• PLAY+ links active outdoor play with human-animal-environmental health. • Framework built using scoping review, conceptual mapping, and expert consultations. • Active outdoor play connects climate, human-animal bonds, and stewardship. • Most policies neglect active outdoor play's role in One Health–gap remains. • PLAY+ should be further refined and validated given its predominantly anthropocentric grounding. There has been growing recognition of the interconnections between human health, environmental sustainability, and ecosystem resilience. Positioning active outdoor play as a potential catalyst and ally in advancing human, animal, and environmental health, this study developed and validated a framework linking active outdoor play and One Health. The framework development followed a structured, multi-step process incorporating a scoping review, conceptual mapping, and expert consultations. Based on the results of the scoping review, a conceptual mapping exercise was undertaken to visually represent the interconnections between active outdoor play and One Health, which was then validated by key informants ( n = 16) selected based on their expertise and leadership in the relevant topic areas. A total of 23 scholarly articles addressed the potential interconnectedness of active outdoor play, human-animal relationships, and environmental responsibility. Three themes emerged: 1) outdoor play environments and climate resilience ( n = 6), 2) human-animal interactions and public health ( n = 10), and 3) environmental stewardship and responsibility toward planetary health ( n = 7). Nine policy documents were identified, of which eight did not make direct references to active outdoor play. Informed by the evidence, the PLAY+ (Play, Land, Animals, You and +) framework was created. Insights from an expert survey further refined the framework. While the framework highlights the interconnected benefits of active outdoor play across human, animal and environmental health domains, it is equally important to recognize associated risks and unintended consequences. As such, the framework should be views as conceptual, heuristic tool that encourages precautionary approaches, continued empricial evaluation, and context-sensitive implementation.

Timely discharge of patients who are clinically ready to be discharged from hospitals to the next point of care is a common health system challenge. Ensuring safe and effective discharge holds new urgency, given the backlogs and increased waiting times for inpatient services in many countries after the COVID-19 pandemic. The study aimed to identify policy options for addressing delayed discharges in six European countries (Denmark, France, Germany, the Netherlands, Norway, and Sweden), and to summarise available evidence on their effectiveness. Experts from the Health Systems and Policy Monitor (HSPM) network of the European Observatory on Health Systems and Policies and additional country experts identified relevant policies and initiatives up to November 2023. When evaluations were available, the experts also provided information on their findings. The data collection was followed by a qualitative, cross-country comparative analysis. A total of 17 policies or initiatives were identified in the study countries. Hospital-based initiatives included discharge planning and transitional care. Community and home care initiatives included municipal emergency beds, intensive home rehabilitation, and assisted discharge. Cross-sectoral initiatives ranged from coordination efforts at the regional and municipal levels to decision support systems and financial incentives. Several common factors or principles underpin many of the identified policies and initiatives. These include clarity of responsibility, effective planning and communication, resourcing of community-based capacity, possible unintended consequences of financial penalties, and the need to adopt a systemic approach.

When does management using artificial intelligence lead to unintended consequences? A case study using ‘smart’ traps

The unintended consequences of accountability: Quasi-experimental evidence from policing in Pakistan

Assessing water-energy-food-ecosystem nexus policy trajectories under uncertainty in the Inkomati-Usuthu water management area, South Africa

This paper examines the impact of Targeted Regulation of Abortion Providers (TRAP) laws on the supply and composition of maternal healthcare providers, particularly obstetrician-gynecologists (OB/GYNs). We exploit the staggered enactment of TRAP laws across U.S. states from 2010 to 2021 using a propensity score matching and stacked difference-in-differences approach. Our analytic sample includes physician-, county- and state-level measures of OB/GYN supply, newly graduated OB/GYNs, medical school and residency program applicants, nurse practitioners (NPs) and physician assistants (PAs) who practice women's healthcare, as well as advanced practice nurse midwives. TRAP law enactment is associated with a statistically significant reduction of 2.09 in OB/GYN supply per 100,000 females aged 15-44 (6.6% relative to the baseline). This decline is particularly pronounced among OB/GYNs aged 55-64. For OB/GYNs under 34, the estimates suggest a decline but this finding should be interpreted cautiously given pre-trends. TRAP laws also are associated with a reduction in the supply of newly graduated OB/GYNs from lower-ranked medical schools. We find no evidence that NPs, PAs, or midwives substitute for the decline in OB/GYNs. Mechanism analyses provide suggestive evidence that the supply contraction operates through exit rather than relocation. These findings highlight unintended consequences of abortion restrictions on broader maternal healthcare provision.

Towards integrated advice for pandemic policies: Insights from a qualitative explorative study on Avian influenza simulation exercises in the Netherlands.

There is global debate about the causes and potential long-term public health harms of population rates of caesarean section above those shown to be beneficial [1]. Rising rates of freebirthing in high income countries are also a concern. Some women choose elective caesarean section or freebirth because they do not trust local maternity services to support them when they are hoping to have a safe, positive physiological labour and birth [2]. Curiously, there is very little focus on how to increase the chance of this outcome for those who value it. The international review of guidelines for normal labour and childbirth published in this volume found that only three of the 25 included documents were rated highly on both quality assessment tools used [3]. However, there was agreement across most guidelines on a range of effective procedures and support techniques. These provide a starting point for rebalancing intrapartum care: but, while necessary, they may not be sufficient. Guidelines are, in theory, a driver of high quality health and social care, but their value in practice depends on a range of conditions. There must be underpinning evidence of sufficient quality and breadth. The recommendations must be acceptable to those providing and those receiving care. They must be feasible to implement, sustainable, and affordable. There should be no foreseeable unintended consequences in terms of inequity, inaccessibility, or down-stream adverse effects. They need to be flexibly drafted and applied, to take account of individual circumstances, values, and decisions, so that the label ‘care outside of guidelines’ is only required in very few unusual cases. Importantly, there needs to be an organisational will to apply them in full, rather than cherry picking aspects that happen to meet existing practice and resources, and that are non-controversial locally. For physiological labour and birth, this is where problems arise. There are still significant research gaps. Intrapartum physiology and psychology are dynamic and highly individual. If organisations and governance systems treat labour and birth guidelines as standardised rules that must be applied to everyone, regardless of their physiology, values and choices, staff will not risk organisational and peer opprobrium by personalising care. If staff in all settings are not skilled, confident and competent in supporting labour and birth progress at a pace that is safe and relevant to the individual [4], they are likely to default to interventions to ensure that birth happens within a standardised timescale. If safe out of hospital options are not available, or if staffing models lead to frequent diverts from birth centres, or refusal to send midwives to home births, women will not have access to places where they are more likely to have a physiological labour and birth. Service user faith in the maternity system will further decline, resulting in increased rates of maternal choice for elective CS or freebirth. Rebuilding trust in maternity services cannot happen without the political, organisational and financial will to make best practice in physiological labour and birth available everywhere, for everyone with this preference. Hernandez-Martinez and colleagues have provided a roadmap. Now maternity services need to use it. S.D. devised and wrote the commentary. The author has nothing to report. The author has nothing to report. The author has nothing to report. S.D. has been a Technical Advisor to the World Health Organisation for a range of their guidelines, including the Intrapartum Care for a Positive Childbirth Experience guideline cited in the associated review. She also led the qualitative evidence synthesis reviews for that guideline. This is a mini-commentary—there are no underlying data to share.

Beyond the hidden curriculum: Power, justice and innovation.

This study investigated the impact of providing feedback to respondents on a dominance-structured choice task on subsequent choice behavior in a discrete choice experiment (DCE). The DCE was conducted among 626 patients with heart failure. Respondents were given a dominance-structured choice task in which two devices (Device A and Device B) offered no benefits but carried risks compared to a "No Device" option. Among those who selected a device option (N=340), half received feedback and an opportunity to revise their choice, while the other half did not. The effect of feedback on preference for the "No Device" option and choice consistency was examined using multinomial, heteroscedastic multinomial logit, and heteroscedastic latent-class logit models. Among those who received feedback (N=170), 71% continued to choose the device options. Feedback recipients were more likely to choose the "No Device" option in subsequent questions (p<0.01). Feedback led to a 25% reduction in choice consistency (p<0.01) and an increased likelihood of choosing the "No Device" option. Impact on consistency varied across latent classes: feedback decreased consistency in the risk-sensitive class but increased consistencyin the anti-device class, highlighting potential unintended consequences. Further research is needed to understand its effects in different contexts and samples.

The unintended consequences of environmental regulation on financial misconduct

The devolution of health systems development to local governments in the Philippines in 1991 brought with it unintended consequences as local chief executives found themselves with new responsibilities for which they were not prepared. These unintended consequences were exacerbated with the implementation of the country's Universal Health Care Act in 2019. To address this problem, the Zuellig Family Foundation, a non-profit and non-government organization based in the Philippines with the aim of improving health outcomes, has designed a local level health governance strengthening intervention: the Bayang Malusog (literally Healthy Communities) Municipal Leadership Development Program (BM-MLDP). The BM-MLDP is a 12-month capacity building intervention for local chief executives and local health officials consisting of deep dive immersions, change management and leadership sessions, sustainability of health reform sessions, and co-design sessions to improve population health outcomes. Its implementation on the municipalities of Balete and New Washington in 2022-2023 contributed to improving and sustaining optimal population health outcomes despite resource constraints. This highlights the potential of health governance and capacity building interventions like the BM-MLDP in improving population health outcomes and advancing the implementation of universal health coverage in resource-constrained, devolved healthcare settings.

The 1992 340B Drug Pricing Program ("340B") started as a narrowly focused program aimed at Public Health Service Act-funded clinics and public hospitals. Today 340B includes two-thirds of all nonprofit hospitals in the United States and accounts for more than $80 billion in discounted drug purchases. Statutory language authorizing 340B is sparse, and attempts to strengthen or cut the program have been stymied by lack of clarity on Congress's original intentions. The object of this study was to clarify Congress's original intentions for 340B. Our qualitative analysis was informed by the collection and analysis of two sources: (1) 175 internal primary source documents and (2) 19 structured interviews conducted with 18 key informants with respect to the creation of 340B. Congress had two intentions in establishing 340B in 1992. The first was to address an unintended consequence of the Medicaid Drug Rebate Program (MDRP), which raised costs on safety-net clinics that received significant discounts on drugs prior to the rebate program. Such core safety-net clinics operate on fixed budgets heavily dependent on federal grants, which also require them to provide free and discounted care to patients regardless of their ability to pay. The purpose of 340B was to exempt these clinics from the best price provision of the MDRP. The second was to establish minimum discounts for drug prices for core safety-net providers. While public hospitals were added because of their safety-net mission, the disproportionate share hospital eligibility criterion were included to qualify two specific hospitals to secure bipartisan support. Congress's original intention for 340B was to enable core safety-net providers to continue to provide drugs to patients regardless of costs in the face of historic drug price increases set off by the MDRP. The current scope of the program exceeds Congress's original intent.

Online postal self-sampling (OPSS) for sexually transmitted infections and blood borne viruses (STI/BBVs) has been introduced in several countries, because it may lower costs, and increase access for service users. There are gaps in the evidence on the equitable delivery to underserved populations beyond men who have sex with men, the implementation and maintenance of programmes and its impact on wider health systems. This study synthesised evidence from the ASSIST research programme, which evaluated the implementation, equity, impacts and economic consequences of OPSS in England (2015-2022), with a focus on understanding how and why unintended consequences may emerge in other contexts. A synthesis using a realist logic of analysis was undertaken across multiple sources of evidence from ASSIST workstreams. Context-mechanism-outcome configurations were developed from a systems perspective. They were iterated through comparisons with initial programme theory and through feedback obtained from sexual health providers, funders, researchers and service users. In England, OPSS appears convenient and achieved higher testing uptake for lower costs per diagnosis. However, there were unintended consequences, principally: (1) difficulties in containing demand for OPSS could result in higher total costs than planned; (2) the introduction of OPSS affected wider sexual health system sustainability, particularly when the context changed; (3) inequalities in sexual health may widen after the introduction of OPSS in part due to missed presentation opportunities. These challenges prompted adaptive responses in health systems, leading to a rebalancing between OPSS and clinic-based services. While the introduction of OPSS in the context of reducing sexual health budgets offers some clear advantages to entirely clinic-based sexual health services, excessive demand and difficulties in access and use risk destabilising sexual health systems and worsening inequalities. Strategic rebalancing of OPSS and clinic-based provision is essential to mitigate unintended effects and ensure equitable, resilient service delivery. https://doi.org/10.1136/bmjopen-2022-067170.

This article examines the current Danish reform of master's programmes as a case of contested marketization in higher education. While the reform aims to produce "labour-market-relevant" graduates by shortening degrees, introducing corporate programmes, and reducing enrolment, it reveals a fundamental tension between two competing economic logics: a neoliberal conception of students as human capital and a conventional view of labour as quantifiable work time. The emphasis on the latter by the Danish coalition government, particularly the Social Democrats, parallels their glorification of vocational work and disdain for intellectualism. Drawing on policy documents and public debate, the article shows how these logics coexist uneasily within the reform, combining aspirations to optimize students' individual investment decisions with efforts to increase the aggregate labour supply. The article further analyses the critiques the reform has generated. While traditional critiques emphasize the erosion of universities' role in cultivating democratic citizens, a "market critique" emerging from economic actors highlights the reform's failure on its own terms. This critique exposes the limits of centralized planning in engineering labour-market outcomes and points to unintended consequences. Building on this analysis, the article develops the concept of "impure resistance" to describe forms of critique that operate within, rather than outside, market rationalities. It argues that such internal critiques can open new avenues for coalition-building in contexts where democratic arguments struggle to resonate, while also underscoring their limitations. The article concludes that effective resistance to marketization must mobilize its internal contradictions rather than oppose it from a single normative standpoint.

ABSTRACTProtected areas (PA) in African savannas support biodiversity and ecosystem services, but are increasingly surrounded by hard land‐use transitions as surrounding human populations grow. Fencing PAs is a potential, yet contested, response to mitigate growing human–wildlife conflicts at their edges. We test the consequences of such conservation fencing for communities neighboring PAs in the Serengeti ecosystem, Tanzania, in a multi‐year before‐and‐after study of an adjacent fenced (Ikorongo Game Reserve) and unfenced (Serengeti National Park) area, using remote sensing, ground transects, and community interviews. We found that conservation fencing contributed to changes in cropland or livestock grazing coverage. In addition, conservation fencing did not have a clear impact on the spatial zonation of specific crop types. Positive perceptions expressed by community members towards the conservation fence were: (i) more success with crop farming due to less time needed for guarding crops against nocturnal elephant damage, (ii) youth shifting their focus from (risky) poaching to crop farming and small business. Negative perceptions included: (i) more land use conflict because grazing lands close to the fence became cropland, where few livestock keeping households with large herds moved to the unfenced site, (ii) restricted access to resources (livestock grazing, thatch grass, water) within the reserve, despite the illegality of their use. We conclude that conservation fencing can strongly benefit farmers near PAs while protecting wildlife, particularly along hard boundaries, but also risks leakage effects (unwanted spillover into nearby areas). Implementing conservation fencing, therefore, requires careful consideration of the larger socio‐ecological landscape, for instance, by accounting for current land uses and changes in the spatial availability of resources resulting from fencing.

Shedding light on direct and indirect effects of antimicrobial photodynamic therapy: A review update.

Exposure to trietazine causes cardiovascular and liver damage and impairs neurodevelopment through oxidative stress and inflammatory mechanisms in zebrafish and transgenic lines.

Multi-omics and in silico assessment of ecological risks posed by agrochemical coatings: Disruption of rhizosphere stress signaling and induction of bulb rot in Fritillaria cirrhosa.

Subnational autocratization presents a significant challenge to liberal democracy, particularly in autonomous minority regions. We explore whether power-sharing institutionalreforms (PSI) foster democratic attitudes among ethnic minorities in autocratizing autonomous regions. Consociational theory suggests PSI alleviate grievances and reduce polarization, thereby strengthening democracy, yet causal evidence remains scarce. Using a pre-registered survey experiment in Gagauzia (Moldova), we test the impact of PSI on democratic attitudes. Our results indicate that while PSI mitigate grievances and polarization, they exert a negative influence on democratic attitudes. Our findings challenge core assumptions of consociationalism and suggest that PSI may yield unintended consequences in the short term.