Unnecessary Barriers Research Articles

Article: The Transition to a Circular Economy: Win–Win for All?

With the increasing recognition of the role of trade policies in supporting sustainability approaches, countries are adopting a wide array of trade measures aimed at greening the industrial sector, and one such example is the transition to a circular economy. A transition towards a more resource-efficient and circular economy is closely intertwined with international trade. As circular economy is gradually turning into a global endeavour with dozens of national circular roadmaps being launched, it is crucial to examine how circular economy approaches interact with the economic and trade diversification objectives of developing countries. Circular economy policies and trade policies need to be aligned so that the transition to the circular economy at the global level does not create unnecessary barriers to trade for developing countries. In this context, the broad objective of this paper is to discuss the potential implications of trade rules linked to circular economy for developing countries.

Permanent Contraception in the childfree population: an exploratory study

OBJECTIVETo describe the childfree population seeking permanent contraception, identify barriers to receiving care, and characterize the incidence of regret. STUDY DESIGNWe conducted a cross-sectional survey of people in the US, 18 years and older, without biological children, and who are seeking or have previously sought a permanent contraception procedure. Participants completed an online REDCap survey distributed over social media platforms, including Reddit, TikTok, and Facebook. RESULTS400 respondents completed the survey, of whom a151 (38%) underwent a permanent contraception procedure, 44 (11%) had found a doctor to perform a procedure, but not yet undergone it, 32 (8%) had been unable to find a doctor to do the procedure, 83 (21%) were seeking a doctor, and 90 (22%) had not yet sought a doctor.Respondents were predominantly white (88%), identified as women (83%), and were diverse in sexual orientation (heterosexual 42%, bisexual 41%). Reasons for seeking permanent contraception included not wanting children (96%), fear of pregnancy/childbirth (70%), the current state of the world (68%), environmental reasons (59%), and medical reasons (32%). Barriers to care included cost of the procedure (30%) and inability to find a doctor who would perform the procedure (42%).Of the 151 respondents who had undergone a permanent contraception procedure, 70 (46%) asked more than one doctor for the procedure. Of those with permanent contraception, 97% answered “yes” to “Do you think sterilization as a permanent method of birth control was a good choice for you?” CONCLUSIONChildfree individuals have a variety of reasons for seeking sterilization and may be at a lower risk of regret than reported in the literature for parous people with permanent contraception. IMPLICATIONSClinicians should be aware of the barriers to permanent contraception for patients who do not desire to have children. Providing patient-centered, individualized care to patients seeking permanent contraception can ensure that patients do not face unnecessary barriers to care and feel heard and empowered to enact their reproductive preferences.

Standard HIPAA Authorization Forms Decreased Response Rates for a Multi-site Pragmatic Trial.

The Health Insurance Portability and Accountability Act (HIPAA) aims to safeguard patient information; however, complex legal language may lead to confusion and mistrust, and hinder enrollment in clinical trials. To evaluate the effect of a standard HIPAA authorization included in mailed survey packets on study enrollment for a multi-site pragmatic trial. This study is nested within an advance care planning pragmatic trial at 50 primary care clinics across three University of California (UC) Health Systems. We included English and Spanish-speaking seriously ill patients. One third of eligible patients received and 2/3 did not receive the HIPAA authorization in their enrollment packet. We compared enrollment rates at 3months and assessed the readability, understandability, and actionability of the standard HIPAA form using the Federal Plain Language Guidelines Checklist for Plain Language, the Automatic Readability Checker consensus calculator (grade 8 is the average reading level for US adults), and the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P, 0-100%, 70% considered the minimum). Of 4632 eligible patients (mean age 71, 48% women, 11% Spanish-speaking, 40% racial/ethnic minority); 1543 received a mailed enrollment packet with a HIPAA form and 3089 did not. Patients mailed the HIPAA form were less likely to enroll (10.2% vs. 14.8%, p < 0.001). The standard HIPAA form scored at the 12th grade reading level, had a PEMAT-P Understandability score of 42%, had an Actionability score of 40%, and only met 50% of Federal Plain Language Guideline Checklist items. The inclusion of a standard HIPAA authorization in mailed enrollment packets for a large pragmatic trial led to lower rates of study enrollment. This study informs how HIPAA authorization forms should be redesigned to be more accessible to patients to prevent unnecessary barriers to research enrollment.

The effects of incivility on student nurses in the clinical setting: A grounded theory approach

AimTo use a grounded theory approach to explore and understand the encounters of undergraduate nursing students with incivility in the clinical setting so that data-informed strategies for addressing this counterproductive behavior could be developed. BackgroundNurses are being called upon to fill ever-increasing responsibilities associated with expanding roles in different specialties within healthcare. One issue that has developed in this high-pressure environment is an increase in incivility in the workplace that spills over into the clinical training environment. As a pervasive problem in the healthcare system, its effects on nursing students could compound the nursing shortage by undermining the integrity of nursing education and discouraging individuals from entering the profession. Therefore, it is vital to construct new theories regarding incivility so that this unprofessional practice can be eradicated or reduced. When this is done, there may be a renewed hope for new nursing students to practice their clinical rotations without feeling disrespected, undermined and intimidated. Students should be able to complete clinical rotations without these unnecessary barriers. DesignQualitative grounded theory using philosophical underpinnings of symbolic interactionism and pragmatism. MethodsA classical grounded theory approach focusing on the Glaserian Model was used to develop an inductively derived theory from the data. Participants were interviewed about their encounters with incivility and then open coding was used to identify recurring concerns on which a model of the effect of these occurrences could be established. The study sample consisted of 32 participants of which 25 were undergraduate nursing students and seven were graduate students who participated in a focus group. Data were collected through face-to-face (in-person and virtual) structured interviews that were audiotaped. These individuals were recruited by flyers posted at varying strategic points on university campuses. ResultsOpen coding of student responses revealed three significant areas of concern: feelings of being disrespected, intimidated and undermined, from which the Inhibiting Actions Theory emerged. ConclusionNursing students' perceptions of incivility and their attitudes and behaviors toward this occurrence culminated in the Inhibiting Actions Theory, which provides a framework for implementing effective policies and personnel training in clinical settings. The hope is that these research findings will be a call to action for introducing systemic changes in the clinical training environment, thereby improving the clinical experiences of nursing students and patients.

Investigating the impact of Accessible Pedagogies on the experiences and engagement of students with language and/or attentional difficulties

AbstractStudents with disability tend to report lower levels of school engagement. To date, research has focused on building students’ extrinsic motivation and self-regulation with limited consideration of the impact of instructional barriers. In this mixed-methods study, we investigated the effect of teachers’ participation in the Accessible Pedagogies™ Program of Learning on the classroom experiences and engagement of 56 Year 10 students with disabilities impacting language and information processing. When asked in interviews what their teacher did to help them pay attention and to understand, students described teachers’ increased use of practices that were the focus of the program. Self-report questionnaire data revealed a positive, statistically significant increase in cognitive engagement for students whose teachers participated in Accessible Pedagogies™. No increase was observed for a Comparison Group. Findings suggest that the reduction of extraneous language and cognitive load through teachers’ use of Accessible Pedagogies™ may have helped students deploy available mental effort to engage in learning, rather than expend that effort to overcome unnecessary instructional barriers. Future research will investigate the impact of Accessible Pedagogies™ with larger samples and a wider range of students.

Rationalizing the Mathematics Requirements for a Master of Biostatistics Program: A Case Study and Commentary

Within a 2-year Master of Biostatistics program, we reconsidered the mathematics requirements for admission, and also the premise that the most distinguishing feature of a top candidate is deep exposure to mathematics. Our assessment took place within a broad curriculum review intended to enhance alignment: aligning programmatic goals with job skills, aligning the use of mathematics within our curriculum with programmatic goals, aligning our admission criteria with our curriculum, and aligning our application materials with these admission criteria. We developed a specific list of mathematical skills required by the curriculum, and are revising the application materials to include self-report on applicant's exposure to and functional mastery of those skills. We illustrate how functional mastery is operationally defined. Our criteria for identifying top candidates was broadened to include those with especial skills in analytics, biology and/or communication (i.e., the three conceptual pillars of our program). Deep mathematical training is one of many ways to become a top candidate. Within STEM fields such as biostatistics, and despite the commonly held assumption that admission criteria should emphasize depth of mathematical training, a systematic analysis suggests that this assumption imposes a gratuitous requirement on applicants. Reconsidering this assumption can help remove unnecessary barriers, reduce challenges, and support success for aspiring or emerging biostatisticians from diverse or multifaceted backgrounds. It is one way to contribute to a more inclusive and equitable learning environment in our STEM discipline. We believe similar programs might benefit from performing this type of analysis and reflection.

U.S. Medical Eligibility Criteria for Contraceptive Use, 2024.

The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

U.S. Selected Practice Recommendations for Contraceptive Use, 2024.

The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1-66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Understanding users of online energy efficiency counseling: comparison to representative samples in Norway.

To achieve substantial energy efficiency improvements in the privately owned building stock, it is important to communicate with potential renovators at the right point in time and provide them with targeted information to strengthen their renovation ambitions. The European Union recommends using one-stop-shops (OSSs), which provide information and support throughout the whole process, from planning to acquisition of funding, implementation, and evaluation as a measure to remove unnecessary barriers. For this paper, we invited visitors of two Norwegian websites with OSS characteristics to answer an online survey about their renovation plans and energy efficiency ambitions. The participants visited the websites out of their own interest; no recruitment for the websites was conducted as part of the study (N = 437). They also rated a range of psychological drivers, facilitators, and barriers to including energy upgrades in a renovation project. Their answers were then compared to existing data from representative samples of Norwegian households regarding home renovation in 2014, 2018, and 2023, as well as data from a sample of people who were engaged in renovation projects in 2014, which was collected by the research team with a similar online survey. Furthermore, 78 visitors completed a brief follow-up online survey one year later to report the implemented measures. We found that visitors of the websites are involved in more comprehensive renovation projects and have substantially higher ambitions for the upgrade of energy efficiency compared to the representative samples. They also perceive stronger personal and social norms, as well as have a different profile of facilitators and barriers. The findings suggest to policymakers that OSSs should be marketed especially to people motivated to upgrade energy efficiency but lack information and are unable to implement their plans alone. Also, the construction industry might refer interested people to such low-threshold online solutions to assist informed and more ambitious decisions.

Analysis on the Modification of Article 5, Paragraph 2 of the WTO's SPS Agreement

Against the backdrop of the World Trade Organization's Agreement on Sanitary and Phytosanitary Measures (SPS Agreement), this study explores how health security measures affect international trade in the context of globalization, particularly in the context of global health crises such as COVID-19. Through an in-depth analysis of the provisions of the SPS Agreement and international trade data, as well as previous studies and case studies, the study made three key recommendations: enhancing transparency in risk assessment, promoting public participation in health policy-making, and facilitating the establishment of mechanisms for cross-border cooperation. These recommendations aim to ensure that member countries not only follow scientific principles when implementing sanitary and phytosanitary measures, but also reduce unnecessary barriers to trade and promote the sustainable development of global trade. The conclusions of the study highlight that these improvements can effectively alleviate the trade uncertainty that may be brought about by health security measures, thereby protecting public health and promoting the healthy growth of international trade.

Spatial and component structure analysis of the inclusive circular economy: SGICE

Modern statistics and scientific research consider the circular economy rather one-sidedly, essentially as recycling and reuse of resources. The article proposes methodology (concept) of the global inclusive circular economy, which can be considered as a complex multidimensional system, the main components of which are the economic, sociological, ecological and circular aspects of the country's life. To achieve this goal, the GNU regression, econometrics and time-series library was used – an applied software package for econometric modeling, a part of the GNU project. Accordingly, we will define the global inclusive circular economy as the SGICE (Global Inclusive Circular Economy) system, characterized by the vector of functions. For the most exhaustive consideration of the entire range of opportunities of the global inclusive circular economy, the study developed and accordingly analyzed the integrated index of the development of the global inclusive circular economy (IGICE) by ecological, economic, social and circular components with isolated weakly correlated indicators. The ranking of countries was carried out separately by the components of the index, on the basis of which circular cores were distinguished: the social component (Belgium, the Czech Republic, USA, China, France, Greece, Austria, Australia), the ecological component (Japan, Denmark), the economic component (Germany, China), which became the basis for the model of formation of global inclusive circular chains. The conducted cluster analysis based on the component indicators of the index of the global inclusive circular economy confirmed the formation of a large circular gap (gap) in the ecological and circular components. This indicator is introduced for the first time and makes it possible to comprehensively analyze the country and highlight additional effects that arise from the moment of implementation of circular business projects and the inclusion of the country (on the basis of firms, corporations) in global circular chains of added value. After all, the main problematic aspects are the illegal trade in waste and growing smuggling, which cause serious negative social consequences and actualize the inclusive component in the justification of the global inclusive circular economy paradigm. Waste reduction combined with wise use of resources has the potential to address the gap resulting from the scarcity of natural resources and a growing global population or consumption. The formation of circular trade will contribute to: the determination of priority materials for trade and the required level of processing capacity, coordination of material quality standards, promoting demand for used goods and secondary raw materials, removing unnecessary regulatory barriers and avoiding environmentally harmful activities such as non-compliance, poor regulation and informal recovery.

Barriers and enablers to accessing perinatal health services for rural Australian women: A qualitative exploration of rural health care providers perspectives.

To identify perceived barriers and enablers for rural women in accessing perinatal care within their own community from the perspective of perinatal health care providers. A qualitative descriptive study design utilising reflexive thematic analysis, using the socioecological framework to organise and articulate findings. Victoria, Australia. Semi-structured interviews were conducted with nine perinatal health care providers who provide care to pregnant women or new mothers in rural communities. Participants were recruited across Victoria in 2023. Providers reported multi-level barriers and enablers that exist for rural women in accessing perinatal care within their communities. Barriers included women's personal circumstances, challenging professional relationships, inequitable service provision, ineffective collaboration between services and clinicians and government funding models and policies. Enablers included strength and resilience of rural women, social capital within rural communities, flexible care delivery and innovative practice, rural culture and continuity of care models. Rural perinatal health care providers perceived that rural women face multiple barriers that are created or sustained by complex interpersonal, organisational, community and policy factors that are intrinsic to rural health care delivery. Several addressable factors were identified that create unnecessary barriers for rural women in engaging with perinatal care. These included education regarding health systems, rights and expectations, equitable distribution of perinatal services, improved interprofessional relationships and collaborative approaches to care and equity-based funding models for perinatal services regardless of geographical location.

Importing US-produced hydrogen and its derivatives into the EU – examples of unnecessary complications, barriers and distinctions

The European Union, like many other nations and governments, is counting on hydrogen to play a big role in the energy transition. The EU has set ambitious import targets for hydrogen. This article will examine and comment on select parts of the EU framework that impact the EU’s plan for importing 10 million tonnes of hydrogen. This framework could have the effect of frustrating trade with third countries. Using the United States as an example of an importer, this article looks at (i) guarantees of origin, (ii) electricity market design, (iii) state aid, (iv) eligible carbon dioxide rules, and (v) the carbon border adjustment mechanism, with a view to ascertaining their effect on imports into the EU. The article finds that the EU framework causes unnecessary barriers to trade and may need to be tweaked to enable trade to fulfil its legislative targets.

Changes in contraceptive method mix following the Colorado Family Planning Initiative

ObjectivesTo describe the changes in contraceptive method use and mix among Colorado Title X clients following the 2009 Colorado Family Planning Initiative (CFPI), which allowed Colorado Title X providers to offer all contraceptive methods without medically unnecessary barriers. Study designUsing data on all visits to Colorado Title X clinics between 2007 and 2016 for women aged 10–49 years, we described trends in contraceptive method use by age group and race/ethnicity prior to and following the implementation of CFPI. ResultsThe implementation of CFPI saw an abrupt increase in Title X visits. Visits subsequently declined steeply for non-Hispanic White clients while visits by Hispanic clients remained at elevated levels. During CFPI, the use of long-acting reversible contraceptives increased while the use of oral contraceptive pills decreased. Nonetheless, oral contraceptive pills remained the most common method used by Title X clients throughout the study period. Changes in the method mix varied by age and race/ethnicity. Method switching was relatively uncommon among established Title X clinic users. ConclusionsCFPI, which removed financial barriers to the most expensive methods, was associated with increases in the use of long-acting reversible contraceptives and changes in method mix that varied by age group and race/ethnicity. ImplicationsCFPI removed barriers to previously inaccessible methods that contributed to changes in the method mix at Title X clinics. That these changes were not uniform across ages and race/ethnicities emphasize that subgroup variation in family planning policy impact stems from heterogeneity in barriers to care and method-specific unmet demand.

Characteristics of adolescents referred for bariatric surgery in Abu Dhabi, United Arab Emirates.

About a third of children and adolescents are overweight or obese in the United Arab Emirates, and referrals for metabolic and bariatric surgery (MBS) are now common. Despite excellent evidence that MBS should be considered in adolescents with severe obesity, it remains a management approach of last resort in many cases. Baseline, real-world data on adolescent patients living with obesity referred for surgery, their characteristics, and how these relate to current and future referral policy are important to ensure best practice. Here we examined the demographic, anthropometric, and clinical characteristics of adolescents referred for MBS over a three-year period to Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, UAE. Ninety-two adolescents living with obesity were recruited: 54.3% were female, the average age was 16.3 ± 2.4 years, and 88.0% of patients had a first-degree relative with a history of obesity and 62% a family history of bariatric surgery. The average BMI was 47.7 ± 10.5, and the average percentage of the 95th percentile BMI was 169.5 ± 38.8%. Complications of obesity (hypertension, type 2 diabetes and prediabetes, dyslipidemia, and liver function abnormalities) were common. Our analysis highlights that there exists a mismatch between the profiles of patients referred for MBS, local guidelines, and international best practice in decision-making for referral to MBS services. While many adolescents in the UAE seem to enjoy family support and experience in the surgical management of obesity, local guidelines need updating to reflect changes in the definitions of obesity, thresholds for referral, and to remove unnecessary developmental stage barriers to increase the window for personalized surgical management.

International Standards for Regulatory Deference Relating to National Food Control Systems: More to Do?

AbstractThis paper describes how the development of texts on regulatory deference by the Codex Alimentarius Commission (CAC) addresses relevant recommendations of the World Trade Organization (WTO) and supports Member countries of CAC in their negotiation and implementation of equivalence agreements. We consider the role and function of CAC within a rules-based multilateral framework, particularly in relation to the development and implementation of equivalence concepts. We then consider whether, through use of equivalence agreements, trade facilitation outcomes have been realised. Our hypothesis is that international standards on regulatory deference promote fair but aspirational standards and support fair practices in the trade of safe food – both vital outcomes for global food security and the achievement of many of the United Nations Sustainable Development Goals. We test this hypothesis against the framework provided by decisions of the WTO Sanitary and Phytosanitary Committee. We argue that the equivalence concepts and guidelines developed by CAC are appropriate but underutilised tools available for Member countries to strike a balance between their right to regulate to protect human, animal or plant life and health and to fulfil legitimate objectives whilst meeting their WTO obligations to avoid measures that constitute unnecessary barriers to trade.

SNAP Student Rules Are Not So Snappy: Lessons Learned From a Qualitative Study of California County Agency Workers

ObjectiveTo examine the college student Supplemental Nutrition Assistance Program (SNAP) application process from the perspective of county agency workers. DesignA qualitative study that included semistructured individual and group interviews (n = 14) between February and December, 2021. SettingNine California counties with a University of California campus. ParticipantsA total of 24 county agency workers who regularly process or advise on college student SNAP applications. Phenomenon of InterestFacilitators and barriers to processing student SNAP applications. AnalysisInterviews were recorded, transcribed, and coded using thematic analysis. ResultsFive themes were identified regarding student applications: (1) a need for more consistency in policy dissemination and program administration, (2) student exemptions and the application process are perceived as challenging for students, (3) facilitators of successfully processing student applications, (4) tracking policy changes is burdensome, and (5) eliminate the student rules. Conclusion and ImplicationsCounty agency workers perceived that students experience unnecessary barriers to accessing SNAP benefits and that implementing the student rules was taxing. Expanding SNAP access to low-income college students could be an equitable solution to mitigate the risk of student hunger while they pursue their degrees.

Against Self-Defeating Climate Policy

This paper contends that the narrow Overton window on climate policy is self-defeating to the goals of many climate activists and policymakers. It gives three examples of policies that do little to address carbon emissions and are likely to fail: (1) how decarbonization policies are destroying electric grid reliability; (2) how the attempt to eliminate the internal combustion engine is leading to the “Cuba-fication” of the automotive fleet; and (3) how the focus on reducing domestic carbon emissions leads to regulatory arbitrage. The paper provides three corresponding recommendations, contending (1) that states should eliminate RTOs and ISOs in favor of vertically integrated utilities and that we should eliminate unnecessary regulatory barriers to the development of new nuclear reactors, (2) that we should promote tech-neutral ways of reducing vehicle emissions, e.g., by authorizing the use of higher-octane fuels, and (3) that domestic industry should be promoted through permitting reform, deregulation, and industrial policy. The paper concludes by positing that self-defeating climate policy predominates because public discourse on climate policy is based on what Eric Voegelin called “gnostism,” which confuses temporal and spiritual concerns, leading to destructive policies that refuse to acknowledge the structure of reality.

"A whole ball of all-togetherness": The interwoven experiences of intimate partner violence, brain injury, and mental health.

Intimate partner violence (IPV) is a global public health crisis, with physical violence leaving IPV survivors at high risk of brain injury (BI). Both BI and IPV have significant physical, psychological, cognitive, and social impacts, including a high risk of mental health concerns, yet there is limited exploration of IPV survivors' experiences with BI and mental health. This study aimed to explore the BI- and mental health-related needs and experiences of IPV survivors from the perspectives of survivors and service providers with the objective of developing knowledge translation materials to raise awareness and support survivors and service providers in addressing these concerns. This qualitative interpretive description study involved 19 semi-structured interviews and two focus group discussions (2-3 participants each) with 24 participants including IPV survivors experiencing BI and mental health concerns as well as IPV, mental health, and BI service providers between October 2020 and February 2021. Three screening questions were used to identify probable BI among survivors. Participants across groups were an average of 48.5±12.7 years old and were predominantly cisgender women (96%), of European origin (75%), with a university degree (71%). Interviews were recorded, transcribed, and thematically analyzed. Across interviews, participants spoke about IPV, BI, and mental health as being complex and interrelated experiences that have impacts across the survivor's life and extend well beyond the abusive relationship. Because of the underrecognized nature of BI in IPV, finding and accessing care requires persistence that survivors spoke of as being like "a full-time job." The benefit of making meaningful connections, particularly with other survivors, was highlighted. Recognition of BI as a contributing factor shaping the lived experience of IPV survivors; acknowledgement that the impacts of IPV, BI, and mental health are far reaching and long lasting; and reducing barriers to finding and accessing appropriate care are critical to better supporting IPV survivors with BI and mental health concerns. Clinicians should consider BI and its lingering impacts among the IPV survivors with whom they work. Health and social policy that supports integration of care and the reduction of unnecessary barriers should be a priority.

Local government competition and resource allocation efficiency

This study confirms that local government competition is an important influencing factor on resource allocation efficiency. The results indicate that local government competition can inspire local governments to better serve local businesses and residents, improve administrative efficiency, reduce unnecessary administrative barriers, and encourage the government to allocate resources more efficiently. Moreover, the heterogeneity analysis results show that the promotion effect of local government competition on resource allocation is more pronounced in areas with lower marketization and in private enterprises. Overall, the results of this study indirectly confirm that building a "proactive government" can optimize the resource allocation efficiency.