Document content was organised in NVIVO using the ten European Citizen Science Association (ECSA) citizen science principles. Best practise guidelines were developed by (a) identifying approaches specific to mental health research or where citizen science and mental health practises differ, (b) identifying relevant published reporting guidelines and methodologies already used in mental health research, and (c) identifying specific elements to include in reporting studies. A total of 14,063 documents were screened. Nine studies were included, from Australia, Belgium, Canada, Denmark, Netherlands, Spain, the UK, and the United States. Citizen scientists with lived experience of mental health problems were involved in data collection, analysis, project design, leadership, and dissemination of results. Most studies reported against some ECSA principles but reporting against these principles was often unclear and unstated. Best practise guidelines were developed, which identified mental health-specific issues relevant to citizen science, and reporting recommendations. These included citizen science as a mechanism for empowering people affected by mental health problems, attending to safeguarding issues such as health-related advice being shared between contributors, the use of existing health research reporting guidelines, evaluating the benefits for contributors and impact on researchers, explicit reporting of participation at each research stage, naming the citizen science platform and data repository, and clear reporting of consent processes, data ownership, and data sharing arrangements. We conclude that citizen science is feasible in mental health and can be complementary to other participatory approaches. It can contribute to active involvement, engagement, and knowledge production with the public. The proposed guidelines will support the quality of citizen science reporting.Partnering with people most affected by mental health problems can transform mental health outcomes. Citizen science as a research approach enables partnering with the public at a substantial scale, but there is scarce guidance on its use in mental health research. To develop best practise guidelines for conducting and reporting research, we conducted a systematic review of studies reporting mental health citizen science research. Documents were identified from electronic databases ( Globally, mental ill health accounts for at least 18% of the global disease burden, with an estimated global annual cost projected at US $6 trillion by 2030 .Mental health systems have been criticised for insufficient attention to human rights,  an over-Citizen science is an emerging approach to enabling public involvement at scale, which therefore has the potential to contribute to mental health system transformation. The European Commission has defined citizen science as public engagement in scientific research activities, where citizens actively contribute to science either with their intellectual effort, surrounding knowledge, or their tools and resources . These aMental health research has an established tradition of utilising participatory research approaches, including through survivor and service user-led research, and in the emerging academic disciplines of mad studies , 28. In This systematic review aimed to synthesise published evidence to develop best practice guidelines for conducting citizen science projects in mental health. The objectives were:To investigate the views of researchers and citizen science contributors regarding the use of citizen science projects in mental health in relation to the ten ECSA principles.To identify the ethical and legal issues arising from citizen science approaches in mental health research.To integrate the findings to development of best practice guideline for future citizen science projects in mental health.This review was conducted as part of the Citizen Science To Achieve Co-production at Scale (C-STACS) Study.This systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines . The revFive sources of data were used. First, a search was conducted across ten electronic databases from inception to the 22nd of March 2022. Due to the cross-disciplinary nature of citizen science, databases from health sciences, social sciences and technology were included. Databases searched were MEDLINE, EMBASE, APA PsycINFO, Cumulative Index of Nursing and Applied Health Literature (CINAHL), Applied Social Science Index and Abstracts (ASSIA), IEEE Xplore, the Social Science Citation Index, Centre for Reviews and Dissemination database, the Cochrane Central Register of Controlled Trials, the Cochrane Library, and Web of Science.https://eu-citizen.science/blog, https://blog.scistarter.org/, https://www.spotteron.net/blog-and-news) for discussions about their citizen science activities, and citizen science platforms  for mental health projects.Second, we searched grey literature in citizen science projects blogs and websites  and two mental health conferences . We then cross-checked for relevant published articles using Google Scholar (first 50 hits).Third, we searched conference proceedings from three citizen science-related conferences  and designed to systematically locate all available peer-reviewed research articles, studies published through citizen science platforms and other grey-literature documents providing information on the use of citizen science in mental health. Studies written in any language were considered. The search strategy used is shown in We included(inclusion criteria) all studies and documents reporting on (i) citizen science as a research approach to engage public contributors in any form of mental health-related research, (ii) citizen science studies that engaged mental health stakeholders, especially people with lived experience of mental health issues, (iii) the experience of conducting or participating in a citizen science project that is related to mental health, or (iv) the use of citizen science approaches to collect data using any form of study design . We excluded (Exclusion criteria) all studies or documents reporting on the use of other predefined participatory research methods, such as codesign, coproduction or surveys and interviews to involve defined community or study participants in mental health-related research using, studies that were not focusing on mental health. In this review, citizen science was defined as non-scientists participating in the research process to advance science, with ‘citizens’ traditionally defined as inhabitants of a particular locale  . Other rThe primary reviewer (OT) searched all databases and other sources, identified articles using the search strategy, uploaded to Endnote X9 and de-duplicated them. The systematic review platform RayyanData from each included publication were independently extracted by two of three reviewers . Descriptive variables extracted were country of study, clinical population , study design , citizen science activity set-up and process details  and researchers’ report .All included studies were treated as primary studies. For example, if an author writes a description of a study that is investigating the use of citizen science on any form of mental health problem, data from the report was extracted regardless of whether the citizen science study was ongoing or completed. The data extraction used a selective approach where the extraction of particular types of data related to the review objectives and questions of interest . Data weThe quality of included studies was not assessed, because the review included a broad range of document types spanning research and non-research articles. Thus, using tools intended to evaluate design quality in research studies was not feasible.The publication text was transferred to QSR International Nvivo 12 Pro for data analysis. The evidence synthesis began by organising the data using the ten ECSA principles for citizen science, shown in The preliminary coding framework consisted of a range of themes describing the operationalisation and definition of each ECSA principle, with sub-themes selected to describe specific reported approaches and experiences of using citizen science. The preliminary framework was iteratively refined and reviewed by all authors. Reviewers maintained reflexivity by consistently discussing to gain a more varied perspective and bringing a broader range of experiences from lived experience, practitioner, and clinical perspectives.The best practice guidelines were developed by the core review team . This involved integrating the coding framework by (a) identifying elements specific to mental health research or where citizen science and mental health practises differ, (b) identifying relevant published reporting guidelines and methodologies already used in mental health research, and (c) identifying specific elements to include in reporting studies. The guidelines were reviewed and refined by the wider reviewer team.Consistent with citizen science, the review team consisted of researchers and non-scientist representatives from civic society organisations. The review team brought a range of disciplinary  and professional  backgrounds, and included multiple civic organisations . Some reviewers also identify with having lived experience of mental health problems or mental health distress, ensuring that lived experience is central to the analysis and interpretation.A total of 23,808 documents  were identified, and after de-duplication, 14,063 documents titles and abstracts were screened for eligibility. Eighteen publications were found eligible for full-text screening and nine articles were eligible and analysed for this review ; Figure n = 3), (n = 1), (n = 1), (n = 1), (n = 1), (n = 1) (n = 1). (n = 4), citizens (n = 2), citizen scientists (n = 1), crowd workers (n = 1) and not stated (n = 1). Duration of involvement by the citizen scientist in participating in the project ranged from less than 10 min up to 12 months.The studies comprised quantitative (n = 3), , 39, 43 (n = 1),  systemat(n = 1),  randomis(n = 1),  project (n = 1),  mixed-me (n = 1)  and citi(n = 1).  All studBeyond the clinical population, there was no clear pattern in other stakeholders being involved in the citizen science projects, with four studies not identifying any other group, and others identifying involvement from relevant workers/leaders, e.g., school principals  or peer The included articles were analysed by synthesising the contents of included studies using the 10 ECSA principles.In most cases, the citizen scientist were involved as contributors; providing data, collecting data or completing tasks for the research project , 44. DatThe included citizen science projects achieved the goal of a genuine scientific outcome. Six included studies used citizen science approach to investigate primary mental health research , 40–44. The included studies indicated that citizen scientists identified their participation in their projects to be beneficial and worthwhile. Motivation to participate included forming social relationships, connectivity and joining a group or community , 40. TheThe professional scientists and researchers identified some benefits of citizen science participation based on its impact on science and citizen scientist. In terms of scientific benefits, conducting and designing citizen science projects was a way of demonstrating a commitment to a shared and collective research approach that is inclusive of researchers, communities and individuals . IntegraMoreover, these benefits are achievable with the presence of supportive initiatives such as IT support, and professional facilitators to facilitate activities on the citizen science platforms . The maiMost citizen scientists in the included studies participated in data collection, , 43, 44 Most projects did not report any aspect of feedback, either citizen scientists receiving project feedback or researchers providing feedback on the use of citizen science data. Only one study reported that evidence generated in their project was disseminated and translated into a societal outcome and knowledge mobilisation, which amplified the voice of indigenous youths in the community . The stuAll included studies reported on the limitation and biases of using citizen science as a research approach. A potential bias reported was in the way researchers frame citizen science task instructions for citizen scientists, thus influencing the citizen scientist’s responses towards the direction of the researcher’s desired outcomes and outputs . AnotherNone of the nine included studies reported public availability of their data. Moreover, one study stated that the study data were not made publicly available because citizen scientists did not consent to data sharing due to privacy and ethical concerns . AnotherFive studies acknowledged their citizen scientists by thanking them for their participation in the acknowledgements section as an un-specified group . , 44. OneAll included studies reported the strengths, limitations, and outcomes of their citizen science projects in relation to their scientific output, data quality, participant experience and wider societal or policy impact.All studies or documents included in this review generated a scientific output in the form of publishing a research publication or project summary report. Three of the included studies reported and published the process and result outcome of the citizen science project , 43, 44.Two studies reported that achieving a high-quality and reliable citizen science data requires the participation of a large number of diverse citizen scientists, , 40. In Citizen scientists were able to use and participate in citizen science projects through online platforms, though high dropout rates were identified and reported by researchers. Researchers reported that citizen scientists dropped out of the project due to the following reasons: lack of time and commitments from citizen scientists due to busy schedules; , 44 techA study reported that the involvement of individuals and other stakeholders in citizen science has the potential to be a catalyst for collective action, leading to an impact on healthcare policy, mental healthcare self-management, and digital health with specifics on the use of digital tools for citizens with mental health issues and their families . ProjectTwo primary researchers included in this review reported to have obtained ethical approval before the commencement of their research , 44. ThrThe small number of studies that met the inclusion criteria for this review indicated the novelty in the use of citizen science as a research approach in mental health research. ECSA health working group has notably stated that the use of citizen science in health research is relatively under-represented, despite its promising potential . All stuTo the best of our knowledge, this is the first systematic review evaluating the use of citizen science in mental health research. We synthesised the reported views of citizen scientists and researchers regarding mental health citizen science projects, including possible ethical and legal issues. The citizen science approach was applied in different mental health research for data collection, analysis, and delivery of interventions with a focus on citizen scientist empowerment, mental health promotion, recovery, and self-management. Our findings indicated that the use of the citizen science approach in mental health research is still in its infancy stages but feasible, because of the small number of eligible studies for this review (only nine studies). Our findings showed that most citizen scientists were involved as contributors and participated in the projects mostly during the data collection stages. Our results showed that citizen science projects encompass the collaboration and partnership between professional scientists and citizen scientists, including taking part in scientific activities, ranging from data contribution to comprehensive participation and project co-creation , 61. ThiCitizen science has the potential to foster citizen engagement and democratise knowledge generation, especially when integrated with established participatory research approaches in health research , 65. CitOur review indicated that citizen scientists included in the studies enjoyed participating in citizen science projects because of their associated benefits. Evidence has shown that participating in citizen science assists in improving scientific literacy, and knowledge reasoning skills and changes public attitudes to science , 68. We The ECSA principle does not guide the management of possible harm that participation in citizen projects poses on citizen scientists, especially people with mental health problems. Additionally, our study found that there was no consensus on the way mental health citizen science research should be reported and conducted, despite available guidelines such as the ECSA principles. All studies included in the review reported their project results and evaluation diversely, without any inference to following any guiding implementation or reporting principle. Despite the growing consensus of citizen science potential, the strategies for the implementation and standardised guidelines for measuring citizen science metrics and reporting are sparse , 30. TheAll the studies included in our review were conducted in high-income countries. This supports evidence that there is sparse usage of citizen science approach in low-income countries, which is attributed to researchers and the public unfamiliar with the approach, and cultural differences about the use of online and technology platforms for research , 74. In We reported in our study that most projects did not report any aspect of feedback, either by the citizen scientists receiving project feedback or researchers providing feedback on how the citizen science data were used. The ECSA principle encouraged the provision of feedback to citizen scientists about how their data is used and processed. The provision of research feedback to citizen scientists promotes possible future involvement between citizens and professional scientists, ensures the use of relevant outcome measures,  and imprIn our opinion. There is the potential for ‘citizen science’ to be a contentious term in mental health, due to its implied acceptance of the terms and assumptions of science by people with lived experience of mental health, and the potential for inadvertent exclusion of people who do not identify as citizens. One study has highlighted that the meaning of ‘citizen’ is different between many Western countries and the rest of the world and that the terms ‘science’ and ‘research’ are more frequently associated with the novelty of findings in the West compared to the East Asia such as Japan where it does not communicate novelty . Hence, The strengths of this review include the use of multiple sources both large databases, citizen science project-specific platforms and websites to search for eligible studies, the involvement of analysts bringing diverse perspectives, and the originality of this first-in-field review. The review’s inclusion and exclusion criteria allowed for different studies including grey literature to be included in the review, if eligible. However, a limitation of our study was that most of the included studies were found through empirical research databases, and most of the grey literature websites and platforms screened lacked sufficient information required for inclusion in the review. Another limitation of our study is that the reasons for non-inclusion at title and abstract screening stage were not recorded. To maximise comprehensiveness, we included studies investigating Autistic Spectrum Disorder, which in some settings would not be considered a mental health condition. A stricter interpretation will be warranted as the evidence base diversifies. Also, only two studies reported on the societal outcome and impact of using the citizen science approach in mental health. Our proposed best practice guidelines were inferred based on nine documents, indicating the development of knowledge is in its early stages. We anticipate that the proposed best practice guideline will evolve as experience increases in using citizen science approaches in mental health research. Development in other applications of citizen science indicates this is likely to happen. For example, best practice guidelines have been developed to guide scientists and practitioners in the development and use of digital citizen science applications .Our review found nine studies that used a citizen science approach to mental health. To set this in context, a recent scoping review found only 81 articles that have used the citizen science approach across all health research, they were predominantly in physical activity and nutrition . The useData collected for the study, and a data dictionary defining each field in the set, will be made available to others; this data are what were extracted for use in this review from the included study, this includes ; and the study protocol. The requested data will be made available with publication as an OT and MS conceptualised the study, and OT wrote the first draft of the report. OT, FL, and YK extracted and analysed data. MS had access to and verified all data. All authors contributed to the article and approved the submitted version.This work is funded by UK Research and Innovation (UKRI) Citizen Science Collaboration Grant (Funder reference: BB/V011707/1). MS and SR-E are supported by the NIHR Nottingham Biomedical Research Centre. MS and SR-E are supported by the NIHR Nottingham Biomedical Research Centre (NIHR203310).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Achieving universal health coverage (UHC) is a priority of most low- and middle-income countries, reflecting governments’ commitments to improved population health. However, high levels of informal employment in many countries create challenges to progress toward UHC, with governments struggling to extend access and financial protection to informal workers. One region characterized by a high prevalence of informal employment is Southeast Asia. Focusing on this region, we systematically reviewed and synthesized published evidence of health financing schemes implemented to extend UHC to informal workers. Following PRISMA guidelines, we systematically searched for both peer-reviewed articles and reports in the grey literature. We appraised study quality using the Joanna Briggs Institute checklists for systematic reviews. We synthesized extracted data using thematic analysis based on a common conceptual framework for analyzing health financing schemes, and we categorized the effect of these schemes on progress towards UHC along the dimensions of financial protection, population coverage, and service access. Findings suggest that countries have taken a variety of approaches to extend UHC to informal workers and implemented schemes with different revenue raising, pooling, and purchasing provisions. Population coverage rates differed across health financing schemes; those with explicit political commitments toward UHC that adopted universalist approaches reached the highest coverage of informal workers. Results for financial protection indicators were mixed, though indicated overall downward trends in out-of-pocket expenditures, catastrophic health expenditure, and impoverishment. Publications generally reported increased utilization rates through the introduced health financing schemes. Overall, this review supports the existing evidence base that predominant reliance on general revenues with full subsidies for and mandatory coverage of informal workers are promising directions for reform. Importantly, the paper extends existing research by offering countries committed to progressively realizing UHC around the world a relevant updated resource, mapping evidence-informed approaches toward accelerated progress on the UHC goals. This was further solidified by the landmark agreement reached during the High-Level Meeting on UHC at the 74The World Health Organization (WHO) recommends countries adopt compulsory prepayment mechanisms to better distribute the financial risks related to individuals’ varying health expenses across both time and population . PossiblIrrespective of the choice of prepayment mechanism, many low- and middle-income countries (LMICs) are faced with the challenge of raising revenues in a context with high levels of informal employment. The latter is characterized by labor relations that are mainly based on casual employment, personal and social relations, or kinship rather than on contractual arrangements with formal guarantees: Studies suggest that most workers in informal employment face serious gaps in decent worker protections, including a lack of employment benefits and basic legal and social protection coverage . AdditioIn many countries in SEA, achieving UHC is among the top health policy priorities, reflecting governments’ commitments to improved population health through developing and implementing policies that are responsive to individuals’ and communities’ demands and needs for affordable quality health services , 10. ProConsiderations of equity are further inherent to the pursuit of UHC, aimed at redressing the persistent inequities within and across population groups and geographic areas –14. HoweThe existing literature contains several reviews on HF schemes aimed at extending UHC to IWs in LMICs, which all have been published before or around the introduction of the 2030 Agenda in 2015. Acharya et al.  specificWe conducted a systematic review on HF schemes for extending UHC to near-poor and non-poor IWs in LMICs in SEA in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines , and used citation tracking. Moreover, we screened the reference lists of all included studies and of previous reviews for additional relevant publications  .We used a combination of text words and medical subject headings related to health financing, UHC, and LMICs in SEA for the search strategy which was applied to different databases (see Tables 2–5 in We imported the records identified through the searches into the review software Rayyan for screening and reviewing. Two independent reviewers (AHK and NR) screened all titles and abstracts of the records identified initially for potential eligibility, applying the selection criteria. The full texts were retrieved for all papers included in the first screening stage and reviewed by at least one independent reviewer. One of the reviewers (AHK) then applied the eligibility criteria to the full texts of potentially eligible papers, documenting reasons for exclusion; a second reviewer (NR) independently checked these judgements. Any disagreements between the main reviewers were resolved with the use of a third reviewer.For ease of understanding of the review results, We followed the guidance of the Cochrane Collaboration Qualitative Methods Group and developed a standardized data extraction matrix in Microsoft Excel. Details were captured on the following variables: citation information, geographical origin and setting, study aim(s) and objective(s), study design and methods, study population(s) and target group(s), setting, description of HF schemes, policy scale, starting year and timeframe, main results, conclusions, and recommendations. One reviewer (AHK) independently extracted all data, which was cross-checked by a second reviewer (NR).We used the Joanna Briggs Institute critical appraisal tools for the quality appraisal and risk of bias assessment of all included peer-reviewed articles. The tools provided a coherent set of checklists to appraise key methodological aspects of studies with various designs and to assess the trustworthiness, relevance, and results . Two revThe heterogeneity in the countries, settings, study designs, and outcome measures, among other comparisons reported on in the included articles precluded a formal a meta-analysis. Instead, we used thematic analysis, also known as directed qualitative content analysis, to organize and synthesize the extracted data . We usedTo categorize the effect of the included HF schemes on progress toward UHC, we considered the three dimensions of (1) financial protection, (2) population coverage, and (3) access to health services, outlined by WHO as indicators for measuring country-level progress toward UHC , 42. ForThe electronic database searches generated 4221 studies and we located a further 112 papers through the other search forms described earlier. Following deduplication, we excluded 3534 records as not relevant in the title- and abstract-screening stage. We then assessed the full texts of 321 publications for eligibility and found 156 to meet the eligibility criteria for this systematic review. Most publications were excluded because they did not provide information specific to IWs. The flow of selection is summarized in List 1 in The literature searches yielded multiple publications for each country, enabling data triangulation of both the design of the HF schemes and changes in the three UHC dimensions. However, the number of publications indicated marked variation between countries, reaching from six in Malaysia to 36 in Vietnam . One expOverall study quality of the peer-reviewed articles was medium. Applying the set of Joanna Briggs Institute checklists, the results indicated that a majority obtained a medium (n = 27) or high (n = 26) quality score, while the remaining 14 articles fell into the low-quality category (<60%). Only two studies were RCTs to identify causal mechanisms and both obtained a high quality rating , 47. Mande jure mandatory in Indonesia’s Jaminan Kesehatan Nasional (JKN) and Vietnam’s SHI, both schemes are facing challenges with a lack of enforceability since no penalties for non-participation are in place, creating de facto voluntary schemes [For the eight focus countries of the systematic review, we included eight HF schemes that are currently in place with the aim of extending UHC to near-poor and non-poor IWs.  schemes , 56, 57.de jure voluntary enrolment for IWs in the Social Security Scheme (SSS). In practice, however, there are presently no mechanisms in place for IWs to register with SSS [In Cambodia, the government introduced extensions of the existing Health Equity Funds (HEFs) for the poor in 2018 to provide coverage for a number of clearly defined IW groups (excluding dependents). Participation in this scheme is voluntary as per the legal provisions , 59. Myawith SSS  and thuswith SSS , 61. TheThe basis for entitlement relates to the basic conditions for access to health services under HF schemes. This can be either contributory and require a payment of contribution on behalf of or by the individual to be covered (e.g. SHI) or noncontributory, where coverage is not linked to contribution payments but defined for citizens/residents or specified groups within the country . IndonesThe enrolment process in the eight HF schemes can be broadly divided into two categories: (1) Active, where the IWs themselves are required to seek enrolment with the relevant authority, and (2) Automatic, where beneficiaries are automatically enrolled by responsible authorities once eligibility is confirmed, with little or no involvement in the process. In four of the eight included HF schemes , beneficiaries must actively seek enrolment/registration, generally by visiting the competent authority , 73, 74.In addition to beneficiaries’ contributions, revenue sources for the analyzed HF schemes include mainly general government tax revenues. These comprise of direct  and indirect taxes  . NotablyGiven the (on average) low financial capacity of IWs, other crucial aspects are the level of subsidization and any remaining co-payment requirements . In three out of eight schemes, IWs of all income levels receive full subsidies from public revenues , with no registration fees or co-contributions , 59, 69.Considering revenue raising methods and subsidies together, HF schemes can be categorized into three broad, practical approaches to extending UHC discussed in relevant literature: (1) extending coverage down from civil servants and the formal sector; (2) using a combination of prepayment and tax-based subsidies; and (3) extending coverage upward from schemes subsidizing the poor , 27. Foude facto limited pooling and effective cross-subsidization [A variety of pooling arrangements exist in the analyzed HF schemes, which can be broadly classified into single- and multiple-pool arrangements. Only in Indonesia, IWs are included into a single national pool with contributors and/or beneficiaries of other population groups  . In the dization , 72, 86.dization , 59, 62.Table 8 in HBPs are defined by the government in all HF schemes, though based on differing national processes. Notably, Thailand’s UCS is currently the only HF scheme reviewed in this study that bases HBP decision-making on transparent procedures and systematic assessment methods for inclusion or exclusion of services and/or for price negotiations of products ) , 55. TheSeveral HF schemes have co-payment requirements (user charges) in place, requiring service users to pay nominal fees or a certain percentage of their health service expenses , assuming that these largely comprise of IWs and their dependents.The following sections explore progress toward UHC realized under the eight HF schemes, categorized by the three indicators: population coverage, financial protection, and access to health services (utilization). For many HF schemes, the available evidence is sparse, and the account of progress made gives a broad indication of trends that should be interpreted with caution. Data on changes in CHE and impoverishment for IWs since the introduction of the HF schemes is not available for all countries. Importantly, for those countries in which civil servants and formal sector employees are covered under separate designated HF schemes , the sections on financial protection and utilization present data differentiated along income quintiles . Excepting Malaysia and the Philippines, where OOPE have been continuously increasing over the past years , 76, 106Most articles reported on measures of utilization of outpatient and inpatient health services in general, with only one study looking at indicators for specific health conditions . OutcomeVarious articles analyzed factors influencing IWs’ enrolment/registration and retention (i.e. sustainability of insurance premium payments) in the HF schemes, more specifically HISs. While the exact factors differed to some degree between articles as a function of differing country contexts and HF scheme characteristics, several recurring factors positively influencing enrolment and retention were identified. Among these were older age and improved education of the insured person and the household head, living in urban areas, smaller household size, poorer health status and increased likelihood of being ill a greater number of times in the past year, higher household income and income stability, perception of premiums as acceptable, perceived supply-side readiness of public facilities , enhanced insurance awareness and literacy, and increased convenience of enrolment/registration, payment, claims management, and referral procedures , 120–123In this systematic review, we assessed and synthesized peer-reviewed and grey literature publications reporting details on the HF arrangements LMICs in SEA implemented with the aim of extending UHC to near-poor and non-poor IWs. Results from the included publications suggest that explicit commitments to UHC have strong positive effects on population coverage, while voluntary modes of participation and reliance on active enrolment and/or registration of specific population groups seems unfavorable if rapid coverage expansions are to be achieved. Regarding data on progress of the UHC indicators financial protection and access to health services (utilization), available evidence showed overall positive effects since the introduction of the analyzed HF schemes with reductions in OOPE, catastrophic health expenditure and impoverishment, and increases in utilization rates for IWs. Notwithstanding these positive results for several of the analyzed HF schemes, there is relatively scant evidence that provides a broad indication of trends that warrant a conservative interpretation.The following sections explore the available evidence in more detail and provide reflections on possible reasons for and the further significance of the review findings for the extension of UHC to IWs in LMICs both regionally and globally. We also consider the influence of specific institutional features of the analyzed HF schemes on UHC progress and challenges in the context of high labor force informality.Overall, country evidence suggests that schemes—and countries—with explicit commitments to achieving UHC that adopted universalist approaches have reached the highest population coverage of IWs. Coverage rates varied across HF schemes and coverage data disaggregated by population groups were not available for all schemes. In schemes reaching below 100% coverage, the composition of the unenrolled groups was generally unknown, though IWs in lower middle-income groups were expected to make up the bulk of the uncovered people in several countries  , 124. OnThe included evidence indicates that enrolment and registration procedures bear influence on both speed and percentage of population coverage under any HF scheme. The highest rate of currently uncovered population groups was found in HF schemes that rely on active enrolment and/or registration of specific population groups, rather than employing a universalist approach. Active enrolment and registration by individuals requires awareness of the HF scheme and their eligibility status, as well as the literacy and competence to navigate the administrative processes, which might not be the case for IWs . Howeverde jure or de facto) voluntary enrolment due to enforcement challenges, adverse selection may result as evidenced in Indonesia, the Philippines, and Vietnam; disease history reportedly influenced beneficiaries to enroll and maintain an active enrolment status with regular contribution payments, while fewer illness episodes and low insurance utilization increased premium dropout rates [Furthermore, in schemes with  and the services received by the population in practice (i.e. de facto), leading to implicit rationing. This can compromise the government’s trustworthiness and credibility in public health service provision, and is leveraged by private providers trying to attract patients by delivering, for instance, services unavailable in the public sector or reducing waiting times [The health benefits package is directly connected to the depth of service coverage and affects the degree of financial protection a HF scheme offers to the covered population. In several of the analyzed HF schemes there are differences in what services the HBP sets out to provide to covered IWs , and the schemes’ effects on utilization were inherently heterogeneous and sensitive to differences in context. Additionally, the extent to which increased utilization by IWs constitutes improvement in welfare depends largely on the level of existing unmet need which is thus filled . OverallGovernance arrangements and government stewardship warrant mention given their decisive importance for effective health financing policy making and implementation, particularly in the context of high labor force informality . A 2019 This review revealed a lack of effective pooling and strategic purchasing mechanisms in most of the analyzed HF schemes, leaving a potential to use information to create deliberate incentives for equitable resource redistribution and efficiency increases unfulfilled . In addiThe evidence included in this systematic review does not offer a “best model” for countries aiming to extend UHC to IWs. Nevertheless, a lot can be learned from sharing global, regional, and country-level experience in this field, which suggests a number of desirable directions for reform , 18. FucNotwithstanding the systematic approach in searching for eligible literature, relevant publications may have been omitted. Conducting searches in other electronic databases and/or on other development partner or governmental websites beyond the ones searched, as well as consulting country experts for relevant literature may have yielded additional relevant publications, and the fact that only English-language publications were eligible for this review may have introduced the risk of missing key data due to language bias. Additionally, many studies were excluded because there was no clear-cut distinction between the population groups for which they analyzed the effects of the respective HF schemes. These might have reported on potentially relevant evidence that we consequently missed, though the extent to which additional publications would affect the main results and conclusions of this systematic review is unclear. Furthermore, quality appraisal for non-randomized studies was complicated due to the heterogeneity inherent in this category of study designs. There is currently no consensus on which tool(s) to use for appraising the methodological quality of non-randomized studies . We therBased on this systematic review it can be concluded that there is relatively limited evidence on changes in the three UHC indicators of population coverage, financial protection, and access to health services for several HF schemes. The overall quality of the peer-reviewed articles was medium with variations in applied study designs and methods. These methodological and data limitations should be addressed by rigorous studies to better understand the relation between efforts to extend UHC to IWs and improvements in key UHC indicators. As a general trend, IW population coverage as well as rates of their financial protection and service utilization increased since the introduction of the HF schemes, though with effects strongly depending on context and features of the respective scheme. Countries adopting HF schemes consistent with international directions on desirable features of reform, i.e. compulsory enrolment and subsidization for lower-income groups, generally show more favorable results.S1 File(DOCX)Click here for additional data file.


Maize is widely used for food, animal feed, and industrial raw material in Nigeria. This paper documents the important changes that characterize Nigeria's maize production and area expansion along with contributing factors that have transformed maize from a backyard food crop to a dominant food security and commercial crop. Using both secondary and primary data on maize production and varietal adoption over the last six decades, we found that Nigeria now produces ten times more maize than it did in 1960 and four times more maize than it did in 2005. Our findings further suggested that government policies and institutional arrangements that promoted access to and use of modern inputs and increased demand of maize grain for food, feed, and other industrial uses have played major roles in transforming maize from a backyard crop to a dominant staple and commercial crop in Nigeria. Considering the impeding climate change threats to food security in Nigeria, policy interventions should be tailored towards further scaling-up of stress resilient and climate-smart maize varieties to improve the productivity, income, and resilience of smallholder farmers. This requires strong support not only to get recently released superior improved varieties into the hands of smallholder farmers but also to accelerate varietal turnover. •Maize is widely used for food, animal feed, and industrial raw material in Nigeria.•Nigeria’s maize production growth is driven by both area expansion and adoption of yield enhancing modern inputs.•Rapid growth in maize grain demand for processed food, feed, and other industrial uses is an important driver of maize production growth in Nigeria.•Scaling stress resilient improved maize varieties is key to improve smallholders’ food security and climate resilience. The crop is also an important source of cash income for farmers and contributes significantly to agro-industrial development particularly in the livestock feed industry (Maize is a crop of notable interest for food security in many parts of sub-Saharan Africa (SSA) . As in oindustry .Following its arrival in West Africa in the 15th century , maize bUntil the mid to late 1970s, maize production in the Nigerian savanna was limited to homesteads. However, as demand for maize grain for food, animal feed, and other industrial products increased, significant expansion in maize production occurred in the savannas where it became a prominent commercial crop competing with other indigenous cereals . The sprWhile the current yields in Nigeria of around 2 tons per hectare are much lower than what can be attainable with the available improved production technologies and suitable production environments, the rate of production and area expansion has been remarkable over the last 60 years. What are the key contributing factors to the significant expansion of maize production in Nigeria? How much is due to expanded use of inputs such as improved seed and fertilizers versus area expansion? In an attempt to address these questions, this paper analyzes and synthesizes available evidence on maize production, productivity and varietal adoption over the last six decades. More specifically, using both secondary and primary data sources, including nationally representative household surveys, this paper provides descriptive evidence on the drivers of maize sector transformation including (i) commercialization of maize to meet increased demand for food, feed and industrial use, (ii) accelerated release of stress resilient, productive and adapted maize varieties coupled with increased availability of certified seeds to farmers, (iii) the establishment and changing landscape of the private sector, and (iv) supportive government policies that stimulated accelerated production of maize in the country by facilitating farmers’ access to and use of productivity-enhancing inputs such as improved seed and fertilizer. Finally, using DNA-Fingerprinting based varietal identification, the paper provides descriptive evidence on varietal traits associated with greater adoption in Nigeria.2www.naerls.gov.ng) and obtained additional production statistics from the Nigerian National Bureau of Statistics (NBS)  secondary data sources including past studies, public policy documents, government statistics, and project documents; and (2) primary data from nationally representative farm and household level variety monitoring and adoption surveys. Although several national and state level agencies provide agricultural production related statistics for Nigeria, these data are often not comprehensive and nationally representative. Hence, for our main analysis, we compiled comprehensive long term national level production, area and yield estimates from the Wet Season Agricultural Performance Survey Reports of the National Agricultural Extension and Research Liaison Services (NAERLS) (cs (NBS) . These scs (NBS)  and the To complement the NAERLS, NBS and FAO data, we compiled additional micro-level data from large-scale and nationally representative farm and household surveys. These included: (a) the Nigeria Country Plan Baseline and Varietal Monitoring survey , (b) the project survey for the Drought Tolerant Maize for Africa  and (c) the Nigerian Living Standards Measurement Study-Integrated Surveys on Agriculture . These data are nationally representative and provide comparable statistics across space and time. The NIBAS survey was conducted across six states in Nigeria, including Benue, Kaduna, Kano, Katsina, Nasarawa, and Niger that are representative of the maize belt of the country. Similarly, the DTMA survey was conducted across 18 major maize producing states in the country, and thus represented the maize farming households in Nigeria. Both the NIBAS and DTMA surveys provided data on varietal choice, source of improved seed, seed purchasing history, trait preferences, yield and other key socio-economic characteristics from a nationally representative sample of approximately 3000 maize growers in Nigeria. To circumvent traditional survey-based measurement errors in estimating varietal adoption, NIBAS used a novel DNA-fingerprinting based varietal identification to accurately identify maize varieties grown by farmers in Nigeria. We used the DNA-fingerprinting based varietal tracking information to document the extent of maize area planted with improved maize varieties and the area-weighted average age of the maize varieties grown in the country.33.1As shown in From 1961 to 2020, maize production and harvested area increased by 984% and 450%, respectively. Holding input and land use constant, Nigeria now produces ten times more maize per year than it did in 1960. As shown in Since the 1980s, the steady growth of maize production has coincided with several maize research initiatives in the country that have led to the development and release of suitable maize varieties by the national partners in collaboration with IITA . What is1The relative changes in maize area expansion and yield improvements over the period from 1990 to 2020  was launched due to the staggering demand of maize grain for human consumption, poultry feed and industrial use . The foc10.13039/100015539Federal Government of Nigeria launched the Agricultural Transformation Agenda (ATA) and introduced a Growth Enhancement Support (GES) scheme with the aim of increasing the productivity of smallholders through a mobile phone based targeted subsidy (STMA) projects. For instance, the GES facilitated the distribution of fertilizer and improved seeds to more than 4.1 million farmers in 2013 and 7.2 million farmers in 2014  in Nigeria started breeding maize in the 1950s and released 16 maize varieties between 1950 and 1975 . With thd Striga . These iPrior to 2007, 37 open pollinated maize verities (OPVs) and 25 hybrids were released in Nigeria, representing 44% of the total number of released varieties. As shown in 3.2.3A competitive seed sector is critical to ensuring the timely availability of high-quality seeds of improved varieties to smallholder farmers at affordable prices . The sucAs part of the Agricultural Transformation Agenda (ATA), the Federal Government of Nigeria introduced the GES scheme in 2011 to provide farmers with subsidized seeds of improved maize varieties and fertilizer . The ATA3.2.4It is widely recognized that the development, dissemination, and adoption of high yielding improved varieties is the primary pathway through which technological change in the agricultural sector can achieve productivity gains . EvidencSimilarly, certified maize seed production in Nigeria increased from about 5314 MT in 2010/11 to over 60,000 MT in 2020/21 . At the 6Continual replacement of old varieties with new and superior varieties with high yield potential and tolerance to multiple stresses can maximize farmers' benefits and adaptation to changing climate . Such fa3.2.5It is commonly argued that modern farm-inputs are rarely adopted in isolation as adopting a basket of complementary inputs is advantageous for farmers . A combiTo quantify the contribution of complementary farm inputs to maize productivity in Nigeria, we examined the correlation between maize yields and use of improved seed and inorganic fertilizers based on the NIBAS and DTMA datasets. We use standard ordinary least squares (OLS) and instrumental variable (IV) regression approaches to estimate the association between adoption of improved maize varieties and maize yields. Estimates reported in In Nigeria, adoption of improved maize varieties with varying maturity and drought tolerance could improve food security without significant productivity gains, particularly in marginal environments. This is possible particularly in the dry savannas of Nigeria where maize area expansion occurred through replacement of the less productive millet and sorghum varieties to improve overall food availability. Consistent with the findings of previous studies , estimat3.2.6In Nigeria, rapid growth in maize demand for food, feed and industrial uses has been an important driver of the dramatic growth in maize production in the last two decades . Driven 7Maize utilization trends for animal feed in Nigeria using the food balance sheets of the FAO  are pres84In this paper, we documented the important changes that characterize Nigeria's maize production and area expansion over the last couple of decades. Using both secondary and primary data on maize production, productivity, and varietal adoption, we described the major drivers and mediating factors of the maize sector transformation in Nigeria. In this section, we provide additional insights with a focus on unexploited opportunities for further transformation of the maize sector of Nigeria along with implications for future research, policy, and public investment.First, although impressive strides have been made in the development and promotion of improved maize varieties across diverse agro-ecological zones in Nigeria , there iSecond, despite substantial achievements in terms of increasing the production of certified maize seeds, accelerating varietal turnover, and reducing varietal age in farmers' fields, the potential demand for certified maize seed in Nigeria is still high and maize yields in the country remains at about 2 tons per ha and lags far below the yields achieved in other major maize-producing countries . The low productivity of maize in Nigeria is partly attributed to market imperfections that constrain farmers’ access to high-quality certified seeds of recently released improved maize varieties . Bold etA third opportunity is the development, dissemination, and adoption of hybrid maize seed. Both the certified seed production data and the DNA-fingerprinting based variety identification revealed that most of the improved maize varieties grown by farmers in Nigeria are OPVs. While conventional OPVs are generally regarded as less productive than hybrids, stress tolerant OPVs can withstand harsh environments, compared with local varieties, providing farmers with yield advantages , 2017. TAccelerating varietal turnover represents another potential intervention area for maximizing the impact of improved maize varieties in Nigeria. As breeding is largely an incremental process in which subsequent generations of maize varieties will be superior in grain yields, resistance to pests and disease, and nutritional quality , farmersThere is scope and opportunity for new research. First, research is needed to understand the varietal traits associated with greater adoption  and their economic value . Second, rigorous research is needed to understand the commercial viability of various types of certified seed business and marketing strategies to better inform policymakers about effective and practical marketing strategies that could stimulate demand in an inclusive and cost-effective manner. Finally, it would be important to expand the evidence base on the sources of maize production and area growth in greater depth, especially with respect to quantifying and decomposing the contribution of technical change and demand-side drivers using detailed and dis-aggregated sub-national level data. Sub-national level analysis of land use changes across space and time would also be vital to better understand the sources of area expansion and the implications of this change for future land use.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Candida albicans with low hemolytic effects. The application of machine intelligence in the sphere of biological sciences has led to the development of automated tools. The progress made in this area has also paved the way for producing new drugs more quickly and effectively. However, we also identified that further advancements are still needed to complete the AFP libraries.Antifungal peptides (AFPs) comprise a group of substances with a broad spectrum of activities and complex action mechanisms. They develop in nature via an evolutionary process resulting from the interactions between hosts and pathogens. The AFP database is experimentally verified and curated from research articles, patents, and public databases. In this review, we compile information about the primary databases and bioinformatics tools that have been used in the discovery of AFPs during the last 15 years. We focus on the classification and prediction of AFPs using different physicochemical properties, such as polarity, hydrophobicity, hydrophilicity, mass, acidic, basic, and isoelectric indices, and other structural properties. Another method for discovering AFPs is the implementation of a peptidomic approach and bioinformatics filtering, which gave rise to a new family of peptides that exhibit a broad spectrum of antimicrobial activity against  Fungal infections in humans are constantly evolving with multiple resistance mechanisms developing in fungi . TherefoThe mechanisms of action of AFPs have been widely described in the literature, particularly those obtained from microorganisms  and planCandida spp. ” OR (Fungi) OR (Database screening) OR (Databases) OR (Bioinformatic) OR (Machine learning methods) OR  OR (Membrane lipids) AND (Human immune system) AND (New therapies) OR (Production) “[All Fields]” OR  OR (Defensins) OR (Protegrin) OR (Amphiphilic) OR .Revisions and guidelines were included, along with non-English articles. Primary outcomes included the source, structure, and toxic effects of AFPs.Some cases of unavailable data (NA) were found. Data extracted from bibliographic searches are illustrated in the PRISMA flow diagram .Bioinformatics tools are used for antifungal peptide discovery as part of a global strategy to discover AMPs from a variety of organisms covering the six kingdoms . For this purpose, comprehensive databases serve as reference sites to find curated information about known AFPs. Furthermore, with the help of statistical classification and prediction methods, the first steps have been taken toward the prediction of new molecules with specific sequence characteristics and physicochemical properties. However, further research is needed to optimize and validate the best methods for establishing an international, standardized methodology.


Cancer is a leading cause of death during childhood and in low- and middle-income countries survival rates can be as low as 20%. A leading reason for low childhood cancer survival rates in low- and middle-income countries such as Tanzania is treatment abandonment. Contributing factors include poor communication between health care providers and children’s guardians, insufficient cancer knowledge, and psychological distress.Our aim is to respond to Tanzanian guardians’ poor adherence to children’s follow-up care after treatment for acute lymphoblastic leukemia with the help of mobile health  technology. Our goal is to increase guardians’ adherence to children’s medications and follow-up visits and to decrease their psychological distress.Following the Medical Research Council framework for developing and evaluating complex interventions, we will undertake the GuardiansCan project in an iterative phased approach to develop an mHealth intervention for subsequent testing. Public contribution activities will be implemented throughout via the establishment of a Guardians Advisory Board consisting of guardians of children with acute lymphoblastic leukemia. We will examine the acceptability, feasibility, and perceived impact of Guardians Advisory Board activities via an impact log and semistructured interviews (study I). In phase 1 (intervention development) we will explore guardians’ needs and preferences for the provision of follow-up care reminders, information, and emotional support using focus group discussions and photovoice (study II). We will then co-design the mHealth intervention with guardians, health care professionals, and technology experts using participatory action research (study III). In phase 2 (feasibility), we will examine clinical, methodological, and procedural uncertainties associated with the intervention and study procedures to prepare for the design and conduct of a future definitive randomized controlled trial using a single-arm pre-post mixed methods feasibility study (study IV).Data collection for the GuardiansCan project is anticipated to take 3 years. We plan to commence study I by recruiting Guardians Advisory Board members in the autumn of 2023.By systematically following the intervention development and feasibility phases of the Medical Research Council Framework, and working alongside an advisory board of guardians, we intend to develop an acceptable, culturally appropriate, feasible, and relevant mHealth intervention with the potential to increase guardians’ adherence to children’s follow-up care after treatment of acute lymphoblastic leukemia, leading to a positive impact on children’s health and chances to survive, and reducing distress for guardians.PRR1-10.2196/48799 Cancer is a leading cause of death during childhood ,2. In hiA major reason for low survival rates in LMIC is treatment abandonment, which is defined as failure to start  or continue curative treatment for 4 or more consecutive weeks -12. CommMobile health  interventions may represent a solution to address guardians’ unmet needs, reduce treatment abandonment, and ultimately improve childhood cancer survival rates. Specifically, mHealth interventions may provide guardians with follow-up treatment reminders, educational information about cancer and treatment, and emotional support. Across sub-Saharan Africa, national-level digital health strategies and architectures are being implemented and are endorsed by the United Nations and the World Health Organization . mHealthmHealth interventions could also provide emotional support to guardians. mHealth apps using cognitive behavioral therapy (CBT) principles are effective for common mental health difficulties , and we Our goal is to increase guardians’ adherence to children’s medications and follow-up visits and, second, to decrease their psychological distress. Our overall objectives are to (1) implement public contribution activities throughout the GuardiansCan project via the establishment of a Guardians Advisory Board (GAB) and to examine the acceptability, feasibility, and perceived impact of GAB activities (study I); (2) to explore guardians’ needs and preferences concerning the provision of follow-up care reminders, information, and emotional support (study II); (3) to co-design an mHealth intervention providing guardians with follow-up care reminders, relevant information, and emotional support (study III); and (4) to examine clinical, methodological, and procedural uncertainties associated with the intervention and study procedures to prepare for the design and conduct of a future definitive RCT of the mHealth intervention (study IV).Following the revised United Kingdom Medical Research Council (MRC) framework for developing and evaluating complex interventions , we willThe GuardiansCan project is divided into two main phases in accordance with the MRC Framework: (1) intervention development and (2) feasibility, with data anticipated to be collected over a 3-year period. We will follow published guidance to conduct the intervention development phase, paying attention to involving stakeholders, reviewing published evidence, developing a program theory, and considering future real-world implementation ,34, and The GuardiansCan project is an international collaboration between Tanzania and Sweden. Uppsala University (Sweden) is the responsible academic institution with research primarily coordinated from Muhimbili National Hospital (MNH), a National Referral and University Teaching Hospital located in Dar es Salaam, Tanzania. MNH provides basic and advanced medical and surgical treatments, and is a strategic center for the implementation of eHealth aligning with the Tanzania National Road map of eHealth Investment 2017-2023 . MNH is Regarding general access to mobile phones, Tanzania’s mobile subscription rate per 100 population is 85%, with Android (Google) being the dominant operating system ,39. A stFor each planned study, we intend to recruit guardians from 7 regions in Tanzania including Dar es Salaam, Dodoma, Iringa, Lindi, Morogoro, Mtwara, and Pwani, and the island of Zanzibar (a semiautonomous state and part of the United Republic of Tanzania). The regions represent urban and rural areas in Tanzania and have been selected to facilitate including guardians with different cultural backgrounds and accessibility to Dar es Salaam see . RecruitWe aim to involve guardians of children treated for ALL in the managing and undertaking, analysis and interpretation, and dissemination phases of the GuardiansCan project, and examine the acceptability, feasibility, and perceived impact of GAB members’ contribution to the GuardiansCan project from the perspective of GAB members and public contribution coordinators.The full public contribution plan for the GuardiansCan project will be published elsewhere. We aim to recruit 6 to 8 guardians of children treated for ALL at MNH, representing different genders and coming from rural and urban communities, into the GAB. Workshops will be held with GAB members, facilitated by public contribution coordinators who are Kiswahili speakers with GAB members contributing to the undertaking and managing, analysis and interpretation, and dissemination phases of the GuardiansCan project. Examples of public contribution activities include, but are not limited to, designing detailed study protocols for studies II-IV, assisting in writing participant information sheets and consent forms, data collection , data interpretation and sense-making of findings, developing a dissemination plan, and helping to distribute findings within community settings.Public contribution activities will be recorded in an impact log  immediatResearchers in our group who are not involved in public contribution activities and conversant with Kiswahili will read impact logs, with impacts  extracted and summarized. Summaries of impacts will be presented for discussion with GAB members and public contribution coordinators to aid sense-making and interpretation of results. Two members of the research team who are not involved in GAB activities will analyze semistructured interviews using manifest content analysis . DescripFollowing the MRC Framework  throughoWe aim to explore (1) perceived needs and preferences concerning the receipt of follow-up care reminders, information, and emotional support; (2) attitudes toward mHealth interventions; and (3) perceived barriers and facilitators of mHealth intervention use.An explorative qualitative design with data collected via focus group discussions combined with photovoice techniques will be used -47. PhotParticipants will be guardians of the children treated for ALL at MNH and health care professionals  working at the pediatric oncology unit at MNH. We will include guardians who meet the following inclusion criteria: (1) are at least 18 years of age; (2) whose child has been discharged within the last 3-36 months from MNH after receiving main treatment for ALL ; (3) are able to speak Kiswahili; (4) have completed primary school education , but not tertiary education; (5) can provide written informed consent via ink signature; and (6) are able to travel to attend focus group discussions.A member of the research team will speak to interested health care professionals working at the pediatric oncology unit at MNH face-to-face or over the telephone to provide more study information. Those who wish to participate will be provided with a study information sheet and consent form. Written informed consent or alternatively verbal recorded consent over the telephone or via a secure videoconferencing system will be obtained. After provision of informed consent, background and sociodemographic characteristics will be collected, that is, age, gender, profession, length of time in profession, professional qualifications, and length of time working with pediatric oncology.An oncologist or a nurse will call identified guardians to explore inclusion criteria and their initial interest. A member of the research team will call guardians who fulfill the inclusion criteria and are interested in participation to provide more detailed verbal study information. Guardians interested in participating will be invited to the first focus group discussion. We will provide guardians with (1) a study information sheet and (2) consent form and written informed consent (via ink signature) will be obtained prior to data collection.A series of 2 focus group discussions with health care professionals (n≈6-8) at MNH will be held in Kiswahili. We will hold a series of 6 focus group discussions combined with photovoice with guardians . We plan to conduct focus groups in Dar es Salaam at a venue where participants can share their thoughts and feelings in privacy. It is anticipated that guardians will meet approximately once every 2 weeks for a 12-week period with each focus group lasting approximately 3 hours. However, the exact venue, frequency, and duration of focus group discussions will be planned in collaboration with the GAB.Focus groups with guardians will be combined with photovoice techniques -47. We wFocus group discussions will be moderated and notes taken with the assistance of an observer, a GAB member who will help facilitate discussions. We will audio-record focus group discussions and they will be transcribed verbatim by a person conversant in Kiswahili. An external translation company will translate transcripts to English and back-translate it to Kiswahili to facilitate analysis by the whole research team. Transcripts will be anonymized.Data will be analyzed using manifest content analysis . Two memWe aim to identify: (1) intervention content informed by findings from study II, behavioral change techniques -53 and eA qualitative design based on principles from participatory action research (PAR) will be used ,58, placParticipants include guardians of the children treated for ALL at MNH, meeting the same inclusion criteria as study II, and health care professionals working in pediatric oncology care, and technology experts, including mobile operator technicians.We anticipate identifying health care professionals and technology experts via in-person networks and guardians via MNH patient records, following the same recruitment procedures used in study II.Approximately 8 face-to-face PAR iterative meetings will be held in Kiswahili at a venue where participants can share their thoughts and feelings in privacy. Each meeting is anticipated to last approximately 3 hours, including a refreshment break. Before the first meeting, background and sociodemographic characteristics from participants will be collected. Some meetings will only include guardians or health care professionals and technology experts, and some meetings will be combined.Each meeting will have a predefined theme to focus the discussions and we will predevelop topics in collaboration with GAB members. PAR meetings will be conducted in iterative cycles and each meeting will involve cycles of collaboration, discussion, reflection, and evaluation. At the beginning of each meeting, we will present the agenda and participants will be encouraged to add items to the agenda. Action plans related to the topic will be developed collaboratively and at the end of each meeting, participants will individually reflect on the group discussions by answering open-ended questions and will be encouraged to provide suggestions for the upcoming meeting . An initPAR meetings will be facilitated and notes taken with the assistance of an observer, who will be a GAB member. Meetings will be audio-recorded and will be transcribed verbatim by a person native in Kiswahili. An external translation company will translate transcripts to English and back-translate to Kiswahili to facilitate analysis by the whole research group. Transcripts will be anonymized. Participants’ input at meetings and on action plans will be discussed by meeting facilitators, the research team, and the GAB who jointly plan further actions.Data will be analyzed  using manifest content analysis  in a “reWe aim to determine (1) intervention acceptability from the perspectives of guardians and health care professionals; (2) feasibility of the intervention; and (3) feasibility and acceptability of study methods and procedures.We will undertake a single-arm pre-post mixed methods pragmatic feasibility study ,36,59.Participants will be guardians (1 per child) whose child has been discharged from MNH after receiving main treatment for ALL  with the inclusion or exclusion criteria informed by studies II and III findings and GAB member involvement.Exact recruitment procedures will be informed by GAB member involvement. It is anticipated the recruitment period will take 6 months. To examine recruitment feasibility, the study invitation materials will include the possibility for guardians who decline participation to provide reasons for nonparticipation and consent to take part in an interview to explore potential decisions not to participate. Written informed consent (via ink signature) will be obtained prior to data collection and being provided with access to the intervention. In addition to the intervention, guardians will receive care from health care professionals as per normal clinical practice.We anticipate recruiting a sample of between 20 and 40 participants, following recommendations for feasibility studies  and, as We plan to collect data at screen, baseline, and posttreatment follow-up (12 months post intervention). In line with our feasibility objectives , we willTo examine the feasibility of data collection, the following clinical data will be collected: (1) adherence to child’s medications as per discharge instructions ; (2) attendance of follow-up visits at MNH or another hospital as per discharge instructions; (3) number and types of complications after discharge, number of readmissions after discharge, and progress of children’s cancer; and (4) psychological distress as measured with the Kiswahili adaptation of the Kessler Psychological Distress scale , cancer Participant flow will be illustrated in accordance with the CONSORT  diagram for feasibility and pilot studies . We willWe will report: (1) GAB activities and perceived impact of activities following the GRIPP2 (Guidance for Reporting Involvement of Patients and the Public) checklist ; (2) quaWe will process data in accordance with the Swedish Patient Data Act (2008:355), the General Data Protection Regulation (EU 2016/679), and the Tanzania National Institute of Medical Research policy . TanzaniThe GuardiansCan project will be conducted in accordance with the Declaration of Helsinki . InformeMembers of the GAB (study I) will receive reimbursement for their contribution, which includes travel and living cost and an allowance equivalent to the government daily subsistence allowance for ISCED level 4 personnel: 75,000 Tanzanian Shillings (≈US $31). Guardians participating in study II will receive mobile phones to facilitate the use of photovoice techniques. Guardians participating in studies II-IV will also receive reimbursement for any travel and living costs incurred.Data collection for the GuardiansCan project is anticipated to take 3 years. We plan to commence study I by recruiting Guardians Advisory Board members in the autumn of 2023.The development of interventions to address childhood cancer treatment inequalities and avoidable deaths from childhood cancer in LMIC is a high public health priority. To the best of our knowledge, this is the first study to seek to increase guardians’ adherence to children’s medications and follow-up visits after treatment for ALL, decrease guardians’ psychological distress via the use of mHealth, and represents an opportunity to increase childhood cancer survival rates in LMIC such as Tanzania.Despite the piloting of mHealth interventions across sub-Saharan African countries, mHealth interventions are seldom scaled-up due to factors such as lack of stakeholder involvement and consideration of the implementation context . To overWe did not involve guardians as public contributors when developing the overall research plan, limiting our ability to plan study procedures in advance that maximize acceptability and feasibility for guardians. However, we plan to overcome this limitation by embedding public contribution via the GAB throughout the GuardiansCan project, including activities related to the managing and undertaking, analysis and interpretation, and dissemination phases of the project. As planned currently, we will only recruit guardians from 7 geographical regions of Tanzania. Therefore, results may not be generalizable to guardians located in other regions of Tanzania, including guardians located at very long distances from the pediatric oncology unit at MNH. We will not include guardians who have not completed at least primary school; therefore, the proposed mHealth intervention may not be suitable for guardians who have not attained primary education.The proposed mHealth intervention and research have significant potential to promote equitable and sustainable care for families struck by ALL in Tanzania, adding to the capacity building of health care services in Tanzania. Our research may have a positive impact on children’s health and chances to survive, and guardians’ ability to provide for the family as a result of reduced costs for treatments, transportation, and long periods of hospitalization. The mHealth intervention also has significant potential to be a clinical and cost-effective solution, optimally prepared alongside key stakeholders for the implementation and a real-world clinical impact. The project, and the novel and robust methodological approach being taken, will also add to the existing evidence base concerning how mHealth interventions should be developed and tested, which may be of benefit to patients and informal caregivers for a variety of different conditions and unmet needs.


We looked for all of these to be represented in the two issues that comprise this Research Topic. See more about the breadth and depth of this issue in the discussion that follows.The Editorial Team is pleased to release this second Research Topic on Community Health Workers (CHW) to bring forward trends in the field including recruitment, integration, . Their paper discusses CHRs and CHR managers' involvements and perceived level of integration within health care teams and the broader public health systems addressing the social and structural determinants of health. They also discuss lessons learned from the COVID-19 pandemic responses in the tribes. Wennerstrom et al. discuss their original research that included a national cross-sectional survey of CHWs working with Medicaid managed care organizations (MCOs). Key findings from this research related to integration of CHWs into MCOS included: 85% of CHWs made referrals; 75% conducted social screenings; 54% assisted with care planning; 52% conducted health screenings; and 49% participated in case reviews (49.3%). Wennerstrom et al. suggest that CHWs' roles in MCOs focus on supporting clinical care and making referrals for social issues and not on community-level concerns. The authors recommend that MCOs ensure that CHWs: have professional freedom to develop community- based solutions; receive equitable compensation; and have promotion opportunities. Jeyakumar et al.'s original research study explored the current functioning and sustainability of Aboriginal Health Workers (AHWs)—core primary healthcare (PHC) providers— of First Nations peoples in New South Whales (NSW) PHC organizations. Results identified five categories of change required to ensure AHW sustainability and retention: community connection, recognition, value, support, and an inclusive health system—with both service and system level factors influencing each change category. The authors conclude that ensuring sustainability of the AHW workforce will require a system-wide paradigm shift that includes holistic health approaches and suggest the need for future studies co-designed with ACCHOs  to help inform this change.Integration of CHWs into interdisciplinary teams and into leadership positions is not as intuitive as integrating clinical workforce team members, such as nurses or clinical social workers. For organizations and systems who are new to the CHW model, organizational readiness is critical. The following papers discuss approaches to training supervisors and managers, as well as lessons learned around CHWs in leadership roles. Masquillier and Cosaert discuss some arguments of CHW integration in health systems, such as an innovation or just an emergency response through the COVID-19 pandemic. In Belgium, the pandemic served as a catalyst that revealed various gaps and disparities in the system, including shortages and unmet needs of socio- economically vulnerable communities. The authors elevate the need to build the CHWs' role in supporting “equitable and accessible healthcare for all, by looking beyond emergency responses.” Strengthening the CHW workforce involves formulating a long-term vision and ensuring sustainable funding, both of which were “set in motion by the COVID-19 pandemic.” In their original mixed methods research study, Ajisegiri et al. explored CHW roles and practices related to the delivery of non-communicable disease (NCD) services at primary health care (PHC) facilities in four Nigerian states; traditional CHW work in Nigeria has focused on infectious diseases and maternal and child health services. Study findings demonstrated that CHWs frequently delivered services beyond the scope of practice stipulated in the Nigerian National Standing Orders for CHWs; the need to serve the community primarily motivated these informal task-shifting practices. The authors assert that provision of services related to NCDs both partially support health system functions and address unmet needs but could also lead to variable care quality and safety. The authors recommend ways to mitigate potential adverse impacts and to strengthen CHW roles in the health system, including: a stronger enabling policy environment to support NCD task-sharing; investment in continuous CHW capacity building; improved guidelines for implementation at the point of care, and improved coordination processes between PHC and higher-level facilities. In their original research, Smithwick et al. conducted a mixed-method study on the limited professional and career building pathways for CHWs contributing to lower wages, lack of career advancement, turnover, attrition, and workforce instability. Study findings stressed the importance of retaining skilled and experienced CHWs and educating health professions about CHWs' critical roles, which will decrease attrition, enhance professional growth, and improve program quality. Findings also suggest that higher wages, valuing lived experience over formal education, and participation in additional training opportunities should constitute the primary factors considered for career advancement.In addition to building CHW capacity and organizational readiness, organizations successful in CHW integration share some common strategies. Success begins with the right recruitment—individuals from the communities they serve with lived experiences who demonstrate key CHW qualities and attributes . SeveralKillough et al. present a brief research report on CHW's unique perspectives of frontline CHWs who identified actionable barriers and facilitators that may impact representation of diverse groups in health research. As trusted members of the community, CHWs recognize their roles as facilitators in ensuring their community receive resources and benefit from being involved in research; as gatekeepers, CHWs take on the role of protectors so their community doesn't experience further trauma when engaging in research. Bush et al. present original research focused on the evaluation of a CHW-led self-management blood pressure (SMBP) program, which strove to improve hypertension management through raising awareness, education, navigation, advocacy, and resource assistance. Outcome measures indicate this CHW-led intervention improved management of hypertension through education on lifestyle changes  impacting overall health and quality of life.As more CHWs become integrated into public health and healthcare systems, assessing the continuous impact CHWs have on population health management outcomes is important. These assessments are often criticized for lacking proper methodologies or participants' protection, especially those in more vulnerable populations. Nielsen et al. share their lessons learned through an evaluation of the impact of the CHW certification in Massachusetts. Through a CHW survey pre-certification in 2016 and post- certification in 2021, they report on the 5-year efforts to a statewide CHW certification, as well as the impact. Their findings also revealed important gaps in the CHW research that are much needed to build a broader bank of knowledge in this area.With any profession, validation of their competencies through some process of certification, licensure or registration is required. These requirements are more stringent for those working in healthcare settings. For the CHW workforce, more states have adopted or are examining CHW certification, which are often tied to requirements for billing, which in turn have direct implications on sustainability. This Research Topic of eleven articles highlighted the following key areas needing further examination in order to continue to strengthen the community health worker practice. First, CHW programs, employers, and supervisors must acknowledge and commit to involving CHWs in all aspects of programs, leadership, and decision-making, aligning with “Nothing about us without us.” Further research is needed on how to engage CHWs equitably. Second, the CHW practice has moved from acknowledging the essential role of CHWs to establishing and implementing a vision for CHW integration. The COVID-19 pandemic exposed many disparities and layers of population health management where CHWs can play impactful roles, especially in healthcare settings. Future studies can focus on actual integration practices of this vital workforce into complex systems and the impact value of CHW-integrated practices and CHW roles. Finally, funding support for CHW sustainability is still a major issue. More studies are needed on developing funding models to sustain the workforce. This Research Topic may not offer a complete picture but rather insights to building the CHW workforce and elements for strengthening the practice. We hope these articles shed new knowledge to inform and guide your practice. We also hope to build on efforts in these two issues that make up this Research Topic to lift up unheard community members, CHWs, and other voices in frontline practice settings to help us deepen our understanding of the field. We also expect to build on the tradition of CHWs playing roles as Peer Reviewers in future editorial endeavors to ensure authentic representation of voices—and most importantly, the accurate representation of CHW practice in published work about the CHW field.LL: Conceptualization, Methodology, Writing—original draft, Writing—review and editing. JJ: Conceptualization, Methodology, Writing—original draft, Writing—review and editing. DF: Conceptualization, Methodology, Writing—review and editing. ER: Conceptualization, Methodology, Writing—review and editing.


Poor health-related behaviours are root causes of a large number of chronic conditions; however, this study is the first to develop guideline-based quality measures targeting health-related behaviours through generic non-pharmacological secondary prevention and rehabilitation in municipal primary health care for persons with chronic conditions.n = 11) was established and included a patient representative, health care professionals, researchers, and key specialists. The process for developing quality measures was led by methodologists and encompassed a modified Research and Development/University of California at Los Angeles (RAND/UCLA) study to evaluate consensus in the expert panel. The consensus recommendations were directed to a steering group including the Danish Ministry of Health, the Danish Regions, and the Local Government Denmark.From January 2020 to September 2021, a consensus study was conducted in accordance with the current scientific recommendations for developing guideline-based quality measures. A clinical expert panel (The expert panel rated 102 clinical practice recommendations. Consensus was demonstrated on 13 quality measures assessing whether the patients are offered participation in and adhere to: self-management, smoking cessation, physical exercise training, nutritional efforts, and preventive consultation on excessive alcohol consumption; whether the patients participate in a closing meeting, whether they are offered follow-up, and whether reasons for dropout are documented.The identified quality measures constitute a framework for assessing the quality of non-pharmacological prevention and rehabilitation in municipal primary health care for persons with chronic conditions. The next steps focus on field testing of the quality measures to refine measure criteria and assess implementation. A close link between clinical practice, the evidence and practice recommendations, the data infrastructure, economic considerations, and national priorities was a key to the consensus process. Chronic conditions often transcend disease groups , and theIn 2019, The Local Government Denmark initiated a programme on behalf of the Danish Government with the aim of establishing a framework for nationwide quality assessment of non-pharmacological secondary prevention and rehabilitation in municipal primary health care for persons with chronic conditions. This included the development of generic QMs addressed in this consensus study. The clinical topic of the QMs was selected and operationalized a priori to the consensus study by a dedicated expert panel . AccordiThe objective of this study was to develop QMs for generic non-pharmacological secondary prevention and rehabilitation for persons with chronic conditions in primary health care .A consensus study was conducted from January 2020 to September 2021. Dedicated methodologists and researchers  led the study using the methodological framework demonstrated in the This study follows the most recent scientific recommendations for developing guideline-based QMs , and foln = 5), a patient representative (n = 1), key researchers in the area of chronic conditions, cross-sectoral care, and rehabilitation of whom one represented the hospitals (n = 2), and key experts representing the Danish Health Authority’s official clinical practice recommendations for chronic conditions (n = 1), the national infrastructure of the approximately 80 official clinical quality databases (n = 1), and the IT-infrastructure in primary health care (n = 1). A representative of general practice declined to participate. The expert panel was assembled based on the following criteria of representation: relevant reflection of disciplines, sectors and geographical areas, the patient perspective, and key clinical and quality infrastructure specialists.The interdisciplinary clinical expert panel of 11 members included frontline staff and leaders of primary health care rehabilitation centres  were analysed by a common classification used: ‘No consensus’ (median score 0–3), ‘Uncertain’ (median score 4–6), and ‘Consensus’ (median score 7–10) . ConsensBetween 9 (81.8%) and 11 (100%) of the panel members participated in three formal meetings, the online review of the official clinical practice recommendations, and two surveys . The expThe panel members disputed the lack of high-quality evidence on generic care pathways for chronic conditions; for example, translating the QMs for adherence to the care components into measurable fractions with clearly defined numerators and denominators are challenged by the lack of evidence. Also, concerns were reported about the lack of infrastructure related to data and IT-systems as well as the burden of data collection in terms of time and costs. Integrating registrations in the existing electronic patient records was perceived essential in order to reduce the burden. Furthermore, the expert panel members stressed the importance of coherence between the quality assessment in the municipalities and the established infrastructure of the clinical quality databases  in order to assess cross-sectoral care.The identified set of QMs constitutes a framework for assessing the quality of non-pharmacological secondary prevention and rehabilitation in municipal primary health care for persons with chronic conditions targeting healthy lifestyle and self-management. Key to the consensus process was a close link between the clinical practice, existing clinical practice recommendations based on the highest level of evidence, and strategic partnerships to safeguard economy and coherence with the national IT- and quality infrastructure.The study adheres to the most recent scientific recommendations for developing guideline-based QMs  and is rThe results of this study promote an individualized multidisciplinary programme of interventions that support healthy lifestyle and self-management as well as scheduled follow-ups . This isThe expert panel members raised concerns about the burden of data collection. This agrees with previous research demonstrating that difficulties in reaching consensus on guideline-based QMs predominantly concern feasibility and economical judgements . Also, dThe Global Burden of Disease study 2019 calls for rehabilitation to be brought close to communities as an integral part of primary health care , and theThe QMs constitute a framework for assessing and improving the quality of non-pharmacological secondary prevention and rehabilitation for persons with chronic conditions in municipal primary health care. The next steps focus on field testing of the QMs to refine measure criteria and assess implementation.mzad097_SuppClick here for additional data file.


Fellowship accreditation is crucial to ensure adequate clinical education for physicians in training, yet there is limited data on use of accreditation survey results for program quality improvement. The Accreditation Council for Graduate Medical Education (ACGME) administers annual surveys to trainees and core faculty to monitor education and identify potential non-compliance with ACGME accreditation standards. Our purpose is to describe the creation of an internal program review process for program improvement based on results of nationally implemented accreditation surveys.We collected data from standardized ACGME survey responses administered to core faculty and fellows at our academic Infectious Diseases fellowship program. The identification of areas scoring lower than 20% in comparison with national average prompted creation of a Special Program Review (SPR) committee comprised of a program director, a program coordinator, and a trainee from programs outside of the program under review. This committee met separately with core faculty, trainees, and program leadership to compile an assessment of each survey component and opportunities for improvement. This review process of survey results was completed annually from 2020-2022.Between 2020-2022, surveys were completed by 100% of fellows (7/7 or 8/8) and up to 92% of core faculty (11/12). Key findings raised concerns involving clinical education, faculty supervision, patient safety, and teamwork. Actions taken in response to the SPR included the creation of: an updated backup and weekend coverage system, new didactic curricula, a morbidity and mortality conference, documentation limits, informal fellow/faculty dinners, opt out counseling, and a division culture committee.A non-punitive internal review process mimicking accreditation standards is valuable for program assessment and improvement as means to identify areas of risk for accreditation issues at a national level. This review process is generalizable, as all accredited programs complete the survey annually. The quality improvement interventions taken will differ depending on survey findings and areas to be addressed.All Authors: No reported disclosures