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The patchwork of laws and regulations that affect abortion access in the United States has become increasingly complex since the 2022 Dobbs v. Jackson Women's Health Organization U.S. Supreme Court decision that gave states the right to enact and enforce policies facilitating or restricting abortion access. The authors examined state, local, and institutional policies in Virginia-which is one of the only remaining states in the South post- Dobbs with legal access to abortion care past 13 weeks gestational age-to better understand how the policy landscape is influencing provision of care in the state. The authors reviewed existing legislation, bills, and sources detailing the policy landscape in Virginia and interviewed a sample of clinicians and nonclinicians working at organizations providing or supporting abortion care. The study principally focused on state laws, local policies and actions, institutional policies, and reported implementation experiences affecting access to abortion care., (Copyright © 2024 RAND Corporation.)

The implementation and enforcement of state and local abortion policy can vary significantly between medical clinics and depend on the context and the individual decisionmakers involved. Research conducted prior to the U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization showed that, when providers are unclear about potentially conflicting or changing local and state policies (formal and informal) or enforcement, many err on the side of caution and become more restrictive in their practices. However, it is unknown whether and to what extent state and local policies and practices adapted in the wake of Dobbs have influenced providers' practices. The authors conducted an initial study of laws and policies post-Dobbs in one state, North Carolina, to better understand the policy landscape and gather perspectives from staff in facilities or organizations that provide or support abortion care. This study served as a unique opportunity to explore laws and policies, as well as implementation experiences, given North Carolina's Senate Bill 20, which instituted a gestational limit of 12 weeks and 6 days, as well as other provisions, including a 72-hour in-person consent requirement. The findings highlight the reported impacts of Senate Bill 20 on facilities, providers, and patients, as well as other local and institutional policies on abortion care access. This work highlights the importance of understanding legislation and its underlying provisions to ensure a complete picture of implementation factors and potential impacts., (Copyright © 2024 RAND Corporation.)

Objectives: To examine physical therapist awareness and utilization of imaging referral privileges in the United States (US) and how it relates to direct access frequency., Methods: This study utilized survey data collected in 2020-2021 from US physical therapists. Subjects were asked about imaging referral jurisdictional authority in their state. Responses were analyzed for accuracy and compared to the level of jurisdictional authority and its impact on imaging referral. Analysis of imaging skills performance and imaging referral practices were compared to direct access frequency., Results: Only 42.0% of physical therapists practicing in states that allow imaging referral were aware of this privilege. Those practicing where imaging referral was allowed via state legislation were significantly more likely ( p  < 0.01) to be aware of this privilege (71.4%) compared to those granted by the state board (25.2%). Those aware of their imaging referral scope were more likely ( p  < 0.01) to practice imaging referral (44.5%) compared to those who were unaware (3.2%). Direct access frequency was positively associated with imaging skill performance and imaging referral practice ( p  < 0.01). Doctors of Physical Therapy, residency/fellowship-trained physical therapists, and board-certified physical therapists all reported practicing greater frequency of direct access ( p  < 0.01)., Discussion/conclusion: There is a striking lack of awareness of imaging privileges among physical therapists as influenced by the level of jurisdictional scope. These results suggest that the lack of awareness may have a dampening effect on diagnostic imaging referrals. The American Physical Therapy Association should consider engaging with state boards to raise imaging privilege awareness.

Background: To understand the impact of laws raising minimum legal sales age for tobacco products to age 21, researchers and policymakers need to recognize how recommended policy components vary across states. This paper identified and reviewed policy components across 43 jurisdictions that have enacted Tobacco 21 (T21) laws since 2015., Methods: Using NexisUni's database of state laws and legislation, we evaluated T21 laws in effect as of January 2024 and assessed for the incorporation of six components recommended in proposed model legislation: 1) age verification; 2) tobacco retailer licensing; 3) provisions to suspend or revoke a license; 4) unannounced inspections; 5) retailer civil or criminal penalties; and 6) provisions that allow for more stringent local laws., Results: Only one state included all six components we reviewed, including limiting penalties to civil fines. All jurisdictions included a provision to change the legal sales age of purchase and 37 imposed requirements on retailers to verify identification. Thirty-eight jurisdictions had licensing programs, but only 31 included license suspension or revocation provisions for underage sales. Twenty-three jurisdictions preempt localities from imposing more stringent requirements. Twenty-five jurisdictions use a mix of civil and criminal or solely criminal penalties and 21 jurisdictions have penalties for underage purchasers., Conclusions: Our database of recommended T21 components with effective dates can be merged with other datasets to facilitate policy evaluation. We discuss ways to enhance research and data collection in this area, and recommend that states update MLSA laws to adopt all recommended policy components., Competing Interests: The authors have no conflicts of interest to declare., (© 2024 The Author(s).)

Purpose: End-of-life law governs end-of-life decision-making in clinical practice. There has been little analysis of the specific legal issues relevant to allied health professionals working in end-of-life care., Method: A scoping review was undertaken to identify and examine the extent, range, and nature of literature on the legal issues relevant to end-of-life practice for Australian speech-language pathologists and social workers, including current gaps. Literature was identified by searching six electronic databases, Google Scholar, the websites of relevant professional organisations and State/Territory health departments, scanning reference lists, and drawing on existing knowledge. Data charting and thematic analysis of findings was performed., Result: Twenty documents were included, spanning various document types. Most focused on adult clinical practice. Documents demonstrated that the two professions encounter similar legal issues., Conclusion: Key gaps exist in the literature. Findings will inform these professionals of the legal issues relevant to their clinical practice and inform the development of further resources.

Health systems have committed their path to universal health coverage using health planning to accomplish their goals of efficiency, equity and sustainability. Chile, a high-income country with a public-private mix health system, has made significant progress through several successive health policies implemented in the last 20 years which have been consistent with this approach. However, in the last 5 years, the national congress has produced several disease-specific laws, which have been mainly promoted by the civil society. These laws indicate the actions the health authority must perform to tackle the needs of the affected population, which ultimately determine the priorities of the health system. We argue that this legal pattern has become an alternative path to priority-setting, as opposed to health planning. We claim this "legal path" is a mechanism used by civil society in a context where the health authority fails to implement a robust and legitimate prioritization process. Although these laws have brought benefits to patients suffering the corresponding conditions, we highlight this approach does not guarantee improvements in equity, efficiency and health system performance. Instead, we advocate for taking back the control of the priority-setting based on health planning, through a new institutionalization of health technology assessment and quality of care., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Espinoza, Cabieses, Goic and Andrade.)

Contingency management (CM) involves provision of incentives for positive health behaviors via a well-defined protocol and is among the most effective treatments for patients with substance use disorders (SUDs). An understanding of laws affecting incentives for health behaviors and outcomes, including contexts in which incentives are already permitted, could inform efforts to disseminate CM. We conducted a systematic NexisUni legal database review of state statutes and regulations effective during 2022 to identify (a) laws that explicitly permit or prohibit delivery of incentives to patients, employees, or insurance beneficiaries for SUD-specific behaviors or outcomes, and (b) laws that explicitly permit delivery of incentives for any health behaviors or outcomes. We identified 27 laws across 17 jurisdictions that explicitly permit delivery of incentives for SUD-related behaviors or outcomes, with most occurring in the context of wellness programs. No state laws were identified that explicitly prohibit SUD-specific incentives. More broadly, we identified 57 laws across 29 jurisdictions permitting incentives for any health outcomes (both SUD- and non-SUD-related). These laws occurred in the contexts of wellness programs, K-12/early childhood education, government public health promotion, and SUD treatment provider licensing. Considering the urgent need to expand evidence-based SUD treatment in rural and underserved areas throughout the US, these findings could inform efforts to develop laws explicitly permitting provision of incentives in SUD care and enhance efforts to disseminate CM more broadly., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Inc.)

Background: Health professionals and medical students have knowledge gaps about the law that governs end-of-life decision-making. There is a lack of dedicated training on end-of-life law and corresponding research on the impact of this type of training., Objective: To examine the impact of online training modules on key concepts of end-of-life law on Australian health professionals' legal knowledge and their self-reported confidence in applying the law in practice., Methods: Online pre- and post-training surveys were completed by training participants. The optional surveys collected demographic data, directly assessed legal knowledge and measured self-reported confidence in applying the law in clinical practice, before and after training., Results: Survey response rates were 66% (pre-training) and 12% (post-training). The final sample for analysis (n = 136 participants with matched pre- and post-training surveys), included nurses, doctors, allied health professionals, medical students and a small number of non-health professionals. Following completion of the online training modules, legal knowledge scores significantly increased overall and across each domain of end-of-life law. Participants were also more confident in applying the law in practice after training (median = 3.0, confident) than before training (median = 2.0, not confident)., Conclusions: This study found that completion of online training modules on end-of-life law increased Australian health professionals' legal knowledge and self-reported confidence in applying the law in clinical practice. Participants demonstrated some remaining knowledge gaps after training, suggesting that the training, while effective, should be undertaken as part of ongoing education on end-of-life law. Future research should examine longer term outcomes and impacts of the training., (© 2023. The Author(s).)

Background: Cancer is a public health issue in Brazil. To mitigate exposure to risk factors, change habits and ensure access to cancer care, an increasing number of bills are presented every year. This article analyzes the changes proposed in these bills, portraying how the representatives perceive and respond to the challenges imposed by cancer on the healthcare system and society., Methods: Through a systematic search on the Brazilian House of Representatives website, this exploratory study examines cancer-related bills presented up to 2022., Results: Of 1311 bills identified, 310 met the inclusion criteria and were categorized based on their content. The increasing annual number of cancer bills reflects the interest of representatives on the topic. The cancer types addressed correspond to the most prevalent ones, except for the colorectal. The most common strategy is primary prevention (n: 129), proposing the reduction of risk factors exposure or the promotion of protective ones, followed by tertiary (n: 106) and secondary (n: 36) strategies, targeting, respectively, cancer treatment/management and its early diagnosis/detection. On the nature of proposed changes, most seek to implement increased healthcare access (n: 125), production/sale (dis)incentives for goods containing carcinogens (n: 60), and fiscal/financial (dis)incentives (n: 53)., Conclusion: The identified gaps - such as the limited use of data and evidence to support what is proposed, overlapping but fragmented efforts with previous bills, scarce efforts directly addressing the determinants of health, and the low rate of conversion to law - entails opportunities to advance the Legislative propositions., Policy Summary: To effectively respond to cancer-related challenges, is essential that the Legislative branch takes into account what is already being proposed or being left out, inputs from society, real-world data, and the results produced by the multisectoral policies in place., Competing Interests: Declaration of Competing Interest We confirm that there are no known conflicts of interest associated with this publication., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Women are an integral part of the military, comprising 17.2 percent of the active-duty force. They are the fastest-growing subpopulation in the military. In recent years, the Department of Defense (DoD) and military services have been deliberately recruiting women because they represent a higher percentage of the recruitable population than their male counterparts. Service women and their civilian counterparts have been and are serving in roles that are essential to military readiness. The Dobbs v. Jackson Supreme Court ruling will limit service women's and DoD civilian women's access to reproductive health care and affect the health of these critical populations. In this article, the authors use publicly available data to provide an estimate of the scope of the effects of the decision on the health and readiness of the U.S. armed forces. They estimate how many military-employed women's reproductive health options have been or might soon be limited and identify force readiness-related concerns, such as effects on the military health care, education, and child care systems, as well as on military recruiting and retention., (Copyright © 2023 RAND Corporation.)

Objective: The scope and types of health interventions in the dying process are the subject of a social and professional debate that has been increasing in recent years. The objective of the study was focused on analyzing the perceptions of professionals and relatives of patients who have recently died and assessing the degree of compliance with the rights established in the current legislation on this subject., Methods: Qualitative research with a hermeneutical phenomenological approach carried out in 2019 by conducting and analyzing two discussion groups with health professionals from hospital and primary care, and four groups with relatives of recently deceased patients, divided by age ranges: 18- 30 years old, 31-45, 46-60 and over 60., Results: The total number of people included in the study was 28 participants. Family members and professionals find it difficult to communicate with each other in the context of health care at the end of life. Family members and professionals agree on their preference to die at home. There are specific deficiencies in knowledge about the terminology used at the end of life. The term "euthanasia" is the one best known by family members., Conclusions: Deficiencies in knowledge of the rights established in the regulations related to the death process have been detected, both in relatives of patients and in professionals. These deficiencies contribute to breaches of legal regulations. Communication difficulties related to death between the professionals-patient-family trinomial are the most relevant related factor.

We had the opportunity to know a judicial decision in relation to a nonagenarian COVID-19 patient, which is clarifying regarding the complex issue of involuntary admission and involuntary treatment of the elderly. The judge authorized the involuntary admission but denied the possibility of imposing medical treatment against the will of the patient. This situation invites us to review the different types of involuntary admission that our legal system provides and how involuntary medical treatment is regulated according to its purpose and the patient's ability to decide. In the field of public health, the determining element to be able to impose any sanitary measure against the will of the patient is the risk to the health of the population. In the case presented, the judge rejects the possibility of authorizing medical treatment for not contributing anything from the point of view of public health. However, it does authorize involuntary admission as it is essential to guarantee isolation., (Copyright © 2021 SEGG. Publicado por Elsevier España, S.L.U. All rights reserved.)

On 19 June 2019 the Voluntary Assisted Dying Act 2017 (Vic) came into effect, making Victoria the first state in Australia to permit the practice of 'voluntary assisted dying'. As defined in the legislation, voluntary assisted dying refers to "the administration of a voluntary assisted dying substance and includes steps reasonably related to such administration", "for the purpose of causing a person's death". In essence, the model of voluntary assisted dying established in Victoria is designed for patients within the final weeks or months of life, who may receive medical-assistance to 'choose the manner and timing of their death'. The purpose of this paper is to overview the clinical implementation of voluntary assisted dying in Victoria, attending to three broad challenges: balancing tensions in policy goals and ensuring the legislated 'safeguards' function as intended, translating the complex legislation into clinical practice, and managing conscientious objection to voluntary assisted dying. While there is somewhat limited information available regarding the practice of voluntary assisted dying in Victoria, available data and anecdotal reports indicate the implementation of the state's complex model of voluntary assisted dying has not been without challenges, particularly in terms of balancing the legislated 'safeguards' and patient access to voluntary assisted dying, and translating aspects of the complex legislation into clinical practice. The release of more systematic voluntary assisted dying data by the state, alongside independent research into the operation of voluntary assisted dying, is necessary to better evaluate the implementation and impact of voluntary assisted dying as a new component of clinical practice.

The COVID-19 pandemic has forced a rapid adoption of telemedicine over traditional in-person visits due to social restrictions. While telemedicine improves access and reduces barriers to healthcare access for many, several barriers and challenges remain for persons with disabilities, and novel challenges have been exposed, many of which may persist long-term. The challenges and barriers that need to be systematically addressed include: Infrastructure and access barriers, operational challenges, regulatory barriers, communication barriers and legislative barriers. Persons with disabilities are a vulnerable population and little attention has been placed on their healthcare access during the pandemic. Access and communication during a healthcare encounter are important mediators of outcomes for persons with disabilities. Significant, long-term changes in technological, regulatory, and legislative infrastructure and custom solutions to unique patient and health system needs are required to address these barriers going forward in order to improve healthcare access and outcomes for persons with disabilities., (Published by Elsevier Inc.)

Background: The rising prevalence of disability due to noncommunicable diseases and the aging process in tandem with under-prioritization and underdevelopment of rehabilitation services remains a significant concern for European public health. Over recent years, health system responses to population health needs, including rehabilitation needs, have been increasingly acknowledging the power of law and formal written policies as strategic governance tools to improve population health outcomes. However, the contents and scope of enacted legislation and adopted policies concerning rehabilitation services in Europe has not been synthesized. This paper presents a concise overview of laws and policies addressing rehabilitation in five European countries., Methods: Publicly available laws, policies, and national action plans addressing rehabilitation issues of Sweden, Italy, Germany, the Netherlands and the United Kingdom were reviewed and descriptive documents analyzed. Actions found in national health policies were also evaluated for compliance with the key recommendations specified in the World Health Organization's Rehabilitation 2030: Call for Action. Results : Across countries, legal and policy approaches to rehabilitation planning varied in scope and reach. While all countries entitle citizens to rehabilitation services, comprehensiveness of coverage varied. Health legislation of Germany and Netherlands recognizes access to rehabilitation as a human right for persons with disabilities, while Sweden and the United Kingdom acknowledge its importance in disability laws for achieving substantive equality for persons with disabilities. Regarding policies, in all countries but Italy, targeted universalism remains the predominant strategy governing rehabilitation services, as demonstrated by the lack of comprehensive, national action plans for rehabilitation addressing the general population. Nevertheless, references found in disease specific policies indicate a solid consensus that rehabilitation remains an integral component of the care continuum for those experiencing disability., Conclusion: Although a universal approach to rehabilitation coverage is institutionalized in national legislation of the countries examined, this approach is not expressed in formal policies. Targeted strategies aiming to ensure access to subpopulation groups with higher perceived needs for rehabilitation prevail, indicating a strong political will towards the reduction of health inequalities and the promotion of human rights of people experiencing disability. Results obtained from conducting this descriptive review provide the basis for future appraisals of the situation regarding rehabilitation service and policy development in Europe., Competing Interests: The authors declare no conflict of interest.

The U.S. Department of Defense (DoD) and U.S. Department of Veterans Affairs (VA) health systems provide services through a mix of direct care, delivered at government facilities, and purchased care, provided through the private sector, mainly by community-based providers who have entered into contracts with third-party administrators (TPAs). In the interest of expanding DoD-VA resource sharing that may lead to greater efficiencies and cost savings, the DoD/VA Joint Executive Committee is exploring options to integrate DoD and VA's purchased care programs. This preliminary feasibility assessment examined how an integrated approach to purchasing care could affect access, quality, and costs for beneficiaries, DoD, and VA and identified general legislative, policy, and contractual challenges to implementing an integrated purchased care program. An integrated approach to purchasing care is feasible under current legal and regulatory authorities, but policy changes may be needed-and the practicality of such an approach depends on the contract and network design. For example, legal/regulatory changes in how contracts are established would be required to achieve any real savings to the government. There are also differences in the populations served by TRICARE (DoD health care) and VA, particularly in terms of age and geographic location. Implementation would be further complicated by contractual differences in the TPA contracts for VA and DoD as they relate to network standards, provider payments, network participation requirements, and reporting requirements and incentive structures. As a result, there are significant uncertainties with respect to increased efficiency or cost savings for the government., (Copyright © 2020 RAND Corporation.)

Background : The Mental Capacity Act (2005) (MCA) provides a legal framework for advance planning for both health and welfare in England and Wales for people if they lose mental capacity, for example, through mania or severe depression. Aims : To determine the proportion of people with bipolar disorder (BD) who utilise advance planning, their experience of using it and barriers to its implementation. Methods : National survey of people with clinical diagnosis of BD of their knowledge, use and experience of the MCA. Thematically analysed qualitative interviews with maximum variance sample of people with BD. Results : A total of 544 respondents with BD participated in the survey; 18 in the qualitative study. 403 (74.1%) believed making plans about their personal welfare if they lost capacity to be very important. A total of 199 (36.6%) participants knew about the MCA. A total 54 (10%), 62 (11%) and 21 (4%) participants made advanced decisions to refuse treatment, advance statements and lasting power of attorney, respectively. Barriers included not understanding its different forms, unrealistic expectations and advance plans ignored by services. Conclusion : In BD, the demand for advance plans about welfare with loss of capacity was high, but utilisation of the MCA was low with barriers at service user, clinician and organisation levels.

The frequency of legislation changes and their utility is a subject of interest and always under debate with pro and contra arguments. In the current study, the perception of students regarding medical legislation changes was analyzed. In general, no statistically significant differences were found between the sub-groups of students, thus underlining a unitary perception. The general perception is that changes in legislation are made too often. Moreover, only a small part of the analyzed group agrees on the utility of these changes. Finally, it seems that income is the main driver for students as future employees in the medical system. Also, significant differences between males and females' perceptions are emphasized, and legislation changes should take into account the primary drivers. Other issues, such as corruption, stability, and performances should be the key points in legislation changes. These results should be a challenge for all stakeholders, in particular for policymakers., (©Carol Davila University Press.)

Objective: To describe and compare the regulatory framework governing policies on rapid/alternative access to medicines (expanded access and compassionate use) in South American countries., Method: An exploratory descriptive study with analysis of documents was performed. In addition to a literature review, official rules issued by regulatory agencies were reviewed if available. Information was collected on how countries define the concepts of expanded access and compassionate use, clinical phase in which the medicine becomes available for these alternative uses, and role of physicians and sponsors., Results: Argentina, Brazil, Chile, Peru, and Uruguay were included in the study. The information obtained revealed that the regulatory scenario is more structured in Argentina and Brazil than in the other countries. In Chile, rules on expanded access and compassionate use are available, however without an explicit definition of these concepts. In Peru and Uruguay, important definitions are missing regarding expanded access. The search did not reveal any databases with information on expanded access and compassionate use programs, supporting the notion that empirical data to evaluate the results of these policies are lacking., Conclusions: All the countries analyzed have a regulatory framework that contemplates rapid/alternative access to medicines by patients at risk. However, databases and transparent information are lacking, preventing a snapshot of the medicines covered and patients benefiting from alternative access programs and assessments of these policies in South America., Competing Interests: Conflitos de interesse. Ninguno declarado por los autores.

With the recent legalization of recreational cannabis use in Canada, questions remain concerning optimal regulation to minimize harms and ensure public health and safety. Patterns of use are subject to change following legalization, and it is important to consider the potential adverse effects that this may have on public health. Important areas of consideration are methods of consumption (e.g., vaping, edibles) and product proliferation; acute and long-term health and behavioural effects (including impaired driving); and use in vulnerable groups, such as children and youth, pregnant women, individuals with mental illness, individuals with low socio-economic status, and Indigenous populations. To support harm reduction measures and evidence-based policy, there is a need to anticipate the potential ramifications that legalization of recreational cannabis use may have on public health in Canada.

Trans men are people who, based on their genitals, were assigned the status of female at birth. However, their identity and their way of living gender do not correspond to the socially established norms. In this paper, we discuss the different perspectives in relation to transgender people and their desire for parenthood. This review, and the basis of this paper, is inspired by the case of a trans man who desired gestation with his own genetic material. He began the cycle of assisted reproduction when he was a legally recognized woman, but that attempt ended with a miscarriage. From that assisted reproduction cycle, four embryos remained frozen. After the failed experience of gestation, the person completed his transition. Now legally a man, he attempted to gestate using his reproductive organs. This literature review aimed to identify relevant studies describing the relationship between transgender person and biological parenthood. This study comprehensively addresses important aspects one should know when considering a transgender pregnancy. These factors include biological, psychological, social, and legal issues. After reviewing the state-of-the-art information on trans parenthood, the main conclusion is that 'the desire to have a child is not a male or female desire but a human desire'., Competing Interests: The authors declare no conflict of interest.

Objective: The objective of this study is to prepare a "Concept Map on Health and Intellectual Property in Central America and the Dominican Republic" in order to help identify the main access barriers to health, especially medicines, and to guide state authorities toward actions to improve the efficiency and effectiveness of policies., Methods: The report "Concept Map on Public Health and Intellectual Property, Regional Perspective: Central America and the Dominican Republic" was analyzed. Then the knowledge generation and management methodology was applied and a search strategy was identified to recover the information for preparation of the concept maps., Results: The legal framework and institutional structure, as well as policies, programs, plans, and strategies for health and intellectual property, were identified. A set of barriers that hinder access to medicines was also identified, as well as solutions to overcome them., Conclusions: In Central America and the Dominican Republic, health strategies, policies, programs, and plans are in place, but unfortunately their scope and degree of dissemination is uneven. This, together with social and economic factors, explains why health inequity persists between and within countries. The identified barriers to access to medicines included the expansion and strengthening of the rights of pharmaceutical patent-holders, problems with implementing the flexibilities of the Agreement on Trade-related Aspects of Intellectual Property Rights, pricing policies, and strict regulatory standards., Competing Interests: Conflictos de interés. Las autoras declaran no tener conflictos de interés.

This report examines the experiences of Small Island Developing States in the Caribbean- Barbados, Dominica, Jamaica, and in the Pacific- Fiji, Nauru, and Tonga with specific governmental regulatory measures to reduce the risk of obesity and associated diet-related chronic noncommunicable diseases (NCDs), as well as the obstacles and opportunities encountered. Guided by the diet-related indicators of the World Health Organization (WHO) Noncommunicable Diseases Progress Monitor 2017, the authors reviewed legislation, country reports, articles, and the databases of WHO and the World Trade Organization to identify relevant regulatory measures and to establish the extent of implementation in the selected countries. Obesity prevalence ranged from 25.9% in Dominica to 41.1% in Tonga. The principal diet-related measures implemented by the selected countries were fiscal measures, such as sugar-sweetened beverage taxes and import duties to encourage greater consumption of healthy foods. Governmental action was weakest in the area of restrictions on marketing of unhealthy foods. If they are to reduce their current high rates of obesity and associated NCDs, Caribbean and Pacific states need to intensify implementation of diet-related regulatory measures, particularly in the area of marketing of unhealthy foods and beverages to children. Key implementation challenges include financial and staffing constraints and the need for increased political will to counter industry opposition and to allocate adequate financial resources to keep advancing this agenda., Competing Interests: Conflicts of interest: None declared.

Objective: Compare World Health Organization (WHO) guidelines for contraception in a human rights framework with the existing regulatory frameworks of Bolivia, Colombia, and Uruguay and evaluate which aspects of those regulations need to be developed., Methods: A systematic analysis was based on the WHO analytical framework "Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations" to determine whether the legislation of Bolivia, Colombia, and Uruguay contain general references to the population, specific references to adolescents, or do not refer to the topic. To this end, 36 documents related to contraception were analyzed: 9 from Bolivia, 15 from Colombia, and 12 from Uruguay., Results: It was confirmed that each country's legislation complies with several WHO recommendations. The three countries have strengths in nondiscrimination and in opportunity for informed decision-making, and have weaknesses in accessibility, quality, and accountability. Acceptability is a strength in Colombia and Bolivia, and confidentiality is a strength in Bolivia and Uruguay. Colombia has weaknesses in availability, confidentiality, and participation., Conclusions: Comparison of national legislation with WHO guidance helps to see the strengths and weaknesses of national regulatory frameworks and to see opportunities to improve regulations., Competing Interests: Conflictos de interés. Ninguno declarado por los autores

This paper discusses the crucial effects of Turkish health and migration laws on Syrian refugees' access to public health services and social determinants of health. Key aspects of current Turkish laws affect the health of both refugees and Turkish citizens in many ways. The huge influx of refugees is increasing communicable disease risks, overcrowding hospitals, and more generally straining financial and health resources. Turkey's United Nations membership and its candidacy for European Union (EU) have led to increased alignment of Turkey's refugee and migration policies with international law. Major differences remain, however, and Turkey's remaining noncompliance with international refugee laws is a major force driving Syrian refugee's flight to EU countries, as refugees desperately seek the right to better health and social services.

Background: Apps targeted at health and wellbeing sit in a rapidly growing industry associated with widespread optimism about their potential to deliver accessible and cost-effective healthcare. App developers might not be aware of all the regulatory requirements and best practice principles are emergent. Health apps are regulated in order to minimise their potential for harm due to, for example, loss of personal health privacy, financial costs, and health harms from delayed or unnecessary diagnosis, monitoring and treatment. We aimed to produce a comprehensive guide to assist app developers in producing health apps that are legally compliant and in keeping with high professional standards of user protection., Methods: We conducted a case study analysis of the Australian and related international policy environment for mental health apps to identify relevant sectors, policy actors, and policy solutions., Results: We identified 29 policies produced by governments and non-government organisations that provide oversight of health apps. In consultation with stakeholders, we developed an interactive tool targeted at app developers, summarising key features of the policy environment and highlighting legislative, industry and professional standards around seven relevant domains: privacy, security, content, promotion and advertising, consumer finances, medical device efficacy and safety, and professional ethics. We annotated this developer guidance tool with information about: the relevance of each domain; existing legislative and non-legislative guidance; critiques of existing policy; recommendations for developers; and suggestions for other key stakeholders., Conclusions: We anticipate that mental health apps developed in accordance with this tool will be more likely to conform to regulatory requirements, protect consumer privacy, protect consumer finances, and deliver health benefit; and less likely to attract regulatory penalties, offend consumers and communities, mislead consumers, or deliver health harms. We encourage government, industry and consumer organisations to use and publicise the tool.

Policymakers must balance the complex and sometimes conflicting objectives of ensuring access to care, limiting the financial burden on patients, and controlling overall costs. States differ in how they handle involuntary out-of-network charges-i.e., payment for care when a patient does not have the option of selecting a hospital in his or her health plan's network. New Jersey's current regulations emphasize patient protection, in that patients are only responsible for the portion of the cost that they would have incurred for in-network care, and health plans must pay the remainder of the provider's charges. This policy is seen as contentious by health plans, who argue that they have been made responsible for paying whatever charges a hospital submits, and proposals to limit payments for involuntary out-of-network care are being debated in the state legislature. This study seeks to inform the current debate (as of October 2016) by analyzing the role of out-of-network payments in New Jersey hospitals' financial performance and simulating the effect of policies to limit charges for involuntary out-of-network care. The authors' estimates suggest that implementing New Jersey Bill A1952, which proposes a limit of between 90 and 200 percent of Medicare rates for involuntary out-of-network hospital care, would have reduced payments for hospital care by commercial plans by between 6 and 10 percent during 2010 through 2014. Assuming no change in operating expenses and no recoupment of lost out-of-network revenues, the cap would have led to an operating loss at between 48 and 70 percent of hospitals.

The aim of this study was to review the current legislation and rules in Brazil that involve quality assurance of animal products during food service reception. Published federal legislation and technical regulations were verified to present a broad general approach to raw material reception. Food service determinations included specifications of the criteria for evaluating and selecting suppliers, verifying the transport system, reception area requirements, and inspecting raw material. For product approval, the packaging, labeling, and temperature should be evaluated. However, periodic microbiological, physicochemical, and sensory support assessment analyses are not required for receiving animal products. For the safety of the raw material, it was concluded that the largest impacts came from the regulation and supervision of the food sector provider because of the challenges of food service and a lack of requirements to use more complex evaluation methods during the reception of raw materials.

By 1965, the policies and programs of Lyndon B. Johnson's Great Society brought optimism to black physicians and a new wave of resistance against black civil rights advocates in the American South. The largest of the first Head Start programs, Child Development Group of Mississippi (CDGM), had its roots in Freedom Summer 1964 and the Medical Committee for Human Rights. Like other proposed programs with strong medical components, CDGM was caught in a legislative Bermuda triangle created by the powerful Mississippi congressional delegation to maintain white supremacy and plantation economics. Physician-led investigations exposed the extraordinary level of poor health among Mississippi's black children, supported Head Start as a remedy, and awakened the white medical establishment to health disparities of the Jim Crow period. It was also the beginning of positive change in the previously silent white medical community in the South and their support of civil justice in health., (Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

The civil rights and social legislation of the Great Society following the Civil Rights Act of 1964 was slow to provide relief for black in the South. Mississippi Senator James Eastland led an effort to defund Head Start, including his state's program, Child Development Group of Mississippi (CDGM), a program with a strong medical component. A senatorial committee, including Robert Kennedy, came to investigate CDGM in 1967. The unimaginable poverty, hunger, malnutrition and chronic disease found in black families was vehemently denied by Eastland. Visits of physician groups then corroborated the findings. The Mississippi delegation made sure that food relief never came and funding for CDGM ceased. Health services were lost to 6000 impoverished children. The epic television documentary, Hunger in America, soon premiered on network television. It triggered ongoing efforts to address health disparities, including implementation of the National Nutrition and Health Survey (NHANES). Similar physician leadership is needed to address the lasting health disparities in our country., (Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: In many parts of the world, ongoing deficiencies in health systems compromise the delivery of health interventions. The World Health Organization (WHO) identified four functions that health systems need to perform to achieve their goals: Efforts to strengthen health systems focus on the way these functions are carried out. While a number of studies on health systems functions have been conducted, the stewardship function has received limited attention. In this article, we evaluate the extent to which the Botswana Ministry of Health (MoH) undertook its stewardship role., Methods: We used the WHO Health Systems Performance Assessment Frame (HSPAF) to guide analysis of the stewardship function of the Botswana's MoH focusing on formulation of national health policies, exerting influence through health regulation, and coalition building. Data were abstracted from published and unpublished documents. We interviewed 54 key informants comprising staff of the MoH (N = 40) and stakeholder organizations (N = 14). Data from documents was analyzed through content analysis. Interviews were transcribed and analyzed through thematic analysis., Results: A lack of capacity for health policy development was identified. Significant policy gaps existed in some areas. Challenges were reported in policy implementation. While the MoH made efforts in developing various statutes that regulated different aspects of the health system, some gaps existed in the regulatory framework. Poor enforcement of legislation was a challenge. Although the MoH had a high number of stakeholders, the mechanisms for stakeholder engagement in the planning processes were weak., Conclusion: Problems in the exercise of the stewardship function posed challenges in ensuring accountability and limited the health system's ability to benefit from its stakeholders. Ongoing efforts to establish a District Health System under control of the MoH, attempts to improve service delivery at a national level and political will to strengthen public-private engagement mechanisms are some of the prospects that can improve the MoH's stewardship function., (© 2016 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: It has become clear in recent years that a healthy lifestyle, including physical exercise is crucial for health maintenance. Nevertheless, most people do not exercise regularly. Physician intervention is beneficial in increasing patient exercise. In Israel, the 1994 "Sports Law" regarding exercising in a gymnasium requires a physician's written authorization, but does not direct the physicians what they should ascertain before issuing the certificate. This pre-exercise certificate has been widely discussed in Israel over the last year as the law is to be revised to enable using a modification of the PAR-Q+ (Physical Activity Readiness questionnaire) patient questionnaire as a screening tool. This will leave the requirement for a pre-exercise certificate for a less healthy population, yet without clear instructions to the primary care physician on criteria for ascertaining fitness. Our aim was to evaluate how primary care physicians deal with the ambiguity of defining health criteria for issuing exercise authorization/certificate., Methods: We used an anonymous ten-item attitude/knowledge multiple choice questionnaire with an additional 13 personal/education and employment questions. We assessed each potential predictor of physician attitude and knowledge in univariate models., Results: 135 useable questionnaires were collected. Of these, 43.7 % of the doctors will provide the pre-exercise certificate to all their patients; 63 % were aware of their HMO/employers guidelines for issuing certificates; 62 % stated they complied with these guidelines, and 16 % stated they did not follow them. In addition, 70 % of the physicians reported regular exercise themselves, an average of 4.12 h/week. These physicians tended to provide the pre-exercise certificate to all patients unconditionally, as compared to physicians that did not exercise regularly. (46 % vs. 14.5 %, p < 0.01)., Conclusions: Most Israeli primary care physicians will provide the required certificate allowing their patients to exercise in the gym. There is a wide variation as to what physicians check before providing the certificate. The modification of the law has made the need for standardization of the nature of what is expected of primary care physicians more urgent. A large portion of physicians exercise on a regular basis - and exercising physicians are more positive regarding pre-exercise certificates. Our study clearly shows a gap in knowledge transfer; and we call for a standardized approach to pre-exercise certificates utilizing computerized patient medical files.

This paper discusses from a sociological perspective one of Catholicism's fronts of public intervention in the development and enactment of health legislation. In particular we analyze the debate in parliamentary committees on the so-called "death with dignity" law (No. 26742), for which a group of bioethics experts was convened to counsel senators regarding the scope and limits of the law. The majority of the invited experts advocated a personalist bioethics perspective, which is a theological bioethics development of contemporary Catholicism. In the debate no representatives of other faiths were present, reinforcing the widely studied overlap between Catholicism and politics in Argentina.

Vulnerable research participants deserve special protection because of their increased risks of being wronged. Yet, paradoxically, the conduct of trials involving vulnerable groups is sometimes inescapable to develop safe and efficient therapies suitable to these groups. The key question is therefore how to protect vulnerable research participants from harm and exploitation without excluding the populations they belong to from the benefits of research. The European Union faced this challenge in April 2014 when adopting the new Regulation on clinical trials, which will replace the currently applicable 2001 Clinical Trials Directive in 2016. In order to assess the protection of vulnerable persons in the new Regulation, this paper makes four suggestions: first, the need to adopt a risk-based approach to vulnerability in biomedical research; second, to better distinguish between decisional vulnerabilities and health-related vulnerabilities; third, to emphasise the need to preserve the freedom of consent of subjects with decisional vulnerability, who are more susceptible to undue influence; and finally to assert the need of actively promoting specific clinical trials involving people with physical or psychological vulnerabilities. In conclusion, this paper claims that the protection of vulnerable subjects still needs to be improved in the new EU Regulation., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Developments in professional practice can be related to ongoing changes in relations of power among professionals, which often lead to changes in the boundaries of practices. The differing contexts of practices also influence these changing relations among health professionals. Legislation governing professional practice also differs from country to country. In Brazil, over the past 12 years, in a climate of deep disagreement, a new law to regulate medical practice has been discussed. It was sanctioned, or made into law, but with some notable changes, in July 2013. Of interest to us in this paper are the ways the proposed legislation, by setting out the boundaries and scope of medical practice, 'interfered' in the practices of other health professions, undermining many 'independent' practices that have developed over time. However, even taking into account the multiple routes through which practices are established and developed, the role of legislation that seems able to contradict and deny the historical realities of multiple, intersecting practices should be critically interrogated. In this paper, we use the theoretical resources of poststructuralist thinking to explore gaps, ambiguities, and power relations implicit in the discourses that constituted this law. We argue that although the new law can be understood as a social and political device that will interfere in the organization of other health professions' practices, such legislation is only part of what constitutes change in a consolidated professional practice. And while it is important to understand the effects of such legislation, healthcare practices are also realized or 'made real' through ongoing relations of knowledge and power, including, as we will see in this case, activities of resistance. The problem, then, is to understand the practical arrangements, including legislation, traditions and routines, values and knowledge that come to shape the practices of nursing in a particular context., (© 2015 John Wiley & Sons Ltd.)

The aim of this paper is to reflect the situation of health legislation alignment in Turkey in its accession process to the European Union and Customs Union Agreement, and to discuss the the EU's health priorities of in parallel with the Turkish ones. The health legislation alignment processes consist of three titles which are: European Union alignment process, the harmonization done in the framework of membership to Council of Europe, and the obligations under the Customs Union Agreement. Significant human resources are required for the adoption of the legislations which make ethically imperative the discussion of whether there is a harmony among the priorities of both parities. Unless this harmony and paralellisim is shown, the human resources appointed for the adoption of health legislation process would not prove their efficiency and effectiveness. In this article, the Customs Union and formal negotiations for full EU membership are included in the phrase "the alignment process to European Union". Council Decisions 1/95 and 2/97 ground on the obligations provided by the Customs Union Agreement. The reference document used to discuss the formal negotiation process for full membership to European Union is the Turkish National Program for the Adoption of the EU Acquis 2008-2013. The legislative obligations of Turkey arising from its membership of the Council of Europe, which has significant contributions to the medical legislation especially in the field of medical ethics, are also included in this article.

Context: This article examines trends in state-level childhood vaccine policies in the United States from 1998 to 2012 and explains the trajectories for both vaccine-critical and proimmunization legislative efforts. Successful mobilization by vaccine critics during the height of the autism and thimerosal scares (roughly 1998 to 2003) yielded a few state-level expansions for the most permissive type of exemption from vaccine mandates for public school attendance, those based on personal beliefs. Vaccine-critical positions, however, have largely become discredited. How has vaccine critics' ability to advance preferred policies and prevent the passage of unfavorable legislation changed over time?, Methods: We created a unique data set of childhood vaccine bills (n = 636), introduced from 1998 to 2012 across the 50 state legislatures, and coded them by type of effort (exemption, mandate, mercury ban, and information policies) and outcome. We then mapped out the trends in vaccine policies over time. In order to contextualize the trends we identified, we also reviewed numerous primary sources and conducted interviews with stakeholders., Findings: In general, we found that vaccine critics' legislative success has begun to wane. In only 20 bills in our data set were vaccine critics able to change policy in their preferred direction via the legislative process. Only 5 of those wins were significant (such as obtaining a new philosophical exemption to vaccine mandates), and the last of these was in 2007. Critics were more successful at preventing passage of proimmunization legislation, such as mandates for the human papillomavirus (HPV) vaccine., Conclusions: Recent legislation in California, Oregon, and Washington that tightened philosophical exemptions by means of informational requirements suggests that vaccine politics may be entering another phase, one in which immunization supporters may be able to counter increasing opt-out rates, particularly in states with recent outbreaks and politicians favoring science-based policies., (© 2014 Milbank Memorial Fund.)

Background: Waterpipe tobacco smoking (WTS) popularity is increasing world-wide, and health effects are emerging in the light of evidence that WTS is perceived by users as less harmful than cigarette smoking. However, there remains a paucity of available evidence from which to draw firm conclusions about its public health significance., Aims: This narrative review aims to summarize WTS literature to date to inform tobacco control specialists and health-care professionals about this phenomenon and help them to assess whether or not WTS should become a public health priority., Methods: Standard electronic databases as well as conference proceedings and personal libraries were searched in English, French and Arabic with inclusive terminology for the variety of names given to WTS., Findings: Waterpipe smoke contains significant levels of toxins, some of which are known to be carcinogenic to humans. Recent epidemiological trends have established an increasing prevalence of WTS in the Middle East and the United States, particularly among adolescents. It is used commonly across multiple ethnicities and both genders with less of a social gradient than cigarette smoking. Attitudes and beliefs have been researched widely and several reasons for believing it is less harmful than cigarette smoking include water filtration and social acceptability. A wide range of diseases have been associated with WTS, but research in this area is relatively underdeveloped and a better evidence base is needed. Worryingly, the waterpipe industry, including waterpipe cafes, operates in an almost completely unregulated market and employs deceptive marketing techniques to attract new users., Conclusions: Waterpipe tobacco smoking (WTS) appears to be on the increase, especially among younger users, and therefore represents a potential public health concern. While legislators should consider enforcing and extending existing tobacco laws to a growing WTS industry, further research is required to fill gaps in the literature and provide evidence-based interventions for tobacco control specialists and health-care professionals., (© 2013 Society for the Study of Addiction.)