This scoping review sought to describe the policy actions that urban local governments globally have implemented to facilitate healthy and environmentally sustainable diet-related practices.Urban local government authorities.Five databases were searched to identify publications which cited policies being implemented by local governments within the 199 signatory cities of the Milan Urban Food Policy Pact (MUFPP) that targeted at least one healthy and sustainable diet-related practice. Grey literature was then searched to retrieve associated policy documentation. Data from both sources were charted against the MUFPP’s monitoring framework to analyse the policy actions included in each overarching policy.n 29; 81 %), considered health , equity  and the broader food system beyond dietary consumption . Of the 66 policy actions described, the most common involved food procurement within public facilities  and establishing guidelines for school-feeding programs .From 2624 screened peer-reviewed studies, 27 met inclusion criteria and cited 36 relevant policies amongst signatory cities to the MUFPP. Most were from high income countries (This review has demonstrated that urban local government authorities are implementing policies that consider multiple phases of the food supply chain to facilitate population-wide uptake of healthy and sustainable diet-related practices. Opportunities exist for local governments to leverage the dual benefits to human and planetary health of policy actions, such as those which discourage the overconsumption of food including less meat consumption and the regulation of ultra-processed foods. The EAT-Lancet Commission advised that to nourish a growing population within planetary boundaries, ‘nothing less than a Great Food Transformation’ is required, including a global shift towards healthy and sustainable diets, p448. To achieve planetary health, that being ‘the health of human civilisation and the state of the natural systems on which it depends’ p1978, effective governance at global, national and local levels is critical,8,9. At a national level, governments have committed to meet targets set within the UN Sustainable Development Goals, the Paris Climate Agreement and the Decade for Action on Nutrition. These national commitments require local action, whereby ‘municipalities – with their close connections to residents, local businesses and civil society organisations – are key to the implementation of most SDG’, p10.Our planet’s ability to sustain human life into the future is under immediate threat. The global food system is creating more greenhouse gas emissions than any other single contributor, depleting natural resources such as land and water, and driving biodiversity loss. It has been argued that local authorities which govern urban cities have a role to play in this food system transformation,7. Hosted in Milan , the World Expo 2015, brought together government stakeholders, civil society, non-government organisations and corporations to determine how the world can sustainably nourish a growing population. In the lead up to this event, the Mayor of Milan led a dialogue on the role of urban cities to achieve this, amongst leaders from 46 cities and an advisory group representing relevant international organisations and scientific experts. This resulted in the development of the Milan Urban Food Policy Pact (MUFPP), the first International guide on urban food policies, which was launched at the World Expo 2015. Delegates from over 100 cities globally signed the Pact, publicly committing to developing sustainable food systems that are: (i) inclusive, resilient, safe and diverse; (ii) provide healthy and affordable food to all people in a human rights-based framework and (iii) minimise waste and conserve biodiversity while adapting to and mitigating impacts of climate change,17. A review conducted by Candel (2019) identified that approximately one-quarter (n 23) of MUFPP signatory cities had developed local food policies. His review described the commonalities and differences between food policies designed to affect dietary consumption by targeting any phase of the food supply chain, from food production to waste. Missing from the literature, however, is a comprehensive description of relevant policies and their associated policy actions which specifically target the consumption phase of the food supply chain, as a component of the broader food system. With local government authorities proposed as critical stakeholders in shifting population diets, this review provides valuable insight as to where current policy action is being focused and where gaps exist,16.By 2030, it is anticipated that 60% of the global population will live in urban areasConducted through a public health nutrition lens, this scoping review was undertaken to document policies cited in the peer-reviewed literature that local governments within MUFPP signatory cities have implemented since 2015, to target desirable healthy and sustainable diet-related practices.,20,21 was used with reporting conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines,23. Scoping review methodology was used due to the broad nature of the research question and to allow for an emerging body of research to be explored and evidence from diverse sources to be included, regardless of quality,24. A review protocol was registered with the Open Science Framework.A 5-staged approach for scoping reviewsPolicy’ refers to the over-arching planned approach to achieve pre-determined, desired outcomes. ‘Policy actions’ refer to the activities included in the strategic plan developed in order to achieve the overarching policy objectives. ‘Healthy and sustainable diet-related practices’ refer to the specific activities that an individual engages in to source, store, prepare, consume and dispose of the food that makes up their overall diet. For example, a municipality may have a Local Food System Strategy (policy), which includes a community garden (policy action) to promote increased consumption of locally grown fruit and vegetables (diet-related practice).To explain the sequential approach taken for this review, an understanding of the following terminology is required. ‘To describe the types of policy that local governments globally are implementing to promote the uptake of healthy and environmentally sustainable diet-related practices, these sub-questions were considered: (1) Which healthy and sustainable diet-related practices are local governments targeting? (2) What is the relationship between the broader geographical, economic and political context and the rationale for the type of policy that has been implemented? (3) Are these policies part of a broader intervention? (4) Is health, equity and the broader food system considered? If so, how? (5) Is evaluation of these policies being planned for? If so, how? Is evidence used in the design and implementation of these policies? and (6) If so, how?, p7. Healthy and sustainable population-level reference diets and recommendations to inform dietary guidelines have since been derived from the large body of evidence,27. However, for the purpose of this review, a comprehensive list of specific diet-related practices for policy-makers to target was required. As this did not exist in the literature, these were defined by the authors and reported elsewhere. Thirteen diet-related practices were identified and categorised ; ‘local government’  AND ‘policy’  AND ‘food’ (diet) AND ‘environmental sustainability’ . Results were exported via Endnote into Covidence software to facilitate collaborative screening.Five databases , were searched on July 29, 2019, filtering for papers published in English after 2015, when the MUFPP was established. The search combined the following terms with their synonyms (n 199 cities as of 1st August 2019), focus on urban settings and be published after 2015. Restricting the sample to only signatory cities of the MUFPP was done to restrict the size of this study and to refine the scope by identifying policies from cities that had publicly committed to improving both health and sustainability outcomes of their local food system. Hawkes and Halliday’s (2017) holistic definition was adopted to inform the inclusion criteria, whereby they define urban food policy as ‘a concerted action on the part of city government to address food-related challenges… grassroots, citizen-led actions that are independent of governments do not constitute urban food policies per se’, p9. For the purpose of this review, this definition of urban food policy was adopted whereby single-issue policies as well as multi-faceted policies, often with an integrated, holistic approach beyond food, were considered.To meet inclusion criteria for this review Table , studies. The lead researcher (Author 1) completed data extraction on all items with fortnightly review  to further refine the extraction process and inclusion criteria to ensure included studies enabled the research questions to be answered comprehensively.Two researchers (Authors 1 and 5) completed the screening of titles and abstracts, with a third (Author 3) engaged to resolve discrepancies. Full-text papers were retrieved (Author 1) and each assessed against the inclusion criteria by 2 researchers . Data extraction using Microsoft Excel was piloted via double-extraction  with a subset of 6 papers to check for accuracy and consistency. As per the non-linear and iterative nature of scoping review methodology, the data extraction method was refined based on consultation throughout this double-extraction processData extraction from included peer-reviewed publications; year, authors, title, citation, study aim, study design, targeted population, cited policy(s), MUFPP signatory city and key findings.Retrieval of associated policy documents from the grey literature  cited by publications identified in step one. The policy title was entered into Google (incognito mode) and the first 10 results were scanned to find the documentation that was most relevant and recent, the most primary source (media commentary was excluded) and reported in English (or translation provided). Retrieval of cited policy documents was conducted between January and April 2020; and, consideration of health, equity and the broader food system, planned evaluation, effectiveness of the policy and process for integrating evidence into policy development. Where detail was missing from the policy documents, the peer-reviewed publication from step one was reviewed to populate the spreadsheet.Data were extracted from the retrieved policy documents, as follows: name and location of policy, MUFPP signatory city(s), related policies, policy aim, description of policy actions, role of local government, targeted diet-related practice(s), category(s) of action according to the MUFPP Monitoring FrameworkTo answer the research questions, a 3-staged process was followed to chart the data: . To answer the research question, all policy actions described within the policy documents were identified and mapped against the MUFPP’s Framework of Action. This framework, developed by the Food and Agriculture Organisation in consultation with signatory cities, is organised into 6 categories,17. Directed content analysis was used to categorise each of the policy action. Descriptive analysis was then used to derive a count of frequency, geographic and economic context, and targeted diet-related practice from the charted data. All authors approved final categorisation and reporting of results.A modified PRISMA flowchart was completed to report the sources of peer-reviewed publicationsThe original database search yielded 2624 results, from which 147 remained after removing duplicates and screening the title and abstract ,54,55,56 most applied qualitative research methods (n 21) and used either content, document or policy analysis (n 16), interviews (n 11) or case studies (n 10) to address study aims . Most studies targeted local government stakeholders such as leaders and city planners (n 21), while approximately one-third included stakeholders from other levels of government (n 9) and several engaged primary producers of food (n 3).Of the included studies . Most policies were implemented in cities within a high-income country , with the majority in Europe and Central Asia  , rather than merely consultative  or as a funding source . Example policies include ‘Ghent en Garde’, a local food policy (Belgium), the ‘San Francisco Zero Waste’ commitment (USA) and the Nairobi Urban Agriculture Promotion and Regulation Act (Kenya).Thirty-six policies which met inclusion criteria were cited in these studies (see online %) Table . Most powhere to source food , with increasing intake of plant-based foods , in the what to eat category and adopting waste minimisation strategies  in the how to eat category, also targeted frequently. Some policies targeted action across all 6 phases of the food supply chain , or at least 2 phases , while few  focused on just one phase. The majority of policies considered health , equity  and the broader food system, beyond either the consumption phase of the supply chain or the local government’s geographic boundaries . Many policies described elements of evaluation , such as measurable targets, partnership with research institutions or data collection tools.Within these policies, the most commonly targeted healthy and sustainable diet-related practices were those within the category of n 14; 39 %) or the process used to integrate this evidence . The type of evidence described to inform the policy-making processes included government statistics, resident concern, advocacy led by community organisations and grey literature. Of the policies that did report on the way this evidence was integrated into the policy-making process, approaches ranged from public meetings, roundtable events, stakeholder workshops, formal prioritisation processes, farmer forums, women-led community consultations, surveys, speaker sessions and advisory group meetings. Individuals involved in these processes included government employees, citizens , primary food producers, lawyers, researchers, chefs, procurement officers, social planners, funders, gardeners and teachers. These details are available in the ‘policy development’ section of S6: Data extraction from policy documents.Supplemental Material Many policies failed to report on the type of evidence used to inform the policy-making processes  and the least number of actions aligned with the food supply and distribution category . The policy actions most frequently described however were in the food supply and food distribution category and involved food procurement for food service in public facilities , establishing guidelines for school feeding programs  and allocating urban garden plots for food production and education opportunities for people experiencing disadvantage . In observing the regions, most of the 11 policy actions which targeted social and economic equity outcomes were implemented in North America , compared with Europe and Central Asia , Latin America and Caribbean  and Sub-Saharan Africa . Food waste policy actions were only identified in Europe and Central Asia  and North America . Not all policy actions could be linked directly to specific healthy and sustainable diet-related practices however most targeted multiple practices. Based on this analysis of policy actions, of the 13 desirable healthy and sustainable diet-related practices, those most commonly targeted were waste-minimisation practices , selecting food grown using sustainable food production practices valuing and respecting Indigenous knowledges , strengthening local food systems by connecting with primary producers  and eating locally available foods Within the 36 policies, a total of 66 policy actions were identified with actions falling into all 6 categories of the MUFPP Monitoring Framework Table . The higThis review demonstrates the leadership role played by local governments in developing and implementing policy to promote the uptake of healthy and environmentally sustainable diet-related practices. Existing policies have been mapped against the MUFPP Monitoring Framework to characterise and identify gaps in policy action and highlight exemplars, as described within the following key observations., p14. The High-Level Panel of Experts on Food Security and Nutrition (2017) also supports this whole-of-system approach, and recommends that action across the food supply chain is critical to influence peoples’ dietary patterns. Although beyond the scope of this review, further research is warranted to explore the capacity of local governments to support multi-sectorial governance with monitoring and evaluation to measure the impact of this whole-of-system approach.Many of the policies led by local government to facilitate the uptake of healthy and sustainable diet-related practices adopted a holistic approach. That is, policy action was directed across multiple phases of the food supply chain, rather than simply focusing on the consumption phase, and health and equity were considered in the desired outcomes. A core value in effective urban food policies, as identified by Sonnino (2019), is taking this systemic approach to food, where all phases of the food supply chain are considered and food’s ‘multidimensional connections with different social contexts, sectors and other community systems’ is acknowledgedGhent en Garde which demonstrated a holistic approach. Ghent en Garde included activity across the food supply chain including production , distribution , retail (e.g. farmers markets), consumption (e.g. public facilities serving less meat and more plant-foods) and waste . The Ghent en Garde policy aims to improve health by updating tender processes for public facility food services , ensuring that all food served at publicly funded events on Thursdays is vegetarian, and raising citizen awareness through social marketing campaigns to eat less meat, and consume more local, organic and seasonal foods. Ghent also invested in strategies to address equity such as creating social employment through food, in social restaurants, social grocers and in local production and distribution of food.This review highlighted a number of comprehensive local government policies, such as Belgium’s Bristol’s Good Food Action Plan presents another example of a holistic approach, by linking with neighbouring local governments, transforming unused public land into edible gardens and acknowledging the value of good quality soil and insect pollinators for local food production. Bristol defines good food as ‘not only tasty, healthy affordable, but also produced and distributed in a way that is good for nature, workers, animal welfare and local businesses’. This policy addresses health by supporting schools to achieve the Mayor’s Award for Excellence by including nutrition, health and gardening in the curriculum and connecting emergency food relief services with local producers of fresh, healthy food. Bristol also piloted a campaign, ‘Flexitarian City’, by promoting a flexitarian diet in local restaurants and communities. In considering equity, urban agriculture initiatives allocate garden plots for people seeking asylum and the Kitchen on Prescription program involves prescribing accessible cooking, gardening and nutrition training opportunities for individuals experiencing disadvantage. Local governments are demonstrating a holistic approach to food system transformation by considering equity in their policy actions; this could be strengthened however as not all local governments had considered this.food supply and distribution category of MUFPP’s framework for action. Policy actions from this category included investment in infrastructure, technology and transportation to connect consumers with producers, revitalisation of local food manufacturing, processing, distribution and storage businesses through tax exemptions and expanding alternative retail options to connect consumers with producers. The reason why this category had the least policy options requires further research. It may be that local governments do not consider this area to be part of their mandate, or perhaps a gap in competency and knowledge exists at the local level relating to these activities, requiring funds and resources from national governments to address this gap.Local government policy actions were found to target multiple phases of the food supply chain to shift dietary patterns. However, this review yielded the least policy actions for the . Local governments have a unique role in operationalising ‘on the ground’ action to enable nations to achieve ambitious global sustainable development targets,62. As the level of government closest to their constituents, they can be more agile and responsive to changing needs and innovation opportunities than national governments, moving more rapidly from the agenda-setting phase to policy implementation,62. This review identified that local government authorities played a role of leadership or ownership in policy action for the majority of policies, rather than one of stakeholder representation or consultation. This highlights internal commitment to make urban food systems more sustainable, resilient and equitable, as demonstrated by these cities’ pledges to the MUFPP.It has been argued that local government is critical to achieving the ambitious global and national targets needed for food sustainability is one of these, and others include the C40 Good Food Cities Declaration (https://www.c40.org/other/good-food-cities), and regional networks such as Europe’s Edible Cities Network (www.edicitnet.com). Second, opportunities to enhance capacity were shown to exist within local governments themselves. McCartan and Palermo also found that food policy councils led by local government can provide a forum to combine practical and technical expertise across sectors, and increase capacity through partnerships in an environment where funding is often limited. Third, strategies to connect researchers with local governments facilitated the translation of evidence into practice and enhanced knowledge about the relations between food systems  and between phases of the food supply chain (e.g. supply and distribution). Finally, policies identified in this review engaged citizens and professionals with technical expertise in decision-making. Examples of this included establishing producers’ networks to facilitate urban, peri-urban and rural linkages, and logistics, nutrition and sustainability experts to inform land use, zoning and new building requirements.A range of policies was identified which have effectively enhanced local government capacity to lead policy action. First, formal structures and networks outside of local governments were shown to facilitate collaborative action and collective capacity and provided opportunities for local government leadership. The MUFPPet al. (2015). Publicly funded settings such as schools, hospitals, community centres, prisons and early learning centres are suitable settings for local governments to fulfil their commitment to achieve planetary health targets. These settings serve large and socio-economically varied groups of people and can shape consumers’ behaviour through their regular interaction with the food environment. Local governments may possess regulatory and legislative powers to manipulate these food environments, and align government spending for food procurement, supply and promotion with public priorities.Food procurement policies in schools were identified as a popular approach by local governments to promote healthy and sustainable diet-related practices and induce systemic change across the food supply chain, as has previously been described by Hawkes et al. (2015) concluded that Brazil’s Family Farming program which uses legislation to enforce 30 % of Brazilian government funding is used to buy food directly from local family farms, increased the nutritional quality of school menus. These examples demonstrate that although focused on one setting, food procurement policies can trigger action across phases of the food supply chain and facilitate a number of healthy and sustainable diet-related practices.Some procurement policies were enforced nationally, yet implemented at the local government level , and others were developed at the local level in Vienna (Austria), Ghent (Belgium), Copenhagen (Denmark), London (United Kingdom), New York City and San Francisco (United States of America). Policy actions included in this review comprise: use of tender processes and legislative mechanisms to promote organic, local, fair-trade food production practices; eco-friendly food packaging and transport; and, school menus with less processed and animal-derived foods and more plant-based and nutritious foods. Comment on the effectiveness of these policies is beyond the scope of this review, however, Goncalves ,4. According to Springmann (2020) practices with the greatest potential to improve health and sustainability are those which limit animal-derived foods, in particular beef and dairy, increase wholegrain and plant-based foods and avoid over-consumption. This discussion will therefore describe how local governments are promoting these 3 desired practices in particular, and identify some of the trade-offs that exist as well as opportunities to achieve double-wins for human and planetary health.While all 13 healthy and sustainable diet-related practices are important to achieve food system transformation, particularly in middle and high-income contexts, some have greater potential than others. This review identified that local governments are promoting less animal-derived foods by updating school feeding guidelines, incentivising procurement practices in commercial and public food service facilities and investing in social marketing campaigns. Policy documents describe the environmental impact of eating less meat as a more dominant message than the health benefits thereof.First, actions to limit the intake of animal-derived foods were identified in less than a third of policies. Eating less animal-derived foods has been demonstrated to improve health, by lowering mortality risk from CVD and some cancers, and reduce environmental degradation, by reducing greenhouse gas contribution, water usage and biodiversity loss.In considering approaches to increase wholegrain and plant-based food intake, actions targeting this practice were identified in nearly three quarters of the policies included in this review. It is important to note that the health and environmental benefits rely on the adoption of sustainable agricultural practices and various trade-offs exist. For example, while organic farming is more environmentally sustainable, there are consequences for food security because yields may be lower and produce is often more expensive to purchase. This review identified that local governments are promoting plant-based food consumption by investing in urban agriculture, redirecting rescued fresh produce to emergency food relief services and connecting producers with consumers through alternative retail avenues such as farmers markets. Local governments often framed these policy actions as achieving social and economic benefits, acknowledging that poor fruit and vegetable intake is disproportionately experienced by people experiencing disadvantage, however they were less likely to describe the environmental benefits,67,68. For example, New York City’s Food Standards (2011) policy was primarily intended to reduce diet-related disease by reducing over-consumption, but included sustainability considerations in its supporting documentation.The third diet-related practice to discuss in relation to win-wins is the avoidance of over-consumption of food beyond biological requirements. This practice was promoted by one-third of identified policies, however these primarily focused on the health benefits of reducing overweight and obesity. The environmental benefits of avoiding overconsumption of food are being overlooked, despite convincing evidence that this diet-related practice will reduce deforestation, biodiversity loss, ocean acidification, air, water and soil pollution which result from producing food not deemed essential to nourish life,4,65. However, this win-win scenario is complicated by trade-offs which challenge local governments to simultaneously promote health, social justice and environmental sustainability. For example, in promoting organic food production to benefit human health and the environment, governments must consider the lower yields, higher land requirements and increased cost to consumers. To address these complex trade-offs, trans-disciplinary evidence from health, nutrition, environment, the social sciences and beyond must inform policy action to support best-practice across the entire food supply chain.There is an increased urgency being placed on policy-makers to consider both health and ecological implications of the food system and dietary recommendationsAs described above, this review presents 4 key observations to inform future policy action: (1) a holistic approach is being taken by local governments, with consideration of the broader food system, health and equity; (2) local government authorities can lead local action towards global planetary health targets however require enhanced capacity; (3) publicly funded facilities are suitable settings for holistic policy to be implemented; and (4) progress is needed to promote the double win  of recommended diet-related practices. however this is just one publication within a large, and rapidly expanding body of evidence to describe healthy and sustainable diets.The scope of this review was refined to include an exploration of policies that were cited within literature sourced from scientific databases. This presents some limitations: (i) policies from low-middle income countries have not been adequately represented most likely due to variance in the degree to which governments can engage academic resources to publish outcomes of policy action; and (ii) current best practice examples may have been missed simply because they have not yet been published in the scientific literature. In refining the scope to MUFPP signatory cities, this review does not include the many progressive policies that exist globally that are independent to the MUFPP movement. To identify relevant policy actions, this review referred to 13 diet-related practices identified by the authors in a previous study. Likewise, research into the effectiveness and cost-efficiencies of the policies identified in this review, across a range of geographic contexts, is recommended in order to support local governments to develop and implement policies that have the best chance of achieving food system transformation to improve human health and environmental sustainability.Further research is required to explore the intricacies of local government policymaking, such as how policies and their goals are prioritised, why some policy actions receive investment over others and how success and failure can effectively be definedThis scoping review identified policies that promote healthy and environmentally sustainable diet-related practices. Local governments are considering both health and equity in their choice of policy actions to shift population-level diets; engaging a diverse range of stakeholders in the policy-making process; creating governance structures which connect with neighbouring areas and key stakeholders; and using public procurement policy actions as a common strategy to address wide-ranging challenges across the food supply chain.Local government authorities, at the interface between citizens and state and national decision-makers, have a critical role to play in shifting population-level food consumption. This review showcases policies from cities committed to the MUFPP, to inform local government authorities seeking a more comprehensive policy response. By localising global sustainable development targets, food policy can promote healthy and sustainable diets to drive the food system transformation required to sustain human lives into the future, within planetary boundaries.


Effective actions for the fishery and aquaculture sectors to contribute toward improving nutrition rely on an understanding of the factors influencing fish intake, particularly amongst vulnerable populations. This scoping review synthesises evidence from 33 studies in the African Great Lakes Region to examine the influence of food environments on fish acquisition and consumption. We identified only two studies that explicitly applied a food environment framework and none that linked policy conditions with the contribution of fish to diets. Economic access to fish was represented in the largest number of included studies (21 studies), followed by preferences, acceptability and desirability of fish (17 studies) and availability and physical access (14 studies). Positive perceptions of taste and low cost, relative to other animal-source foods, were drivers of fish purchases in many settings; however, limited physical and economic access were frequently identified as preventing optimal intake. In lakeside communities, fish were increasingly directed toward external markets which reduced the availability and affordability of fish for local households. Few studies considered intra-household variations in fish access according to age, gender or physiological status, which represents an important knowledge gap. There is also scope for future research on seasonal influences on fish access and the design and rigorous evaluation of programmes and policies that address one or more constraints of availability, cost, convenience and preferences. Achieving sustainable, equitable and large-scale improvements in food and nutrition security is amongst the greatest global challenges. Progress to date has been uneven, with recent estimates that one in three people 33.6%) in Eastern Africa is chronically undernourished . Of 41 c3.6% in EInternational development agencies, researchers and funders increasingly seek to position specific commodities or sectors in relation to wider food systems. There is value in operationalising food systems frameworks within a “whole-of-diet” approach : to idenFish provide a rich source of bioavailable micronutrients, long-chain polyunsaturated fatty acids (PUFAs) and high-quality protein and have the potential to increase the nutritional adequacy of diets based on staple foods . In manyWhile capture fisheries will continue to provide the majority of fish to African diets, fish imports and aquaculture are expected to grow and may narrow the fish supply gaps in the Eastern African sub-region . ForesigBeyond national fish supply targets, there is a need to consider the temporal, geographic, socioeconomic, cultural, gender and age-related factors that influence the acquisition and consumption of fish and, ultimately, its relative contribution to nutrition and health. Food environment frameworks have not typically been linked to a single commodity, but to consider the ways in which surroundings and circumstances influence the breadth of dietary options and choices which exist within a given setting. Their use has been most extensive in high-income countries, historically associated with the “obesogenic” nature of an environment ,17,18. W2 [The African Great Lakes are amongst the most important freshwater ecosystems globally: rich in aquatic biodiversity  and supp2  and incl2 . The AfrThis paper presents findings of a scoping study conducted to identify factors that mediate fish intake by populations in the AGLR. Whilst previous reviews have examined production trends, supply constraints and linkages with food and nutrition security ,23,24, wThis study follows PRISMA-ScR guidelines to review existing literature, consider the scope and types of knowledge available and identify and analyse gaps in the evidence base ,26. Our Fish* AND (food OR diet* OR nutri* OR consum* OR intake OR eat* OR purchas* OR buy* OR bought OR trade OR acqui*) AND )).a priori by specific themes or dimensions of a food environment. The search was conducted in April 2021, using Web of Science and Scopus. Returned articles were exported to EndNote reference manager for removal of duplicates, title and abstract screening, article examination and data extraction. This process was conducted by two researchers, with consensus reached on the inclusion and exclusion of articles. Our review considers both quantitative and qualitative research findings. All study designs were eligible for inclusion, including case studies, cross-sectional studies and impact evaluations. We included studies published since 2010 in peer-reviewed journals in English. Charting of data involved extraction of details on research design, geographic location, sample size, population group, relevant methods and indicators, key findings, authors and year of publication  avaAs shown in Availability and physical access to fish were most commonly described in terms of proximity to water bodies. Inclusion of small fish as part of a common meal for young children in Bukoba District in Tanzania, but not in Kiboga District in Uganda, was attributed to the former communities being close to Lake Victoria . SimilarWe found only one study that examined direct participation in fishing activities as a predictor of household fish consumption. Fishing households consumed fish more often and in larger quantities compared to non-fishing households, regardless of wealth, but this effect was greatest amongst poor households . In the Five studies examined fish availability and access in the context of markets. In Tanzania, a twofold higher likelihood of fish consumption in Morogoro Region, compared to Dodoma Region, was attributed to greater market access . A studyTwo studies considered the influence of gender on fish access. Qualitative research to characterise the dietary practices of men in central and southern Tanzania highlighted that fish was amongst foods commonly accessed outside the home, from restaurants or street vendors during the course of the day, but uncommon for other family members to consume in household meals . Near LaEconomic access was the most studied dimension of the food environment within studies included in this review. The low cost of fish, relative to meat, was identified as a driver of fish consumption in eastern and western Kenya , southerPrice was the main barrier to fish consumption in Nairobi , where dClarias gariepinus), compared to availability, perceived quality and taste preferences, in rural [Caregivers of young children in Malawi identified fish and meat as “rare foods”, consumed infrequently due to their high price . In contin rural  and urbain rural  settingsin rural .Analysis of nationally representative data from Malawi revealed a higher probability of fish consumption to be associated with greater household wealth, as measured by expenditure quintiles . Poor hoIn a Malawian study that found demand for greater quantities of tilapia to be associated with higher levels of education of household food decision makers, the authors suggested that this reflected higher disposable income . Men andIn rural Malawi, severe food insecurity was associated with a threefold lower probability of consuming fish or meat for pregnant women and a fivefold lower probability for breastfeeding women ; howeverStudies reporting on preferences, desirability and acceptability of consuming fish considered the influence of sensory attributes (14 studies), cultural factors (8 studies) and convenience (2 studies). Around three quarters of low-income urban households in Nairobi  and LusaFindings from Malawi revealed maternal taste preferences for fish  predicted higher fish consumption during the dry season , and tasTanzanian women living by Lake Ruwe reported a preference for oily fish to save money on cooking oil and fish that produced a tasty broth when boiled, suitable for young children . Women iIn low-income urban households in Zambia, a large majority of women (90%) reported no change in fish consumption during their pregnancy or lactation . AmongstFish was named as a special food that should be consumed during pregnancy by women attending antenatal clinics in Lusaka, though women did not convey knowledge about its significance for specific maternal, foetal or infant outcomes . In contThe role of fish in diets was one of the few differences in food cultures between two rural study sites in Kenya, whereby small fish were considered a core food for young children and their households in communities close to Lake Victoria, but not in a drought-prone area of Eastern Province . EthnogrOf five studies that included findings related to food quality, three related to consumers’ understanding of health and nutritional attributes of fish. In areas of central and western Kenya with large numbers of commercial fish farmers, consumers reported perceptions of “good quality” to be the main driver of fish purchases, while very few were guided by health attributes or nutritional value . Women iCaregivers in rural Kenyan communities ranked whole small fish lower than chicken in terms of perceived health attributes for children . In contOne study amongst HIV-exposed children in Blantyre, Malawi, reported a significant increase in fish consumption (22% to 47%) after a six-month nutrition support programme, which included nutrition education sessions that encouraged enrichment of infant porridges with dried or ground small fish . In BlanConcepts and frameworks relating to the food environment are gaining prominence in the Global South; however, to date, studies in which these have been explicitly applied have largely been conducted in upper middle-income countries . In thisAvailability and physical access emerge as key determinants of fish consumption, though often as an inference based on the location of study sites, rather than direct assessment of households’ engagement in fishing activities or opportunities for market purchases. This corresponds with several studies’ findings that a higher likelihood of children consuming fish is associated with proximity to coastal areas or inland water bodies ,63,64. EThe influence of consumer preferences on fish purchases varied between settings, with findings suggesting that product traits such as taste may influence food acquisition to a greater extent in urban areas than in rural areas. In the single consumer acceptance study in this review, consumers responded favourably to a novel processed fish product, which could improve access to a nutrient-rich food with a prolonged shelf-life . FindingWhile most studies included in this review were cross-sectional, many described temporal changes in fish access or intake—including between dry and rainy seasons , followiIntra-household food and nutrient distribution varies between settings, with some included studies describing culturally sanctioned patterns that favour adult men and younger household members over women, and others finding no consistent pattern ,69,70. MOur review has highlighted substantial variation in food environments, even on the shores of the same lake. There is a need for context-specific assessments to understand the social, ecological and economic characteristics of fisheries, and different trajectories and trade-offs with aquaculture development, in the AGLR , and forLow availability and unaffordability of fish was reported to limit fish intake in ten included studies. The fisheries and aquaculture sectors have tended to emphasise the need to increase production volumes; however, concurrent actions to improve safety and efficiency of fish processing also have the potential to increase the contribution of fish to human diets . EnhanceGeographic lengthening of value chains, combined with appropriate processing technologies and market infrastructure, has the potential to enable consumption by greater numbers of people in areas distant to fisheries and aquaculture production systems, including nutritionally vulnerable groups and those in urban food deserts  ,75. SuchDiets that meet global guidelines to maximise both human and planetary health  may be pFish-enriched snack foods or supplements, which take advantage of the peak season for fish capture, may present opportunities to improve the diets of undernourished and nutritionally vulnerable population groups within the region, through convenient and targeted delivery of nutrients at a relatively low cost ,82. BehaAs a scoping review, this paper does not claim to have comprehensively identified all relevant studies on this topic but offers a structured appraisal of the current evidence base and research landscape. An alternative search strategy might include search terms specifically related to dimensions of one or more food environment frameworks. This might yield search results relating to areas under-represented or not identified through our search, such as policy conditions. The search was restricted to English language publications and did not include grey literature, including institutional reports , which may offer additional insights into drivers of food choice.Innocenti Framework, which considers intra-household dynamics, eating patterns and the role of caregivers as mediators of children’s and adolescents’ diets [Decision making about what to eat reflects a complex set of considerations, which vary between settings, households and individuals. The use of food environment frameworks to evaluate food acquisition and consumption—considering fish within the wider diet—can provide sound evidence to guide policy and investment decisions to improve nutrition outcomes. This is particularly urgent in areas such as the AGLR, and Sub-Saharan Africa more broadly, where food and nutrition insecurity is persistent, severe and projected to increase. Identifying differential access to fish between, and within, households is essential to ensure that increases in national fish supply actually translate to nutritional benefits for the most vulnerable. Of recent food environment frameworks, variation in food access between household members is most directly articulated by the s’ diets . ExploriThis scoping study identifies several priorities for future research: (1) capturing temporal variation in fish acquisition and consumption, which is likely to accompany annual seasonal changes, as well as economic, environmental or political shocks that affect availability and affordability; (2) evaluating how expansion of export and urban markets and interregional trade affect fish access in lakeside and more distant communities; and (3) developing interventions, including supply increases, value chain developments or behaviour change strategies, that respond to the identified constraints of cost, availability, convenience and perceptions about quality and suitability for children. Integrated food systems research and development, with a focus on addressing constraints in rural and urban food environments, offers the potential to translate increased fish supply into improved dietary intake and nutritional status of people in the AGLR.


Tinnitus disability is a heterogeneous and complex condition, affecting more than 10% and compromising the quality of life of 2% of the population, with multiple contributors, often unknown, and enigmatic pathophysiology. The available treatment options are unsatisfactory, as they can, at best, reduce tinnitus severity, but not eliminate its perception. Given the spread of tinnitus and the lack of a standardized treatment, it is crucial to understand the economic burden of this condition. We conducted a systematic review of the literature on PubMed/MEDLINE, Embase, the Cochrane Database of Systematic Reviews (CDSR) and Google Scholar, in order to identify all the articles published on the economic burden of tinnitus before 1 April 2021 . Out of 273 articles identified through our search strategy, only five articles from studies conducted in the United States of America (USA), the Netherlands and the United Kingdom (UK) provided data on tinnitus’s economic costs. Three studies provided mean annual estimates per patient ranging between EUR 1544 and EUR 3429 for healthcare costs, between EUR 69 and EUR 115 for patient and family costs and between EUR 2565 and EUR 3702 for indirect costs, including productivity loss. The other two studies reported an annual mean cost of EUR 564 per patient for tinnitus-related clinical visits, and total costs of EUR 1388 and EUR 3725 for patients treated with a sound generator and Neuromonics Tinnitus Treatment, respectively. Our comprehensive review shows a gap in the knowledge about the economic burden of tinnitus on healthcare systems, patients and society. The few available studies show considerable expenses due to healthcare and indirect costs, while out-of-pocket costs appear to be less financially burdensome. Comprehensive health economic evaluations are needed to fill the gaps in current knowledge, using a unified method with reliable and standardized tools. Tinnitus is a continuous auditory perception in the ears or head in the absence of a corresponding external stimulus . TinnituWhen disabling and impacting daily functioning, tinnitus is a heterogeneous and complex condition with multiple associated biological, psychological and contextual contributors, which often remain unknown . MoreoveConsequently, people suffering from this condition try out various possible treatments, one after the other , and refThus, tinnitus management carries a significant financial burden for both healthcare systems and society, including patients . ExpenseGiven the spread of tinnitus and the currently still relatively low investment in tinnitus research , which lThe following scientific databases were considered to conduct this systematic literature search: PubMed/MEDLINE, Embase and the Cochrane Database of Systematic Reviews (CDSR). A search on Google Scholar was also performed in order to identify relevant articles published in scientific journals not indexed in those databases. In addition, the databases of the World Health Organization (WHO), Eurostat and the Organisation for Economic Co-operation and Development (OECD) were consulted to retrieve possible additional relevant information about direct and indirect costs associated with tinnitus and related quality-adjusted life years. The search strategy was designed for PubMed and then adapted for use in the other databases. Search terms included terms for the condition and the considered outcome ). We did not apply any restriction on publication time, considering all scientific articles published in English before the search date. Articles published in a language other than English were excluded from the review. Reference lists of other reviews were also checked to identify other potentially relevant publications.On 1 April 2021, we applied the search strategy. Overall, through PubMed, 137 publications were identified, with an additional 14 on Embase, 28 on CDSR and 170 publications on Google Scholar. Excluding duplicates, we obtained a total of 273 publications .In order to be eligible, studies had to provide data on direct or indirect costs due to the management of tinnitus disability in human subjects. We excluded studies on animals or biological tissues. We did not apply restrictions on the type of study design; thus, studies considered for inclusion were: cross-sectional studies (including population-based surveys on specific sub-populations), case–control studies, cohort studies, clinical trials and case series. Both original articles and reviews were considered, while unpublished studies, conference abstracts and proceedings, dissertations, theses and, more generally, non-peer-reviewed papers were not considered.We combined those publications detected on various databases in an EndNote library . In the first screening, two reviewers evaluated titles and abstracts independently to identify publications that met our inclusion criteria. The reviewers independently assigned scores 1–5 to the articles as follows: 1 = Publication not pertinent or of limited interest for our review; 2 = Publication probably not pertinent or of limited interest; 3 = Not possible to evaluate based on title/abstract/keywords only; 4 = Publication probably pertinent or of interest; 5 = Publication pertinent or of clear interest for our review. After the first screening, the two reviewers’ scores were added, obtaining total scores ranging from 2 to 10. A publication with a combined score of 4 or less was not considered for further evaluation. In the second screening, the full text of all the potentially eligible studies was retrieved and independently assessed for eligibility by two reviewers.For each publication satisfying the eligibility criteria, we collected: (a) general information on the publication , (b) study characteristics , (c) data on direct and indirect costs for tinnitus management, and (d) the model used to compute the estimates (including adjustments). In order to allow for comparisons, all costs were converted from the local currency into EUR . Data extraction was performed using Microsoft Excel and EndNote X7.Out of 273 identified publications, 26 were included after the first screening of titles and abstracts. Of these, only five articles met the eligibility criteria and were included in the present systematic review. No relevant additional information was found in the databases of the WHO, Eurostat and OECD. A cross-sectional study from the Netherlands provided direct and indirect annual mean costs per patient. Total annual mean healthcare costs added up to EUR 1544, patient and family costs to EUR 69 and costs due to productivity loss to EUR 3702 [A randomized controlled trial (RCT) from the Netherlands conducted in 2007–2011 on 492 tinnitus patients estimated annual mean direct and indirect costs per patient divided by usual care (UC) and specialized care (SC). The study provided healthcare costs , patient and family costs  and costs due to a loss of productivity . Thus, estimates for the total annual costs  were EUR 5980 for UC and EUR 6283 for SC .The last eligible included study was a cohort study conducted in the UK, estimating mean annual direct costs expressed as healthcare costs only. The mean annual total healthcare costs were EUR 1938 . IndirecThe costs identified in studies that provided healthcare, patient and family and indirect costs are graphically presented in This is the first systematic review summarizing direct and indirect costs for tinnitus management in the current practice, based on the published scientific literature. Although there is a wide consensus among scientific and clinical professionals that tinnitus is associated with high direct and indirect healthcare costs, our systematic review identified only five studies that calculated costs for tinnitus management ,20,22,23One aspect that emerged from most studies in the scientific literature and other relevant databases was the lack of comprehensive and detailed information on tinnitus costs, except for two studies from the Netherlands. Cost categories ideally include both direct costs  and indirect costs, including societal costs  ,24. ThisIn our systematic review, two of the studies reporting information on the economic burden of tinnitus were conducted in the US ,23, two However, an attempt for a broad estimation of the total costs in the EU could pursue the following path: The first step would be to broadly translate expenses to the average income of these countries and then consider the average EU income. The second step would be to extend these estimates to the whole EU, taking into account that various epidemiological studies estimated a prevalence of tinnitus exceeding 10%, which means that at least 30 million people in the EU live with tinnitus.Additionally, comparisons between countries on the costs of various treatments for tinnitus management are lacking in the current literature. For future health economic evaluations of treatments for disabling tinnitus, consensus on a set of standardized and homogenous evaluative tools is of high importance, in order to facilitate cross-country and cross-study comparisons.Only one study conducted in the Netherlands investigated the impact of tinnitus severity on costs, showing that the more disabled patients had significantly higher healthcare costs compared to patients with mild to moderate complaints . In factTo our knowledge, this is the first systematic review providing a synthesis of the healthcare and societal costs of tinnitus at an individual level in the scientific literature. Strengths of this review include the comprehensive search strategy conducted on a large set of scientific databases, including PubMed/MEDLINE, Embase and the CDSR. Moreover, an additional search on Google Scholar and databases of the WHO, Eurostat and OECD was conducted in order to check for relevant articles published in scientific journals not indexed in the previously mentioned databases. The detailed procedure used for selecting articles and data extraction further assures the qualitative value of this systematic review. Limitations include the relatively small number of included studies, leading to low generalizability of results across countries and across patient groups.https://uniti.tinnitusresearch.net accessed on 1 April 2021). Within UNITI, a large multicenter randomized controlled trial will be carried out in five clinical centers across Europe. The cost analysis methodology of the studies from the Netherlands [This systematic review found only a few studies dealing with the economic burden of tinnitus, none of which were published in recent years (2018–2021). Thus, it is important to be able to make some updated and validated statements about the economic impact of tinnitus on the individual and society. Future studies are needed to provide new detailed data on the healthcare and societal costs for tinnitus. Such studies are useful today because of their implications for health policy . The framework for calculating tinnitus costs must include data from various countries see  and mustherlands ,19 will The current status of the scientific literature highlights a serious lack of studies estimating, in detail, the economic burden of tinnitus on healthcare systems, patients, their families and society. Available studies show considerable expenses due to healthcare costs and indirect costs—mainly costs for productivity loss—while out-of-pocket costs appear to be less financially burdensome. Findings also indicate a direct relationship between tinnitus severity and related costs. Insights from existing studies point to several under-investigated but tinnitus-relevant predictors, such as country of origin, socio-economic factors and individual patients’ sex, age, educational level and tinnitus severity and duration. Identifying the economic burden of tinnitus in various cost categories is crucial to better understand tinnitus healthcare organization and treatment implementation in current practice in various countries and consequently reduce unnecessary costly and ineffective treatment strategies for patients and healthcare systems.


Although the potential of big data analytics for health care is well recognized, evidence is lacking on its effects on public health.The aim of this study was to assess the impact of the use of big data analytics on people’s health based on the health indicators and core priorities in the World Health Organization (WHO) General Programme of Work 2019/2023 and the European Programme of Work (EPW), approved and adopted by its Member States, in addition to SARS-CoV-2–related studies. Furthermore, we sought to identify the most relevant challenges and opportunities of these tools with respect to people’s health.Six databases  were searched from the inception date to September 21, 2020. Systematic reviews assessing the effects of big data analytics on health indicators were included. Two authors independently performed screening, selection, data extraction, and quality assessment using the AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews 2) checklist.The literature search initially yielded 185 records, 35 of which met the inclusion criteria, involving more than 5,000,000 patients. Most of the included studies used patient data collected from electronic health records, hospital information systems, private patient databases, and imaging datasets, and involved the use of big data analytics for noncommunicable diseases. “Probability of dying from any of cardiovascular, cancer, diabetes or chronic renal disease” and “suicide mortality rate” were the most commonly assessed health indicators and core priorities within the WHO General Programme of Work 2019/2023 and the EPW 2020/2025. Big data analytics have shown moderate to high accuracy for the diagnosis and prediction of complications of diabetes mellitus as well as for the diagnosis and classification of mental disorders; prediction of suicide attempts and behaviors; and the diagnosis, treatment, and prediction of important clinical outcomes of several chronic diseases. Confidence in the results was rated as “critically low” for 25 reviews, as “low” for 7 reviews, and as “moderate” for 3 reviews. The most frequently identified challenges were establishment of a well-designed and structured data source, and a secure, transparent, and standardized database for patient data.Although the overall quality of included studies was limited, big data analytics has shown moderate to high accuracy for the diagnosis of certain diseases, improvement in managing chronic diseases, and support for prompt and real-time analyses of large sets of varied input data to diagnose and predict disease outcomes.International Prospective Register of Systematic Reviews (PROSPERO) CRD42020214048; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214048 Big data analytics tools handle complex datasets that traditional data processing systems cannot efficiently and economically store, manage, or process. Through the application of artificial intelligence (AI) algorithms and machine learning (ML), big data analytics has potential to revolutionize health care, supporting clinicians, providers, and policymakers for planning or implementing interventions , faster In 2018, the World Health Organization (WHO) proposed the expedited 13th General Programme of Work (GPW13), which was approved and adopted by its 194 Member States, focusing on measurable impacts on people’s health at the state level to transform public health with three core features: enhanced universal health coverage, health emergencies protection, and better health and well-being .Therefore, the aim of this study was to provide an overview of systematic reviews that assessed the effects of the use of big data analytics on people’s health according to the WHO core features defined in the GPW13 and the EPW. We included complex reviews that assessed multiple interventions, different populations, and differing outcomes resulting from big data analytics on people’s health, and identified the challenges, opportunities, and best practices for future research.This study was designed to provide an overview of systematic reviews in accordance with guidelines from the Cochrane Handbook for Systematic Reviews of Interventions, along with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the QUOROM  guidelines -8. The sTo identify records assessing the effect of big data analytics on people’s health, aligned with the WHO health indicators defined in the GPW13 , a comprReferences were imported into reference management software (EndNote X9) and duplicates were removed. Unique records were uploaded onto the Covidence Platform  for screening, data extraction, and quality assessment. A manual search of reference lists was performed to supplement the search.Number of persons affected by disasters Domestic general government health expenditure Prevalence of stunting in children under 5 (%)Prevalence of wasting in children under 5 (%)Prevalence of overweight in children under 5 (%)Maternal mortality ratio Proportion of births attended by skilled health personnel (%)Under 5 mortality rate (per 1000 live births)Neonatal mortality rate (per 1000 live births)New HIV infections (per 1000 uninfected population)Tuberculosis incidence Malaria incidence (per 1000 population at risk)Hepatitis B incidence Number of people requiring interventions against neglected tropical diseases (NTDs)Probability of dying from any of cardiovascular disease (CVD), cancer, diabetes, chronic renal disease (CRD) (aged 30-70 years) (%)Suicide mortality rate Coverage of treatment interventions for substance-use disorders (%)Total alcohol per capita consumption in adults aged >15 years Road traffic mortality rate Proportion of women (aged 15-49 years) having need for family planning satisfied with modern methods (%)Universal Health Coverage (UHC) Service Coverage IndexPopulation with household expenditures on health >10% of total household expenditure or income (%)Mortality rate attributed to air pollution Mortality rate attributed to exposure to unsafe water, sanitation, and hygiene (WASH) services Mortality rate from unintentional poisoning Prevalence of tobacco use in adults aged ≥15 years (%)Proportion of population covered by all vaccines included in national programs  (%)Proportion of health facilities with essential medicines available and affordable on a sustainable basis (%)Density of health workers International Health Regulations capacity and health emergency preparednessProportion of bloodstream infections due to antimicrobial-resistant organisms (%)Proportion of children under 5 years developmentally on track  (%)Proportion of women (aged 15-49 years) subjected to violence by current or former intimate partner (%)Proportion of women (aged 15-49 years) who make their own decisions regarding sexual relations, contraceptive use, and reproductive health care (%)Proportion of population using safely managed drinking-water services (%)Proportion of population using safely managed sanitation services and hand-washing facilities (%)Proportion of population with primary reliance on clean fuels (%)3)Annual mean concentrations of fine particulate matter (PM2.5) in urban areas (μg/mProportion of children (aged 1-17 years) experiencing physical or psychological aggression (%)Vaccine coverage for epidemic-prone diseasesProportion of vulnerable people in fragile settings provided with essential health services (%)Prevalence of raised blood pressure in adults aged ≥18 yearsEffective policy/regulation for industrially produced trans-fatty acidsPrevalence of obesity (%)Number of cases of poliomyelitis caused by wild poliovirusPatterns of antibiotic consumption at the national levelPeer-reviewed publications categorized as systematic reviews assessing the effects of big data analytics on any of the GPW13 and EPW health indicators and core priorities were included, regardless of language and study design. We only considered studies in which the search was performed in at least two databases, and included a description of the search strategy and the methodology used for study selection and data extraction. We only included studies that evaluated concrete relationships between the use of big data analytics and its effect on people’s lives, according to the WHO strategic priorities and indicators. Along with the 46 indicators listed in Although big data analysis is capable of handling large volumes of data, rather than focusing on the data volume/size, we focused on the process that defines big data analytics, which includes the following phases : (1) datThe following data were extracted from the retrieved articles: publication information, journal name and impact factor, study characteristics, big data characteristics, outcomes, lessons and barriers for implementation, and main limitations. Data were individually extracted by team members and cross-checked for accuracy by a second investigator.Two researchers independently assessed the studies using the AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews 2) checklist, which includes the following critical domains, assessed in 16 items: protocol registered prior to review, adequacy of literature search, justification for excluded studies, risk of bias in included studies, appropriateness of meta-analytic methods, consideration of bias risk when interpreting results, and assessing the presence and likely impact of publication bias . ApproprResults are reported in summary tables and through a narrative synthesis, grouping studies assessing the same disease or condition, and identifying challenges and opportunities. We also schematically represent the evidence and gaps from these reviews as an overall synthesis.The search retrieved 1536 publications, 112 of which were duplicates. Most of the studies were excluded after title and abstract analysis (n=1237), leaving 185 selected for full-text screening, and 35  were ultNo standard critical appraisal tools were mentioned. Among the 12 reviews that performed any quality assessment, the Quality Assessment of Diagnostic Accuracy Studies 2 tool was used in four reviews demonstrating an overall low risk of bias ,16,27,28Summary features and main findings of the 35 systematic reviews are presented in Many reviews included data collected from electronic medical records, hospital information systems, or any databank that used individual patient data to create predictive models or evaluate collective patterns ,40,42-45The purposes of the reviews varied broadly. Generally, they (1) outlined AI applications in different medical specialties; (2) analyzed features for the detection, prediction, or diagnosis of multiple diseases or conditions; or (3) pinpointed challenges and opportunities.Most of the studies assessed the effects of big data analytics on noncommunicable diseases ,40-44. FAI tools associated with big data analytics in the care of patients with diabetes mellitus (DM) were assessed in six reviews that included 345 primary studies ,32,38,40Various studies assessed the ability of big data analytics to predict individual DM complications such as hypoglycemia, nephropathy, and others ,32,38. SFive reviews reported on AI, data mining, and ML in psychiatry/psychology ,19,25,45The use of ML algorithms for early detection of psychiatric conditions was also reported ,45. ML wOnly one review used social media to generate analyzable data on the prevention, recognition, and support for severe mental illnesses . The stuTwo reviews reported the application of big data analytics and ML to better understand the current novel coronavirus pandemic ,37. One Another review focused on SARS-CoV-2 immunization, and proposed that AI could expedite vaccine discovery through studying the virus’s capabilities, virulence, and genome using genetic databanks. That study merged discussions of deep learning–based drug screening for predicting the interaction between protein and ligands, and using imaging results linked to AI tools for detecting SARS-CoV-2 infections.Four studies described the utility of ML, computerized clinical decision systems, and deep learning in oncology ,28,29,31One study evaluated ML techniques in a genomic study of head and neck cancers, and found a wide range of accuracy rates (56.7% to 99.4%) based on the use of genomic data in prognostic prediction. Lastly, two studies reported accuracy levels ranging from 68% to 99.6% when using deep learning algorithms in the automatic detection of pulmonary nodules in computerized tomography images.Six studies described the effect of big data analytics in cardiology ,16,21,42Similarly, two studies assessed the use of intelligent systems in diagnosing acute coronary syndrome and heart failure ,21, demoScores to identify patients at higher risk to develop QT-interval prolongation have been developed, and predictive analytics incorporated into clinical decision support tools have been tested for their ability to alert physicians of individuals who are at risk of or have QT-interval prolongation .Regarding stroke, two systematic reviews evaluated using ML models for predicting outcomes and diagnosing cerebral ischemic events ,44. GeneSeveral studies reported significant improvement in disease diagnosis and event prediction using big data analytics tools, including remarkable enhancement of sepsis prediction using ML techniques . AnotherOne review focused on the diagnostic accuracy of AI systems in analyzing radiographic images for pulmonary tuberculosis, mostly referring to development instead of clinical evaluation . In studOne review also assessed multiple sclerosis diagnosis. Among detection methodologies, rule-based and natural language processing methods were deemed to have superior diagnostic performance based of elevated accuracy and positive predictive value . This stAsthma exacerbation events and predictive models for early detection were evaluated in one review, which reached a pooled diagnostic ability of 77% (95% CI 73%-80%) . Among tTwo reviews analyzed the use of big data analytics and AI in public health ,30. One Two systematic reviews provided narrative evaluations of the challenges of big data analytics in health care ,39. EvidCurrent Challenges1. Data structure: issues with fragmented data and incompatible or heterogeneous data formats2. Data security: problems with privacy, lack of transparency, integrity, and inherent data structure3. Data standardization: concerns with limited interoperability, data obtention, mining, and sharing, along with language barriers4. Inaccuracy: issues with inconsistencies, lack of precision, and data timeliness5. Limited awareness of big data analytics capabilities among health managers and health care professionals6. Lack of evidence of big data analytics on the impact on clinical outcomes for peoples’ health7. Lack of skills and training among professionals to collect, process, or extract data8. Managerial issues: ownership and government dilemma, along with data management, organizational, and financial issues9. Regulatory, political, and legal concerns10. Expenses with data storage and transferFuture Perspectives and Opportunities1. To improve the decision-making process with real-time analytics2. To improve patient-centric health care and to enhance personalized medicine3. To support early detection of diseases and prognostic assessment by predicting epidemics and pandemics, improving disease monitoring, implementing and tracking health behaviors, predicting patients’ vulnerabilities4. To improve data quality, structure, and accessibility by enabling the improvement of rapid acquisition of large volumes and types of data, in a transparent way, and the improvement of data error detection5. To enable potential health care cost reduction6. To improve quality of care by improving efficient health outcomes, reducing the waste of resources, increasing productivity and performance, promoting risk reduction, and optimizing process management7. To provide better forms to manage population health either through early detection of diseases or establishing ways to support health policy makers.8. To enhance fraud detection9. To enhance health-threat detection plans by governmental entities10. To support the creation of new research hypothesesThis overview is the first to assess the effects of big data analytics on the prioritized WHO indicators, which offers utility for noncommunicable diseases and the ongoing COVID-19 pandemic. Although the research question focused on the impact of big data analytics on people’s health, studies assessing the impact on clinical outcomes are still scarce. Most of the reviews assessed performance values using big data tools and ML techniques, and demonstrated their applications in medical practice. Most of the reviews were associated with the GPW13 indicator “probability of dying from any cardiovascular disease, cancer, diabetes, chronic respiratory disease.” This indicator outranks others because of the incidence, prevalence, premature mortality, and economic impact of these diseases . SimilarThe low to moderate quality of evidence suggests that big data analytics has moderate to high accuracy for the (1) diagnosis and prediction of complications of DM, (2) diagnosis of mental diseases, (3) prediction of suicidal behaviors, and (4) diagnosis of chronic diseases. Most studies presented performance values, although no study assessed whether big data analytics or ML could improve the early detection of specific diseases.Clinical research and clinical trials significantly contribute to understanding the patterns and characteristics of diseases, as well as for improving detection of acute or chronic pathologies and to guide the development of novel medical interventions . HoweverMany systematic reviews reported simple or inappropriate evaluation measures for the task at hand. The most common metric used to evaluate the performance of a classification predictive model is accuracy, which is calculated as the proportion of correct predictions in the test set divided by the total number of predictions that were made on the test set. This metric is easy to use and to interpret, as a single number summarizes the model capability. However, accuracy values and error rate, which is simply the complement of accuracy, are not adequate for skewed or imbalanced classification tasks , because of the bias toward the majority class. When the distribution is slightly skewed, accuracy can still be a useful metric; however, when the distribution is severely skewed, accuracy becomes an unreliable measure of model performance.For instance, in a binary classification task with a distribution of  for the classes , a “dumb classifier” that simply chooses the class “healthy” for all instances will have 95% of accuracy in this task, although the most important issue in this task would be correctly classifying the “sick” class. Precision , which captures the fraction of correctly classified instances among the instances predicted for a given class ; recall or sensitivity, which captures the fraction of instances of a class  that were correctly classified; and F-measure, the harmonic mean of precision and recall calculated per class of interest, are more robust metrics for several practical situations. The proper choice of an evaluation metric should be carefully determined, as these indices ought to be used by regulatory bodies for screening tests and not for diagnostic reasoning . The mosAnother pitfall identified among the included reviews was the lack of reporting the precise experimental protocols used for testing ML algorithms and the specific type of replication performed.There is no formal tool for assessing quality and risk of bias in big data studies. This is an area that is ripe for development. In how and why the models achieve their results, applicability and trust of the models in real-world scenarios are severely compromised. Therefore, we urge the testing and assessment of supervised, unsupervised, and semisupervised methodologies, with explanation and interpretation to justify the results. Moreover, we encourage hyperparameter optimization to achieve adjusted improvement of models, enhance model generalizations for untrained data, and avoid overfitting to increase predictive accuracy.High variability in the results was evident across different ML techniques and approaches among the 35 reviews, even for those assessing the same disease or condition. Indeed, designing big data analysis and ML experiments involves elevated model complexity and commonly requires testing of several modeling algorithms . The divOnly two published systematic reviews evaluated the impact of big data analytics on the COVID-19 pandemic. Primary studies on COVID-19 are lacking, which indicates an opportunity to apply big data and ML to this and future epidemics/pandemics ,37. As oAlthough DSS are an important application of big data analytics and may benefit patient care -58, onlyThis overview of systematic reviews updates the available evidence from multiple primary studies intersecting computer science, engineering, medicine, and public health. We used a comprehensive search strategy  with a predefined published protocol, precise inclusion criteria, rigorous data extraction, and quality assessment of retrieved records. We avoided reporting bias through the dual and blinded examination of systematic reviews and by having one review author standardizing the extracted data.Choose an appropriate evaluation measure for the task and data characteristics, and justify your choiceDifferent evaluation measures such as accuracy, area under the receiver operating characteristic curve, precision, recall, and F-measure capture different aspects of the task and are influenced by data characteristics such as skewness , sampling bias, etc. Choose your measures wisely and justify your choice based on the aforementioned aspects of the task and the data.Ensure the employment of appropriate experimental protocols/design to guarantee generalization of the resultsAuthors should use experimental protocols based on cross-validation or multiple training/validation/test splits of the employed datasets with more than one repetition of the experimental procedure.  The objective of this criterion is to analyze whether the study assesses the capacity of generalization of each method compared in the experiments. The use of a single default split of the input dataset with only one training/test split does not fit this requirement. Repetitions are essential to demonstrate the generalization of the investigated methods for multiple training and test sets, and to avoid any suspicion of a “lucky” (single) partition that favors the authors’ method.Properly tune, and explicitly report the tuning process and values of the hyperparameters of all compared methodsThe effectiveness of big data solutions and machine-learning methods is highly affected by the choice of the parameters of these methods . The wrong or improper choice of parameters may make a highly effective method exhibit very poor behavior in a given task. Ideally, the parameters should be chosen for each specific task and dataset using a partition of the training set , which is different from the dataset used to train and to test the model. This procedure is known as cross-validation on the training set or nested cross-validation.Even if the tuning of all methods is properly executed, this should be explicitly reported in the paper, with the exact values  used for each parameter and the best choices used. When the tuning information is missing or absent, it is impossible to determine whether the methods have been implemented appropriately and if they have achieved their maximum potential in a given task. It is also impossible to assess whether the comparison is fair, as some methods may have been used at their maximum capacity and others not.Pay attention to the appropriate statistical testsAuthors should employ statistical significance tests to contrast the compared strategies in their experimental evaluation. Statistical tests are essential to assess whether the performance of the analyzed methods in the sample  is likely to reflect, with certain confidence, their actual performance in the whole population. As such, they are key to support any claim of superiority of a particular method over others. Without such tests, the relative performance observed in the sample cannot, by any means, be extrapolated to the population. The choice of the tests should also reflect the characteristics of the data .Make the data and code freely available with proper documentationOne of the issues that hampers reproducibility of studies, and therefore scientific progress, is the lack of original implementation (with proper documentation) of the methods and techniques, and the unavailability of the original data used to test the methods. Therefore, it is important to make all data, models, code, documentation, and other digital artifacts used in the research available for others to reuse. The artifacts made available must be sufficient to ensure that published results can be accurately reproduced.Report other dimensions of the problem such as model costs (time) and potential for explainabilityEffectiveness of the solutions, as captured by accuracy-oriented measures, is not the only dimension that should be evaluated. Indeed, if the effectiveness of the studied models is similar and sufficient for a given health-related application, other dimensions such as time efficiency (or the costs) to train and deploy (test) the models are essential to evaluate the practical applicability of such solutions. Another dimension that may influence the decision for the practical use of a big data or a machine-learning method in a real practical situation is the ability to understand why the model has produced certain outputs . Solutions such as those based on neural networks may be highly effective when presented with huge amounts of data, but their training and deployment costs as well as their opaqueness may not make them the best choice for a given health-related application.However, limitations exist. The inferior quality scores based on the AMSTAR 2 tool might reflect incomplete reporting and lack of adherence to substandardized review methods. There is neither an established bias risk tool specifically for big data or ML studies nor any systematic way of presenting the findings of such studies. Furthermore, most studies provided a narrative description of results, requiring summarization. Nevertheless, all of the reviews were inspected by most authors, and the most relevant data were condensed in the text or in descriptive tables.Big data analytics provide public health and health care with powerful instruments to gather and analyze large volumes of heterogeneous data. Although research in this field has been growing exponentially in the last decade, the overall quality of evidence is found to be low to moderate. High variability of results was observed across different ML techniques and approaches, even for the same disease or condition. The diversity of big data tools and ML algorithms require proper standardization of protocols and comparative approaches, and the process of tuning the hyperparameters of the algorithms is not uniformly reported. Important characteristics essential for replicability and external validation were not frequently available.Additionally, the included reviews in this systematic review addressed different health-related tasks; however, studies assessing the impact on clinical outcomes remain scarce. Thus, evidence of applicability in daily medical practice is still needed. Further studies should focus on how big data analytics impact clinical outcomes and on creating proper methodological guidelines for reporting big data/ML studies, as well as using robust performance metrics to assess accuracy.


Integrated care aims to improve access, quality and continuity of services for ageing populations and people experiencing chronic conditions. However, the health and social care workforce is ill equipped to address complex patient care needs due to working and training in silos. This paper describes the extent and nature of the evidence on workforce development in integrated care to inform future research, policy and practice.A scoping review was conducted to map the key concepts and available evidence related to workforce development in integrated care.Sixty-two published studies were included. Essential skills and competencies included enhancing workforce understanding across the health and social care systems, developing a deeper relationship with and empowering patients and their carers, understanding community needs, patient-centeredness, health promotion, disease prevention, interprofessional training and teamwork and being a role model. The paper also identified training models and barriers/challenges to workforce development in integrated care.Good-quality research on workforce development in integrated care is scarce. The literature overwhelmingly recognises that integrated care training and workforce development is required, and emerging frameworks and competencies have been developed. More knowledge is needed to implement and evaluate these frameworks, including the broader health and social care workforces within a global context. Further research needs to focus on the most effective methods for implementing these competencies. Internationally, governments have committed to integrated health systems to improve access, quality and continuity of services for our increasingly ageing population and people experiencing chronic disease 23. Patie245Before evaluating the research into workforce development in integrated care, some definitions are needed. The WHO defines integrated care as:The management and delivery of health services such that people receive a continuum of health promotion, health protection and disease prevention services, as well as diagnosis, treatment, long-term care, rehabilitation, and palliative care services through the different levels and sites of care within the health system and according to their needs .By ‘health and social care workforce’, we mean ‘the different kinds of clinical and non-clinical staff responsible for public and primary health interventions’ .Barriers to implementing integrated services are well-described in the literature. They include a lack of clear, systematic understanding of integrated care among key stakeholders  and a la910Similar barriers exist in workforce development. For example, training curricula for healthcare workers do not promote experience and skills in community and integrated care settings 13. Stude1510Professionals need to manage health and care rather than disease and cure. To work in teams across professions and sectors, they need to acquire a non-traditional set of knowledge, skills and attitudes . Althoug9A scoping review was selected to map the key concepts and available evidence of how education, training and workforce development in integrated care systems have been implemented and represented in the literature. The goal is to synthesise the research into education and training by mapping or articulating current knowledge about these critical concepts derived from various study designs. A scoping review is particularly relevant in this field, as emerging evidence makes it challenging to undertake systematic reviews : and scoThe research questions, protocol, scoping review process and inclusion criteria for the search strategy were developed in consultation with a group of experts with knowledge of integrated care and working in health and social science. These experts assisted with the initial review of full articles for inclusion and a descriptive numerical summary of the evidence. The scoping review followed Levac’s  recommenTable 1). Although an integrated workforce includes many stakeholders , the scoping review focuses on the training of health and social care workers.A broad question, key concepts, target audience and intended outcome, were defined for the study (see Table 1) were developed with the lead researcher and context experts from the scoping study team, as Levac et al. [Figure 1. The final set of databases was selected for their multi-disciplinary content and inclusion of health and social services. The review only includes studies published after 2013 when the definition of integrated care used by the WHO and adopted for the present study was introduced.All search strategies and databases  was refined through ongoing discussions with the research team. From here, empirical and non-empirical articles were included in the final selection of studies and these were analysed to define the extent, range and nature of the material available.The search strategy (see Table 1 shows the data that was extracted from the selected studies. These fields were chosen to outline the scoping review process.Table 1). Thematic analysis was used to identify the themes and findings of the study. These were articulated into tables to make it easier for the reader to interpret [Key results included a list of themes and competencies for workforce training on integrated care and a list of identified training models . The final full-text screening yielded 62 records .The peer-reviewed literature on integrated care and workforce development is sparse, despite international recommendations for preparing the health and social care workforce to work within this model 237. A to23Table 2). Most studies originated from the United States and Europe (see Table 2). Sixteen of the studies related to training clinicians, such as social workers and psychologists, targeting individuals with mental health or substance abuse conditions.Most selected studies were empirical and demonstrated systematic collection and analysis of evidence. In contrast, the non-empirical studies included personal reflections, observations, an editorial, a book chapter and systematic reviews . For example, one study developed a framework for action in the WHO European region, developing competency clusters and a competency consolidation cycle [The studies describe several models for education and training, varying by target audience and methods  student selection, (2) faculty selection, (3) curriculum design, (4) workplace, (5) community participation and (6) health system .Good health and social care depend on the workforce overcoming barriers identified in this scoping review and accepting that the biomedical model alone cannot satisfy modern health care . Moreove6011136021Workforce planning and interprofessional education and practice is essential when implementing a system in integrated care and must be designed around patients and populations, not professions 2111, rep2191148The literature embraces workforce alignment of activities across health and social systems and settings 26 and ex202123641130211133The selected studies suggested that training programmes need to incorporate caregiver training, education and support , althougOnly small-scale studies limited to specific health professionals such as physicians, psychologists and social workers were found in this scoping review. Those found were based predominantly in the United States or Europe. Thus, the literature provides no examples from resource-poor countries, international studies or consensus from a range of experts across countries and professions. The selected studies favoured siloed approaches with no studies mentioning other professions such as nursing, allied health and social care. Traditional siloed models no longer provide an appropriate response to patient need. Therefore, we need to find ways to use, prepare and train the more comprehensive health and care workforce to manage an ever-increasing and diverse patient population.The literature is primarily composed of journal articles presenting opinions along with literature reviews. The selected studies were descriptive but general about the nature of workforce development in integrated care. Descriptions of education and training were predominately aimed at highly qualified and academically trained professionals, especially doctors and social workers. A limited number of studies specifically discussed workforce competencies and education and training models but primarily addressed management and leadership. Education and training need to considerably move up the ladder of priorities if we want to achieve sustainable integrated care in the next generation.Although a range of competency tools and education frameworks have been developed , no stud202164It helps to have a clear understanding of the characteristics of an ideal collaborative practitioner. The results from this scoping review suggest that in the perfect workplace, health and social care providers have the capacity and knowledge to create personalised solutions for people who present with complex issues and follow standardised health pathways and protocols 56. These54415162133343864111516343739152127531641540This scoping review has highlighted significant gaps in the research to describe and evaluate workforce training and integrated care development. The knowledge gaps cannot be solved effectively by collecting data across the United States and European countries and focusing on similar disciplines. A global plan is needed to understand the leadership requirements, implementation processes, evaluation outcomes and policy levers to create an integrated, people-centred workforce within diverse healthcare systems and sectors. There is an urgent need to develop new academic programmes, competencies and training models, knowledge transfer, and leadership to build a people-centred health workforce and a more integrated healthcare and social care sector approach. Investments are needed in research and implementation studies to foster a greater understanding of the actual content of care required within these new systems. Practice recommendations identified from this scoping review include: (1) student selection, (2) faculty selection, (3) curriculum design, (4) workplace, (5) community participation and (6) health system.The additional file for this article can be found as follows:10.5334/ijic.6004.s1Appendix.Supplemental Table 1 Recommendations for Workforce Development in Integrated Care.