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INTRODUCTION: We previously reported global regional differences in smoking cessation outcomes, with smokers of US origin having lower quit rates than smokers from some other countries. This post-hoc analysis examined global regional differences in individual-level and country-level epidemiological, economic and tobacco regulatory factors that may affect cessation outcomes. METHODS: EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study) was a randomised controlled trial that evaluated first-line cessation medications and placebo in 8144 smokers with and without psychiatric disorders from 16 countries across seven regions. Generalised linear and stepwise logistic regression models that considered pharmacotherapy treatment, psychiatric diagnoses, traditional individual-level predictors (eg, demographic and smoking characteristics) and country-specific smoking prevalence rates, gross domestic product (GDP) per capita, relative cigarette cost and WHO-derived MPOWER scores were used to predict 7-day point prevalence abstinence at the end of treatment. RESULTS: In addition to several traditional predictors, three of four country-level variables predicted short-term abstinence: GDP (0.54 (95% CI 0.47, 0.63)), cigarette relative income price (0.62 (95% CI 0.53, 0.72)) and MPOWER score (1.03 (95% CI 1.01, 1.06)). Quit rates varied across regions (22.0% in Australasia to 55.9% in Mexico). With northern North America (USA and Canada) as the referent, the likelihood of achieving short-term abstinence was significantly higher in Western Europe (OR 1.4 (95% CI 1.14, 1.61)), but significantly lower in Eastern Europe (0.39 (95% CI 0.22, 0.69)) and South America (0.17 (95% CI 0.08, 0.35)). CONCLUSIONS: Increased tobacco regulation was associated with enhanced quitting among participants in the EAGLES trial. Paradoxically, lower GDP, and more affordable cigarette pricing relative to a countrys GDP, were also associated with higher odds of quitting. Geographical region was also a significant independent predictor. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT01456936.

OBJECTIVES: To investigate the impact of no cost sharing on paediatric care on usage and health outcomes, and whether the effect varies by household income levels. DESIGN: Regression discontinuity design. SETTING: Nationwide medical claims database in Japan. PARTICIPANTS: Children aged younger than 20 years from April 2018 to March 2022. EXPOSURE: Co-insurance rate that increases sharply from 0% to 30% at a certain age threshold (the threshold age varies between 6 and 20 years depending on region). PRIMARY OUTCOME MEASURES: The outpatient care usage (outpatient visit days and healthcare spending for outpatient care) and inpatient care (experience of any hospitalisation and healthcare spending for inpatient care). RESULTS: Of 244 549 children, 49 556 participants were in the bandwidth and thus included in our analyses. Results from the regression discontinuity analysis indicate that no cost sharing was associated with a significant increase in the number of outpatient visit days (+5.26 days; 95% CI, +4.89 to +5.82; p

ObjectivesTo examine how sales of sexual and reproductive health (SRH) products varied among pharmacies in Kenya using administrative data, leveraging natural variation in the COVID-19 pandemic and accompanying policy restrictions between 2019 and 2021.Design and settingEcological study of pharmacies in Kenya.Participants761 pharmacies using the Maisha Meds product inventory management system (capturing 572 916 products sold).OutcomesSales quantity, price and revenue of SRH products sold per pharmacy per week.ResultsCOVID-19 deaths were associated with a -2.97% (95% CI -3.82%, -2.11%) decrease in sales quantity, a 1.09% (95% CI 0.44%, 1.72%) increase in sales price and a -1.89% (-1.00%, -2.79%) decrease in revenues per pharmacy per week. Results were similar when considering new COVID-19 cases (per 1000) and the Average Policy Stringency Index. Results differed substantially between individual SRH products-a large decrease in sales quantity in pregnancy tests, injectables and emergency contraception, a modest decrease in condoms and no change in oral contraception. Sales price increases were similarly varied; four of the five most sold products were revenue neutral.ConclusionsWe found a robust negative association between SRH sales at pharmacies in Kenya and COVID-19 reported cases, deaths and policy restriction. Although our data cannot definitively point to reduced access, existing evidence from Kenya regarding unchanged fertility intentions, increases in unintended pregnancies and reported reasons for non-use of contraceptives during COVID-19 suggests a prominent role of reduced access. While policymakers may have a role in sustaining access, their role may be limited by broader macroeconomic problems, such as global supply chain disruptions and inflation, during supply shocks.

ObjectiveFor large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy.DesignThe modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys.SettingThe work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care.ParticipantsThe panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems.Outcome measuresThe study planned to formulate a research agenda, implications for practice and recommendations for policy.ResultsFor research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients.ConclusionsRecommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

ObjectivesWe aim to quantify shifts in hospitalisation and mortality and how those were related to the first three phases of the epidemic and individuals' demographics and health profile among those with a positive test for SARS-CoV-2 treated at the Mexican Social Security Institute's facilities from March 2020 to October 2021.DesignRetrospective observational study using interrupted time series analysis to identify changes in hospitalisation rate and case fatality rate (CFR) by epidemic wave.SettingData from the Mexican Institute of Social Security's (IMSS) Online Influenza Epidemiological Surveillance System (SINOLAVE) that include all individuals that sought care at IMSS facilities all over Mexico.ParticipantsAll individuals included in the SINOLAVE with a positive PCR or rapid test for SARS-CoV-2.Primary and secondary outcome measuresMonthly test positivity rates, hospitalisation rates, CFRs and prevalence of relevant comorbidities by age group.ResultsFrom March 2020 to October 2021, the CFR declined between 1% and 3.5%; the declines were significant for those 0-9, 20-29, 30-39, 40-49 and 70 and older. The decline was steep during the first wave and was less steep or was temporarily reversed at the beginning of the second and third waves (changes in the trend of about 0.3% and 3.8%, and between 0.7% and 3.8%, respectively, for some age groups), but then continued to the end of the analytical period. Prevalence of diabetes, hypertension and obesity among patients testing positive also declined-two for most age groups (reductions of up to 10 percentage points for diabetes, 12 percentage points for hypertension and 19 percentage points for obesity).ConclusionData suggest that the decrease in COVID-19 fatality rate is at least partially explained by a change in the profile of those contracting the disease, that is, a falling proportion of individuals with comorbidities across all age groups.

ObjectivesVitamin A deficiency affects an estimated 29% of all children under 5 years of age in low/middle-income countries, contributing to child mortality and exacerbating severity of infections. Biannual vitamin A supplementation (VAS) for children aged 6-59 months can be a low-cost intervention to meet vitamin A needs. This study aimed to present a framework for evaluating the equity dimensions of national VAS programmes according to determinants known to affect child nutrition and assist programming by highlighting geographical variation in coverage.MethodsWe used open-source data from the Demographic and Health Survey for 49 countries to identify differences in VAS coverage between subpopulations characterised by various immediate, underlying and enabling determinants of vitamin A status and geographically. This included recent consumption of vitamin A-rich foods, access to health systems and services, administrative region of the country, place of residence (rural vs urban), socioeconomic position, caregiver educational attainment and caregiver empowerment.ResultsChildren who did not recently consume vitamin A-rich foods and who had poorer access to health systems and services were less likely to receive VAS in most countries despite potentially having a greater vitamin A need. Differences in coverage were also observed when disaggregated by administrative regions (88% of countries) and urban versus rural residence (35% of countries). Differences in vitamin A coverage between subpopulations characterised by other determinants of vitamin A status varied considerably between countries.ConclusionVAS programmes are unable to reach all eligible infants and children, and subpopulation differences in VAS coverage characterised by various determinants of vitamin A status suggest that VAS programmes may not be operating equitably in many countries.

IntroductionAs of July 2022, a little over one-third of Guatemalans were fully vaccinated. While COVID-19 vaccination rates are not officially reported nationally by racial/ethnic groups, non-governmental organisations and reporters have observed that COVID-19 vaccination rates are especially low among high-risk Indigenous populations. We conducted one of the first studies on COVID-19 vaccine acceptance in Indigenous populations in the Central Highlands of Guatemala, which aimed to better understand the barriers to COVID-19 vaccine uptake and how to improve vaccine promotional campaigns.MethodsIn November 2021, we conducted eight focus group discussions (FGDs) with 42 Indigenous men and women and 16 in-depth interviews (IDIs) with community health workers, nurses and physicians in Chimaltenango and Sololá. Using a participatory design approach, our qualitative analysis used constant comparative methods to understand the inductive and deductive themes from the FGD and IDI transcripts.ResultsWe found three major overarching barriers to vaccination within the sampled population: (1) a lack of available easily understandable, linguistically appropriate and culturally sensitive COVID-19 vaccine information; (2) vaccine access and supply issues that prevented people from being vaccinated efficiently and quickly; and (3) widespread misinformation and disinformation that prey on people's fears of the unknown and mistrust of the medical establishment and government.ConclusionWhen developing COVID-19 vaccine messages, content should be culturally relevant, appropriate for low-literacy populations and in the languages that people prefer to speak. Promotional materials should be in multiple modalities (print, radio and social media) and also have specific Maya cultural references (dress, food and concepts of disease) to ensure messaging connects with intended targets. This study supports the need for more robust research into best practices for communicating about COVID-19 vaccines to marginalised communities globally and suggests that policy makers should invest in targeted local solutions to increase vaccine uptake.

ObjectiveReports of efficacy, effectiveness and harms of COVID-19 vaccines have not used key indicators from evidence-based medicine (EBM) that can inform policies about vaccine distribution. This study aims to clarify EBM indicators that consider baseline risks when assessing vaccines' benefits versus harms: absolute risk reduction (ARR) and number needed to be vaccinated (NNV), versus absolute risk of the intervention (ARI) and number needed to harm (NNH).MethodsWe used a multimethod approach, including a scoping review of the literature; calculation of risk reductions and harms from data concerning five major vaccines; analysis of risk reductions in population subgroups with varying baseline risks; and comparisons with prior vaccines.FindingsThe scoping review showed few reports regarding ARR, NNV, ARI and NNH; comparisons of benefits versus harms using these EBM methods; or analyses of varying baseline risks. Calculated ARRs for symptomatic infection and hospitalisation were approximately 1% and 0.1%, respectively, as compared with relative risk reduction of 50%-95% and 58%-100%. NNV to prevent one symptomatic infection and one hospitalisation was in the range of 80-500 and 500-4000. Based on available data, ARI and NNH as measures of harm were difficult to calculate, and the balance between benefits and harms using EBM measures remained uncertain. The effectiveness of COVID-19 vaccines as measured by ARR and NNV was substantially higher in population subgroups with high versus low baseline risks.ConclusionsPriorities for vaccine distribution should target subpopulations with higher baseline risks. Similar analyses using ARR/NNV and ARI/NNH would strengthen evaluations of vaccines' benefits versus harms. An EBM perspective on vaccine distribution that emphasises baseline risks becomes especially important as the world's population continues to face major barriers to vaccine access-sometimes termed 'vaccine apartheid'.

ObjectiveIdentify advertising strategies used to market opioids to women and children.DesignQualitative content analysis of internal pharmaceutical industry documents released in litigation, dated between 1999 and 2017.SettingUSA.ParticipantsOpioid manufacturers (Janssen, Ortho-McNeil, Purdue, Teva (Actavis), Janus, Cephalon); women; children.Primary and secondary outcome measuresAdvertising campaigns, industry executive statements regarding marketing goals METHODS: We examined ((DATASET) link: https://www.industrydocuments.ucsf.edu/drug/) documents released in State of Oklahoma v. Johnson & Johnson (2019) to identify marketing strategies and campaigns developed by opioid manufacturers that focused on children and women, as well as public records, including websites developed by manufacturers and their allies, to confirm whether marketing campaigns proposed in internal industry documents were implemented. Documents identified as relevant were coded for themes based on expectations drawn from previous research on marketing using internal industry documents, which included making emotional appeals and understating the risks of addiction.ResultsWe found that opioid manufacturers sought to recruit coaches and school nurses to encourage opioid use by children, developed unbranded initiatives suggesting adolescents ask providers for pain care medications, suggested that opioid use could reduce health risks associated with untreated pain among women and advocated to policy makers that women faced unmet needs for pain medication.ConclusionsThe USA strictly regulates direct marketing of medications but does not place the same restrictions on indirect marketing and unbranded campaigns, which encourage people to seek treatment without indicating the names of specific products. Opioid manufacturers in the early 21st century appear to have relied largely on unbranded campaigns for marketing, which they described externally as public health promotion and internally as a way to increase sales of opioids. The rapid increase in opioid use concomitant with these campaigns suggests that additional scrutiny of this kind of marketing may be needed in order to protect vulnerable groups.

ObjectiveTo examine factors associated with accrual rate in industry sponsored clinical trials supporting US Food and Drug Administration (FDA) cancer drug approvals from 2015 to 2020.Design, setting and participantsRetrospective cross-sectional study included 194 pivotal trials supporting cancer drug approvals by the US FDA from 2015 to 2020.InterventionsClinical trials were analysed for the type of blinding, primary endpoint, whether crossover was specified in the publication, study phase, line of therapy, response rate, investigational sites, manufacturer and randomisation ratio.Main outcome measuresThe main outcome was the rate of accrual, which is the number of patients accrued in the study per open month of enrolment.ResultsThe study consisted of 133 randomised (68%) and 61 (32%) non-randomised clinical trials. In randomised studies, we found the accrual rate was higher in trials investigating first and second line drugs (adjusted rate ratios (aRR): 1.55, 95% CI 1.18 to 2.09), phase III trials (aRR: 2.13, 95% CI 1.48 to 2.99), and for studies sponsored by Merck (aRR: 1.47, 95% CI 1.18 to 2.37), adjusting for other covariates. In contrast, the primary endpoint of a study, presence of crossover, single agent response rate, the number of investigational sites, population disease burden and skewed randomisation ratios were not associated with the rate of accrual. In the non-randomised adjusted model, the accrual rate was 2.03 higher (95% CI 1.10 to 3.92) for clinical trials sponsored by manufacturer, specifically Merck. Primary endpoint, crossover, trial phase, response rate, the number of investigational sites, disease burden or line of therapy were not associated with the rate of accrual.ConclusionIn this cross-sectional study, line of therapy, study phase and manufacturer were the only factors associated with accrual rate. These findings suggest many proffered factors for speedy trial accrual are not associated with greater enrolment rates.

ObjectivesWe aimed to examine the use and factors associated with the provision of low-value care in Japan.DesignA multicentre observational study.SettingRoutinely collected claims data that include all inpatient and outpatient visits in 242 large acute care hospitals (accounting for approximately 11% of all acute hospitalisations in Japan).Participants345 564 patients (median age (IQR): 62 (40-75) years; 182 938 (52.9%) women) seeking care at least once in the hospitals in the fiscal year 2019.Primary and secondary outcome measuresWe identified 33 low-value services, as defined by clinical evidence, and developed two versions of claims-based measures of low-value services with different sensitivity and specificity (broader and narrower definitions). We examined the number of low-value services, the proportion of patients receiving these services and the proportion of total healthcare spending incurred by these services in 2019. We also evaluated the 2015-2019 trends in the number of low-value services.ResultsServices identified by broader low-value care definition occurred in 7.5% of patients and accounted for 0.5% of overall annual healthcare spending. Services identified by narrower low-value care definition occurred in 4.9% of patients and constituted 0.2% of overall annual healthcare spending. Overall, there was no clear trend in the prevalence of low-value services between 2015 and 2019. When focusing on each of the 17 services accounting for more than 99% of all low-value services identified (narrower definition), 6 showed decreasing trends from 2015 to 2019, while 4 showed increasing trends. Hospital size and patients' age, sex and comorbidities were associated with the probability of receiving low-value service.ConclusionsA substantial number of patients received low-value care in Japan. Several low-value services with high frequency, especially with increasing trends, require further investigation and policy interventions for better resource allocation.

ObjectivesNurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians.Design, setting and participantsUsing nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination.ExposuresNPs/PAs.Main outcome measuresUse of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines.ResultsBefore propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p95% of NP/PA visits including the NP/PA-physician combination.Conclusions and relevanceWhile U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.

OBJECTIVES: To determine whether experiences of off-the-job training in domestic (DT) and overseas study (OS) settings are associated with work performance and work-family conflict in physicians. DESIGN, SETTING AND PARTICIPANTS: We conducted a national cross-sectional survey in 77 public hospitals across seven provinces in China between July 2014 and April 2015. Participants were 3182 physicians. EXPOSURE: Participants were categorised into four groups: none, DT only, OS only and DT and OS. PRIMARY OUTCOME MEASURES: Work performance was assessed by work engagement, career attrition and patient-centred care. Work-family conflict was assessed by affecting care for family, feeling guilty towards family and receiving complaints from family. RESULTS: A total of 25.89% participants had experienced DT only, 8.71% OS only and 8.47% DT and OS. After adjustment for potential confounders, participants who had experiences of DT and OS compared with those with no training were more likely to report positive work performance (pride in work: OR=2.11, 95% CI: 1.43 to 3.10; enjoyment of work: OR=1.67, 95% CI: 1.11 to 2.51; turnover intention: OR=0.54, 95% CI: 0.38 to 0.77; early retirement: OR=0.63, 95% CI: 0.45 to 0.89; and exhaustion: OR=0.66, 95% CI: 0.45 to 0.98) and less work-family conflicts (feeling guilty towards family: OR=0.51, 95% CI: 0.35 to 0.74; and complaints from family: OR=0.66, 95% CI: 0.47 to 0.91). We found no obvious association between DT/OS experience with patient-centred care. CONCLUSIONS: Physicians with DT and OS experiences are more likely to have better work performance and less work-family conflict than those without such experience. Physicians face increasing pressure to pursue continuing education and experience associated distress. Therefore, hospitals and government policy-makers should promote DT and OS.

ObjectivesVaccine hesitancy may represent a barrier to effective COVID-19 immunisation campaigns. This study assesses individual, disease-specific and contextual factors associated with COVID-19 vaccine acceptance among a nationally representative sample of older Brazilian adults.DesignCross-sectional analysis of data from household interviews and a supplementary telephone survey.SettingBrazil and its five geographic regions.ParticipantsData are derived from 6584 individuals aged 50 years and over who participated in the second wave of the Brazilian Longitudinal Study of Aging.Primary and secondary outcome measuresSurvey-weighted multinomial logistic regression assesses factors associated with intending, not intending or being uncertain about one's intention to vaccinate against COVID-19.FindingsSeventy-one per cent of study participants intend to receive a COVID-19 vaccine once available, while 17% (representative of nearly 9 million people) have no intention to vaccinate, and 12% are still undecided. Besides age, demographic and health-related factors related to COVID-19 severity and complications were not associated with intention to vaccinate. Those who most trusted social media or friends and family for COVID-19 information and those who did not trust any information source were 68% and 78% more likely to refuse vaccination, respectively, as compared with those who trusted official information sources. People who inconsistently used face masks when outside were 3.4 times more likely than consistent face mask users to intend to refuse vaccination. Higher municipal COVID-19 fatality rates were negatively associated with vaccine refusal.ConclusionsMost national COVID-19 immunisation strategies identify older individuals as among those prioritised for early vaccination, given their increased risk of more severe symptoms and complications of the disease. Because individual, disease-specific, and contextual factors were associated with vaccine acceptance, there is a clear need for multilevel and multichannel information and outreach campaigns to increase COVID-19 vaccine acceptance among vulnerable older populations.

ObjectiveMusculoskeletal problems like hip and knee osteoarthritis and low-back pain are preference sensitive conditions. Patient engagement strategies (PES), such as shared decision-making and motivational interviewing, can help align patients' preferences with treatment options and potentially reduce spending. We assess the association of physician practice-level adoption of PES with utilisation and spending.DesignCross-sectional study in which patients were matched across low, moderate and high levels of PES via coarsened exact matching.SettingPrimary and secondary care in 2190 physician practices.Participants39 336 hip, 48 362 knee and 67 940 low-back patients who were Medicare beneficiaries were matched to the 2017-2018 National Survey of Healthcare Organizations and Systems.Primary and secondary outcome measuresTotal hip replacement (THR), total knee replacement (TKR), 1-2 level posterior lumbar fusion (LF), total annual spending, components of total annual spending.ResultsTotal annual spending for patients with musculoskeletal problems did not differ for practices with low versus moderate PES, low versus high PES or moderate versus high PES, but spending was significantly lower in some categories for practices with relatively higher PES adoption. For hospital-owned and health system-owned practices, the ORs of receiving LF were 0.632 (95% CI 0.396 to 1.009) for patients attributed to practices with high PES compared with patients attributed to practices with moderate PES. For independent practices, the odds of receiving THR were 1.403 (95% CI 1.035 to 1.902) for patients attributed to practices with moderate PES compared with patients attributed to practices with low PES.ConclusionsPractice-level adoption of PES for patients with musculoskeletal problems was generally not associated with total spending. PES, however, may steer patients toward evidence-based treatments. Opportunities for overall spending reduction exist as indicated by the variation in the subcomponents of total spending by PES adoption.

ObjectivesIn February 2020, the US Food and Drug Administration issued a guidance restricting the sales and distribution of cartridge-based e-cigarettes with flavours other than tobacco and menthol. Disposable devices were exempt from this guidance. This study examined the prevalence of disposable pod use and flavour preference compared with refillable pod and other e-cigarette users among vape shop customers.DesignCross-sectional study.SettingIn July 2019-March 2020, trained data collectors visited 44 vape shops in California with permission to recruit customers from shop owners.ParticipantsIntercept interviews with 276 customers were conducted.Outcomes and proceduresCustomers were grouped based on self-reported device type used most often (disposable pod, refillable pod and other e-cigarettes). Groups were compared on self-reported demographics, flavours preferred, daily e-cigarette use, preferred nicotine concentration levels and cigarette use.ResultsOf the 276 customers surveyed, 11.2% used disposable pods in the past 30 days. Among disposable pod users, fruit/candy (80.7%), mint (77.4%) and menthol (67.7%) were common preferred flavours, while tobacco flavours were less commonly preferred (19.4%). When compared with refillable pod and other non-pod e-cigarette device users, disposable pod users were younger, used higher nicotine concentration levels, were more likely to prefer mint and menthol flavours and use e-cigarettes as their first product, while less likely to ever use cigarettes and use e-cigarettes daily.DiscussionDespite using higher nicotine levels and preferred menthol/mint flavours more often than users of other devices, disposable pod users reported lower prevalence of lifetime smoking and daily vaping and were younger. Given the current findings, regulations addressing non-tobacco flavours and nicotine concentration in disposable pod devices merit consideration in efforts to reduce vaping in younger adult never smokers.

ObjectivesTo estimate the health characteristics and racial/ethnic health disparities among a probation cohort in Hennepin County. We hypothesised the probation population would have higher health needs compared with the general population as well as significant racial/ethnic health disparities.DesignCross-sectional study using linked administrative records.ParticipantsOf 7992 eligible individuals, 5873 met inclusion criteria of 6 or more months of eligibility for a full-benefit Minnesota healthcare plan.SettingProbation system in Hennepin County in 2016.OutcomesWe compared health condition prevalence among our probation cohort with survey data from the general population and analysed by race/ethnicity. We also measured sociodemographic characteristics, including the use of safety-net services.ResultsIndividuals were predominantly male (80.5%), young (mean age: 35.5 years), and disproportionately black or African American (52.9%). A majority of individuals enrolled in Medicaid were eligible via Medicaid expansion (65.9%). Compared with the general population, individuals on probation had higher rates of substance use disorders (66.5% vs 8.1%), mental illness (55.3% vs 14.4%) and many physical conditions (eg, asthma: 17.0% vs 12.5%, chronic kidney disease: 5.8% vs 0.2%). White individuals on probation were significantly more likely than black or African American individuals to have a diagnosed substance use disorder (71.6% vs 62.0%) or mental health disorder (64.9% vs 48.5%), but fewer chronic physical health conditions (average: 0.52 vs 0.73 chronic physical conditions).ConclusionsIndividuals on probation have high health needs, which vary substantially by race/ethnicity. Without attention to this variation, interventions to address health conditions in this population could worsen racial/ethnic disparities.

ObjectiveTo investigate the factors associated with serious psychological distress (SPD) during the COVID-19 pandemic in Japan.DesignNationwide cross-sectional study using survey data.SettingInternet survey using sampling weights for national estimates conducted between 25 August and 30 September 2020 in Japan.ExposuresDemographics (age, gender), socioeconomic status (income level, employment type, educational attainment, marital status, family composition and caregiving burden); the experience of domestic violence (DV), the state of emergency and fear of and stigma related to COVID-19.Main outcome measuresPrevalence of SPD, defined as Kessler 6 Scale score ≥13.ResultsAmong 25 482 respondents, 10.0% met the criteria of SPD. Overall, women (adjusted OR (aOR) 1.59; 95% CI 1.17 to 2.16; p=0.003), ages 15-29 (aOR 2.35 compared with ages 45-59 years; 95% CI 1.64 to 3.38; p

ObjectiveTo investigate the association between participation in government subsidies for domestic travel (subsidise up to 50% of all travel expenses) introduced nationally in Japan on 22 July 2020 and the incidence of symptoms indicative of COVID-19 infections.DesignCross-sectional analysis of nationally representative survey data.SettingInternet survey conducted between 25 August and 30 September 2020 in Japan. Sampling weights were used to calculate national estimates.Participants25 482 survey respondents (50.3% (12 809) women; mean (SD) age, 48.8 (17.4) years).Main outcome measuresIncidence rate of five symptoms indicative of the COVID-19 infection (high fever, sore throat, cough, headache, and smell and taste disorder) within the past month of the survey, after adjustment for characteristics of individuals and prefecture fixed effects (effectively comparing individuals living in the same prefecture).ResultsAt the time of the survey, 3289 (12.9%) participated in the subsidy programme. After adjusting for potential confounders, we found that participants in the subsidy programme exhibited higher incidence of high fever (adjusted rate, 4.7% for participants vs 3.7% for non-participants; adjusted OR (aOR) 1.83; 95% CI 1.34 to 2.48; p

OBJECTIVES:The aim of this study was to characterise the resources and challenges for surgical care and referrals at health centres (HCs) in South Wollo Zone, Ethiopia. SETTING:Eight primary HCs in South Wollo Zone, Ethiopia. PARTICIPANTS:Eight health officers and nurses staffing eight HCs completed a survey. DESIGN:The study was a survey-based, cross-sectional assessment of HCs in South Wollo Zone, Ethiopia and data were collected over a 30-day period from November 2014 to January 2015. PRIMARY AND SECONDARY OUTCOME MEASURES:Survey assessed human and material resources, diagnostic capabilities and challenges and patient-reported barriers to care. RESULTS:Eight HCs had an average of 18 providers each, the majority of which were nurses (62.2%) and health officers (20.7%). HCs had intermittent availability of clean water, nasogastric tubes, rectal tubes and suturing materials, none of them had any form of imaging. A total of 168 surgical patients were seen at the 8 HCs; 58% were referred for surgery. Most common diagnoses were trauma/burns (42%) and need for caesarean section (9%). Of those who did not receive surgery, 32 patients reported specific barriers to obtaining care (91.4%). The most common specific barriers were patients not being decision makers to have surgery, lack of family/social support and inability to afford hospital fees. CONCLUSIONS:HCs in South Wollo Zone, Ethiopia are well-staffed with nurses and health officers, however they face a number of diagnostic and treatment challenges due to lack of material resources. Many patients requiring surgery receive initial diagnosis and care at HCs; sociocultural and financial factors commonly prohibit these patients from receiving surgery. Further study is needed to determine how such delays may impact patient outcomes. Improving material resources at HCs and exploring community and family perceptions of surgery may enable more streamlined access to surgical care and prevent delays.

ObjectivesAlthough tobacco is the leading preventable cause of death in the USA, it is routinely sold in pharmacies. In 2008, San Francisco became the first city in the USA to pass a tobacco-free pharmacy ordinance. Over the next decade, 171 municipalities enacted similar policies, and in 2018, Massachusetts banned tobacco sales in pharmacies. Our objective was to assess the perceived effects of tobacco-free pharmacy policies on displays, sales, customer visits and counselling.DesignObservational study and survey.SettingIn 2017, we visited Walgreens and CVS stores in San Francisco and nearby San Jose, which allows tobacco sales, to assess placement of tobacco and over-the-counter tobacco cessation products (nicotine replacement therapy or NRT). We surveyed an employee at each site regarding the impact that tobacco-free pharmacy policies had had on customer traffic and sales of NRT.ParticipantsWe obtained display data from 72 pharmacies and collected surveys from 55 employees (76% response rate).ResultsA majority of respondents at tobacco-free pharmacies (55%) reported that the policy had not affected customer visits. In comparison, 70% of respondents at tobacco-selling pharmacies believed that eliminating tobacco sales would reduce the number of customers visiting their stores. Pharmacies that were tobacco free and those that sold tobacco reported comparable displays, sales and counselling for NRT.ConclusionsPharmacies operating under tobacco-free policies did not report reduced customer visits. Greater awareness of this outcome could help pharmacies implement public health recommendations to eliminate tobacco sales.

ObjectiveTo assess the effect of cannabis legalisation on health effects and healthcare utilisation in Colorado (CO), the first state to legalise recreational cannabis, when compared with two control states, New York (NY) and Oklahoma (OK).DesignWe used the 2010 to 2014 Healthcare Cost and Utilisation Project (HCUP) inpatient databases to compare changes in rates of healthcare utilisation and diagnoses in CO versus NY and OK.SettingPopulation-based, inpatient.ParticipantsHCUP state-wide data comprising over 28 million individuals and over 16 million hospitalisations across three states.Main outcome measuresWe used International Classification of Diseases-Ninth Edition codes to assess changes in healthcare utilisation specific to various medical diagnoses potentially treated by or exacerbated by cannabis. Diagnoses were classified based on weight of evidence from the National Academy of Science (NAS). Negative binomial models were used to compare rates of admissions between states.ResultsIn CO compared with NY and OK, respectively, cannabis abuse hospitalisations increased (risk ratio (RR) 1.27, 95% CI 1.26 to 1.28 and RR 1.16, 95% CI 1.15 to 1.17; both p

ObjectivesThe study aimed to qualitatively examine the perspectives of US-based physicians and academic global health programme leaders on how global health work shapes their viewpoints, values and healthcare practices back in the USA.DesignA prospective, qualitative exploratory study that employed online questionnaires and open-ended, semi-structured interviews with two participant groups: (1) global health physicians and (2) global health programme leaders affiliated with USA-based academic medical centres. Open coding procedures and thematic content analysis were used to analyse data and derive themes for discussion.Participants159 global health physicians and global health programme leaders at 25 academic medical institutions were invited via email to take a survey and participate in a follow-up interview. Twelve participants completed online questionnaires (7.5% response rate) and eight participants (four survey participants and four additionally recruited participants) participated in in-depth, in-person or phone semi-structured interviews.ResultsFive themes emerged that highlight how global health physicians and academic global health programme leaders perceive global health work abroad in shaping USA-based medical practices: (1) a sense of improved patient rapport, particularly with low-income, refugee and immigrant patients, and improved and more engaged patient care; (2) reduced spending on healthcare services; (3) greater awareness of the social determinants of health; (4) deeper understanding of the USA's healthcare system compared with systems in other countries; and (5) a reinforcement of values that initially motivated physicians to pursue work in global health.ConclusionsA majority of participating global health physicians and programme leaders believed that international engagements improved patient care back in the USA. Participant responses relating to the five themes were contextualised by highlighting factors that simultaneously impinge on their ability to provide improved patient care, such as the social determinants of health, and the challenges of changing USA healthcare policy.

ObjectivesWe sought the perspectives of lead public health officials working to improve health equity in the USA regarding the drivers of scientific evidence use, the supply of scientific evidence and the gap between their evidentiary needs and the available scientific evidence.DesignWe conducted 25 semistructured qualitative interviews (April 2017 to June 2017) with lead public health officials and their designees. All interviews were transcribed and thematically analysed.SettingPublic health departments from all geographical regions in the USA.ParticipantsParticipants included lead public health officials (20) and their designees (5) from public health departments that were either accredited or part of the Big Cities Health Coalition.ResultsMany respondents were using scientific evidence in the context of grant writing. Professional organisations and government agencies, rather than specific researchers or research journals, were the primary sources of scientific evidence. Respondents wanted to see more locally tailored cost-effectiveness research and often desired to participate in the planning phase of research projects. In addition to the scientific content recommendations, respondents felt the usefulness of scientific evidence could be improved by simplifying it and framing it for diverse audiences including elected officials and community stakeholders.ConclusionsRespondents are eager to use scientific evidence but also need to have it designed and packaged in ways that meet their needs.

OBJECTIVE:There has been concern that an increase in billing for high-intensity emergency care is due to changes in coding practices facilitated by electronic health records. We sought to characterise the trends in billing for high-intensity emergency care among Medicare beneficiaries and to examine the degree to which trends in high-intensity billing are explained by changes in patient characteristics and services provided in the emergency department (ED). DESIGN, SETTING AND PARTICIPANTS:Observational study using traditional Medicare claims to identify ED visits at non-federal acute care hospitals for elderly beneficiaries in 2006, 2009 and 2012. OUTCOMES MEASURES:Billing intensity was defined by emergency physician evaluation and management (E&M) codes. We tested for overall trends in high-intensity billing (E&M codes 99285, 99291 and 99292) and in services provided over time using linear regression models, adjusting for patient characteristics. Additionally, we tested for time trends in rates of admission to the hospital and to the intensive care unit (ICU). Next, we classified outpatient visits into 39 diagnosis categories and analysed the change in proportion of high-intensity visits versus the change in number of services. Finally, we quantified the extent to which trends in high-intensity billing are explained by changes in patient demographics and services provided in the ED using multivariable modelling. RESULTS:High-intensity visits grew from 45.8% of 671 103 visits in 2006 to 57.8% of 629 010 visits in 2012 (2.0% absolute increase per year; 95% CI 1.97% to 2.03%) as did the mean number of services provided for admitted (1.28 to 1.41; +0.02 increase in procedures per year; 95% CI 0.018 to 0.021) and discharged ED patients (7.1 to 8.6; +0.25 increase in services per year; 95% CI 0.245 to 0.255). There was a reduction in hospital admission rate from 40.1% to 35.9% (-0.68% per year; 95% CI -0.71% to -0.65%; P

Objectives: Study objective was to map the current literature on the economic effects of priority setting at the system level in healthcare., Design: The study was conducted as a scoping review., Data Sources: Scopus electronic database was searched in June 2023., Eligibility Criteria: We included peer-reviewed articles published 1 January 2020-1 January 2023. All study designs that contained empirical evidence on the financial effects or opportunity costs of healthcare priority setting were included excluding disease, condition, treatment, or patient group-specific studies., Data Extraction and Synthesis: Two independent researchers screened the articles, and two additional researchers reviewed the full texts and extracted data. We used Joanna Briggs Institute checklists to assess the quality of qualitative, quasi-experimental and economic evaluations and the mixed methods appraisal tool for the mixed method studies. Synthesis was done qualitatively and through descriptive statistics., Results: 8869 articles were screened and 15 fulfilled the inclusion criteria. The most common study focus was health technology assessment (7/15). Other contexts were opportunity costs, effects of programme budgeting and marginal analysis, and disinvestment initiatives. Priority setting activities analysed in the studies did not achieve cost savings or cost containment (4/15) or have mixed findings at best (8/15). Only five studies found some indication of cost savings, cost containment or increased efficiency. Also, many of the studies consider costs only indirectly or qualitatively., Conclusions: All in all, there is very little research addressing the pressing question of whether explicit priority setting and priority-setting methods can support cost containment on a health service system level (regional or national). There is limited evidence of the economic effects of priority setting., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This article critically evaluates the European Commission's 2024 Implementing Regulation (IR) on conflicts of interest (COIs) management for stakeholders in the European Union (EU) Joint Clinical Assessment (JCA), with a focus on individual experts such as clinicians and patient representatives., Key Findings: The IR is the first EU-level framework to assess COIs in the context of health technology assessment (HTA). The regulation requires experts involved in the JCA to submit annual declarations of interest for both financial and non-financial interests and presents a matrix on whether these conflicts should disqualify them from participating in the joint work. We compared the IR to COIs-management approaches from other European national HTA bodies and found that the IR is closely modelled after the French guidelines. Concerns include potential over-representation of experts from a small number of countries, lack of guidance on organisational COIs, and ambiguities in how the size of financial interests are disclosed. Unclear resource allocation for enforcement could also hinder compliance., Conclusions: The IR marks progress in EU-wide HTA collaboration, but improvements in transparency, expert diversity, and comprehensive COIs management are needed to ensure impartiality in the JCA process., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

This work grew from an interest in understanding how private data are used for health system governance in low-income and middle-income countries (LMICs)., Objective: We conducted a scoping review to understand how the public sector collects routine data from the private health sector and uses it for governance purposes. The private health sector was defined to include both formal and informal, for-profit or non-profit, actors delivering healthcare services., Findings: We identified 4014 individual English language studies published between 2010 and 2021. We reviewed titles and abstracts of all, with 50% reviewed by two authors to ensure a common application of inclusion criteria. 89 studies were selected for review in full; following this, 26 articles were included in the final selection as they directly report on the use of routine private sector data for governance in LMICs. Only English language studies were included, limiting the scope of possible conclusions., Results: Data were most commonly collected by the Ministry of Health or a subministerial office, with extraction from District Health Information System 2 specifically cited for three studies. 16 studies collected data on infrastructure and distribution, 15 on service delivery, 12 on health financing, 7 on pharmaceuticals and other consumables, 4 on health workforce, 4 on quality of care and 4 on epidemic surveillance., Conclusion: The studies identified provide examples of the public sector's capacity to collect and use data routinely collected from the private sector to perform essential governance functions. The paucity of studies identified is an indication that more attention is needed to ensure that this key area of health system governance is undertaken and that lessons learnt are shared. This review provides insights to understanding private sector health data collection and use for governance in LMICs, and for guiding activities to assess and improve this according to country context and capacity., Competing Interests: Competing interests: All authors attest that they were funded by the World Bank as employees or consultants during the conceptual development of this paper; SK is employed by the World Bank and AF and BO'H have ongoing contracts for unrelated work with the World Bank. No authors have royalties, consulting, payment or honoraria, expert testimony, meeting support, stock options or any other kind of support related to this work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Most first-time biomedical research grant applications are not funded. In the challenging research funding climate, resubmitting a grant application is a necessary task for scientists. Identifying which factors influence their decision to resubmit and the success of resubmissions will inform funders and applicants. However, data on resubmissions are fragmented and under-reported. In this scoping review, we aimed to summarise (1) the outcomes of resubmitting biomedical research grant applications and (2) the demographic characteristics of scientists who resubmitted grant applications., Design: Scoping review with reporting informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses., Data Sources: MEDLINE, CINAHL, EMBASE, Cochrane Central Registrar of Controlled Trials CENTRAL, PsycINFO, Web of Science and grey literature sources were searched through November 2022., Eligibility Criteria: We included peer-reviewed and grey literature records from the biomedical sciences that reported outcomes of the resubmission process (eg, resubmission success rate, rate of resubmission) and information about the scientists who resubmit grant applications (eg, sex, race, career stage)., Data Extraction and Synthesis: Data were extracted independently by two reviewers. The data were cross-referenced and any conflicts were resolved via consensus. Data were summarised descriptively and presented in tables and figures., Results: Resubmissions represented a substantial proportion of applications (lowest prevalence rate: 4%; highest prevalence rate: 56%) in a given funding cycle and were reliably more successful than first-time applications (lowest success rate: 16%; highest success rate: 82%)-a phenomenon associated with several sociodemographic, institutional and project-related factors. There was conflicting evidence about the relationship of sociodemographic-related, institution-related and project-related factors to resubmission likelihood and success., Conclusion: The resubmission process is a time-consuming and often frustrating experience for researchers. Our review identified opportunities to streamline and improve the process to enhance the biomedical research landscape., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Climate change is a paramount global health threat with multifaceted implications. Societal change is required to mitigate the negative effects of climate change, as well as help people adapt to the associated health risks. This requires situation-specific, large-scale data to help scientists and policymakers understand public perceptions and behaviours and identify the levers to increase public readiness to act against climate change and protect health. The Planetary Health Action Survey (PACE) assesses this readiness to act as a regular monitoring of representative samples in Germany. The ongoing monitoring seeks to develop and refine an integrated conceptual model of the trait-like readiness to act, comprising policy acceptance, political participation and individual behaviours as indicators of the trait. It also proposes as set of determinants to explain different levels of readiness to act. This study protocol provides newly developed valid measurement instruments and the methodological details of the monitoring., Method and Analysis: PACE assesses indicators of the readiness to act and a set of sociocognitive factors predicting the readiness to act in continuous cross-sectional data collections. The latter comprise climate change knowledge, trust in institutions, perceived health risks, self-efficacy, social norms and perceived effectiveness of policy measures. The online questionnaire is updated regularly. Data collection involves non-probabilistic quota samples from Germany (n≈1000 at each collection)., Ethics and Dissemination: The project adheres to the ethical guidelines of the University of Erfurt and the German Research Foundation. Ethical clearance was granted by the University's Institutional Review Board (No #20220525/No #2024-01). Participants are guaranteed confidentiality and anonymity, and informed consent is obtained before participation. Results will be published in peer-reviewed journals. Additionally, we aim to inform and empower the public and support stakeholders (media, policymakers, climate protection organisations) in preparing climate communication and assisting policymakers through the project website including an interactive tool, detailed reports and short summaries for practitioners., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study assessed the trends and patterns of antimicrobial consumption (AMC) from 2020 to 2021, 2021-2022 and 2022-2023 at the Benjamin Mkapa Zonal Referral Hospital (BMH) in Dodoma, Tanzania., Design: A retrospective cross-sectional study was conducted to collect AMC data for three financial years with respective denominators. The data were computed using the AMC Tool 2019 v1.9.0 and defined daily dose per 1000 inhabitants per day (DID)., Setting: The BMH, Dodoma, Tanzania., Participants: This study surveyed quantities of antimicrobials procured at the BMH. It did not have any human participants., Outcome Measures: AMC was quantified in DID. The comparisons were made based on the DID of all surveyed antimicrobials, taking into account oral and parenteral administration and based on pharmacological classes. Further, DIDs were presented based on the 2023 WHO Access (A), Watch (W) and Reserve (R) (AWaRe) classification., Results: In 29 assessed antimicrobials, the DIDs for 2020-2021, 2021-2022 and 2022-2023 were 3.0852, 3.5892 and 3.9213, respectively. The average DID per year was 3.5319, with a mean of 2.4207±1.9765 DID per year. The topmost consumed antimicrobials over the 3 years (doxycycline, azithromycin, amoxicillin/beta-lactamase inhibitors, ampicillin/cloxacillin, amoxicillin/flucloxacillin, ceftriaxone, nitrofurantoin and clarithromycin) account over 90% of consumption. The most highly consumed therapeutic classes were beta-lactam antibacterial penicillins (34.71%), macrolides, lincosamides, streptogramins and others (25.75%), followed by tetracycline (23.88%). The AWaRe categorisation and antimicrobials not recommended (ANR) distribution were as follows: Access-51.61%, Watch-31.96%, Reserve-0.00%, and ANR-16.43%, respectively., Conclusion: For every 1000 patients attending the BMH per day, our study found 2.4207±1.9765 DIDs of an antimicrobial were consumed. The most consumed antimicrobials include doxycycline, azithromycin, amoxicillin/beta-lactamase inhibitor, ceftriaxone and metronidazole. To combat antimicrobial resistance effectively, it is imperative to institute a hospital policy for antimicrobial stewardship that prioritises the utilisation of a hospital formulary and antibiograms for the procurement of antimicrobials at the BMH., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The primary aim of this research is to uncover the underlying factors that shape hospital selection criteria among individuals in Lebanon., Design: Cross-sectional study., Setting: A survey was circulated across social media platforms and messaging applications in Lebanon from February to May 2023. This questionnaire aimed to gauge participants' opinions on the importance of various factors in their hospital selection process., Participants: A total of 746 participants filled out the survey. We targeted Lebanese adults who were not hospitalised at the time of survey submission., Main Outcome Measures: We performed an exploratory factor analysis to examine the underlying structure of our 70-question survey. Reliability analysis was conducted using Cronbach's alpha and McDonald's omega. Factor scores were derived by aggregating raw scores and computing the mean., Results: The survey results identified eight key factors that accounted for 58.02% of the total variance, with excellent sampling adequacy (Kaiser-Meyer-Olkin=0.921, Bartlett's p<0.001). These factors exhibited good internal consistency, as indicated by Cronbach's alpha values for each factor. Ranked by importance for hospital selection, the factors are: staff qualities (α=0.773), administrative services (α=0.801), reputation (α=0.773), ease of access (α=0.704), room attributes (α=0.796), architectural and physical surroundings (α=0.828), luxury amenities (α=0.849) and affiliation and ownership (α=0.661)., Conclusion: This paper highlights the hospital characteristics that people may value before selecting a hospital. This insight provides an opportunity for hospital managers to refine their services, ensuring better resonance with people's anticipations. Beyond this, it sheds light on areas where hospitals could strategically invest to elevate their competitive edge in the healthcare market., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To generate evidence about changes in the research and development (R&D) investment of Chinese chemical pharmaceutical companies before and after the implementation of the national pooled procurement, to respond to the concerns that significant price reductions might negatively affect R&D investment, and to facilitate the evidence-based decision-making for improvement of the national pooled procurement., Methods: This retrospective study employed the fixed-effects models with robust SEs to analyse the changes in R&D investment intensities of 76 A-share listed Chinese chemical pharmaceutical companies before and after the procurement implementation in 2019. The analyses were based on a panel data set between 2013 and 2022. Subgroup analyses were conducted to account for the heterogeneity of the target companies. The bootstrap hypothesis test method was employed to assess potential variations across the different subgroups., Results: Following the procurement implementation, the R&D investment intensity (RDI) of the target companies increased by 1.9% (p<0.05) compared with the RDI before the procurement implementation. Successful bidders exhibited a higher RDI of 2.2% (p<0.01) compared with that of the other suppliers. The RDI of companies engaged in traditional Chinese medicine (TCM) production was found to be 2.4% lower (p<0.01) than that of companies not involved in TCM production. Similarly, the companies engaged in the production of active pharmaceutical ingredients (APIs) had a 1.6% lower (p<0.01) RDI than those not involved in API production., Conclusions: This study found that the enthusiasm of Chinese chemical medicines companies towards investing in R&D following the medicines regulatory reforms was not suppressed when the pilot pooled procurement was expanded and continued. The overall level of RDI following the pilot was higher than that before the pilot during the entire observation period. The enhanced investment in R&D has been a distinctive feature of Chinese chemical pharmaceutical companies that position themselves with more substantial market competitiveness., Competing Interests: Competing interests: JS was involved in the programme 'Viral hepatitis treatment M&E in China' in collaboration with the 'WHO'. YL was involved in the programme 'Health Insurance and Medical Collaboration Research' in collaboration with the 'State Council Leading Group for Advancing Healthcare System Reform' and the programme 'Research on the Transformation of Medical Insurance Administration in the New Era' in collaboration with the 'National Healthcare security administration'. QL, QW and ZW have no competing interests to declare., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Health interventions that require significant change to individual lifestyles or social norms can pose a challenge for widespread public acceptability and uptake. At the same time, over the last two decades, there has been increasing attention paid to the rise of populist movements globally, defined by 'the people' pushing against 'an elite' viewed as depriving the people of their sovereignty. To understand potential overlap in these two areas, this study aims to synthesise existing international evidence on linkages between populist attitudes and reduced uptake, acceptability, adherence and/or effectiveness of public health interventions. The goal of this work is to create a conceptual framework that can be used to inform policy strategies aimed at widening the impact of public health interventions., Methods and Analysis: A systematic review will be performed via searches across databases and websites relevant to public health and social science research, informed by preliminary searches on the topic. There will be no language restrictions, but included studies will be limited to those produced since 2008, the year of the global financial crisis, from which most current literature on populism dates. Risk of bias will be assessed using validated tools according to study design. Due to expected heterogeneity across included studies, this will be a systematic review without meta-analysis. Findings will be synthesised narratively, and the strength of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. The review will be reported according to the Systematic Reviews without Meta-Analysis reporting guidelines., Ethics and Dissemination: Ethical review is not required for this study. Public dissemination will be informed via consultation with our Patient and Public Involvement and Engagement Strategy Group, along with reporting via peer-reviewed publication, relevant international conferences, a policy brief and a workshop with public health and communications experts., Prospero Registration Number: CRD42024513124., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objective: The collection of comprehensive data from post-authorisation trials for conditionally authorised anticancer medicines is frequently delayed. This raises questions about the feasibility of post-authorisation randomised controlled trials (RCTs) that aim to address remaining uncertainties. Therefore, this study explored factors that facilitate or impede the feasibility of post-authorisation RCTs from the perspective of stakeholders directly involved in the design, medical-ethical approval, and conduct of these RCTs., Design: We conducted four qualitative focus groups (FGs)., Setting: FG discussions focused on the oncology setting in European context., Participants: Twenty-eight European patients, physicians, medical ethicists and pharmaceutical industry representatives participated in the FGs., Intervention: Respondents were informed about the topic and the purpose of the FGs before and at the start of FG discussions. An FG script was used to guide the discussion, which was informed by 14 semi-structured interviews with various stakeholders., Results: We identified factors with the potential to impact feasibility related to trial design, trial conduct, factors external to a trial and post-authorisation interaction with regulators. Factors that may be particularly relevant for the post-authorisation setting include the choice of relevant endpoints and the inclusion of a fair comparator (trial design), strategies to increase patients' and physicians' willingness to participate (trial conduct), and external factors relating to a medicine's commercial availability, the presence of competing medicines and trials and the perceptions about clinical equipoise. Post-authorisation interaction with regulators about how to obtain comprehensive data was deemed necessary in cases where a post-authorisation RCT seems infeasible., Conclusions: Based on the identified factors, our findings suggest that patient recruitment and retention could be assessed more in-depth during regulatory feasibility assessments at the time of granting conditional marketing authorisation and that sponsors and regulators should better inform patients and physicians about the remaining uncertainties for conditionally authorised medicines and the necessity for post-authorisation RCTs. By enhancing the evaluation of trial feasibility, timely completion of post-authorisation RCTs may be facilitated to resolve the remaining uncertainties within a reasonable timeframe., Competing Interests: Competing interests: GSS reports he received institutional research support from Agendia, AstraZeneca, Merck, Novartis, Roche, Seagen, and consulting fees from Biovica and Seagen, all outside the scope of this study. PBvH reports she worked for the Medicines Evaluation Board during the conduct of this study and that she transitioned to ProPharma during the finalisation of this study. The other authors report no conflicts of interest in relation to this study., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To summarise PEEP's (Professionals for Ethical Engagement of Peers-a group of consultants with lived and living experience of substance use) outputs and gain insights into PEEP's impact and suggestions for the future., Design: Included an environmental scan to collate PEEP activities and outputs and a participatory qualitative design using thematic analysis., Setting: British Columbia, Canada., Participants: Eight members of PEEP and nine staff/people who consulted PEEP were interviewed., Results: PEEP members are co-authors/acknowledged for their input in 25 peer review publications and 16 reports; PEEP members co-presented or were co-authors on 33 presentations. PEEP meets by Zoom two times per week and is paid monthly via honorarium from the Provincial Health Service Authority at a current rate of $C30 per hour. Four themes emerged from our interviews: (1) What is PEEP? (PEEP provides a sense of community, holds systems accountable and inspires others), (2) PEEP Process (suggestions for improvement: consultants should be prepared and involve PEEP throughout the process and report how PEEP's insights were used), (3) PEEP Outcomes (PEEP members gain skills and confidence, PEEP provides a reality check, consultants learn from PEEP, and input leads to practice changes) and (4) Future of PEEP (sustainable funding and opportunities for growth are critical)., Conclusion: PEEP is a cohesive group whose input is well-respected and influences policy and programmes. Given the ongoing drug toxicity emergency, it is critical to continue to support and expand PEEP., Competing Interests: Competing interests: JAB was involved in the initial creation of PEEP; KL, CB, PC, EH, IH, JL, JM and KS are current staff or members of PEEP. KD and AD have no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In the evolving healthcare landscape of the United Arab Emirates (UAE), establishing cost-effectiveness thresholds (CETs) is pivotal to informing decision-makers about the value of health technologies., Objective: This study aimed to establish CETs for the UAE that harmonise with international standards while reflecting the nation's unique healthcare needs and economic context., Setting: United Arab Emirates., Methods: A multitiered methodology was employed, involving a literature review, a panel of national experts and workshops with key stakeholders, including healthcare providers, government health departments and healthcare payers. The panel and workshops were integral in assessing global CET practices and their applicability to the UAE providing a preliminary framework for CET in the UAE. Structured voting sessions were then conducted allowing voting on crucial aspects of CET to determine the baseline threshold, multipliers for severity, rarity and health gain, and methodologies for quantifying disease severity., Results: CETs were linked to the economic status of the UAE, with a baseline threshold of 0.75 times the gross domestic product per capita for one quality-adjusted life year gained. A multiplier system was introduced to reflect societal views on disease severity, disease rarity and the relative health benefit of health technologies. Based on the voting results, disease rarity was deemed the most crucial factor, receiving a maximum multiplier of 3X, while severity and health gain were assigned a maximum of 2X. The multiplier values for both disease severity and relative health gain would be determined on a continuous scale. The proportional or relative shortfall method would be used to assess disease severity., Conclusions: The proposed CET framework for the UAE will be dependent on local generation of cost-effectiveness evidence. Periodic review of CETs based on initial experiences ensures the responsiveness of policymakers to the changing healthcare and economic environment., Competing Interests: Competing interests: Syreon Middle East was a contractual partner of Bayer. AF, ZK and SAb are shareholders in Syreon Middle East. NK is an employee in Syreon Middle East. The remaining 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., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aimed to examine patient delay, diagnosis delay and treatment performance among patients with tuberculosis (TB) in Shanghai, China in 2018-2020 focusing on disparities between migrant and local patients with TB., Design: Mixed-method study., Setting and Participants: Quantitative data were collected from the TB information management system in Shanghai; 17 533 bacteriologically confirmed and clinically diagnosed patients with pulmonary TB registered in 2018-2020 were included. Qualitative interviews were conducted with TB administrators (n=3) and community healthcare providers (two groups, n=10 in total) from Shanghai., Main Outcome Measures: Patient delay, diagnosis delay and treatment completion were examined by resident type using descriptive analysis and logistic regressions. Qualitative interviews were conducted to understand factors associated with the disparities., Results: From 2018 to 2020, migrant patients with TB accounted for 44.40% of total cases. There was no significant difference in patient delay between migrant and local patients (18.47 days on average). 22.12% of migrants and 16.52% of locals experienced diagnosis delays exceeding 14 days, respectively. After adjusting for all variables, migrant patients (OR 1.30, 95% CI 1.18 to 1.44) and initial care seeking at general hospitals (OR 3.76, 95% CI 3.45 to 4.09) were associated with a higher probability of diagnosis delay. 93.9% of migrant patients and 89.4% of the local patients had a successful TB treatment without statistically significant difference after adjusting for all variables. Qualitative interviews revealed a standard approach to managing patients with TB in Shanghai no matter their resident type. Young migrant patients who were able to maintain their jobs in Shanghai often had better treatment adherence. Despite patients' COVID-19 fear and limited care access in 2020, TB treatment minimally affected for both due to community-based case management., Conclusions: Migrant patients were more likely to experience diagnosis delay. It should improve awareness and knowledge of TB among healthcare professionals at general hospitals to mitigate the risk of diagnosis delay., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To compare the premarket and postmarket evidence of safety and efficacy of direct oral anticoagulants approved for stroke prevention in atrial fibrillation patients across four major regulatory agencies., Design: Cross-sectional., Setting: European Medicines Association (EMA), US Food and Drug Administration (FDA), Health Canada and Australian Therapeutic Goods Administration (TGA)., Participants: Apixaban, dabigatran, edoxaban and rivaroxaban marketing authorisations., Outcome Measures: Concordance among regulatory agencies with respect to (1) premarket evidence used to establish efficacy and safety and (2) postmarket safety boxed warnings and postmarketing study requirements., Results: Apixaban, dabigatran and rivaroxaban were approved by each of the four regulatory agencies; edoxaban was only not approved by TGA. For premarket efficacy evidence, there was concordance across all agencies in terms of phase 3 trials for three (75%) drugs, sample size for three (75%) drugs, primary endpoints for four (100%) drugs, numerical results for three (75%) drugs, agency interpretation of results for four (100%) drugs and number of phase 2 trials for three (75%) drugs. For the premarket safety evidence, there was concordance across all agencies in terms of phase 3 trials for three (75%) drugs, sample size for two (50%) drugs, primary endpoints for four (100%) drugs, numerical results for three (75%) drugs, agency interpretation of results for three (75%) drugs and number of phase 2 trials for zero (0%) drugs. For postmarket safety information, FDA was the only agency that issued boxed warnings (for three (75%) drugs). Additionally, EMA and TGA required postmarketing studies (for four (100%) and two (50%) drugs, respectively), while FDA and Health Canada did not have any postmarketing requirements., Conclusions: There was a high degree of concordance in the phase 3 trial premarket evidence used to establish efficacy and safety of direct oral anticoagulant approvals across four major regulatory agencies, but discordance in the phase 2 trial premarket evidence used, as well as in postmarket safety boxed warnings and postmarketing study requirements. These discrepancies highlight opportunities for further harmonisation in the evaluation and regulation of medical products globally., Competing Interests: Competing interests: TZ have no potential competing interest to disclose. MM and JSR currently receive research support through Yale University from Arnold Ventures outside the submitted work. JSR reported receiving grants from the US Food and Drug Administration; Johnson and Johnson; Medical Device Innovation Consortium; Agency for Healthcare Research and Quality; National Heart, Lung, and Blood Institute and Arnold Ventures outside the submitted work. JSR is also an expert witness at the request of relator attorneys, the Greene Law Firm, in a qui tam suit alleging violations of the False Claims Act and Anti-Kickback Statute against Biogen that was settled in September 2022., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In Colombia, 4.3% of the population 5 years or older lives with a disability. They face higher levels of poverty and social exclusion compared with persons without disabilities. This article aims to understand the factors associated with access to preventative and curative health services for people with disabilities in Colombia. Additionally, it explores whether access to health services for people with disabilities changed during the COVID-19 pandemic., Design: This is a population-based repeated cross-sectional study., Setting: This study took place in Colombia, from 2018 to 2021., Data Sources and Participants: National Quality of Life Survey datasets in Colombia from 2018 to 2021, including people 5 years or older, were reviewed. People were classified into three groups: person with any disability, person with multiple disabilities and person without disabilities., Primary and Secondary Outcome Measures: A multinomial regression model was used to calculate the probability of access to preventative services during the previous year in four categories: general practitioner (GP) and dentist, GP only, dentist only and no consultation. A logistic model for curative consultations with and without hospitalisation in people who reported having a health problem., Results: People with disabilities demanded more preventative health services, except for dental services, compared with people without disabilities. Similarly, they experienced more health problems and demanded more curative services than people without disabilities, except during the year 2020, when no significant differences were found between people with and without disabilities. For people with disabilities, poverty was not associated with a lower likelihood of consultation, except for preventative dental consultations, which were significantly lower for poor people with disabilities. In addition, the subsidised insurance regimen was identified as an important variable in the utilisation of healthcare in Colombia., Conclusion: People with disabilities in Colombia demand more health services compared with people without disabilities. Despite being in a worse condition according to various socioeconomic indicators, few factors affect their demand for healthcare services. The COVID-19 pandemic was associated with a significant reduction in the probability of access to outpatient treatment services during 2020 for people with disabilities. Longitudinal studies and comparison with other Latin American countries are recommended., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The objective of this review was to scrutinise the impact of urban green spaces on heat-related morbidity and mortality., Design: This systematic review was meticulously carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines DATA SOURCES: A comprehensive search was conducted across PubMed, Scopus and Google Scholar including studies from January 2000 to December 2022., Eligibility Criteria: Studies that examined the influence of urban green spaces on heat-related morbidity and mortality, including randomised controlled trials, observational and modelling studies, were included., Data Extraction and Synthesis: A total of 3301 publications were initially identified, out of which 12 studies met the inclusion criteria and were selected for analysis. The selected studies were predominantly from high-income and upper-middle-income nations (95%)., Results: The research points towards a pattern where regions abundant in green spaces report lower rates of heat-related morbidity and mortality in contrast to those with sparse greenery. Additionally, urban vegetation appears to exert a positive influence on mental health and well-being, potentially aiding in offsetting the adverse health repercussions of high temperatures., Conclusion: Urban green spaces play a vital role in mitigating heat-related health risks, offering a potential strategy for urban planning to address climate change and enhance public health. Additional research is required to thoroughly comprehend the magnitude of urban greenery's impact on heat-related morbidity and mortality, as well as its interplay with other variables, including air pollution, socioeconomic status, among others., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: During the last decade, extensions of therapeutic indications have been one of the most common methods to extend the lifecycle of a medical product in the post-authorisation phase and to increase the use and sales of medicines. The aim of this study was to gain understanding of the lifecycle of cancer medicines and especially the role and level of evidence extensions in comparison to first indications., Materials and Methods: We identified all new outpatient cancer medicines approved by the European Medicines Agency between 2010 and 2020 and the extensions to their indications. We compared general study design characteristics from the European public assessment reports using critical appraisal tools and clinical added value assessments., Results: We identified altogether 55 new outpatient cancer medicines, 31 of which had one or more extension(s) of indication and 24 had no extension of indication. In total, there were 57 extensions. The most common extension of indication was a change in the treatment line (35%). Compared with first indications, the overall quality of studies supporting extensions was better in terms of study designs. The proportion of medicines providing CAV was higher in extensions compared with first indication of medicines with and without extensions., Conclusions: Based on different assessments and perspectives, we found that extensions of indications are a very common and important part of extending the lifecycle of outpatient cancer medicines in Europe. Our findings also suggest that the clinical value of cancer medicines increases with extensions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the importance of rural internships to observed medical workforce distribution outcomes up to 8 years post-medical school., Design and Setting: Cohort study of medical graduates of The University of Queensland (UQ), Australia., Participants: UQ graduates who were medical interns in Queensland's public health system between 2014 and 2021 and observed working in Australia in 2022. Internship location was defined as being metropolitan or rural, along with other key rural exposures of whether they are of rural origin (childhood) and whether at least 1 year of clinical training at medical school was in a rural location., Primary Outcome Measure: Current work location was collected from the Australian Health Practitioner Regulation Agency (AHPRA) in 2022, classified as either rural or metropolitan and measured in association with their internship location., Results: From 1930 eligible graduates, 21.5% took up a rural internship, which was associated with rural origin (OR 1.5, 95% CI 1.2 to 2.0) and medical school rural immersions of either 1 year (OR 2.8, 95% CI 2.1 to 3.7) or 2 years (OR 5.8, 95% CI 4.4 to 7.7). Completing a rural internship was associated with currently working rural (47% vs 14%, OR 4.6, 95% CI 3.5 to 5.9), which weakened the observed (adjusted) effect of rural origin (OR 1.5, 95% CI 1.2 to 2.0) or medical school rural immersions (1 year: OR 1.4, 95% CI 1.0 to 1.9; 2 years: OR 1.7, 95% CI 1.2 to 2.3). All combinations of the key rural exposures that included rural internship had the highest proportions currently working rurally (range 32-69%) compared with the combinations with a metropolitan internship (range 12-22%)., Conclusions: Internship location appears to be a critical factor in shaping medical workforce distribution decisions. This evidence supports the need for strengthened and expanded rural training pathways after medical school. In particular, clearer pathways into specialty programmes via rural internships are likely to support increased numbers choosing (with confidence) to preference rural internship first and subsequently more working in rural areas long term., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Despite the increasingly evidenced positive impacts of green space on human physical and mental health, green spaces remain inequitably distributed across different socioeconomic groups. Urban planning and design should prioritise the development and maintenance of urban green spaces, especially for vulnerable and marginalised populations while thinking about protecting them from the effects of green gentrification. This scoping review will explore how the concepts of equity, diversity and inclusion are integrated into the design, the planning and policy development of urban green spaces. Also, we will explore what are the efforts made to incorporate equity, diversity, and inclusion concepts into the planning, design and policy development of urban green spaces to make them equitable for vulnerable and marginalised populations., Methods and Analysis: This protocol is based on the methodology developed by Arksey and O'Malley and improved by Levac et al . The search will be done in conjunction with a professional librarian, to include studies in all languages. The review will include multidisciplinary databases: Ovid MEDLINE, Ovid EMBASE, CINAHL, Web of Science and GeoBase. The search will be done from each database's inception to February 2024. We will present our results narratively and will conduct a thematic analysis using the urban green equity framework. This framework will guide our understanding of the interplay between the spatial distribution of urban green spaces and the recognition of diverse voices in urban greening decision-making., Ethics and Dissemination: This scoping review will not require ethical approval since it will be collected from publicly available documents. The results of this scoping review will be presented as a scientific article, social media and public health or environmental conferences organised by environmental organisations or academic institutions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Healthcare systems around the world exhibit inherent systemic inequities that disproportionately impact marginalised populations. Digital health technologies (DHTs) hold promising potential to address these inequities and to play a pivotal role in advancing health equity. However, there is a notable gap regarding a comprehensive and structured overview of existing frameworks and guidelines on advancing health equity and a clear understanding of the potential of DHTs in their implementation. To this end, our primary objectives are first to identify prevalent frameworks and guidelines that promote health equity and second to pinpoint the contemporary role of DHTs as an avenue for implementing these frameworks and guidelines. This synthesis will guide future DHTs, ensuring equitable accessibility and effectiveness and ultimately contributing to enhancing health equity among marginalised populations., Methods and Analysis: This work adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Reviews. To identify pertinent evidence, we will employ seven electronic databases (PubMed, EMBASE, Cochrane, PsycINFO, Scopus, Web of Science and WISO) encompassing the fields of medicine, healthcare and social sciences. Moreover, selected grey literature will be considered. We will include primary and secondary studies published in English between 2010 and 2023 that focus on (technology and non-technology-based) frameworks and guidelines for health equity improvement. Each article will undergo an independent assessment for eligibility, followed by the extraction of pertinent data from eligible sources. Subsequently, the extracted data will be subjected to qualitative and quantitative analyses, and findings will be presented using narrative and descriptive formats., Ethics and Dissemination: Ethical approval is deemed unnecessary for this scoping review, as it involves synthesising existing knowledge. The findings from this study will be disseminated through peer-reviewed publications., Protocol Registration: https://osf.io/94pht., Competing Interests: Competing interests: All authors are affiliated with the Centre for Digital Health Interventions (CDHI), a joint initiative of the Institute for Implementation Science in Health Care, University of Zurich, the Department of Management, Technology and Economics at ETH Zurich, and the Institute of Technology Management and School of Medicine at the University of St. Gallen. CDHI is funded in part by CSS, a Swiss health insurer, the Swiss growth-stage investor MTIP and the Austrian health provider Mavie Next. TK was also a co-founder of Pathmate Technologies, a university spin-off company that creates and delivers digital clinical pathways. However, CSS, Mavie Next or Pathmate Technologies were not involved in this research., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Although the disclosure of medical errors is an integral component of medical ethics, it remains inconsistent in practice worldwide. Despite various explanations of why healthcare professionals reveal their mistakes to patients, comprehensive comparisons and evaluations of this topic remain lacking. The objective of this review is to evaluate the experience of medical error disclosure among medical professionals who have been involved in such errors., Methods and Analysis: This work will focus on studies involving medical professionals from various countries who work in hospital settings and have obtained an understanding of and firsthand experience with medical error disclosure. This review will include qualitative studies. Studies published in databases such as PubMed, Embase, EBSCO, OVID, Web of Science, ScienceDirect, China National Knowledge Infrastructure, Wanfang Data and Cochrane Library from 1 January 2000 to 30 April 2024 will be searched as part of this research. Additionally, OpenGrey will be searched manually to obtain supplementary information. The search will be conducted starting in May 2024 and will include both Chinese-language and English-language literature. The systematic review will follow the Joanna Briggs Institute's (JBI) methodology for systematic reviews of qualitative evidence and use the JBI System for the Unified Management, Assessment and Review of Information online program. Study authenticity will be investigated via the Qualitative Research Authenticity Evaluation Tool provided by the JBI Evidence-Based Health Care Centre, and data extraction will be performed via the Qualitative Assessment and Review Instrument data extraction tool. The results will be integrated via a pooled integration methodology and evaluated in terms of reliability via the ConQual qualitative systematic evaluation evidence grading tool., Ethics and Dissemination: Ethical approval is not required for the study because the review will be based on pre-existing data available in the literature. The results of this systematic review will be submitted to peer-reviewed journals and presented at relevant conferences., Prospero Registration Number: CRD42024494360., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Worldwide, more immigrants experience vitamin D (vitD) deficiency than non-immigrants. Recommendations in current clinical practice guidelines (CPGs) concerning vitD are inadequate to address vitD deficiency among immigrants, and there are concerns regarding the quality of guidance in these CPGs., Objectives: This study aimed to identify and evaluate the quality of published CPGs addressing vitD and immigrants' health using the Appraisal of Guidelines for Research and Evaluation-II (AGREE II) tool and clarify the recommendations pertaining to vitD and immigrant populations in these CPGs., Methods: We performed a systematic search to identify the most recent CPGs across various databases (Ovid MEDLINE ALL, Embase and Turning Research Into Practice), guideline repositories and grey literature. Two reviewers independently conducted study selection and data abstraction and evaluated the quality of the included guidelines using the AGREE II tool., Results: We identified 25 relevant CPGs; 21 focused on vitD and 4 covered immigrants' health. Around one-quarter of the included CPGs were high quality (≥60% in at least four of the six domains, including 'rigour of development'). The highest mean scores among the six AGREE II domains were for 'clarity of presentation' and 'scope and purpose'. About 4.8% (1/21) of the CPGs on vitD had immigrant-related recommendations. VitD recommendations were emphasised in one out of the four immigrant health CPGs (25%). CPGs covering immigrants' health and vitD were inadequately systematically appraised. Moreover, recommendations regarding vitD were insufficient to address the growing epidemic of vitD deficiency among immigrant populations., Conclusion: The insufficient recommendations for vitD fail to address the rising vitD deficiency among immigrants, highlighting a critical gap in healthcare provisions. Urgent national and international efforts are needed to develop comprehensive CPGs, bridging research, policy and practice disparities. Future guidelines must prioritise routine vitD screening, supplementation protocols for vulnerable immigrant groups, and culturally appropriate interventions to improve health outcomes for immigrants globally., Prospero Registration Number: CRD42021240562., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Adverse drug reaction (ADR) reporting systems are critical for monitoring and managing drug safety. However, various factors influence the willingness to use these systems. This study aimed to investigate the willingness to use ADR reporting systems through an integrated model of the Technology Acceptance Model (TAM) and Task-Technology Fit (TTF) theory, conducting a multicentre qualitative study from the user's perspective., Methods: This study used qualitative research methods, including in-depth interviews with clinicians, nurses, pharmacists and administrators who reported ADRs through the National Adverse Drug Reaction Monitoring System (NADRMS) and the China Hospital Pharmacovigilance System (CHPS). The interviews were audio-recorded, transcribed verbatim and analysed using QDA Miner software for data management and thematic analysis., Results: Eighteen healthcare workers from five healthcare organisations participated in the study. They found the ease of use and usefulness of the current NADRMS and CHPS to be acceptable. The essential technical requirements identified included accuracy, standardisation, timeliness and confidentiality. However, challenges such as inaccurate information capture, unstable interfacing with medical record systems, low reporting efficiency and lack of data sharing were highlighted. Overall, front-line healthcare workers exhibited a generally negative attitude towards using NADRMS and CHPS, driven more by necessity than preference. Factors influencing their willingness to use these systems included ease of use, practicality, risk perception and social impact, with varying attitudes and requirements observed between user groups., Conclusion: This study provides practical recommendations that can be readily implemented to enhance the effectiveness and sustainability of ADR reporting systems. While front-line users in China acknowledged the systems' ease of use and usefulness, they also noted significant gaps in technological adaptation. They expressed the need for improvements in data openness and sharing, accessibility and system intelligence., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The presence of food product indicators may facilitate consumers in making informed healthy choices. However, it may also mislead consumers. This study aims to determine the prevalence of food products carrying food product indicators; the compliance of products bearing Malaysia's Healthier Choice Logo (HCL) and nutrition and health claims (NHC) towards the local regulations; and the credibility of the aforementioned products as healthy food products based on the international regulation in the Malaysian market., Method: This is a cross-sectional market survey conducted from February to May 2023 on 3428 products sold in Malaysian supermarkets. Product information including the brand, name, nutrition information panel, food product indicator (front-of-pack nutrition labelling, NHC, other claims), ingredients list and manufacturer or importer were collected. Compliance of products carrying NHC and HCL is evaluated against local guidelines. Credibility as a healthy product is evaluated against the WHO Nutrient Profile Model for the Western Pacific Region on a subsample (products with HCL and/or NHC)., Results: 53% of food products surveyed had food product indicators (n=1809). A total of 32% carried at least one NHC (n=1101), of which 47% had excellent overall compliance (n=522). Only 4% carried Malaysia's HCL (n=138), of which 48% had excellent nutrient compliance (n=66). Only 13% of the products carrying Malaysia's HCL and NHC could be identified as absolute healthy food products as defined by the WHO standard (n=147)., Conclusion: Although half of the products surveyed had food product indicators, merely half of them had excellent compliance towards the standards. Only 13% of the subsample qualified as healthy food products. Voluntary application of the local HCL was low among food industries. Ensuring high standards of compliance and credibility of food products in the Malaysian market is crucial for food companies and government authorities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Two decades have passed since the beginning of the Iraq War in 2003. Iraq has long suffered from conflicts and instability, where the people have limited access to healthcare. The coronavirus disease (COVID-19) pandemic brought additional disruption to health service provision., Objectives: At the midpoint towards universal health coverage (UHC) in 2030, this study aims to gain a better understanding of the trends of UHC progress in Iraq in the context of the conflicts and the COVID-19 pandemic and to indicate possible pragmatic options., Design: This study employed Bayesian hierarchical regression models to estimate trends and projections of health service availability and coverage indicators up to 2030. Furthermore, for health service coverage, four scenarios were defined based on the availability of health services, and projections were made for each scenario up to 2030., Setting: Our approach used the yearly data from the Ministry of Health and four nationally representative household surveys between 2000 and 2020. We evaluated the subnational-level progress in three health service availability indicators and 13 health service coverage indicators in 18 governorates in Iraq from 2000 to 2030., Results: The findings from 2000 to 2020 revealed a lack of progress in the indicators of health facility and inpatient bed, and pronounced detrimental effects from major conflicts and the pandemic on all measured health service coverage indicators. Despite these setbacks, several health service coverage indicators demonstrated resilience and elasticity in their recovery. The projected trends for 2021 to 2030 indicated limited alternations in the health service availability. By 2030, five health service coverage indicators will achieve the designated 80% targets. A scenario-based analysis predicts improved coverage of antenatal care, and child immunisation and treatment if health service availability is bolstered to globally recommended standards. Under this scenario, several governorates-Anbar, Baghdad, Nainawa, Qadissiyah, Salahaddin, Thiqar and Wasit-presented improved health service coverage in more indicators., Conclusion: Strengthened health service availability has the potential to significantly improve fragile health service coverage indicators and in more vulnerable governorates., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)