scholarly journals Assessment of Need for Recovery and Its Relationship With Work Characteristics and Health in a Sample of Chinese Doctors: A Cross-Sectional Survey

2021 ◽  
Vol 9 ◽  
Author(s):  
Tao Sun ◽  
Yu Shi ◽  
Dong Yin ◽  
Shu'e Zhang ◽  
Xiaohe Wang
Keyword(s):  
Health Outcomes ◽  
Online Survey ◽  
Well Being ◽  
Considerable Effect ◽  
Targeted Prevention ◽  
System Reform ◽  
Work Characteristics ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Need For Recovery

Background: China is launching an unprecedented health care system reform. However, the long-term interests of doctors seem to have been ignored during this process especially considering that the work environment and work-life balance for doctors have severely deteriorated over the past decade.Their well-being and health are facing substantial threats due to heavy workloads and inadequate recovery opportunities. This study aimed to investigate the extent of need for recovery (NFR) among Chinese doctors and to examine their work-related fatigue. The study also examines the relationship of NFR with workplace satisfaction and health outcomes among Chinese doctors.Methods: A total of 2,617 doctors from 30 administrative regions in China participated in this study to assess the need for recovery and its relationship with work characteristics and health. A cross-sectional survey was conducted using the Chinese version of the Need for Recovery Scale (NFRS). Participants were invited to complete an anonymous online survey during May 2016. Data were analyzed using descriptive statistics, one-way ANOVA, reliability analysis, Pearson correlations, and hierarchical multiple regression analysis.Results: Significant differences in NFR scores were found across demographic characteristics such as age, service years, hospital levels, educational attainment, professional positions, work shifts, and working time. Regardless of any illnesses they might be experiencing, about 70.0% of participants remained at their job even though many doctors (22.1%) must continue working under the policies of the organization, which led to more pronounced NFR (P < 0.001). Further, a higher NFR was negatively related to workplace well-being and self-reported health outcomes of participants.Conclusions: Work-induced fatigue is a growing threat to doctors in China and their recovery opportunities are extremely limited in the workplace. High NFR exerts a considerable effect on their workplace well-being and health. China's hospital managers should pay close attention to the fact that doctors have little chance of recovery, and should offer doctors' positive encouragement and support to enhance well-being. To improve doctors' working conditions, targeted prevention policies must be introduced by policymakers to control this spreading crisis.

scholarly journals Doctors’ perception of support and the processes involved in complaints investigations and how these relate to welfare and defensive practice: a cross-sectional survey of the UK physicians

BMJ Open ◽  
2017 ◽  
Vol 7 (11) ◽  
pp. e017856 ◽  
Author(s):  
Tom Bourne ◽  
Bavo De Cock ◽  
Laure Wynants ◽  
Mike Peters ◽  
Chantal Van Audenhove ◽  
...  
Keyword(s):  
Online Survey ◽  
Well Being ◽  
Adverse Outcomes ◽  
Perceived Support ◽  
Survey Study ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Final Sample ◽  
Perception Of Support ◽  
The Uk

ObjectiveHow adverse outcomes and complaints are managed may significantly impact on physician well-being and practice. We aimed to investigate how depression, anxiety and defensive medical practice are associated with doctors actual and perceived support, behaviour of colleagues and process issues regarding how complaints investigations are carried out.DesignA survey study. Respondents were classified into three groups: no complaint, recent/current complaint (within 6 months) or past complaint. Each group completed specific surveys.SettingBritish Medical Association (BMA) members were invited to complete an online survey.Participants95 636 members of the BMA were asked to participate. 7926 (8.3%) completed the survey, of whom 1780 (22.5%) had no complaint, 3889 (49.1%) had a past complaint and 2257 (28.5%) had a recent/current complaint. We excluded those with no complaints leaving 6144 in the final sample.Primary outcomes measuresWe measured anxiety and depression using the Generalised Anxiety Disorder Scale 7 and Physical Health Questionnaire 9. Defensive practice was assessed using a new measure for avoidance and hedging.ResultsMost felt supported by colleagues (61%), only 31% felt supported by management. Not following process (56%), protracted timescales (78%), vexatious complaints (49%), feeling bullied (39%) or victimised for whistleblowing (20%), and using complaints to undermine (31%) were reported. Perceived support by management (relative risk (RR) depression: 0.77, 95% CI 0.71 to 0.83; RR anxiety: 0.80, 95% CI 0.74 to 0.87), speaking to colleagues (RR depression: 0.64, 95% CI 0.48 to 0.84 and RR anxiety: 0.69, 95% CI 0.51 to 0.94, respectively), fair/accurate documentation (RR depression: 0.80, 95% CI 0.75 to 0.86; RR anxiety: 0.81, 95% CI 0.75 to 0.87), and being informed about rights (RR depression 0.96 (0.89 to 1.03) and anxiety 0.94 (0.87 to 1.02), correlated positively with well-being and reduced defensive practice. Doctors worried most about professional humiliation following a complaint investigation (80%).ConclusionPoor process, prolonged timescales and vexatious use of complaints systems are associated with decreased psychological welfare and increased defensive practice. In contrast, perceived support from colleagues and management is associated with a reduction in these effects.

scholarly journals Resilience, well-being, depression symptoms and concussion levels in equestrian athletes

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Annika McGivern ◽  
Stephen Shannon ◽  
Gavin Breslin
Keyword(s):  
Mental Health ◽  
Online Survey ◽  
Well Being ◽  
Depression Symptoms ◽  
Physical And Mental Health ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Content Type ◽  
Mental Health Support ◽  
History Of

Purpose This paper aims to conduct the first cross-sectional survey on depression, Resilience, well-being, depression symptoms and concussion levels in equestrian athletes and to assess whether past concussion rates were associated with depression, resilience and well-being. Design/methodology/approach In total, 511 participants from Canada, Republic of Ireland, UK, Australia and USA took part in an international cross-sectional, online survey evaluating concussion history, depression symptoms, resilience and well-being. Findings In total, 27.1% of athletes met clinically relevant symptoms of major depressive disorder. Significant differences were shown in the well-being and resilience scores between countries. Significant relationships were observed between reported history of concussion and both high depression scores and low well-being scores. Practical implications Findings highlight the need for mental health promotion and support in equestrian sport. Social implications Results support previous research suggesting a need for enhanced mental health support for equestrians. There is reason to believe that mental illness could still be present in riders with normal levels of resilience and well-being. Originality/value This study examined an understudied athlete group: equestrian athletes and presents important findings with implications for the physical and mental health of this population.

scholarly journals The effect of COVID-19 on mental well-being in Switzerland: a cross-sectional survey of the adult Swiss general population

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Laura Diaz Hernandez ◽  
Stéphanie Giezendanner ◽  
Roland Fischer ◽  
Andreas Zeller
Keyword(s):  
Mental Health ◽  
At Risk ◽  
Online Survey ◽  
Well Being ◽  
Population Based ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Health Concerns ◽  
Mental Health Concerns ◽  
Mental Well Being

Abstract Background In addition to the threat of the COVID-19 pandemic to physical health, mental health is challenged by the emotional response to the situation and the official measures taken to stop the pandemic. This study aimed to assess the prevalence of impaired mental well-being due to COVID-19 and explore associated factors. Methods The study was an observational, population-based, nationwide, cross-sectional online survey of a representative sample of the general Swiss population performed between March and April 2020. Participants reported on mental well-being, self-isolation/quarantine, their risk for developing severe COVID-19, and their work situation. Multivariable logistic regression analyses assessed risk factors for impaired mental well-being due to the pandemic. Results Data from 1022 individuals were analysed. The median age was 44 years (range 18 to 78) and 49% were women. A third of respondents reported that the COVID-19 pandemic impaired their mental well-being and almost half reported specific mental health concerns. Impaired mental well-being was associated with having health problems (OR = 1.88, 95% CI: 1.29–2.74, vs no problems), being or living with someone at risk for severe COVID-19 (OR = 1.38, 95% CI: 1–1.9,), smoking (OR = 1.8, 95% CI: 1.24–2.61), living in urban residential environments (OR = 1.62, 95% CI: 1.13–2.32, vs rural), not being able to work due to closed workplace (OR = 1.66, 95% CI: 1.04–2.67), aged between 18 and 29 years old (OR = 1.99, 95% CI: 1.32–3.01, vs 45 to 59 years old), and living in a single household (living with someone, OR = 0.65, 95% CI: 0.44–0.97,vs single household). Overall, the most significant covariates of impaired mental well-being were specific mental health concerns: feeling depressed (OR = 7.21, 95% CI: 4.5–11.55), feeling less pleasure in doing things than before (OR = 6.28, 95% CI: 4.1–9.62), feeling anxious (OR = 6.13, 95% CI: 3.91–9.59) and feeling lonely (OR = 4.08, 95% CI: 2.53–6.58). Conclusion Impaired mental well-being can carry long-term consequences. We encourage policymakers to implement strategies to promote mental health during this pandemic situation. Special attention should be addressed to the youngest, those at risk for severe COVID-19 and those with government-imposed work restrictions.

scholarly journals Understanding the Cumulative Burden of Basic Needs Insecurities: Associations With Health and Academic Achievement Among College Students

2020 ◽  
pp. 089011712094621 ◽  
Author(s):  
Cindy W. Leung ◽  
Sara Farooqui ◽  
Julia A. Wolfson ◽  
Alicia J. Cohen
Keyword(s):  
College Students ◽  
Academic Success ◽  
Online Survey ◽  
Basic Needs ◽  
Well Being ◽  
Anxiety And Depression ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Grade Point ◽  
Fair Poor

Purpose: Food insecurity is a concern on college campuses and is correlated with other basic needs insecurities. We examined the cumulative burden of food, financial, and housing insecurities on college students’ health and academic performance. Design: Cross-sectional survey. Setting: Large, public Midwestern university. Sample: A total of 793 college students completed an online survey in 2018 (43% response rate). Measures: Food, financial, and housing insecurity were measured using validated instruments. Primary outcomes were general health status, anxiety and depression, and grade point average (GPA). Analysis: Weighted linear and logistic regression analyses were used to examine associations between cumulative basic needs insecurities and primary outcomes. Results: Approximately 11% of students experienced all 3 insecurities. Compared to fully secure students, students with all 3 insecurities were more likely to have anxiety and depression (odds ratio [OR] = 4.65, 95% CI: 4.31-5.01), fair/poor health (OR = 4.06, 95% CI: 3.73-4.42), and lower GPA (β = −0.19, 95% CI: −0.30 to −0.09), adjusting for sociodemographic characteristics. Conclusion: Interventions that address multiple basic needs insecurities are needed to promote college students’ well-being and foster academic success.

scholarly journals Impostor Phenomenon in the Nutrition and Dietetics Profession: An Online Cross-Sectional Survey

2021 ◽  
Author(s):  
Matthew J. Landry ◽  
Dylan A. Bailey ◽  
MinJi Lee ◽  
Samuel Van Gundy ◽  
Audrey Ervin
Keyword(s):  
Job Satisfaction ◽  
Online Survey ◽  
Well Being ◽  
Impostor Phenomenon ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Logistic Regression Models ◽  
Registered Dietitian Nutritionists ◽  
Prevention Methods ◽  
Nutrition And Dietetics

AbstractBackgroundImpostor phenomenon (IP) (also known as impostor syndrome) describes high-achieving individuals who, despite their objective successes, fail to internalize their accomplishments and have persistent self-doubt and fear of being exposed as a fraud or impostor. Despite robust literature describing the effects of IP in other health care professions, there is an absence of research within the nutrition and dietetics profession.ObjectiveTo assess the prevalence and predictors of IP within the nutrition and dietetics students and practitioners.DesignAn online cross-sectional survey was conducted.Participants/setting1,015 students, dietetic interns, and currently practicing and retired nutrition and dietetic technicians registered, and registered dietitian nutritionists provided complete responses.Main outcome measuresImpostor phenomenon was assessed with the Clance Impostor Phenomenon Scale (CIPS). Self-reported Job satisfaction and well-being were assessed using validated scales.Statistical analysesDescriptive statistics were summarized and reported using frequency counts and percentages. Unadjusted logistic regression models were used to assess the relationship between IP and sociodemographic outcomes, job satisfaction, and well-being.ResultsRespondents were primarily female, non-Hispanic White, and practicing dietitians. The average CIPS score was 66.0 ± 16.3 (range 22-99). 64% of survey respondents (n=655) experience intense or frequent IP and 62% (n=628) had a CIPS score ≥62. Older age, educational attainment, professional level, and membership in Academy groups were associated with lower IP scores. Greater Social media use was associated with higher IP scores. Job satisfaction and overall well-being were inversely correlated with impostor phenomenon (p<0.001).ConclusionsFindings from an online survey suggest that a majority of nutrition and dietetics students and practitioners experience IP. Our results reinforce the need to recognize and address this issue by raising awareness, using early prevention methods, and supporting individuals who are younger and/or new to the profession.

scholarly journals Beyond PPE: a mixed qualitative–quantitative study capturing the wider issues affecting doctors’ well-being during the COVID-19 pandemic

BMJ Open ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. e050223
Author(s):  
Lyndsey Jayne Cubitt ◽  
Yu Ri Im ◽  
Ciaran James Scott ◽  
Louise Claire Jeynes ◽  
Paul David Molyneux
Keyword(s):  
Mental Health ◽  
Online Survey ◽  
Negative Impact ◽  
Positive Impact ◽  
Working Hours ◽  
Well Being ◽  
Physical And Mental Health ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Increased Risk

The COVID-19 pandemic has brought unprecedented challenges to the medical workforce. This has put them at increased risk of burnout at a time when levels are already worryingly high in the profession, with recent studies consistently showing that around half of doctors meet the validated criteria for burnout.ObjectivesTo understand the wider factors influencing and impacting upon hospital doctors’ well-being during the COVID-19 pandemic in England.DesignCross-sectional survey and mixed quantitative–qualitative analysis.SettingAcute National Health Service (NHS) Foundation Trust in England.ParticipantsAn online survey was circulated in early June 2020 to all 449 doctors employed by the Trust. 242 doctors completed the survey (54% response rate).Primary outcome measuresQuestions assessed occupational details, self-reported changes in physical and mental health, satisfaction with working hours and patterns, availability of personal protective equipment (PPE), medication and facilities, communication and sought to identify areas seen as having a significant effect on doctors’ well-being.Results96% of respondents requiring PPE were able to access it. Nearly half of the respondents felt that their mental health had deteriorated since the start of the pandemic. Over a third stated that their physical health had also declined. Issues identified as having a negative impact on doctors included increased workload, redeployment, loss of autonomy, personal issues affecting family members, anxiety around recovery plans, inadequate access to changing and storage facilities and to rest areas that allow for social distancing. Doctors appreciated access to ‘calm rooms’ that were made available for staff, access to clinical psychology support, free drinks and free car parking on site.ConclusionThe emerging themes are suggestive of increased burnout risk among doctors during the COVID-19 pandemic and encompass factors well beyond shortage of PPE. Small organisational initiatives and the implementation of changes suggested by survey respondents can have a positive impact on doctors’ well-being.

scholarly journals Impact and Perspectives of Pediatric Dental Care during the COVID-19 Pandemic Regarding Unvaccinated Children: A Cross-Sectional Survey

2021 ◽  
Vol 18 (22) ◽  
pp. 12117
Author(s):  
Nelly Schulz-Weidner ◽  
Maximiliane Schlenz ◽  
Norbert Krämer ◽  
Sarra Boukhobza ◽  
Katrin Bekes
Keyword(s):  
Patient Care ◽  
Dental Care ◽  
Online Survey ◽  
Demographic Data ◽  
Well Being ◽  
Pediatric Dentistry ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Pediatric Dentists ◽  
The Impact

The pandemic caused by the COVID-19 virus has led to enormous challenges in pediatric dental care. In contrast to adults, many children are without any symptoms of disease if infected with COVID-19 and are not vaccinated. The aim of this study was to conduct an inquiry into the perspective of pediatric dentists in Germany towards the impact of COVID-19 on daily patient care during the lockdowns caused by the pandemic. All members of the Germany Society of Pediatric Dentistry were invited to participate in an online survey. The questionnaire focused on five topics: safety measures, well-being/knowledge, patient care, prospects, and demographic data. A total of 549 pediatric dentists participated (58.11% females, 8.2% males, 0.18% inter/diverse, and 33.51% no answer). In total, 75.2% of the dental clinics were open during the first lockdown (LD1) and 78.1% during the second lockdown (LD2). In LD1, only 22.2% were operating at full capacity, while 40.1% were open with restrictions, and 11.8% only offered emergency treatment. In LD2, 71.2% of practices were operating again and resumed offering all treatment methods. A significant decrease in pediatric patients was reported due to the fact of COVID-19. Furthermore, measures, such as oral hygiene and recall appointments, were reduced. Measures that were performed after the lockdown were mainly aerosol-generating procedures and extractions as well as general anesthesia or sedation. The increased willingness to treat in the second lockdown has shown that pediatric dentists have adapted to the pandemic conditions, which seems to be of great importance, especially in view of the problem of unvaccinated children.

scholarly journals Self-reported mental health status of pregnant women in Sweden during the COVID-19 pandemic: A cross-sectional survey

2021 ◽  
Author(s):  
Ho-Fung Chung ◽  
Ewa Andersson ◽  
Hsuan-Ying Huang ◽  
Ganesh Acharya ◽  
Simone Schwank
Keyword(s):  
Mental Health ◽  
Health Outcomes ◽  
Pregnant Women ◽  
Acute Stress ◽  
Well Being ◽  
Poor Mental Health ◽  
Mental Health Outcomes ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Acute Stress Reaction

Abstract Background: The COVID-19 pandemic has contributed to unprecedented worries and challenges for pregnant women due to social restrictions and changes in maternity care provision. We aimed to investigate the mental health impact of COVID-19 pandemic on pregnant women in Sweden and explore factors associated with poor perinatal mental health in this specific context. Method: This was a nation-wide cross-sectional survey of pregnant women living in Sweden. Validated questionnaires were distributed through non-profit organizations´ websites and social media channels from May 2020 to February 2021. Perinatal depression, anxiety, and acute stress reaction were assessed using the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder-7(GAD-7) and Impact Event Scale (Revised)(IES-R), respectively. Sociodemographic characteristics and self-perceived mental well-being were also obtained. Factors associated with mental health outcomes were analyzed using multivariate logistic regression model. Results: Among a total of 522 participants, 42.5% (n=222) reported depression (EPDS ≥13), 25.3% (n=132) moderate to severe anxiety (GAD-7 score≥10), and 23.4% (n=122) moderate to severe acute stress reaction (IES-R ≥33). 27.4% participants (n=143, 27.4%) expressed concerns regarding their mental well-being during the pandemic. Pregnant mothers who had sick family members reported more severe poor mental health outcomes than those who did not (median [Interquartile range (IQR)] EPDS scores: 14.0 [8.75 – 18.0] vs 10.0 [6.0 – 14.0], p<.001; median [IQR] GAD7 scores: 7.0 [4.0 – 12.25] vs 5.0 [3.0 – 9.0], p<.001; median (IQR) IES-R scores: 20.0 [9.0 – 38.0] vs 15.0 [7.0 – 28.0], p=.008). Logistic regression analyses revealed that risk factors for poor mental health outcomes were having a sick family member with any illness, unemployment, giving birth, and experiencing an exceptional stressful life event. Having a higher educational level, younger age, and changing career during the pandemic were protective. Conclusion: Depression and anxiety were highly prevalent among pregnant women in Sweden during the COVID-19 pandemic, indicating a need for professional mental health support for this vulnerable group of population. Unemployment was an associated risk factor whereas younger age and higher educational level were protective suggesting an important role of socio-economic factors in modulating the impact of COVID-19 pandemic on perinatal mental health.

scholarly journals Need for recovery amongst emergency physicians in the UK and Ireland: a cross-sectional survey

BMJ Open ◽  
2020 ◽  
Vol 10 (11) ◽  
pp. e041485 ◽  
Author(s):  
Laura Cottey ◽  
Tom Roberts ◽  
Blair Graham ◽  
Daniel Horner ◽  
Kara Nicola Stevens ◽  
...  
Keyword(s):  
Well Being ◽  
Health Condition ◽  
Emergency Physicians ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Out Of Hours ◽  
Need For Recovery ◽  
Electronic Survey ◽  
Occupational Characteristics ◽  
The Uk

ObjectivesTo determine the need for recovery (NFR) among emergency physicians and to identify demographic and occupational characteristics associated with higher NFR scores.DesignCross-sectional electronic survey.SettingEmergency departments (EDs) (n=112) in the UK and Ireland.ParticipantsEmergency physicians, defined as any registered physician working principally within the ED, responding between June and July 2019.Main outcome measureNFR Scale, an 11-item self-administered questionnaire that assesses how work demands affect intershift recovery.ResultsThe median NFR Score for all 4247 eligible, consented participants with a valid NFR Score was 70.0 (95% CI: 65.5 to 74.5), with an IQR of 45.5–90.0. A linear regression model indicated statistically significant associations between gender, health conditions, type of ED, clinical grade, access to annual and study leave, and time spent working out-of-hours. Groups including male physicians, consultants, general practitioners (GPs) within the ED, those working in paediatric EDs and those with no long-term health condition or disability had a lower NFR Score. After adjusting for these characteristics, the NFR Score increased by 3.7 (95% CI: 0.3 to 7.1) and 6.43 (95% CI: 2.0 to 10.8) for those with difficulty accessing annual and study leave, respectively. Increased percentage of out-of-hours work increased NFR Score almost linearly: 26%–50% out-of-hours work=5.7 (95% CI: 3.1 to 8.4); 51%–75% out-of-hours work=10.3 (95% CI: 7.6 to 13.0); 76%–100% out-of-hours work=14.5 (95% CI: 11.0 to 17.9).ConclusionHigher NFR scores were observed among emergency physicians than reported in any other profession or population to date. While out-of-hours working is unavoidable, the linear relationship observed suggests that any reduction may result in NFR improvement. Evidence-based strategies to improve well-being such as proportional out-of-hours working and improved access to annual and study leave should be carefully considered and implemented where feasible.

Priorities in lower limb prosthetic service delivery based on an international survey of prosthetists in low- and high-income countries

2013 ◽  
Vol 39 (2) ◽  
pp. 102-111 ◽  
Author(s):  
Dominik Wyss ◽  
Sally Lindsay ◽  
William L Cleghorn ◽  
Jan Andrysek
Keyword(s):  
Lower Limb ◽  
Online Survey ◽  
Economic Status ◽  
Well Being ◽  
Lower Income ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Practitioner Training ◽  
The World ◽  
Lower Income Countries

Background:Prosthetic services, including the provision of an appropriate prosthesis, are a crucial part of the rehabilitation process for individuals with lower limb amputations. However, globally there exist unique challenges in the delivery of prosthetic services that are limiting rehabilitation outcomes and consequently the well-being and socio-economic status of individuals with lower limb amputations.Objectives:The objective of this work was to explore the issues related to the provision of appropriate prosthetic technologies and to compare these across different economies of the world.Study design:Cross-sectional survey.Methods:An online survey was developed and distributed to prosthetic practitioners providing services in countries around the world. An open-coding thematic content analysis procedure was applied to extract key themes from the data.Results:The response codes defined three overall themes of lower limb prosthetic delivery, and several key differences between higher and lower income countries emerged. Namely, a higher emphasis on part/material availability, practitioner training and durability in lower income countries was found. High costs were an issue raised by practitioners in all countries.Conclusion:Practitioners around the world share many of the same concerns; however, some lower income countries face important and pressing issues that limit their ability to provide adequate prosthetic services.Clinical relevanceThis work highlights the most crucial service and technology-related needs, as perceived by trained prosthetic practitioners, of populations requiring lower limb prosthetic treatment around the world. Additionally, the results may be used to prioritize prosthetic-related health-care initiatives led by other researchers, governments and organizations working to improve services internationally.

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