificial intelligence (AI) and machine learning (ML), robotics, additive manufacturing, biotech applications in discovery and development, nanotechnology for drug delivery and remote detection systems . ImmutabThe consolidation and global accessibility of databanks of traditional knowledge and botanical, chemical and biological information on natural products through a coordinated international effort are necessary . New disEnhanced reproducibility in natural-product research requires new paradigm thinking: as a taxonomist, know precisely what organism is being acquired and processed; as a chemist, know what has been characterized; and as a biologist know, ‘at the time of the test’, what chemical (or matrix) is being evaluated.ML-driven and PCR-driven taxonomic identification is becoming an essential component for sustainable, reproducible sourcing and interfaces inexorably with the application of metabolomics and molecular networking for discerning biosynthetic pathways. Geolocations matter, since an ‘organism’ is not an organism; the name does not define the metabolome. Indeed, metabolic flux changes based on many exogenous parameters.Bioactive metabolites that possess broad biological activities or are widely distributed in plants must be identified during the early discovery stages ,8. TerreIn silico binding studies can define new targets for the synthetic modification of bioactive natural products.Awakening and defining ‘silent’ biosynthetic gene clusters in fungal and bacterial genomes are unexplored discovery sanctuaries for disclosing new metabolites . StructuDeveloping robust, sensitive, rapid and cheap bioassays that preferentially target relevant new mechanisms is essential to identifying new bioactive scaffolds. Basic discovery programs should commence taxonomically, chemically and biologically at the point of acquisition in the field or marine environment. Microfluidic biosensors for in-field extract evaluation and hand-held devices offer rapid detection technology applications. Searching for synergistic and adjuvant compounds or metabolites that overcome drug resistance is a valuable discovery initiative. Establishing the breadth and depth of the genomic impact of a bioactive metabolite through network pharmacology is essential to distinguish true ‘leads’ from ‘hits’ with respect to effectiveness and potential toxicity.Continuing education is critical. Broad-based, advanced degree programs are an integral aspect of training young scientists to conduct interdisciplinary and multidisciplinary, highly collaborative, focused research programs for bioactive natural products for future development. Training programs for established scientists are necessary as philosophies, techniques and instrumentation, including robotics, evolve. Team leaders should understand when to halt a research initiative or change direction based on critical program-assessment criteria.Natural-product drug-discovery programs must contribute globally to addressing the chasm of unmet disease needs and evolve strategies based on sustainable natural resources. Identifying the diseases in which patient needs prevail should occur through dedicated collaborative programs whose success is based on scientific excellence and potentiates the strengths and activities of government, academia and industry. Integration of 4IR technologies is essential for effective natural-product drug discovery. Intellectual territories and egos must be set aside to promote collaborative research to ameliorate significant human healthcare needs for the quality, safety, efficacy, consistency and accessibility of all nature-derived medicinal agents .


The procurement and provision of expert-driven, evidence-informed, and independent science advice is integral to timely decision-making during public health emergencies. The 2019 coronavirus disease (COVID-19) pandemic has underscored the need for sound evidence in public health policy and exposed the challenges facing government science advisory mechanisms. This paper is a jurisdictional case study describing (i) the federal science advice bodies and mechanisms for public health in Canada ; and (ii) how these bodies and mechanisms have mobilized and evolved to procure expertise and evidence to inform decisions during the first two years of the COVID-19 pandemic. We reviewed publicly accessible Government of Canada documents, technical reports, and peer-reviewed articles available up to December 2021. Canada’s federal landscape of science advisory bodies for public health within the Health Portfolio was largely shaped by Canada’s experiences with the 2003 severe acute respiratory syndrome and 2009 H1N1 outbreaks. In parallel, Canada has a designated science advisory apparatus that has seen frequent reforms since the early 2000s, with the current Office of the Chief Science Advisor created within the Science Portfolio in 2018. The COVID-19 pandemic has further complicated Canada’s science advice ecosystem, with involvement from departments, expert advisory groups, and partnerships within both the federal Health and Science Portfolios. Although the engagement of federal departments outside the health sector is promising, the COVID-19 experience in Canada supports the need to institutionalize science advisory bodies for public health to improve pandemic preparedness and ensure rapid mobilization of well-coordinated and independent advice in future emergencies. This review also identified pressing areas for further inquiry to strengthen science advice for public health in Canada, including to assess the independence of science advisory actors and the interaction between federal and subnational authorities. The coronavirus disease 2019 (COVID-19) pandemic has placed significant pressures on the science-policy interface due to its rapidly changing trajectory, considerable health, social, and economic impacts, and constantly evolving evidence base  cases than any other country outside of Asia, where the virus was initially identified Naylor, . Post-H1The science advice “ecosystem” plays a crucial role in supporting the management of pandemic emergencies, which require timely government decisions carrying significant population impacts in the context of uncertainty. Despite accumulating knowledge about the virus over the first two years of the pandemic, COVID-19 remains a whole-of-society crisis necessitating multidisciplinary expertise and evidence on issues ranging from the effectiveness of clinical therapeutics and vaccines to public uptake of protective public health measures amid disease resurgences driven by novel viral variants. As one of the most decentralized federations among high-income countries, Canada presents an interesting case study of mobilizing science advice in a pandemic emergency, since the development of technical guidance is largely within the remit of the federal governmentWe conducted a jurisdictional descriptive case study of Canada’s federal science advice ecosystem, reliant on a literature review of publicly accessible primary  and secondary  documents. Study methodology is detailed in Supplementary file The manuscript findings are organized as follows: first, we document the advisory bodies that constituted the federal science advice ecosystem before the COVID-19 pandemic; then, we discuss how these bodies have been mobilized to inform the COVID-19 response, highlighting new science advisory bodies created for convening experts and generating evidence to inform federal decision-making. In the discussion section, we reflect on the mobilization and evolution of Canada’s federal science advice ecosystem during the first two years of the COVID-19 pandemic in the context of the broader literature on science advice to provide policy and research recommendations. This study was conducted as part of the Evaluation of Science Advice in a Pandemic Emergency (EScAPE) international case series. Box Box 1 List of acronyms usedConstitution Act and federal, provincial, and territorial (FPT) governments may all legislate on matters of health . Authority on matters of health is not covered by a specific provision of the 1867 h Braën, . Throughs Braën, . PT goves Braën, . Municips Braën, . Sciences Braën, .International Health Regulations matters, has a prominent role in a pandemic response , and the Public Health Agency of Canada (PHAC)—together comprising the federal Health Portfolio Fig.  Governm. Health Public Health Agency of Canada Act (2006) subsequently (i) confirmed PHAC as a legal entity responsible for governing public health functions, including emergency preparedness and response; and (ii) established the position of the CPHO—the federal government’s lead public health expert , recommending the creation of a federal public health agency, helmed by a Chief Public Health Officer of Canada (CPHO) Naylor, . The Pubnada Act  subsequeThe CPHO  ranks at the deputy ministerThe PHAC departments and advisory groups that are relevant to a pandemic response are presented in Table Following the 2003 Naylor Report recommendations, the Pan-Canadian Public Health Network (PHN) was established in 2005 to serve as the formal intergovernmental mechanism for FPT collaboration on routine public health issues and public health threats   and is responsible for conducting the Census and over 350 other surveys on the health, social, and economic activities of the public  oversees the Science Portfolio, which is composed of 18 federal departments and agencies Fig. . ISED leEach Science Portfolio department and agency may conduct stakeholder consultations and public opinion research, and convene expert advisory groups —an advisory committee within the Department of Industry  (currently in operation) was established by the Liberal government in 2018 within the ISED department, reporting to the Minister of ISED and the Prime Minister  Network—a network of lead science officials and subject matter experts that work closely with senior officials within each federal department and support the mandate of the Chief Science Advisor   was released after SARS in 2004 and served to position pandemics among the key national security priorities   to inform PHAC’s pandemic messaging to promote public uptake of public health protective measures  developed through Health Canada—COVID Alert —a network of interdisciplinary researchers chaired by the Deputy Minister of Health—was also funded through the federal VOC Strategy in March 2021 to develop mechanisms  to facilitate rapid research on VOCs from the immunology, laboratory science, genomics and sequencing, modeling and computational biology, and public health and social systems perspectives  to support, fund, and harmonize research on COVID-19 seroprevalence and vaccine effectiveness, safety, and immunogenicity, to develop population immunity models that can guide FPT pandemic decisions  to perform this work internally. Arm’s-length actors, such as the NCCs and the CCA, were leveraged to build surge capacity for evidence review, synthesis, and dissemination, as these are the core functions of these organizations. However, while these channels were well-equipped for long-term projects, there remained a need for rapid short-term evidence reviews on focused research questions.Two initiatives were developed to meet this demand: CanCOVID and the COVID-19 Evidence Network to Support Decision-making (COVID-END)  self-organized into a scientific advisory committee during the SARS outbreak in 2003, focusing on quarantine guidelines, as well as hospital isolation precautions, employee screening, and patient transfers Naylor, . Below, Canada’s seemingly ad-hoc approach to science advice during the first two years of the COVID-19 pandemic, involving the formation of advisory bodies with unclear coordination and time-limited mandates, presents a concern not only for ongoing pandemic management, but also—as seen in previous outbreaks—sustained preparedness for future public health emergencies. For instance, while the H1N1 pandemic marked significant engagement of mathematical modeling experts to support decisions related to antivirals, vaccines, and other public health measures  . Second, although most public health measures for COVID-19 are within the remit of subnational authorities in Canada, our focus on science advice at the federal level limits us from commenting on how science advice was mobilized in these subnational structures. Third, the COVID-19 pandemic is still ongoing at the time of writing; thus, our goal was to provide a descriptive account of Canada’s evolving federal science advisory landscape throughout the first two years of the pandemic, rather than to make evaluative inferences about its effectiveness . Furthermore, a recent independent assessment of 100 Government of Canada policies found that inferring whether policies were informed by scientific evidence from publicly available information is difficult (Qaiser et al., This detailed review of the first two years of the COVID-19 pandemic in Canada has highlighted the challenges faced by the federal government in procuring science advice to support decision-making during a public health emergency. In its response to COVID-19, the federal government appeared to follow the existing playbook, which was established after the SARS and H1N1 outbreaks and was largely focused on the health sector. However, the COVID-19 pandemic also fueled a rapid proliferation of time-limited science advisory bodies within both the federal Health and Science Portfolios, with limited and unclear mechanisms for horizontal coordination and collaboration. Although the engagement of federal departments outside the health sector is promising, the COVID-19 experience in Canada supports the need to institutionalize science advisory bodies for public health to improve pandemic preparedness and ensure rapid mobilization of well-coordinated and independent advice in future emergencies. This review also identified pressing areas for further inquiry to strengthen science advice for public health in Canada, such as on COI mitigation strategies and the complex interplay between the federal and subnational science advisory bodies.Supplementary material


Historic science, technology, engineering and mathematics (STEM) disciplinary cultures were founded in a system that was predominately male, white, heterosexual, and able-bodied . Some societal norms have changed, and so has demand for inclusive STEM engagement. However, legacy mental models, or deeply held beliefs and assumptions, linger and are embedded in the STEM system and disciplinary cultures. STEM reform is needed to maximize talent and create inclusive professions, but cannot be achieved without recognizing and addressing norms and practices that disproportionately serve majority vs. minoritized groups. As leading voices in disciplinary work and application, disciplinary and professional societies (Societies) are instrumental in shaping and sustaining STEM norms. We, leaders of the Amplifying the Alliance to Catalyze Change for Equity in STEM Success (ACCESS+) project, recognize the need to provide Society diversity, equity, and inclusion (DEI) change leaders with tools necessary to foster systemic change. In this Perspectives article, we present the Equity Environmental Scanning Tool (EEST) as an aid to help Society DEI change leaders elucidate legacy mental models, discern areas of strength, identify foci for advancement, and benchmark organizational change efforts. We share our rationale and work done to identify, and, ultimately, adapt a Society DEI self-assessment tool from the United Kingdom. We share background information on the UK tool, content and structural changes made to create the EEST, and an overview of the resulting EEST. Ultimately, we seek to increase awareness of a Society-specific DEI self-assessment tool designed to help Society DEI change leaders advance inclusive reform. Success in science, technology, engineering and mathematics (STEM) is commonly believed to be the result of objectively determined talent, training, and hard work. In discussing scientific meritocracy, Taylor  explaineSTEM disciplinary and professional societies (Societies) are uniquely positioned as agents for DEI reform  brought together Minority Affairs Committee (MAC) leaders from five biological Societies to create collective impact around Societies' DEI efforts. These leaders documented and disseminated information on challenges faced as they worked to create systematic inclusive change  to help Society DEI change leaders gain a clearer picture of the ways in which the Society may differentially serve majority and minoritized members.Building on the work of ACCESS, the recently funded National Science Foundation ADVANCE funded Amplifying ACCESS (ACCESS+) partnership project proposed strategies and tools to help cohorts of STEM Society DEI experts, and “first generation equity practitioners” , created by the Royal Academy of Engineering and Science Council  how professional licenses work and are awarded; (b) distinctions in how study programs in universities are accredited; (c) the important role of US. regional and student chapters; and (d) the role of US. Society disciplinary advocacy in providing comment and contribution on issues of national importance. We also took the opportunity to incorporate recent learning on DEI and academic publishing  that informed data collection by Societies. Overall, throughout the adaptation and revision process, we consulted subject matter experts and Society DEI leaders to ensure changes.The EEST is currently undergoing ongoing piloting and refinement with a first ACCESS+ cohort of the original 5 ACCESS biological societies, and a second cohort of 14 predominately engineering societies. Tool refinement efforts are informed by semi-structured interviews, informal interviews, and focus groups with Society cohort change leaders, as well as discussion and outcomes from Community of Practice meetings.via monthly Society DEI change leaders' Community of Practice meetings.The EEST tool is embedded in a process designed to provide integrated support for Society DEI leaders as they guide DEI change. Consistent with prior work on organizational transformation , stakeholders, the profession, and the discipline.Part 1 of the EEST comprises twelve common functions typical of Society operations see .Within each of these 12 Society functions are three sections: (1) Management and Administration, (2) Policies, Procedures and Practices, and (3) Insights and Evaluation. Sections contain between 5 and 15 statements for consideration. We use these three sections to help understand how Societies are embedding DEI into strategies, actions, and impacts. Statements within each section are evaluated on a 5-point Likert Scale  to assess if, and how often, the case of DEI change is enacted in the operations of the society. A “Not Applicable” option is available for statements that do not apply to both individual statements and whole Functions. An overview of sections and example statements are provided below.Management and Administration incorporates statements about the composition of leadership groups, DEI professional development in which leaders are engaged, and governance strategies employed by leaders as related to DEI. Previous research shows that leadership is key to cultural change within an organization  with espoused leadership goals as related to DEI. An example statement in this section, for the “Awards and Recognition” Function, is “The Awards Team has developed and regularly reviews equitable criteria for selecting awardees.” Another example statement is, “The Awards Team engages with other STEM Professional Societies to develop society DEI good practices.”The second section on Insights and Evaluation, asks respondents to consider statements “tracking key indicators of representation and equity; evaluating programmatic interventions and strengthening the institutional research infrastructure to improve data collection, analysis and use” : a case for DEI change has not been madeIdling (Scores = 1–1.99): a case for change is emerging, data and insights are starting to be gathered, actions tend to be informal, isolated bottom-up or one-offDeveloping (Scores = 2–2.99): the case for DEI change is clear, some data are being gathered, responsibility and accountability being formalized, guidelines being developed, activity being launched, connections being madeEngaging (Scores = 3–3.99): the case for DEI change is well-established, data are being gathered and shared, sustained senior level support is in place, skills and capabilities being built, activity catching on, high levels of collaboration, clear signs of changeTransforming (Scores = 4): the case of DEI change is focused on transforming the culture and systems of the organization. Complex qualitative and quantitative data are being routinely, intentionally, and systematically gathered and shared, high levels of dialogue, collaboration and learning, clear evidence of change in individual behavior and organizational cultureIn Part 2, Society respondents are asked to provide information on how DEI efforts are measured by the Society for each of the 12 Functions covered in Part 1. Actual data are not requested, instead Societies are asked to indicate demographic data collected based on “compositional” categories .Part 3 asks the Society team completing the EEST to answer open-ended questions designed to gather information about areas of Society DEI successes and challenges; intersectional strategies employed in Society Functions, and DEI priorities for the future. Specifically, the open-ended questions include: (1) “In what area of DEI has the society made the most progress?” (2) “Of what organizational DEI efforts are you most proud?” (3) “How are you employing an intersectional approach?” (4) “What are the society's main challenges in making progress on DEI?” (5) “What are the Society's DEI priorities for the next 12–24 months?” and (6) “Is there anything else you feel is important to document about the society to benchmark for future consideration?”Inclusive Professional Framework for Societies (Leibnitz et al., In our experience, many Society leaders recognize that STEM is better able to address global concerns when diverse talent is welcomed, supported, and retained in the field (Borman et al., The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.JWP and RC-M completed an initial draft of the manuscript. GML and JWP completed the final revision of the manuscript. All authors contributed to review, edit, revision, and/or addition of new material.This material is based upon work supported by the National Science Foundation under Grant No. 2017953.GML is the Director of ProActualize Consulting, LLC, a consulting business specializing in applying evidence-based strategies to promote inclusive organizational and disciplinary excellence. JWP is the Director of Katalytik, a consulting business based in the United Kingdom focused on promotion and creation of evidence-based equity and inclusion across STEM education and employment. The remaining authors declare that the work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Parallel redundancy protocol (PRP) and high-availability redundancy protocol (HSR) are widely adopted protocols based on IEC 61850 standard to support zero recovery communication networks for time-critical and reliable interactions in power system substations. However, hiring these protocols comes with technical and economic constraints that impact the size of the substation network arrangement. Therefore, we will undertake a theoretical analysis of HSR, PRP, and their combinations to reach a maximum number of nodes in different substation communication architectures regarding IEC 61850 standard message time constraint requirements and IEC 62439-3 standard regulations. We will validate our findings through a simulation in the OPNET Modeler environment. In addition, we considered bandwidth efficiency by prohibiting the extra circulation of packets in the redundancy Box (RedBox) and QuadBox implementation as interfaces for HSR and PRP connection and HSR rings interconnection, respectively, which represent the main hindrance in utilizing the combination of these protocols. The introduction of serial communication to information exchange in the substation domain offered advantages such as increasing communication distance, cabling reduction, efficient bandwidth, and so forth. Several protocols using transmission control protocol (TCP)/(Internet protocol) IP over Ethernet have been hired for communications in substations, including Modbus, Profibus, distributed network protocol 3 (DNP3), and IEC 60870-5 ,2. GivenEach protocol has its advantages and disadvantages. The cost of HSR implementation is lower than PRP since PRP requires two independent LANs. In contrast, PRP offers n + 1 contingencies compared to HSR, which loses its ring arrangement when one of the ring nodes fails. In addition, PRP uses a standard Ethernet frame. As a result, PRP requires no special hardware while HSR has a specialized Ethernet frame incompatible with legacy network equipment. There is also a risk of packet flooding for the HSR ring with an excessive number of hops owing to the generation of duplicate packets in a single ring network infrastructure. This HSR performance mechanism, especially for SV, which produces periodic traffic, exacerbates the situation and reduces bandwidth efficiency. Using RedBox to connect HSR to PRP and QuadBox to provide cascading HSR rings presents another issue that threads the bandwidth by conducting extra traffic to other non-destination rings. Therefore, the deployed substation network architecture requires careful implementation of HSR, PRP, or their combination in substation communication network architecture based on IEC 62439-3 to achieve the tradeoff between each redundant method’s advantages and disadvantages.Scholars have investigated substation redundancy arrangement in three areas, including drawbacks of HSR and PRP implementation improvement, protocol performance comparison, and substation network configuration optimization. Among them, there has been a surge of interest in the first two subjects.Following the description of each HSR required equipment operation, R. Borgohain et al.  announceF. Steinhauser in  describeUp to now, far too little attention has been paid to discovering constraints made by redundancy protocols on substation network arrangement size and optimizing the network performance with the combination of protocols. J. Larenzo et al.  audited Investigation of a cost-effective substation network arrangement with a combination of HSR and PRP;Exploration of difficulties on deploying RedBox and QuadBox as principle equipment in HSR and PRP combination deployment;Determination of IEC 62439-3 based solution for our proposed arrangement’s obstacles;Theoretical and simulation analysis of nominated architectures concerning IEC 61850 communication constraints.The generation of fresh insights into readiness is required for planning substation communication networks concerning cost-effectiveness in deploying HSR and PRP. Therefore, in this study, we will undertake a theoretical analysis of HSR, PRP, and their combinations to achieve the maximum number of nodes in each architecture regarding IEC 61850 message time constraint requirements. The findings will be proved through a simulation in the OPNET Modeler environment. In addition, we considered bandwidth efficiency by prohibiting the extra circulation of packets in the implementation of RedBox and QuadBox as interfaces for HSR and PRP connection and connecting HSR rings, respectively, which represent the main hindrance in utilizing the combination of these protocols. Therefore, the main contributions of this paper are as follows:The outline of the paper is as follows. IEC 61850, as a commonly accepted protocol supporting interoperability in smart grid interactions, specifies three levels of communication inside substations, including process level, bay level, and station level. The station level is where the human–machine interface is located, and transfers required substation monitoring data to the work station and protection messages to the system operator. The bay level is the place where control and protection IEDs are installed and receive commands from the operator at the station level and measures data from current transformers (CT), voltage transformers (VT), merging units (MU), and circuit breakers located in the process level . Manufacd is communication link length and v is propagation speed and equal to 2 × P is the preamble size, L is packet length, and R is link bandwidth (bps).There are novel methods to calculate the end-to-end (ETE) delay for smart grid environment interactions ,30. FollTo avoid latency in transferring critical data in the substations, PRP arranges a redundant network by implementing two parallel separated LANs with similar MAC addresses and the possibility of different topology and performances. The DANPs have two receiver and transmitter ports connected to the same upper layers by a link redundancy entity (LRE). The main tasks of LRE are the generation and removal of duplicate frames achieved by attaching or detaching the redundancy check trailer (RCT), respectively. The RCT, as shown in HSR is another approach to providing a reliable Ethernet network, which contrary to PRP, does not require Ethernet switches to establish a ring structure and consequently offers cost-effective redundancy. As a result of this feature, the only means to link SAN to the HSR ring will be through RedBox, which has the same performance as indicated in The HSR tag, as shown in The number of HSR rings extends by connecting HSR rings with QuadBoxes. Two RedBoxes that connect with a common interlink provide the QuadBox. The device forwards frames without modifying them from one HSR ring to another and can filter multicasts and VLAN traffics. The standard recommends using two QuadBoxes for HSR ring connection to prevent the risk of a single point of failure, as shown in This section examines different approaches for providing redundancy in substations’ communication networks. We initially implement DANH, DANP, RedBox, and QuadBox based on IEC 62439-3 on the OPNET Modeler and then determine the optimum number of nodes for the HSR, PRP, and their combinations considering scalability, latency, and financial aspects.To implement DANH and DANP, we deployed ethernet_wkstn_adv, an editable Ethernet workstation in the OPNET Modeler library, as shown in Given the ETE delay time according to  introducWe examine the accuracy of implemented IEC 62439-3 nodes by comparing the result of simulation and theory in case study 1. Furthermore, the other scenarios will investigate the different combination performances respecting IEC 61850 messages constraint.As illustrated in The amount of ETE delay represented from theory in  is proveAccording to the simple HSR ring theory results, we determine the maximum number of DANH in the HSR ring. To compute the maximum allowable latency by , we consAs a result,  describeUsing QuadBox is also another method for overcoming HSR ring node limitations. Several configurations of HSR with application of QuadBox can be found in ,31. HoweIn this scenario, we consider a PRP arrangement according to In this section, we study the configuration of the substation network with the collaboration of HSR and PRP arrangements. In addition to the complexity of extending the HSR ring with QuadBox, the scalability of PRP requires two separate LANs, which means high investment. Therefore, we need a tradeoff between both methods’ pros and cons. It is also notable that IEC 62439-3 standard does not allow using connected HSR rings with QuadBox when HSR combines with PRP.In this paper, we propose the implementation of HSR and PRP protocols as IEC 61850 recommended redundancy arrangements for digital substations. We discussed both the benefits and limitations of each method. The network size was analyzed based on latency of automated substation messages and throughput characteristics. Additionally, this paper examined the IEC 62439-3 constraints and recommendations in each architecture. However, this study requires complementing research by implementing some real examples of substation arrangements which we consider for future work. There are also other methods to extend scalability of the system such as VLAN arrangement which will be deployed in the future work.


Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations.The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.The online version contains supplementary material available at 10.1186/s43058-022-00321-2. Contributions to the literatureThis paper describes the application of implementation strategies in the Veterans Health Administration, the largest integrated healthcare system in the USA.The paper includes the planned methods to rigorously evaluate the processes and outcomes of two related quality improvement projects to enhance end-of-life decision-making for seriously ill patients.The quality improvement projects that are summarized in this paper will offer insights into effective ways to deploy and adapt audit with feedback and implementation facilitation to achieve clinical outcomes.Patients living with serious illness are at risk for receiving potentially burdensome care that is not aligned with their values and goals –4. ReseaA widely used approach for documenting LST preferences in durable medical orders that can be used within and across community healthcare settings is the Physicians Order for Life-Sustaining Treatment (POLST) paradigm. Originating in Oregon in the 1990s, the POLST paradigm is now a national movement, although each state oversees and directs its own implementation of the program. As a result, there are variations in the titles  as well as the laws and guidance governing their use and implementation . BecauseIn 2017, the Veterans Health Administration (VA) National Center for Ethics in Health Care launched a national quality improvement program called the Life-Sustaining Treatment Decisions Initiative (LSTDI). The aim of the LSTDI is to promote personalized, proactive, patient-driven care for Veterans with serious illness by eliciting, documenting, and honoring their values, goals, and LST preferences. The initiative involves a national policy to standardize practices related to discussing and documenting goals of care and LST decisions, as well as tools, resources, education, and monitoring to support clinicians and facilities in making practice changes . Under tThe VA is the largest integrated healthcare system in the USA and cares for more than nine million Veterans at 170 VA medical centers . BecauseBecause SAPOs and VA LST templates translate patient preferences for LSTs into medical orders that are immediately actionable, these approaches are appropriate for people with serious illness . Two groSince 1965, the VA has paid for eligible Veterans’ care in CNHs that are not part of the VA healthcare system. This care has been expanding dramatically to meet the needs of the aging Veteran population, and the average daily census in the VA CNH program is expected to grow by 80% by 2037 . The VA To address challenges to conducting goals of care conversations and documenting Veterans’ LST preferences, an interdisciplinary team from three VA research centers developed the Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) Quality Improvement (QI) program. Funded by the VA Quality Enhancement Research Initiative (QUERI), PERSIVED aims to improve decision-making and outcomes for Veterans with serious illness by increasing the number and quality of goals of care conversations and documentation of LST preferences in durable medical orders that can be honored in both VA  and non-VA settings . The purpose of this paper is to describe the goals and methods of the PERSIVED program, as well as early experiences in implementing two related but distinct projects.PERSIVED is a partnership between VA-based implementation scientists and two operational offices: VA National Center for Ethics in Health Care and the Geriatrics and Extended Care Program. It involves rigorous process and outcomes evaluation using a stepped-wedge design applied to two related but separate projects. Project 1 focuses on Veterans receiving care through the VA’s HBPC program and project 2 involves Veterans enrolled in the VA CNH program.PERSIVED builds upon earlier work conducted by the team under the auspices of the Long-Term Care (LTC) QUERI program, which examined early implementation of the LSTDI in HBPC programs and Community Living Centers  . The teaReach, Effectiveness, Adoption, Implementation, and Maintenance—and is used to guide evaluation of processes and outcomes. RE-AIM can also be used to identify and measure factors that facilitate or hinder success in achieving broad uptake and success of the intervention. The TICD is a wide-ranging framework that guides understanding of determinants of successful implementation of evidence-based programs in healthcare settings. The TICD consists of seven factors: Guidelines; Health Professionals; Patients; Professional Interactions; Incentives and Resources; Capacity for Organizational Change; and Social, Political, and Legal factors.Two frameworks guided the development of PERSIVED and its evaluation: RE-AIM , 34 and Table Eligible HBPC programs include all those with low LST completion rates (≤ 50% of patients). Geographic diversity is a secondary inclusion criterion. The PERSIVED team assembles a list of eligible programs and shares it with the national HBPC program manager, who personally reaches out to selected programs to offer the opportunity to participate. Recruitment ceases when 12 programs have accepted the invitation.Project 2 is being conducted in six VA CNH programs and focuses on Veterans receiving long-term care (as opposed to short-stay or post-acute care). The approaches for Project 2 differ from Project 1 for a few reasons. First, VA CNH teams oversee and coordinate the care that Veterans in CNHs receive but they do not provide direct care. Second, most VA CNH teams are comprised of registered nurses and social workers but do not include practitioners who are authorized by VA policy to establish LST plans and write LST orders. As a result, VA CNH team members usually are not involved in goals of care conversations or in completing LST templates or SAPOs. For this reason, QI efforts for Project 2 focus on (1) partnering with VA practitioners  to conduct goals of care conversations and complete VA LST notes and orders, as well as SAPOs when appropriate; (2) monitoring, documenting, and communicating the existence of LST orders across all settings where the Veteran receives care; and (3) recognizing and communicating changes in Veterans’ preferences and/or discrepancies among LST notes and orders across settings.Because the PERSIVED team has not previously worked with the VA CNH program, we limited Project 2 to six sites compared with the 12 sites in Project 1. Given the small number of sites, we focused recruitment on CNH program size  and geographically diverse locations rather than LST completion rates, although we avoided sites with high rates of LST template completion .Participating sites for both projects are recruited and enrolled in three cohorts using a stepped wedge design.pre-implementation phase, (2) 15–16-month implementation phase, and (3) 12-month sustainability (maintenance) phase  5–6-month  5–6-montThe pre-implementation phase focuses on activities to prepare site personnel to engage in QI activities. It begins with a virtual kick-off meeting with site leadership and HBPC/CNH team members. At this meeting, PERSIVED team members explain the project, delineate roles, outline expectations of both the PERSIVED team and the site team, and answer questions about the project. Following the kick-off meeting, we conduct additional virtual or, if possible, in-person meetings to 1) engage site leadership and teams and identify key local team members, including site champions; (2) assess barriers and facilitators to project adoption; (3) develop process maps of existing workflows; and (4) measure baseline LST template/SAPO completion rates. Based on our findings, we develop a flexible, tailored implementation facilitation plan for each site, working closely with champions and other team members . Using the TICD framework, we apply rapid qualitative analysis methods –39 to idAlso included in pre-implementation is process mapping, which is an ideal method for mapping complex healthcare workflows. Maps can be used as a communication tool for engaging with healthcare providers as part of the QI process , 41. ProThe implementation phase runs from months 6 to 21. Its activities are anchored by two key implementation strategies: audit with feedback and implementation facilitation. Audit with feedback has been tested through many randomized controlled trials and shown to have a generally positive, though modest, absolute effect of increasing the likelihood of achieving desired behavior change , 43. AudThe second strategy is implementation facilitation, which Kirchner et al. describe as “a multifaceted strategy that applies a variety of discrete strategies…depending on what is needed given the context and characteristics of those that are providing (clinicians) and receiving (patients) the innovation” , 47. FacUsing these two strategies, the implementation phase involves monthly coaching sessions with the champions aimed at increasing their self-efficacy and effectiveness in guiding local teams and partners to meet the project goals. Facilitation begins with the creation of an implementation planning guide specific to the PERSIVED intervention, which is used to guide initial implementation planning meetings. Regular meetings with site champions involve monitoring the implementation plan, discussing and documenting progress, identifying barriers, helping problem-solve and identify solutions, modifying the plan as needed, and providing support, encouragement, and positive reinforcement .PERSIVED team members also review monthly feedback reports with champions. The reports use formats similar to those developed in the LTC QUERI  and inclDuring the sustainability phase months 21–33), participating HBPC and CNH sites will continue to receive the feedback reports. In contrast to the implementation phase, site champions will receive limited coaching and instead be expected to maintain the project independently, including refining process maps as needed and engaging in action planning  [The eventual goal is to achieve a broad-based scale out of the projects to all CNH and HBPC programs, with the potential to improve care for over 40,000 Veterans annually in VA CNH programs and over 50,000 Veterans who receive care in HBPC annually. In this final, post-intervention step, we will analyze process and outcomes data to identify the most effective strategies for successful implementation of our evidence-base practices. Based on these findings, we will develop interactive, web-based toolkits for both projects that are modeled after the successful VA Patient Engagement Toolkit (v/xUtdV) . The tooWe are using mixed quantitative and qualitative data analyses to examine our implementation success across components of the RE-AIM framework. The quantitative measures are listed in Table In the RE-AIM framework, Reach refers to the success of the intervention in reaching the targeted population . Our tarProgram effectiveness will be assessed using two metrics. The primary metric is evidence of an Advance Care Plan, which is a National Quality Forum-endorsed measure and a CMS Meaningful Measure . AlthougThe analytic plan to evaluate success in increasing LST plans and orders at sites is similar to the one we used in the LTC QUERI . BecauseAfter matching, we will use interrupted time series/segmented regression analysis (ITS/SRA)  to evaluThe second metric is the concordance between documented preferences and care received at end of life, which reflects the ultimate goal of our evidence-based practices — to achieve patient-centered/patient-directed care by honoring Veterans’ values and care preferences in the treatments that we provide . We operOur implementation goal is to increase the consistent documentation of LST preferences for veterans served by the participating programs. We set a benchmark of 80% or greater LST template or SAPO completion rates. We will deem the PERSIVED program as successful if all participating HBPC and CNH programs meet this criterion at the end of their respective implementation phases Fig. .We will evaluate the sustainability of the intervention using a similar approach as described above. We will define success in maintenance/sustainability as the percentage of participating HBPC and CNH programs that are able to maintain ≥ 80% LST template or SAPO completion at the end of the sustainability phase. Our goal is that 100% of participating HBPC and CNH programs sustain these high completion rates. Participating programs that do not achieve the benchmark by the end of the implementation phase will be given a 2-month grace period at the beginning of the sustainability phase to meet the benchmark; programs that do not meet the benchmark by that time will be counted as failures in both implementation and sustainability regardless of their completion rates at the end of the sustainability phase.In addition to assessing RE-AIM outcomes, we will also conduct process evaluations during the implementation phase, at months 12 and 18. The evaluation team will conduct interviews with site champions to (1) guide adaptation of champion coaching activities, (2) address new and ongoing barriers, (3) review and revise process maps, (4) prepare sites for sustainability following the period of active implementation, and (5) develop the interactive toolkit and playbooks for use during scale-out. The process evaluation will help us assess and understand the fidelity of implementation, specifically, the degree to which champions share the feedback reports with others, engage in action planning, and meet targets using SMART goals (Adoption and Implementation). We will also evaluate champions’ self-efficacy and perceived effectiveness in participating in the intervention (Effectiveness)  can seem daunting. To address this hurdle, we mapped out the champions’ expected activities along with time estimates and showed potential champions that their commitment would consist of approximately 1 to 2 h per month. Recruiting more than one champion at each site further minimized the time commitment of individual champions.Other threats to the sustainability of the PERSIVED program are the ever-changing priorities of the VA healthcare system as well as local and national VA initiatives. For example, the rollout of Cerner—VA’s new electronic medical record system—will result in changes in how goals of care conversations, advance care planning, and LST preferences are documented and communicated within the system. Both projects plan to engage at least one site where the new electronic health record will be implemented early in the national rollout.The PERSIVED program supports the implementation and dissemination of a complex intervention to elicit, document, and honor seriously ill Veterans’ goals, values, and LST preferences for end-of-life care. Our evidence-based practice—structured goals of care conversations and documentation of LST preferences in durable, actionable medical orders—as well as our measures of effectiveness, are widely recognized as indicative of quality healthcare. As such, PERSIVED can contribute to patient care by testing the effectiveness of our intervention. The program can also support implementation science by reporting results of audit with feedback coupled with facilitation and exploring the reach, adoption, implementation, and sustainability of these approaches.Additional file 1. Examples of Barriers and Strategies to Address Barriers to PERSIVED Implementation. Description: Planning document anticipating potential barriers and implementation strategies to address such barriers.Additional file 2. PERSIVED Site Champion Description and Assessment Tool. Description: A description of responsibilities expected of clinical champions & the assessment tool to measure respondent’s confidence in areas that are important to a successful champion.Additional file 3. Example of Process Map. Description: A process map (redacted) developed with a participating VA CNH program during the pre-implementation phase.Additional file 4. Example of Feedback Report. Description: An example of the feedback reports that are generated each month for participating sites.


The COVID-19 pandemic, climate change-related events, protracted conflicts, economic stressors and other health challenges, call for strong public health orientation and leadership in health system strengthening and policies. Applying the essential public health functions (EPHFs) represents a holistic operational approach to public health, which is considered to be an integrated, sustainable, and cost-effective means for supporting universal health coverage, health security and improved population health and wellbeing. As a core component of the Primary Health Care (PHC) Operational Framework, EPHFs also support the continuum of health services from health promotion and protection, disease prevention to treatment, rehabilitation, and palliative services. Comprehensive delivery of EPHFs through PHC-oriented health systems with multisectoral participation is therefore vital to meet population health needs, tackle public health threats and build resilience. In this perspective, we present a renewed EPHF list consisting of twelve functions as a reference to foster country-level operationalisation, based on available authoritative lists and global practices. EPHFs are presented as a conceptual bridge between prevailing siloed efforts in health systems and allied sectors. We also highlight key enablers to support effective implementation of EPHFs, including high-level political commitment, clear national structures for institutional stewardship on EPHFs, multisectoral accountability and systematic assessment. As countries seek to transform health systems in the context of recovery from COVID-19 and other public health emergencies, the renewed EPHF list and enablers can inform public health reform, PHC strengthening, and more integrated recovery efforts to build resilient health systems capable of managing complex health challenges for all people. The health, social and economic costs of health systems shocks continue to underscore the need for more focus on public health , 2. DespThe essential public health functions (EPHF) are a set of fundamental and interconnected activities and capacities both within and beyond the health sector, required to ensure effective public health actions –8. Pre-CThe unprecedented scale of the impacts of COVID-19 has demonstrated that traditional and siloed approaches to health systems, including traditional health system strengthening focused on clinical services, vertical programmes, health security programmes and humanitarian responses , while pThe concept of EPHFs emerged in the context of a rapidly changing health, social and political landscape in countries worldwide in late twenteeth century , 26, 27.The EPHF list defined by WHO through a Delphi exercise in 1997 represented the first global reference against which countries could benchmark their public health capacities , 27. SinTwenty first century health challenges: can the essential public health functions make a difference?” . Thi. ThiTwenerence?” .Box 1Monitoring and evaluating population health status, health service utilization and surveillance of risk factors and threats to health (emergency management)Managing public health emergency Assuring effective public health governance, regulation, and legislation Supporting efficient and effective health systems and multisectoral planning, financing and management for population health Protecting populations against health threats, including environment and occupational hazards, communicable disease threats, food safety, chemical and radiation hazards (disease prevention and early detection)Promoting prevention and early detection of communicable and noncommunicable diseases Promoting health and well-being and actions to address the wider determinants of health and inequity (communication participation)Ensuring community engagement, participation and social mobilization for health and well-being Ensuring adequate quantity and quality of public health workforce Assuring quality of and access to health services (research)Advancing public health research Ensuring equitable access to and rational use of essential medicines and other health technologies While all EPHFs contain both service delivery and enabling elements, to inform operationalisation, the EPHFs can be further grouped according to activities that are primarily service focused and those that essentially enable the delivery of public health services . This diThere are various entry points into health systems for policies, planning and investments, including disease and life course focused efforts and emergency response and humanitarian efforts. However, these traditional routes have not developed public health capacities sufficiently or comprehensively enough to ensure health systems resilience. EPHFs represent an integrated approach to health system strengthening across the multiple entry points to health systems, providing a bridge between these efforts in policies, planning, implementation and assessment . FocusinBox 2A further comparative analysis of the updated EPHF list against a number of global frameworksFor example, the Primary Health Care Operational Framework identifies 14 levers that are required to accelerate progress in strengthening PHC-oriented systems and advancing UHC ; the IHRTwenty first century health challenges: can the essential public health functions make a difference?”, several interconnected enablers, which are recurrent themes in literatures and based on a review of available global experience with EPHFs, were identified as necessary to ensure adequate investment in and delivery of EPHFs   to vectoPolitical commitment can be solidified through including EPHFs in health legislation, prioritizing EPHFs within health policies, strategies and plans; allocating dedicated funding to EPHFs in multi-year budgets; establishing clear governance structures to lead, coordinate and oversee the delivery of EPHFs, etc.One of the approaches to solidifying political commitment to strengthening public health can be establishing or capacitating a national public health institute (NPHI). An NPHI is a government organization or a network of organizations that are science-based and provide national leadership and coordination of public health efforts to improve population health outcomes , 33–35. Kenya National Public Health Institute Order, 2021  –37, 41. er, 2021 , 43. To er, 2021 , 45, 46.er, 2021 .Global and regional networks and cooperative bodies, such as the International Association of National Public Health Institutes, Africa Centers for Disease Control and Prevention, the European Centers for Disease Control and Prevention have been supporting countries to foster a coherent approach to building public health capacities with strong stewardship for EPHFs, including developing or strengthening NPHIs towards a more systems-oriented role that is reflective and responsive to the growing and evolving profile of global health challenges , 37.The broader determinants of health  and multisectoral nature of public health actions necessitate an approach to public health that goes beyond health systems. Such a public health approach would support intersectoral planning, budgeting and actions to address determinants of health. The EPHFs promote a whole of government and whole of society orientation towards health and wellbeing. The PHC approach also requires governments at all levels to enable actions and accountability beyond the health sector to deliver the EPHFs needed to meet population health needs in peacetime and during emergencies.Accountability is a matter of knowing and agreeing; acting and being responsible; being answerable; and reporting and monitoring –49.A multisectoral approach to accountability provides a means to define the commitments and actions that governmental and non-governmental entities within and beyond the health sector are accountable for and how they might be held accountable within public health agendas , 51. ThiEstablishing multisectoral accountability mechanisms for EPHFs can learn from experiences in existing multisectoral coordination mechanisms in specific areas including One Health platforms. Informed by lessons learnt from the 2014–2016 Ebola crisis, Guinea, Liberia, and Sierra Leone established their national One Health platform structures anchored in the offices of the state head, inter-ministerial committees, or ministries of health; these platforms have facilitated development of national intersectoral action plans for antimicrobial resistance, zoonotic diseases, etc . CoordinA recent effort at the international level towards fostering multisectoral accountability for EPHFs in countries involves a global roadmap to build an integrated and multisectoral public health workforce to implement EPHFs. This roadmap recognizes that various occupations in health and allied sectors deliver EPHFs and calls for mapping, measurement and development of this workforce across sectors , 60.The systematic assessment of EPHF delivery identifies baseline public health capacities and areas for improvement . There aA new approach recently developed in collaboration between WHO and Ireland focuses instead on assessing EPHFs as a whole and at a strategic level . AnotherBox 3In January 2022, Ireland embarked on a reform process with the aim of strengthening public health capacities in light of national and international lessons identified from experience with COVID-19 . A themaCOVID-19 and other public health challenges have repeatedly proven that health systems are vital for social and economic stability and development. Years of underinvestment and lack of a comprehensive public health approach to strengthening health and allied systems have had significant consequences. The majority of countries lack sufficient public health capacities for effective prevention, early warning and case management, and have struggled to maintain essential health services while responding to COVID-19. In addition, countries continue to face other public health challenges, such as noncommunicable diseases, antimicrobial resistance, climate change, an aging population and health inequity, that place increasing demands on already struggling health systems.The case for investment in public health capacities and institutions is increasingly clear , 32, 70.The COVID-19 pandemic is threatening years of progress in global health as backward sliding of the Sustainable Development Goals (SDG) targets has been seen or predicted. COVID-19 reversed the progress made in the fight against tuberculosis, with a 19% drop in number of people treated for drug-resistant tuberculosis in 2020 compared to in 2019 . COVID-1In this perspective article, we proposed several key enablers for applying EPHFs to strengthen health system with strong public health orientation. One of the limitations is grounded in the fact that there are limited resources documenting the application of EPHFs to decision-making and high-level policies and planning in countries, besides EPHF assessment. As more national authorities in Europe, Americas, the Middle East, etc. are utilizing EPHFs or planning to embark on applying EPHFs, we will be able to learn from their experiences. With the consolidated EPHF list as a reference, countries need to secure political commitment to public health and a more integrated approach to health systems strengthening unpinned by EPHFs; reform government structures to ensure clear public health leadership and coordination of intersectoral action for health; strengthen multisectoral accountability for delivering EPHFs; and assess the current state of EPHF stewardship and provision. Action on these interconnected enablers within countries can facilitate greater efficiency, effectiveness and equity in addressing the complex public health challenges of today.The original contributions presented in the study are included in the article/SS, YZ, and GM contributed to the conception and design of the research. YZ and GM collected information and led the analysis. YZ, GM, RS, SM, and SS developed the first draft of the manuscript. SD, GS, NA-M, JF, AM, and EB reviewed the manuscript and provided inputs to reflect global and regional practices. SS coordinated inputs from all authors. All authors read and approved the submitted version.


The functioning of the central nervous system (CNS) is the result of the integration of bidirectional messages between the brain and peripheral organs. Despite the anatomical separation, gut microbiota, i.e., the microorganisms colonising the gastrointestinal tract, is related to the CNS through the so-called “gut–brain axis” that is also involved in immune processes. The recent literature indicates that the gut microbiota may affect brain functions through endocrine and metabolic pathways, antibody production and the enteric network, while supporting its possible role in the onset and maintenance of several neuropsychiatric and neurodevelopmental disorders, such as autism spectrum disorders (ASDs). The term ASDs includes autistic disorder, Asperger’s syndrome, childhood disintegrative and pervasive developmental disorders not otherwise specified different. All these conditions are characterised by persistent deficits in social communication and social interaction, as well as limited and repetitive behaviours, interests or activities. In the last two decades, an impressive number of cross-sectional studies reported significant differences in microbiota composition between children with an ASD and controls, thus strengthening the hypothesis of a possible link between GI dysbiosis and ASD. The amount of studies documenting the possible involvement of microbiota in ASD pathogenesis led to considering whether treatments acting on gut flora could ameliorate ASD symptoms. The available findings, although preliminary, would indicate data gut microbiota might represent an interesting field of research for a better understanding of the pathophysiology of ASD , and possibly a target for the development of innovative treatments just labelled as “psychobiotics”.No significant relationships.


Posttraumatic stress poses a significant threat to a young person’s development. Internet-based delivery could ameliorate barriers to care, but has mostly been tested with adults. This project aimed to (i) adapt the group intervention Teaching Recovery Techniques for online delivery through a participatory process, (ii) investigate the usability of the online format and (iii) pilot the new format.Adaption recommendations were generated through participatory workshops with service users and providers, and consultation with an advisory panel with professionals and parents. Usability testing was conducted with intervention leaders (n = 5) and youth (n = 5). The public involvement in the project was assessed through a multi-method approach including behavioural observations, questionnaires and field notes. A pilot study (n = 14) is ongoing.The workshops focused on safety, participation and learning. Recommendations included an emergency response protocol, communication strategies, and guidance on intervention delivery. Whilst the advisory panel largely agreed, points of disagreement included workshop ideas around personalisation, where the panel conveyed the importance of consistency in manualised interventions. Usability testing highlighted the need for explicit guidance, particularly on safety processes.Online delivery of trauma group support requires adaptions to ensure positive group dynamics, learning and safety. Yet, some adaptions resulting from the usability testing were also relevant to the original format, pointing to the need for more extensive use of usability testing across intervention manuals. The young people, parents and professionals involved in the project provided rich and varied perspectives, illustrating the value of broad stakeholder engagement. The ongoing pilot study explores the feasibility of online delivery, including youth perceptions of the format.• The varied perspectives in the participatory process highlighted the importance of broad stakeholder engagement for interventions to be equally evidence-based and adapted to the target population.• The current pilot study explores the feasibility of online delivery, including youth perceptions of the format, in order to assess the potential for scale up.