research in global perspectives

Programmes & Qualifications

Cambridge international as & a level global perspectives & research (9239).

• Syllabus overview

Cambridge International AS & A Level Global Perspectives and Research is a skills-based course that prepares learners for positive engagement with our rapidly changing world. Learners broaden their outlook through the critical analysis of – and reflection on – issues of global significance. They will develop unique, transferable skills including research, critical thinking and communication by following an approach to analysing and evaluating arguments and perspectives called the 'Critical Path'.

Collaborative skills are enhanced through participation in a team project. The skills gained through study of this course help students to meet the demands of Twenty-First century learning, preparing the transition to higher education and the world of work.

As part of the course learners write a research report on a research question of their choice. You can find out more information on this on the School Support Hub and viewing the supporting documents.

View our Global Perspectives and Research Statement of Support .

The syllabus year refers to the year in which the examination will be taken.

• -->2023 - 2025 Syllabus update (PDF, 145KB)
• -->2026 - 2028 Syllabus update (PDF, 150KB)

Syllabus support

• -->2023-2025 Grade Descriptions (PDF, 118KB)

Syllabus updates

We revise our qualifications regularly to make sure that they continue to meet the needs of learners, schools and higher education institutions around the world, and reflect current thinking. Please see the 2023-2025 syllabus document for full details on the changes.

What are the main changes to the syllabus?

• refreshed the list of Cambridge International AS Level topics
• updated the assessment objectives to make the links to the assessed skills clearer.

What are the main changes to the assessment?

• For Component 3, learners can now choose between recording a live presentation or submitting a presentation with a recorded voiceover. This offers greater flexibility for centres and is more accessible for some students.
• The Cambridge Research Report (Cambridge International A Level) is now marked by Cambridge International. We have discontinued the oral explanation and learners do not submit an Outline Proposal Form.

When do these changes take place?

The updated syllabus is for examination from June 2023 onwards. Examinations are available in March 2023 for India only. Please see the 2023-2025 syllabus above for full details.

We are developing a comprehensive range of materials to help you teach the updated syllabus. These resources will be available from June 2021 onwards (before first teaching) through our School Support Hub and include:

• Scheme of work
• Learner guide
• Teacher guide
• Specimen Paper Answers
• Example Candidate Responses (after first examination).

Face-to-face and online training will be available. For up-to-date information, visit our Events and training calendar .

Endorsed resources

Cambridge International AS & A Level Global Perspectives and Research (Collins)

Encourage critical thinking, self-reflection and independent thought and provide students the opportunity to engage with key global issues. This series comprises a Student’s Book, Workbook and Teacher’s Guide.

Read more on the Collins website

Guide students along the critical pathway as they advance their Twenty-First century skillsets in areas such as research, reasoning, thinking and communication. Includes essay writing support and guidance for forming research questions.

Read more on the Cambridge University Press website

Important notices

We are withdrawing Cambridge International AS & A Level Global Perspectives & Research (9239) from the March exam series. The last March series for this syllabus will be March 2025. 

From 2026, we will only offer this syllabus in the June and November exam series.

We communicated this change to schools in September 2022.

Schools offering Cambridge International AS & A Level Global Perspectives can access resources, courses and build online communities through our . Access the Online Learning area .

For some subjects, we publish grade descriptions to help understand the level of performance candidates’ grades represent.

We paused the publication of grade descriptions in response to the Covid-19 pandemic and the temporary changes to the awarding standard in 2020, 2021 and 2022.

As the awarding standard has now returned to the pre-pandemic standard, we are working to produce up-to-date grade descriptions for most of our general qualifications. These will be based on the awarding standards in place from June 2023 onwards.

The national agency in the UK for the recognition and comparison of international qualifications and skills, UK NARIC, has reviewed Cambridge International AS & A Level Global Perspectives and found that it is comparable to UK A Level and develops skills that are particularly relevant in preparing students for higher education study internationally. Read the executive summary of the UK NARIC report.

Check the Submit for Assessment page and the samples database for information and guidance on submitting moderated and examined work using Submit for Assessment.

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Teachers at registered Cambridge schools can unlock over 30 000 teaching and learning resources to help plan and deliver Cambridge programmes and qualifications, including Schemes of work, Example candidate responses, Past papers, Specimen paper answers, as well as digital and multimedia resources.

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A global perspective on research.

Worldwide advancements in science have increased the importance of connecting researchers globally. Though technology now allows certain types of instant connectivity and emerging nations are spending widely on their research institutions, wide gaps remain, even when talent and subject knowledge may be equal.

Since professional advancement involves teaching and research—with career progress at many institutions dependent on maintaining a continuous research track—quality of scientific research is often compromised in favor of quantity, especially in developing countries where pressure to produce is heavy and resources may be lacking. Unfortunately, this often reduces research in such places to a data-generating process, perpetuating the gap between wealthy and developing countries.

The global research community would benefit from uniform rules for awarding research degrees and uniform guidelines that take into account differences in resources and provide equal opportunities to contribute. High-quality education is the prerequisite for doing high-quality research. Today, the quality of research done in developed parts of world is far above that in developing countries. Financial constraints have created vast differences between standards in differently developed regions of the world, but the developing countries are beginning to show signs of catching up. Assistance will be needed, however.

When research was less dependent on the use of technology and there were fewer security-related issues, research training and career opportunities were somewhat more open to people living in developing countries. The quest for knowledge was something of an individual journey. Then, it was financially feasible to do high-quality research even in developing countries. Research was also of comparably higher quality because there was less competition among researchers on the basis of the number of papers published or patents registered. Until recently, most studies from developing countries were narrowly focused and were conducted by two to three authors, at the most—with very little possibility of financial return.

The situation has changed. With the advancement of technology, research groups are now present in almost every corner of the globe. They are focusing on generating data, publishing papers, and registering patents—but they are not making substantial original contributions to science. Technology in many fields requires massive financial investments in research training, and in hiring researchers, research institutions give preference to local candidates. Security concerns have played an important role in restricting the access of potential candidates from the rest of the world, widening the perception of global “haves” and “have-nots,” at least in terms of research contributions. Universities involved in research in almost all domains of knowledge need to be global literally .

Today’s studies often address old issues using new technology and data-analysis tools. The work is frequently multidisciplinary, and the number of authors involved in any study has significantly increased. Since there is more need for financial support in providing the required technology and other technical support, the principal investigator of any funded project, even without making any considerable intellectual contribution, can get authorship credit for papers that may not be relevant to the investigator’s field of expertise. This is analogous to what is happening between research institutes globally. In the developing world, permission to use laboratory facilities or get technical support is given only on the condition of the grantor’s receiving at least partial authorship credit. In principle, the researcher working on the bench or collecting data should become the first author credited in publication. Since there are comparatively more researchers involved in studies today, there is often disagreement on the order of authorship recognition, but such fights are seldom exposed. Merely filing notice of disagreement can damage a junior researcher’s career. The same can be true of research institutions in remote places when they attempt to gain global parity.

Impact factor scores have been assigned to research journals since 1975 to differentiate high-quality research from routine scientific work and to measure the relative importance of journals within their field. The impact factor of an academic journal represents the average number of citations to recent articles published in the journal. Journals having higher impact factors are considered more reputable, which, in turn, allows them to publish more high-quality work. 

The contribution of any researcher should be evaluated by the cumulative impact factor of his or her publications. Unfortunately, in many places, the number of publications is what is counted. Most of the officials designing policies ignore the fact that individuals doing original work would never be able to generate many papers in a given span of time. Their contributions still could alter the horizon of the understanding in a given field, however. In less privileged parts of the world, an extremely competent researcher who follows the rules and regulations might never be promoted without compromising the quality of his or her work in the race to generate papers. The same could be said for research institutes as a whole in developing countries and, to a lesser degree, in developed ones.

In research, quality should matter more than quantity. Unfortunately, in most of the developing world, quantity is rewarded first, a situation that encourages copycat publication and even plagiarism. Publishing even negative results would help to make the process of learning more transparent.

With security issues and the growth of the Internet, PhD candidates in developing countries are increasingly having to study in local institutions. Connectivity, however, has both positive and negative aspects. Universities in the developing world—in spite of having, more and more frequently, huge buildings and technical support—lack the infrastructure and professional training of their counterparts in wealthier countries. Furthermore, entrance to universities in developing countries is often predicated on doing well on exams that require little more than memorization. The global impact of the work researchers do in “home” institutions is further limited by the language barrier, which keeps some of today’s potentially best scholars from gaining access to internationally recognized institutes for research training.

Such hindrances do not decrease the ambition of researchers in the developing world, nor does it diminish their capability to generate useful hypotheses in the fields of their interest. Even though their facilities may be improving, they are not always in a position to generate data that could support their hypotheses or lead them to discard or modify them. This results in a great loss to the researcher’s immediate scholarly community and to overall knowledge and understanding.

Journals with high impact factors could be part of the solution to the problem of providing better access to global research conversations to researchers in the developing world. These journals could, for example, introduce a section where researchers from all over the world could publish their hypotheses even in the absence of supporting data. Such an approach would bring researchers in the developing world into contact with researchers at other institutions where the needed data could be generated. Encouraging the formation of an independent research evaluation organization to evaluate the submission of research proposals, theses, and published papers, especially in case of authorship disputes, could also be helpful. Researchers from developing countries, after all, can feel bypassed by those from better-funded and more centrally located institutes when they do not receive appropriate credit.

Competent researchers from developing countries often prefer to work abroad, where the environment is more supportive of high-quality research, leaving less competent workers at home. These latter, unfortunately, are the ones who design academic policies that support their own parochial interests while allowing overall standards to deteriorate, increasing the quality gap. There are few explicit global standards to which they need to adhere.

Researcher communities seem to ignore the importance of having competent research groups available in all the disciplines in every region of the globe. More study needs to be done regionally, no matter the field, if we are ever to have global research parity that takes advantage of talent worldwide. Setting comparable standards for research training across the globe should be a matter of concern for all. Research is often focused in commercially significant areas, ignoring the fact that we cannot have new technologies without having done research in basic sciences and other disciplines.

There are large numbers of researchers with PhDs in almost every country, but they are not at all comparable. There are no universally adopted criteria for awarding doctoral degrees, a basic requisite for doing independent research and keeping the quality consistently high.

If we do not opt to change the system, original research could become merely a dream outside of the developed world. I hope we outsiders can learn to learn well and join with the rest before it is too late.

Faiza Abdur Rab is assistant professor in the Department of Food Science and Technology at the University of Karachi in Pakistan. Her e-mail address is [email protected] .

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Local Research and Glocal Perspectives in English Language Teaching

Teaching in Changing Times

• © 2022
• Rubina Khan   ORCID: https://orcid.org/0000-0002-6795-0276 0 ,
• Ahmed Bashir   ORCID: https://orcid.org/0000-0001-7133-2203 1 ,
• Bijoy Lal Basu   ORCID: https://orcid.org/0000-0002-7598-7239 2 ,
• Md. Elias Uddin   ORCID: https://orcid.org/0000-0003-1523-4160 3

Department of English, University of Dhaka, Dhaka, Bangladesh

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• Explores recent trends and developments in the field of English language education
• Showcases research from a heterogeneous group of scholars
• Synthesizes local expertise and culture with innovative ideas from other contexts

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Table of contents (31 chapters)

Front matter, introduction.

Rubina Khan, Ahmed Bashir, Bijoy Lal Basu, Md. Elias Uddin

Socio-cultural Perspectives in ELT

Elt and development in bangladesh: a critical overview.

• Qumrul Hasan Chowdhury

Students’ Uptake of Translanguaging Pedagogies and Translanguaging-Oriented Assessment in an ELT Classroom at a Bangladeshi University

• Abu Saleh Mohammad Rafi

Culture in Language Teacher Education: A South Asian Perspective

• Laxman Gnawali

Snowflakes Versus Ice Cubes in Creative Language Use

• Shree Deepa, Geetha Durairajan

Curriculum and Materials

Economisation of the secondary english curriculum in bangladesh.

• Md. Maksud Ali, M. Obaidul Hamid

Outcome-Based Living ELT Curriculum in Higher Education in Bangladesh

• Muhammed Shahriar Haque, Md. Masudul Hasan

Enacted Curriculum of Private English Kindergartens in Korea: Cases of Three Play-Based English Kindergartens in Seoul

• Jeehee Kim, Tae-Hee Choi

“Stories About Ourselves”: Collaboration, Teacher Development, and Creating Culturally Relevant Graded EFL Reading Materials for Bangladeshi Learners

• Cherie Brown

The Challenges of Developing ELT Materials for Higher Secondary Schools in Bangladesh: The Case of the English Textbook

• Arifa Rahman

Rhizomatic Literacy Through Graphic Novels

• Sonia Sharmin

Educational Technology

Students’ evolved beliefs of tell constraints and benefits: learner voices from an eap programme.

• Farhana Ahmed

Teacher Initiatives for Technology Integration in Higher Education in Bangladesh

Wiki-based collaborative writing: undergraduate learners’ perspectives.

• Anjuman Ara

Using Digital Tools to Enhance Student Engagement in Online Learning: An Action Research Study

• Rumana Rafique

ELT Practices

• Teacher Development
• post-COVID curriculum
• MCQ Item Violation
• Assessment Literacy
• Assessment for Learning
• Curriculum Implementation Strategies
• Reform Message
• National Curriculum Framework in Bangladesh
• ELT Curriculum Change
• Teaching Vocabulary
• Collaborative Writing
• Technology Integration
• Tech-enhanced Pedagogy
• English for Employment; ELT and Development
• Economisation of Education
• English and Globalisation
• Translanguaging Pedagogies
• Cultural Relevance
• Volunteer Teacher Trainers

About this book

Editors and affiliations, about the editors, bibliographic information.

Book Title : Local Research and Glocal Perspectives in English Language Teaching

Book Subtitle : Teaching in Changing Times

Editors : Rubina Khan, Ahmed Bashir, Bijoy Lal Basu, Md. Elias Uddin

DOI : https://doi.org/10.1007/978-981-19-6458-9

Publisher : Springer Singapore

eBook Packages : Education , Education (R0)

Copyright Information : The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022

Hardcover ISBN : 978-981-19-6457-2 Published: 02 January 2023

Softcover ISBN : 978-981-19-6460-2 Published: 03 January 2024

eBook ISBN : 978-981-19-6458-9 Published: 01 January 2023

Edition Number : 1

Number of Pages : XVII, 479

Number of Illustrations : 14 b/w illustrations, 8 illustrations in colour

Topics : Language Education , Teaching and Teacher Education , Sociology of Education , Educational Policy and Politics

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Current Events in Historical Context , Perspectives Daily

Thinking Globally about Student Protest

Precedents from East Asia

John Delury and Jeffrey Wasserstrom | May 30, 2024

As 2024 began, we anticipated spending a lot of time thinking about youth demonstrations. We expected this year to bring debates over ways generations of students were similar and different when it came to politics. And we thought we would find ourselves talking to colleagues a lot about the meanings of arrests and uses of force.

Mongkok neighborhood on the Kowloon Peninsula, one of three Umbrella Movement occupy zone encampments in Hong Kong in 2014. Jeffrey Wasserstrom

This was not because we are clairvoyant. It is because we are historians of East Asia, and 2024 marks significant anniversaries of three major East Asian youth movements: the 35th anniversary of the June 4, 1989, massacre that ended the Tiananmen Spring and the 10th anniversaries of Taiwan’s Sunflower Movement and Hong Kong’s Umbrella Movement.

None of those events is being replicated now on American and European campuses, yet we find ourselves seeing connections and drawing comparisons. Thinking about today’s protests outside of Asia with Asian examples in mind reminds us that repertoires of youth resistance do not stay within geographic borders. When searching for even imperfect historical analogies, going global can help bring into sharper focus stories about protests and patterns in how authorities respond to them.

The Chinese youth movement of 1989 began with protests on various college campuses in mid-April and ended in a massacre near Beijing’s Tiananmen Square on June 4. The struggle in China differed considerably from the current movement in countless ways. To cite just two, the protests focused on domestic issues, not foreign policy, and at its height large contingents of workers and members of other urban classes joined student-led actions. There are, however, instructive parallels. For example, while the term “encampment” was not yet in vogue, many protesters in Tiananmen Square slept out in tents (an “occupation,” in the language of Occupy Wall Street two decades later). Protesters’ tent-filled areas were celebrated as joyous and orderly in some accounts and vilified in others, as they are now. Some observers called for leaving the “patriotic protesters” alone, while others demanded the authorities restore order to “chaos” and end an anarchic situation allegedly created by outside agitators, and do so with force if necessary . By escalating the protest from marches, which have a natural end, to occupation, the students dared authorities to forcibly remove them—and as the tragic events of June 4 showed, the authorities met that challenge with martial law and military action.

By escalating the repertoire of protest from marches to occupation, the students dared authorities to forcibly remove them.

The 1989 protesters set up the encampment not on campuses but in a public space next to the seat of government. A striking parallel with the present, though, is that many Tiananmen activists attended universities famed for having been centers of activism in earlier decades. Many studied at schools that played hallowed roles in the May Fourth Movement of 1919, an event that China’s current rulers view as symbolizing noble protest. As at Columbia University in 2024, before putting up tents in Tiananmen Square some activists had read official school histories and seen promotional materials that extolled incoming classes to take pride in actions that, when they staged what they viewed as variations on them, were dismissed as senselessly disruptive. When those students presented themselves as emulating the historic heroes of May Fourth, their opponents parried by likening their actions to those of discredited historical actors, calling protesters as Red Guards , a negative analogy put forward by referring to them as creators of Cultural Revolution–style “turmoil.”

This year also marks the 10th anniversary of the Sunflower Movement, the biggest student-led protest in Taiwan since the 1990s. In its defining moment, young people took control of the island’s parliament, the Legislative Yuan. Again, an escalatory tactic transformed the protest from an on-campus activity to a more direct challenge to the government. Students were there to voice opposition to a proposed trade agreement with Beijing that they felt would set the country on a perilous course toward domination by China’s Communist Party, which has long claimed that the self-governing island is part of the People’s Republic of China (PRC). Hundreds of thousands of Taiwanese subsequently joined the students for a mass rally outside the presidential office. Just as the Tiananmen protesters presented their struggle as a “ New May Fourth Movement ,” and some US activists now invoke the memory of 1968, the name “Sunflower Movement” paid homage to an earlier struggle in Taiwan with a floral name: the Wild Lily Movement of 1990, a struggle (influenced in part by the Tiananmen protests) that brought real democracy to the island.

The Sunflower Movement ended victoriously in April when the trade bill was withdrawn. That same year, in September, Hong Kong’s Umbrella Movement began . Until an even bigger Hong Kong protest wave five years later , this was the largest sustained urban social movement staged in any part of the PRC since Tiananmen. The Umbrella Movement, named for the way youths blocked pepper spray and tear gas with umbrellas, included the creation of three encampments, each largely populated by young people. A catalyst in expanding the scope of the movement was police treatment of the protesters—actions some defended as a valid effort to end troubling disruptions of important activities, but others saw as a disproportionate response to idealistic youths. With roots in a prodemocracy civic action known as “Occupy Central with Peace and Love,” itself inspired by Occupy Wall Street, the youth activists who set the tone for Hong Kong’s movement took more inspiration from the recent Sunflower struggle across the Taiwan Strait than from what had happened in New York City.

As in Taiwan, government buildings joined streets and squares as targets, a trend that resurfaced and took on special meaning five years later in July 2019 in a brief but dramatic occupation of Hong Kong’s Legislative Council. At the same time, Hong Kong students perfected the art of mobile protest, eluding police suppression as they darted around the city, inspired by the motto from a Bruce Lee video, “be water, my friend.”

None of these three examples provide a perfect analogy for today’s protests on US campuses (no historical event does). Nor do they tell us what will happen next. Each ended differently, and each could have developed differently had key actors made different choices at critical moments.

Repertoires and slogans flow across all borders.

Still, looking to past events in China, Taiwan, and Hong Kong can help us put current events into perspective. Tiananmen reminds us that US universities are not unique as places with celebrated histories of protest, which can be one factor in spurring a new generation of students to action. The Sunflower Movement’s role in influencing Hong Kong events (that were also shaped by Occupy Wall Street) reminds us that repertoires and slogans flow across all borders, but they often have special appeal in nearby or connected places. The Umbrella Movement, which did not see police kill protesters, reminds us that while martyrdom has a special power, sometimes anger at police using what seems undue yet not deadly force is enough to ramp up the number of people joining a struggle.

Transnational flows in the repertoires of dissent and repression have always mattered, and they are more important than ever in the era of Gen Z, digital natives for whom the Berlin Wall has always been rubble and the World Wide Web has never been new. It is unfortunate then that, with a few notable exceptions (such as a commentary by Jan-Werner Müller), the forays into comparison dealing with current protests have moved only across time, not space. In the social media age, when students share songs and symbols faster and further than ever before, it behooves us to move across borders more nimbly.

A final lesson that emerges from East Asian examples is the perpetual underestimation of young people. Just a year ago, many would have doubted that Gen Z students in the United States could sustain an activist movement over a foreign policy issue. On the Chinese mainland before 1989, as well as in Taiwan and Hong Kong early in the 21st century, the conventional wisdom held that the current generation of youth were too self-involved and concerned with material things to care about politics. The Tiananmen, Sunflower, and Umbrella Movements proved those assumptions wrong. Young people’s political involvement is underestimated again and again, from the short-lived “ White Paper Protests ” in China in 2022 to the US students in encampments today.

Therefore, we feel bold enough to venture one prediction. In decades to come, some people who took part in protests during their own youth will claim that a new generation of students are unlikely to follow in their footsteps—and yet again be proved wrong.

John Delury is Tsao Fellow at the American Academy in Rome and professor of China studies at Yonsei University in Seoul, Korea. Jeffrey Wasserstrom is Chancellor’s Professor of History at the University of California, Irvine.

Tags: Current Events in Historical Context Perspectives Daily Asia/Pacific

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Published June 03, 2024

Shifting Perspective: Psychology Major Yasmin Hung Intersects Research and Public Health

Staff Writer

Psychology major and Global Public Health minor Yasmin Hung originally planned to pursue a degree in nursing. She knew she wanted to attend a university with a diverse community and flexible academic programs, and NYU offered both. But, once arriving at NYU, she realized her true passion for global public health.

Yasmin joined the Empower Lab her junior year. Led by Dr. Veronica Ades, the lab is a clinical research and advocacy group working to increase the research conducted on sexual- and gender-based violence. Yasmin credits the lab for introducing her to the importance of public health. She discovered her passion for research too.

“After joining the Empower Lab, my academic perspective shifted,” says Yasmin. “I quickly realized that both research and public health really appealed to me. NYU is a place where you will never be punished for changing your mind, so I switched my major to Psychology. That way, I continued my research and took more courses in public health.”

A Closer Look at the Empower Lab

In the Empower Lab Yasmin conducts research alongside undergraduate, graduate, and medical students . Her lab mates’ focal points span various fields, including public health, medicine, social work, psychology, and sociology. Since joining the lab, Yasmin contributed to projects investigating a diverse range of topics: She researched intimate partner violence and how healthcare providers can use trauma-informed care to support female asylum-seekers in the United States. She also contributed to studies that looked at how clinicians can better integrate trauma-informed care into their practices when treating sexual violence survivors.

“The vision of our research’s impact is very clear. We think about how it will be applied to underserved communities, like womxn, womxn of color, and people who experience sexual violence,” she says. “Moving forward, I always want to conduct research that has a meaningful impact.”

Practical Knowledge from Esteemed Medical Doctors

To fulfill her Global Public Health minor , Yasmin took several courses that complemented her research in the lab. One of her favorite courses Ethics and Clinical Practice was taught by two professors who serve in the Division of Medical Ethics for NYU Langone Health’s Department of Population Health. Both professors are also practicing doctors.

“I found the intersection of clinical ethics, public health, and my work in the lab,” says Yasmin. “And that was interesting. We talked about surrogacy and how religion intersects with public health. Since our professors were practicing physicians, they shared insights from their own experiences in the field. We didn’t just listen to stories or lectures during class. We gained first-hand knowledge from accomplished doctors who had to navigate real ethical dilemmas throughout their career.”

Prepared for the Road Ahead

After graduation, Yasmin plans to pursue a master’s degree in public health. She wants to cultivate new skills and explore research topics in different fields. Due to the flexibility of NYU’s curriculum and the experiential nature of her coursework, Yasmin says she’s prepared for the next phase of her academic journey.

“Because my academic program was so flexible, I took courses in computer and data science. So, my grad school applications are more competitive ,” explains Yasmin. “As a psychology student, I was also required to take a course where I learned how to conduct research from start to finish. This hands-on experience really boosted my confidence. Now, no matter who I’m talking to in grad school, whether it’s a principal investigator or a professor, I know I can talk about the skills I cultivated while conducting a research project all on my own.”

A World of Research Opportunities

Research is clearly key to Yasmin’s NYU story. But, she didn’t always want to pursue research as a full-time career.

“I thought research would be really boring,” she says. “I didn’t understand what people meant when they said NYU was this huge research institution with unmatched resources. When I finally stepped into the research world myself, it clicked.”

As a student researcher, Yasmin has accomplished a lot. She published two pieces in a peer-reviewed undergraduate journal, contributed to a lab that secured funding for research, and presented her work at the NYU’s Undergraduate Research Conference .

“The opportunities here are endless,” says Yasmin. “I wish I would have given research a chance sooner. Once you step into that world, you have access to all of the resources NYU has to offer.”

Public Health Research at NYU Is Advocacy

Public health research at NYU is tightly connected to advocacy, especially at the NYU School of Global Public Health.

Summer Research Inspires Innovation and Exploration

With Tandon’s Undergraduate Summer Research Program, engineering students from across NYU’s campuses solve challenges for a better future.

Research at NYU, Not Just for STEM Majors

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Head of Public Opinion Research Company v. Film Production and Distribution Company

Closed Expands Expression

• Key details

Key Details

• Mode of Expression Audio / Visual Broadcasting
• Date of Decision May 4, 2023
• Outcome Motion Denied
• Case Number 2Pf.20.071/2023/5/I
• Region & Country Hungary, Europe and Central Asia
• Judicial Body Supreme (court of final appeal)
• Type of Law Civil Law
• Themes Artistic Expression, Defamation / Reputation
• Tags Honor and Reputation, Civil Defamation, Misinformation, Disinformation, Public Figures

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Case Analysis

Case summary and outcome.

The Budapest Court of Appeal in Hungary ruled that a political thriller film, based on real events, was sufficiently fictional that the depiction of a person in that film could not constitute an infringement of that person’s reputation. After the film was released and an accompanying communication was published by the film production company, a public official filed a complaint that the film’s depiction of a character closely resembling him was an infringement of his reputation. The lower court found that there had been an infringement and awarded damages. On appeal, the Court of Appeal emphasized that a reasonable viewer of a film would understand that it does not attempt to portray the true facts and so that the depiction of individuals would not be perceived as being factually accurate. The Court found the appeal of the film production company to be well-founded and set aside the lower court’s decision in its entirety.

In October 2021, a well-known Hungarian film producer released a film, Elkúrtuk (“We F*cked Up”), based on real events involving the circumstances and political background of the Budapest riots (mass protests and police excesses) in autumn 2006. On October 20, the production company published a press release, titled “Ministers, criminals and advisers – but which opposition politician is still active today?”, on its website, which listed the important characters – political, public or otherwise – who appeared in the film.

The head of a public opinion research company was one of the real-life characters in the film, and he was identified by name – Endre (the research company head’s first name) – and image in the press release. The research company head believed that the film producer had misrepresented him because, in the communication he was described as one of the characters in the movie who had played a significant role in the political decisions of the then-coalition government in the autumn of 2006 in relation to the riots and was personally present at the time of some important political decisions. The communication said that, as an opinion pollster and head of a well-known opinion and market research institute, he had manipulated polls to show that the support for the then-ruling coalition government was higher than it actually was, and that the support for the largest opposition party, Fidesz, was lower than it actually was. It also said that he was an important participant in the political decisions of the government and the parties of the then-ruling government coalition, and was personally present when decisions were made, and so was in constant contact with the minister without portfolio in charge of civilian intelligence services. The communication claimed that the research company head was involved in the leaking of the Balatonőszöd speech of then-Prime Minister Ferenc Gyurcsány, which caused a great political storm and ultimately led to the protests, and that he himself prepared the communications of the political response to the leaking. The production company’s communication added that the research company head had participated in taking the decision to use unlawful police violence on October 23, 2006.

The research company head submitted that the production company, by misrepresenting true facts, had violated Section 2:45 (2) of Act V of 2013 on the Civil Code. The section concerns “[a] violation of reputation means, in particular, if a person states or spreads untrue facts concerning another person and insulting that person, or misrepresents a true fact.”

The Metropolitan Court of Budapest, as the court of first instance, found that the film production company’s communication – going beyond the level of artistic representation – was not a criticism of the research company head’s public opinion research activities. It found that his role in 2006 was not conveyed to the press and the wider public as a fictional, possible (fictitious) storyline, but instead that the film was based on real events, and that the character in the film was the research company head. The Court found that the research company head was not linked to this character in the movie on any factual basis; there is no evidence that he had any contact with politicians, that he was involved in the decision-making process at the time, that he provided polling data during that period, or that he carried out polling activities used as a basis for political decisions. The Court held that the research company head was not obliged to tolerate this depiction and there was no public interest in the production company conveying a factually unfounded connection between the research company head and the character in the film to the public. Accordingly, the Court held that the company infringed the research company head’s right to reputation, and ordered the company to refrain from further infringement and to pay aggravated damages (compensation for injury to feelings) in the amount of HUF 1 500 000.

Both parties appealed against the first instance decision. In its appeal, the research company head sought an increase in the amount of the aggravated damages to HUF 2 000 000 and an order that the company, if any sequel or sequels of the film included the character concerned, must include a caption stating that the actions of the character did not depict the research company head’s actual actions. The company sought an alteration of the judgment of the court of first instance and the dismissal of the action.

Decision Overview

The Budapest Court of Appeal delivered the judgment. The central issue for the Court’s determination was how to the balance the rights to protection of reputation and to freedom of expression and artistic expression.

The Court stressed that the communication and the film had to be examined together, as the communication stated that the film “brings real people to life”. Accordingly, the Court examined whether the film itself infringed the research company head’s reputation because if it did not, then the communication’s identification of him with the character in the film (and so that character’s actions) could not be an infringement either.

The Court examined the Constitutional Court’s jurisprudence on the conflict of fundamental rights in Constitutional Court decisions 36/1994 (VI. 24.), 7/2014 (III. 7.) and 13/2014 (IV. 18.). It accepted that freedom of expression deserves special protection where the expression concerns a public matter, a public issue or a public figure, and so considered the primary issue to be whether that circumstance existed in the present case. The Court noted that the film “deals with real and unprecedented political and social events in Hungary’s recent history, in its own style, woven into its own fictional storyline. The movie thus deals with a public issue and is therefore legally considered to be an expression made through the means of art on public affairs”. [para. 63]

Having established that the film had a public nature, the Court assessed the research company head’s possible status as a public figure and the extent to which his personality rights could be restricted on this ground. It found that the research company head had undisputedly appeared in the media on several occasions as a public opinion researcher, both at the time of the events of the movie and during its production. He had reported on the support and popularity of certain political parties and politicians and interpreted and evaluated the data underlying this. At the time of the film, the public opinion research company had conducted public opinion research on behalf of the then-ruling government, for which the head had received remuneration – from public money. Accordingly, the Court accepted the parties’ agreement that the research company head was a public figure. [para. 64]

The Court examined the specific characteristics of the film. It referred to the interpretation in the Constitutional Court decision 24/1996 (VI. 25), on the constitutional content of the freedom of artistic creation: “as a fundamental right, it also means the freedom of artistic creation, the freedom of the artist to express himself without any unauthorised restrictions, and the freedom to make his works of art available to the public, and to display and distribute them. (…) [T]he essential content of the right to freedom of artistic expression is the right to perform creative artistic work free from any form of influence by authority and to express freely the opinions expressed through artistic creation, that is, the right to publish the works of art.” The Court noted that the Constitutional Court has ruled, in Constitutional Court decision 13/2000 (V. 12.), on the relationship between the constitutional rights of artistic freedom and freedom of expression, that “artistic expression and criticism (…) are part of the constitutional freedom of expression”.

In determining whether the communication constituted a statement of fact or a value judgment, the Court focused on the characteristics of the film serving as a form of representation and the way in which the communication can be interpreted by the receiving audience and the meaning it may have. The Constitutional Court had stressed that while value judgments can be limited only in the narrowest sense (i.e. in order to protect human dignity or respect for privacy), greater care is required in the context of statements of fact. The Court assessed the film through the eyes of the average viewer and found that since the film is a political action thriller which is primarily an artistic work for the entertainment of the cinema-going audience, the “average viewer is aware that the purpose and effect of feature films is not to repeat an event that has happened in the past realistically, to present it in a documentary style, to reveal facts not known to the public, but to entertain the viewer with a fictional story. It is obvious to the average informed viewer that films of this kind, when viewed on a cinema screen, television or other electronic device, do not reproduce real events through the actors’ performances, but are a visual and aural representation of the filmmakers’ imagination”. [para. 73] It added that, in terms of audience reception, the fact that the film is purportedly “based on the real events” of autumn 2006, does not change the perception of the film. It noted that the fictional character of the film can still be identified by the average viewer, and “the actions of the characters in the movie, which are portrayed as real persons, will not be treated as if they had actually happened in reality”. [para. 74] Accordingly, the Court held that the average viewer did not interpret the messages of the film as true reality, and so information in the movie could not be interpreted as statements of fact.

Accordingly, as statements made by the character similar to the research company head in the film did not constitute statements of fact, there could be no damage to his reputation. The Court found the production company’s appeal to be well-founded and dismissed the research company head’s claim in its entirety.

Decision Direction

Decision Direction indicates whether the decision expands or contracts expression based on an analysis of the case.

Expands Expression

The Court of Appeal affirmed the right of film producers to make films which fictionalize real events, and confirmed that audiences of these types of films are able to recognize the difference between true reality and fiction.

Global Perspective

Global Perspective demonstrates how the court’s decision was influenced by standards from one or many regions.

Table of Authorities

National standards, law or jurisprudence.

• Hung., Fundamental Law of Hungary, art. VI
• Hung., Fundamental Law of Hungary, art. IX
• Hung., Act V of 2013 on the Civil Code, sec. 2:44
• Hung., Act V of 2013 on the Civil Code, sec. 2:45
• Hung., Constitutional Court decision 3051/2022 (II. 11.)
• Hung., Constitutional Court decision 3107/2018. (IV. 9.)
• Hung., Constitutional Court decision 13/2014 (IV. 18.)
• Hung., Constitutional Court decision No. 7/2014 (III. 7.)
• Hung., Constitutional Court decision 13/2000 (V. 12.)
• Hung., Constitutional Court decision 24/1996 (VI. 25.)
• Hung., Constitutional Court decision 36/1994 (VI. 24.)

Case Significance

Case significance refers to how influential the case is and how its significance changes over time.

The decision establishes a binding or persuasive precedent within its jurisdiction.

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Our investment and economic outlook, May 2024

Red time: 14 minutes

“If the AI impact approaches that of electricity, our base case is that [productivity] growth will offset demographic pressures, producing an economic and financial future that exceeds consensus expectations,” Joe Davis, Vanguard global chief economist and the lead researcher, writes in this recent commentary .

The new research harnesses a uniquely long and rich dataset that captures historical shifts in megatrends that have driven about 60% of the change in per capita GDP growth. It finds that, among megatrends that also include demographics, fiscal deficits, and globalization, only technology has been a consistent, powerful driver of not only growth but also the Federal Reserve’s nominal target for short-term interest rates, inflation, and stock market valuations.

Notes: The chart breaks down three drivers of technology: augmentation, efficiency, and transformation. Augmentation refers to technological advances where humans benefit from machines, such as personal computers and power tools, raising productivity and trend employment. Efficiency refers to advances that raise GDP per worker, usually by automating away tasks previously performed by human labor. Transformation refers to GPTs that (eventually) unleash creative destruction through the economy. Our forthcoming research quantifies the prospects of AI transforming the economy in the years ahead.

Source: Vanguard calculations, as of May 2024.

Vanguard’s outlook for financial markets

Region-by-region outlook.

The views below are those of the global economics and markets team of Vanguard  Investment Strategy Group  as of May 15, 2024.

United States

Inflation isn’t yet on a sustainable path toward the Federal Reserve’s 2% target. The headline Consumer Price Index rose 3.4% year over year and 0.3% month over month in April. Core inflation, which excludes volatile food and energy prices, remained elevated, at 3.6% year over year and 0.3% month over month.

• Another closely watched indicator, retail sales volumes, changed little in April compared with March. The pace of sales matters, and Vanguard will watch this indicator closely. But we continue to believe the U.S. consumer remains resilient and will be a catalyst for growth, as this recent article discusses. 
• On top of a greater-than-expected rise in producer prices (0.5% month over month) in April, the data underscore our view that the Fed won’t likely be in position to cut its monetary policy interest rate target (currently, 5.25%–5.5%) this year.
• We recently increased our forecast for 2024 core Personal Consumption Expenditures (PCE) price index inflation from 2.6% to 2.9%. The PCE is the Fed’s preferred inflation measure to guide policymaking,
• We continue to foresee full-year 2024 economic growth slightly above trend around 2%.

Will the Bank of Canada (BOC) begin a rate-cutting cycle next month? The Consumer Price Index (CPI) for April, which Statistics Canada is set to release on May 21, could be key. We expect the BOC to cut its overnight rate target by 25 basis points on June 5, but a rate cut could be in jeopardy if the pace of inflation rises for a second consecutive month.

• As in the U.S., the “last mile” of inflation reduction could be the most challenging. We continue to foresee the year-over-year pace of core inflation falling by year-end into the BOC’s target range of 2%–2.5%. Shelter prices, up 6.5% year over year in March, remain an upside risk amid immigration-fueled population growth.
• We foresee the BOC trimming its overnight policy rate by 50 to 75 basis points this year, to a year-end range of 4.25%–4.5%. (A basis point is one-hundredth of a percentage point.)
• We recently increased our forecast of 2024 economic growth from about 1% to a range of 1.25%–1.5%. Still, restrictive monetary policy skews risks to the downside.
• We forecast a year-end unemployment rate of 6%–6.5% amid weak economic growth. It held steady at 6.1% in April.

Stronger growth momentum, higher energy prices, and a more hawkish outlook for the U.S. Federal Reserve have led us to raise our outlook for the European Central Bank (ECB) deposit facility rate at year-end. We’ve also increased our forecasts for full-year GDP growth and core inflation.

• We foresee three ECB quarter-point rate cuts this year, down from our previous outlook for five such cuts. That would leave the key monetary policy rate at 3.25% at year-end. We continue to anticipate the first rate cut occurring at the ECB’s June 6 meeting.
• We have nudged up our year-end 2024 core inflation forecast to 2.2% from 2.1%.
• We’ve increased our outlook for full-year economic growth to 0.8% from 0.6%.
• Unemployment remained steady at 6.5%, a record low, in March and likely will end 2024 around that level. However, we believe the labor market is softer than unemployment would suggest, as job vacancy rates have receded, labor hoarding remains elevated, and the number of hours worked has stagnated.

United Kingdom

Recent signals point to an uptick in economic activity and a firming of inflation persistence, leading Vanguard to increase its outlook for 2024 GDP growth, from 0.3% to 0.7%, and its outlook for year-end core inflation, from 2.6% to 2.8%.

• We continue to believe the Bank of England (BOE) will cut interest rates in August, but amid more hawkish global monetary policy developments we have dialed down our expectations for the depth of cuts this year. We anticipate a quarterly cadence of monetary policy easing, translating to two cuts in 2024 and four in 2025. That would bring the bank rate to 4.75% by year-end and 3.75% by year-end 2025.
• Our higher full-year GDP forecast reflects a first-quarter recovery, which occurred amid gradually rising real incomes, loosening financial conditions, and improved activity in the euro area. However, we expect full-year 2024 growth to be below trend due to headwinds from still-contractionary monetary and fiscal policy.
• As in the euro area, the labor market’s gradual loosening appears mainly driven by soft factors such as reduced vacancies and fewer hours worked, rather than an increase in unemployment. We foresee a year-end 2024 unemployment rate in a range of 4%–4.5%.

After a strong start to the year and with a four-month deflationary period apparently behind it, China’s economy seems on its way to 2024 GDP growth of “around 5%,” the target set at a Politburo meeting two months ago. However, given continued pressure on the property sector and weak consumer confidence, we remain cautious about the sustainability of growth momentum.

• Especially weak credit data make China’s economic challenges hard to ignore. Total social financing , the broadest indicator of China’s aggregate credit demand—including government bonds, bank loans, and even the shadow banking system—declined by 200 billion yuan (28 billion U.S. dollars) in April, the first negative reading since the indicator was first tracked in 2002. For the first four months of the year, total social financing is down by nearly 20% year over year.
• As part of efforts to stimulate the economy, the government on May 17 will hold the first sales of what is expected to be a 1 trillion yuan (138 billion U.S. dollars) issuance of special long-term treasury bonds. Similar bonds were issued during the 1997 Asian financial crisis, the 2008 global financial crisis, and the 2020 onset of COVID-19. The risk for structural imbalances remains, given policy priorities for investment and manufacturing upgrades over more direct measures to support consumer spending.
• We foresee full-year core inflation around 1% and full-year headline inflation of 0.8%—well below the 3% inflation target set by the People’s Bank of China (PBOC).
• To support the economy and given low levels of inflation, we expect the PBOC to ease its policy rate from 2.5% to 2.2% in 2024 and to cut banks’ reserve requirement ratios. However, we expect any easing in the near-term to be marginal. The Fed’s policy pause may limit room for the PBOC to ease meaningfully.

Sticky inflation continued in the first quarter, a development that the Reserve Bank of Australia (RBA) underscored in its May 7 monetary policy announcement. The RBA left its cash rate target unchanged at 4.35%, a more than 12-year-high level that has been in place for more than six months.

• We forecast that core inflation will fall to 3% on a year-over-year basis by year-end, still above the midpoint of the RBA’s 2%–3% target range. We foresee the RBA being one of the last central banks in developed markets to cut rates, doing so only in 2025.
• We expect the unemployment rate to rise to around 4.6% by year-end, as financial conditions tighten in an environment of elevated interest rates. It was 3.8% in March.
• Productivity has been slow to pick up, contributing to unit labor costs growing at a rate above what would be consistent with the RBA’s 2%–3% inflation target and prolonging the RBA’s path to eventual monetary policy easing.
• We continue to expect that Australia will avoid recession in 2024, with below-trend economic growth around 1%. GDP grew by 1.5% for all of 2023. Australia’s economy was last in recession in 1991.

Emerging markets

Sticky inflation and the path of U.S. policy rates have the attention of central bankers in Latin America’s leading economies. On May 8, Brazil’s central bank cut its key interest rate to 10.5%. Though a smaller cut than it had signaled at its previous policy meeting, it was the bank’s seventh consecutive rate reduction. One day later, Mexico’s central bank held rates steady, having initiated its first cut of the policy cycle a meeting earlier.

• While Banco de México (Banxico) maintained its 11% target for the overnight interbank rate, we have raised our outlook for Banxico’s year-end policy rate by 50 basis points to a range of 9.5%–10%, suggesting cuts of 100 to 150 basis points over the remainder of 2024. (A basis point is one-hundredth of a percentage point.)
• We’ve also modestly increased our forecast for year-end core inflation in Mexico to 3.7%–3.9%, largely in line with Banxico’s view.
• Amid continued strength in the U.S. economy, we recently upgraded our forecast of GDP growth in Mexico . U.S. demand for Mexican goods has remained strong, and domestic wages and consumption are holding up. We expect below-trend 2024 GDP growth of 1.75%–2.25%.
• We continue to forecast about 4% average 2024 GDP growth for emerging markets worldwide , led by growth of about 5% for emerging Asia. We anticipate growth of 2%–2.5% for emerging Europe and Latin America, though U.S. growth could have positive implications for Mexico and all of Latin America.
• All investing is subject to risk, including the possible loss of the money you invest.
• Investments in bonds are subject to interest rate, credit, and inflation risk.
• Investments in stocks and bonds issued by non-U.S. companies are subject to risks including country/regional risk and currency risk. These risks are especially high in emerging markets.

Global Chief Economist and Global Head, Investment Strategy Group

Mr. Davis is Vanguard's global chief economist and the global head of Vanguard Investment Strategy Group, whose research and client-facing team develops asset allocation strategies and conducts research on the capital markets, the global economy, and asset-allocation strategies. Mr. Davis also chairs the firm's Strategic Asset Allocation Committee for multi-asset-class investment solutions. As Vanguard's global chief economist, Mr. Davis is a member of the senior portfolio management team for Vanguard Fixed Income Group. Mr. Davis is a frequent keynote speaker, helped develop Vanguard Capital Markets Model and the firm's annual economic and capital markets outlook, has published white papers in leading academic and practitioner journals, and currently serves on the editorial board of the Journal of Portfolio Management . Mr. Davis earned his B.A. summa cum laude from Saint Joseph's University, his M.A. and Ph.D. in economics at Duke University, and is a graduate of the Advanced Management Program at the Wharton School at the University of Pennsylvania.

• Open access
• Published: 28 May 2024

Situational analysis of hypertension management at primary health care level in São Paulo, Brazil: population, healthcare professional and health system perspectives

• Marta S. Palmeirim 1 , 2 ,
• Yara C. Baxter 3 ,
• Mariana Silveira 4 ,
• Rafael V. Maggion 4 ,
• Beatriz Aquino 4 ,
• Álvaro Avezum 6 , 7 , 8 , 9 ,
• Jasmina Saric 1 , 2 ,
• Louise Morgan 10 ,
• Luciano F. Drager 5 , 11 ,
• Luiz A. Bortolotto 11 , 12 ,
• Suely Miya S. Rollemberg 13 ,
• Marcia M. C. de Lima 13 ,
• Edmir P. R. Albuquerque 13 ,
• Olivia Jones 10 ,
• Peter Steinmann 1 , 2 ,
• Theresa Reiker 3 &
• Johannes Boch 3  

BMC Health Services Research volume  24 , Article number:  668 ( 2024 ) Cite this article

186 Accesses

Metrics details

Government-led, population-wide initiatives are crucial for advancing the management of hypertension − a leading cause of cardiovascular disease (CVD) morbidity and mortality. An urban population health initiative was conducted against this backdrop, focussing on hypertension in the primary health system in São Paulo, Brazil. Within the frame of the initiative and under the supervision and leadership of the municipal health authorities, a situational analysis was conducted on the needs in hypertension management, marking the first phase of a Design Thinking process. This article describes the situational analysis process and presents the identified elements to be strengthened considering hypertension diagnosis, treatment and control.

First, a mixed-methods approach was used, starting with a literature review of municipal hypertension data followed by meetings ( N  = 20) with the local public health administration to assess health system level components. To investigate activities on hypertension diagnosis, treatment and control, nine primary healthcare units were selected from two districts of São Paulo city– Itaquera and Penha– which received an online form addressed to managers, participated in conversation circles of staff and patients, and underwent shadowing of community health agents.

Data gave rise to two main outputs: (i) a patient care journey map; and (ii) a matrix summarizing the identified needs at patient, healthcare professional and health system level for diagnosis, treatment and control of hypertension. Patient awareness and knowledge of hypertension was found to be insufficient and its management needs to be improved. For health professionals, disease awareness, technical training, more time dedicated to patients, and simplified guidelines and clinical decision-making tools for hypertension management were identified as principal needs. The situational analysis found that the healthcare systems efficiency might be improved by establishing defined treatment and care delivery goals with a focus on outcomes and implemented through action plans.

Conclusions

This situational analysis identified several needs related to hypertension control in São Paulo that are in line with global challenges to improve the control of CVD risk factors. Findings were also confirmed locally in an expansion phase of this situational analysis to additional primary care facilities. As a consequence, solutions were designed, promptly taken up and implemented by the municipal health secretariat.

Peer Review reports

Hypertension is the leading cause of death globally. The condition affects about 1.4 billion adults and is the main risk factor for cardiovascular diseases (CVD) [ 1 , 2 ]. The management of hypertension improves cardiovascular population health, reduces early mortality and avoidable hospitalizations [ 2 , 3 , 4 ]. 70% of people with hypertension live in low- and middle-income countries, where health systems are largely focused on the delivery of services for acute healthcare needs, as opposed to managing chronic conditions amenable to prevention. The latter requires long-term sustained engagement and interaction between patients, healthcare professionals and the health system to efficiently manage conditions [ 5 ], improvement in event-free survival along with better quality of life, and medical cost reduction. To achieve these goals, the identification of specific barriers and needs related to effective hypertension control is required to develop targeted interventions and spark the necessary transformation of health systems and their services delivery models [ 6 ].

Like many other countries across the globe, Brazil has undergone a major shift in its epidemiological profile; burdened historically by infectious diseases, the country’s main public health challenges today stem from non-communicable diseases (NCDs) [ 7 ]. The increase of NCDs observed in Brazil and elsewhere was precipitated by an increasingly sedentary lifestyle and changing eating habits, leading to a high prevalence of obesity and other CVD risk factors [ 2 , 8 ]. In 2016, CVDs were the leading cause of morbidity and mortality [ 9 ]. A recent study exploring hypertension prevalence in different South American countries found a 53% prevalence among 5,557 Brazilians aged 35 to 70 years from both rural and urban settings [ 10 ]. Investing in corrective and preventive behavioural approaches in the face of ever-increasing treatment expenses has become a priority for the government [ 11 , 12 ]. Studies have shown that the Brazilian primary health system should be strengthened in the area of disease management pathways (including for NCDs) with a people centred perspective [ 13 ].

The challenges of NCDs, as in other parts of the world, also impact São Paulo city, Brazil’s most populated city, despite the constant efforts of local health authorities to reduce their prevalence and burden [ 14 , 15 ]. In São Paulo, the prevalence of hypertension in the adult population has been estimated to be 23.2% in a telephone-based survey [ 16 ]. However, the same survey found large variability in prevalence within the adult population; in people aged 50 to 69 years of age, the prevalence of hypertension varied from 34.5 to 51.3%. In São Paulo city, half of the population depends on Brazil’s unified public health system (Sistema Único de Saúde; SUS), which, among other services, provides universal coverage and access to free medication [ 17 ]. Through different initiatives and reforms, the public health program for São Paulo focuses on the reduction of mortality due to NCDs and includes hypertension management. Prominent examples are the NCD Strategic Action Plan to which São Paulo state adhered to, the tobacco control laws, salt reduction policies and public sport facility programs, which all have relevance for municipal planning of priorities [ 18 , 19 ]. A study from 2011, investigating care pathways of already diagnosed hypertensive patients in the public health care sector of São Paulo, documented a treatment adherence level of 20% [ 20 ] and that 35–50% of patients treated for hypertension had their blood pressure controlled [ 20 , 21 ]. These findings reveal opportunities to increase treatment adherence, quality of care, access to medicines, patient follow-up and care coordination [ 14 ].

The initiative Better Hearts Better Cities (entitled “Cuidando de Todos” in Brazil), applying the CARDIO (Care, Access, policy Reform, Data and digital, Intersectoral collaboration and local Ownership) approach [ 22 ], was designed as a multidisciplinary, multisector initiative to support local authorities in addressing urban cardiovascular population health, including hypertension as primary risk factor. The initiative was implemented in Ulaanbaatar, Mongolia; Dakar, Senegal; and São Paulo, Brazil. In Brazil, the initiative was executed in collaboration with the São Paulo Municipal Health Secretariat (Secretaria Municipal de Saúde; SMS-SP). This partnership aimed at co-creating and accelerating the implementation of a model to approach NCDs. The implementation methodology was guided by a Design Thinking approach [ 23 ]. The current article details the diagnosis step of the methodology, which focused on assessing the primary needs in the public health system in São Paulo. The identified needs of patients, healthcare professionals and the health system with respect to hypertension diagnosis, treatment and control will be presented.

São Paulo city is one of the five most populous metropolis in the American continent and the largest financial and corporate centre in Latin America [ 24 ]. São Paulo was recently included in the “Global Cities of the Future 2021/2022”, occupying the fourth place of the ten “Megacities of the Future” with the best strategies for attracting foreign direct investment [ 25 ]. With more than 12 million inhabitants on 1,521 km 2 [ 26 ], São Paulo was selected for the implementation of Better Hearts Better Cities. Reasons include the range of opportunities to improve hypertension and CV risk factor control, São Paulo’s urban characteristics such as the close co-existence of high-, low- and middle-income features, the developed health system (SUS) and the complexity of urban management, especially in health [ 27 ]. After agreeing to jointly execute the initiative, the SMS-SP selected the districts of Itaquera and Penha to host the first implementation.

Conceptual approach to problem identification

In São Paulo, the initiative was implemented between 2018 and 2020 in the stages of groundwork, diagnosis, exploration, co-creation, implementation and scale-up. This initiative followed a Design Thinking process [ 23 ], using the double diamond approach [ 28 ]. Besides factual roadblocks and concrete challenges, the Design Thinking process also considers latent needs of the health system. These needs may be abstract and emotional and, as such, can be difficult to express or to recognize in traditional needs assessments [ 29 ]. To address this, Design Thinking focuses on the analysis of the end-user and beneficiary perspective in a clarification step (here referred to as situational analysis). Information collected in this step through interviews and shadowing is essential to frame key issues correctly, identify opportunities for improvement and ideate adequate solutions [ 30 ], which can be subsequently implemented in partnership with the local health authorities. This situational analysis and its results of the health care ecosystem’s needs for patients, healthcare professionals and the system itself are described in the current manuscript. The process used to conduct this situational analysis is aligned with the recommendations of the World Health Organization (WHO) HEARTS package [ 31 ] and the World Heart Federation [ 6 ].

Primary health care structure in São Paulo

The situational analysis took place in 2018 in the district of Itaquera and in 2020 in the district of Penha. These districts were selected due to their representativeness of low- and middle-income communities. Additionally, primary healthcare units (Unidades Básica de Saúde; UBS) with different health system management models are present in these districts; the primary health care network of São Paulo is composed of 450 UBSs (traditional model) [ 32 ] and 117 outpatient medical care centres (Assistência Médica Ambulatorial; AMA) [ 33 ], of which 87 are integrated with a UBS [ 34 ]. The UBS network is staffed by different types of primary care teams (Equipes de Atenção Básica; EAB), including those organized according to the family health strategy (Estratégia Saúde da Família; ESF), a Brazilian management model of primary care delivery [ 35 ]. In Brazil, the organization, management and execution of services and activities of primary health care is the responsibility of the municipality. In São Paulo, health facilities can be directly managed by the SMS-SP (direct administration) [ 36 , 37 ] or, alternatively, the management can be delegated to social organizations (e.g. cooperatives), private companies, non-governmental or philanthropic organizations [ 38 ]. Table  1 depicts the characteristics related to primary care infrastructure in Itaquera, Penha and São Paulo city as a whole.

Situational analysis procedures

The situational analysis was conducted by a team composed of members of the Novartis Foundation (global initiative coordinator), the Instituto Tellus (local implementation partner), the São Paulo Society of Cardiology (Sociedade de Cardiologia da Cidade de São Paulo; SOCESP), as well as members of the SMS-SP. The municipal authorities approved the initiative and its strategy, and took ownership for the execution, facilitated communication with internal stakeholders, helped establish a first technical working group and identified the first implementation districts. The SMS-SP assigned the initiative to the chronic diseases and NCD care (Doenças e Agravos Não Transmissíveis; DANT) technical department. This department was created in 2018 to elaborate a municipal care protocol for NCDs and harmonize the use of different national and international guidelines by physicians in the public health system of São Paulo. Thus, the initiative fully supported the priorities of the SMS-SP.

With this governance established, the team started the first part of the situational analysis by addressing health system components with a focus on primary care delivery. The investigation was conducted at the SMS-SP, in order to understand health system building blocks, such as governance, importance of and priority given to primary care, currently available resources and gaps, data management priorities and available information management systems, current guidelines, their application, and the policy landscape. Special consideration was on other programs related to hypertension in Brazil, and recent initiatives to address other chronic diseases such as diabetes. To complement this information, the team conducted a review of the available literature and municipal data concerning CVDs for São Paulo.

Secondly, continuous follow-up discussions with the NCD technical department at the SMS-SP supported the contextualisation of the findings from the first part of the analysis. Inter-disciplinary workshops with relevant partners (e.g. SMS-SP, public officials representing primary care and/or NCD management, district health care delivery, medical societies, global initiative coordinator, local implementation partner, international scientific partners) were conducted to further deepen the understanding of the health system concerning diagnosis, treatment and control of hypertension. The discussions clarified the relation of municipal strategy to operational execution in the UBS in terms of technical decisions, perception and execution of best practices.

Finally, a total of nine UBS (six in the district of Itaquera and three in the district of Penha) were selected by the SMS-SP to be included in this situational analysis and undergo a thorough investigation using several data collection tools.

Data collection approaches and tools

To gain deep knowledge and understanding of the entirety of the health system, a mixed-methods approach based on the Design Thinking process [ 23 , 39 ] and the AEIOU framework (Activities, Environments, Interactions, Objects, and Users) was pursued [ 40 ]. In addition to the use of these frameworks, to gain a complete understanding of the conditions and potential for interaction with the population in and beyond the health system, other than primary health care unit workers, the team also included relevant focal points within the district, such as community champions (e.g. samba and football club, spiritual leaders) and reference points (e.g. shopping mall, high traffic venues, green areas). Table  2 presents the type of information collected from the different stakeholder groups to help pinpoint unmet needs at primary care level. This was executed using three tools targeting different respondents based on their role in the health system:

An online form consisting of open- and closed-ended questions was applied to collect data for an initial diagnosis of the needs in each UBS (Supplementary files 1 and 2 ; one for Itaquera and one for Penha). An online version of the online form was sent to the UBS managers who were invited to complete it. The online form covered, among other topics, physical and personnel structure of the UBS, use of digital technology, data collection and recording tools and service time of each professional. Additionally, there were a few questions, targeting the work conducted by the community health agents (CHAs), regarding their knowledge around hypertension, their degree of patient engagement, their knowledge on use of medication, and their practice in encouraging healthy lifestyle behaviour. Between the implementation of the online form in Itaquera and Penha, it underwent some adaptations and fine-tuning based on the experience in Itaquera; hence, there were two versions of the online form (Supplementary files 1 and 2 ).

Conversation circles ( n  = 43) were carried out with UBS staff and patients in the UBS offices. For each respondent category, a specific conversation guide with lead questions was available. The goal was to, in each UBS, include one person from each of the following categories: (i) patient; (ii) doctor; (iii) nurse; (iv) community health agent; (v) pharmacist; (vi) admission officer; (vii) UBS manager, and (viii) school health programme manager. Participants were from the same district and selected by the UBS. Additionally, the situational analysis team included experts in the area of cardiovascular health, population health and health systems, among which were directors of medical societies such as SOCESP, NCDs forum [ 41 ] and representatives of the Brazilian Ministry of Health.

Shadowing was conducted by members of the implementation team who observed two CHAs from one selected UBS throughout their day of work [ 40 ]. The main goal of this approach was to understand the relationship between CHAs and hypertensive patients. Additionally, CHAs were asked about their beliefs, attitudes and perception of hypertension, as well as about their observations and perceptions on the population’s diet and physical activity in the context of the disease cluster. Observations and responses were recorded using a standard data collection form (Supplementary file 3 ).

Data analysis

The information gathered by the implementation team using online forms, conversation circles, shadowing activities and government workshops, was compiled, tabulated and systematized by Instituto Tellus. This provided a first assessment of the existing needs, which resulted in two main outputs. The first was a patient care journey map, investigating the interactions between patients and the primary care team and mapping challenges and opportunities. This map served as an interactive and iterative tool during data collection, allowing for the visualization of details of the system through which patients with hypertension navigate and, therefore, helped clarify needs and bottlenecks present at different stages of the patient’s journey. The second main output was a matrix presenting the identified needs presented along three major components (i.e. patients, healthcare professionals and health system) for the diagnosis, treatment and control stages of hypertensive patients.

The gaps identified during this step were taken up in the co-creation sessions with the city health authorities, members of the American Heart Association (AHA), SOCESP and other primary care practitioners for refinement and to brainstorm for solutions. This process has been described in detail elsewhere [ 23 ]. All results were discussed and validated by the SMS-SP, which confirmed the adequateness and provided further input.

All nine UBS managers who were asked to respond to the online form returned it and all 30 people who were planned to include in conversation circles attended.

The nine pilot UBSs were representative of the different UBS administrative models of the Municipality of São Paulo: two traditional UBS, four AMA integrated with a UBSs, and three UBSs with ESF. Of these, one of the traditional UBS was under direct administration and the remaining eight were managed by a social organization. These UBSs served between 12’000 and 39’964 people. The operational models, management types, number of people and adults covered and years in operation for each of the nine UBSs are presented in Table  3 . The newest UBS had been in operation for 10 years, whereas the oldest had been established 45 years ago. In terms of data collection systems, all UBS used SIGA Saúde (Sistema Integrado de Gestão de Assistência à Saúde de São Paulo) for the registration of patients’ appointments and to record basic data, and Gestão de Sistemas de Saúde (GSS; Health system Management), which is the medicines logistics system. It was also found that all nine UBSs had an integrated pharmacy.

The analysis of the results from the nine pilot UBSs revealed that, to improve the quality of the data collected, the online form needed to be revised. Questions that were found to not bring relevant insights were removed, (e.g. “how many functioning printers does your UBS have?”), while additional questions were introduced to fill data gaps noticed.

Patient care journey map

The results from the online forms, conversation circles and shadowing of CHAs were consolidated and mapped out in the patient care journey map (Supplementary file 4 : Figure 1), which catalogues the structure of the observations of primary needs along a timeline. The starting point of each overlapping journey was a research-based fictional persona that represented a particular group (i.e. patient, community health agent, doctor, pharmacist, nurse) [ 42 ]. Each persona’s journey started with a short description of the official requirements from the Brazilian comprehensive health and nutrition promotion practices in primary healthcare (Práticas Integrais de Promoção da Saúde e Nutrição na Atenção Básica; PINAB). The journey also showed explicit and latent needs. By visually exposing the information collected, the team was able to trigger discussions among health managers, clinical team members and health authorities and to understand whether the results obtained by the implementation team corresponded to the actual needs experienced by healthcare professionals and managers. This map helped identify several opportunities on how to improve the patients’ experience. Those participating in the exercise reported that it was the first time this complex system of interactions was depicted in a visual way and was, thus, insightful to gain oversight of paint points, process overlaps and opportunities to optimize team work.

Main needs and barriers identified

The mapped barriers for the different CVD management stages (i.e. diagnosis, treatment and control) for patients, healthcare professionals and the health system resulting from the pilot phase are presented in Table  4 . Conversation circles found, for instance, that the patients’ knowledge and awareness of the importance of hypertension risks and of regularly measuring blood pressure was poor, particularly in men and young people. According to patients, these issues, coupled with a poor understanding of the treatment and problems in the health system such as insufficient staff, in turn, according to health professionals, led to low adherence to treatment. From the patient perspective, for successful control of their blood pressure, they needed a stronger bond and a good relationship with the health staff to increase their engagement.

From the perspective of healthcare professionals, there was a lack of training, and the quality in medical record entries required attention. Concerning treatment, healthcare professionals felt that the training of CHAs on the topic of NCDs, the motivation provided to patients and the quality of guidelines needs to improve. As an example, hypertension was diagnosed following the 7th Brazilian guideline [ 43 ], but the situation analysis revealed that due to the complexity of the guideline, those best-practices are only partially applied. Concerning the control of hypertension, the presented findings showed that healthcare professionals needed more time with patients to explain treatment in detail, but also highlighted some of the inefficiencies in the health system that would need to be resolved.

Concerning the health system, a perception that 15-minute appointments were too short and that this negatively impacted both the diagnosis and treatment steps was mentioned by both health professionals and patients. Finally, the system also lacked clear goals and action plans when it came to diagnosis, treatment, and control (i.e. follow-up of patients).

For each of the needs and barriers identified for patients, health professionals and the health system (Table  4 ), brainstorming sessions led to the outlining of prototype solutions. These prototype solutions later underwent a selection phase and were developed into the solutions that were implemented; these final solutions are presented in a second publication in this series of publications on the Better Hearts Better Cities initiative in Brazil.

The situational analysis and its findings were the first steppingstone of the Design Thinking process used in the urban population health initiative, Better Hearts Better Cities, in São Paulo city. The data captured on health system components and different stakeholders, such as patients, healthcare professionals, managers and decision-makers, has led to the identification of several needs relating to the diagnosis, treatment and control of hypertension in low- and middle-income settings. Findings were used as a basis for the design of specific interventions targeting the identified needs, which were subsequently taken up and implemented.

The analysis showed that the patient’s perspective encompassed elements connected to disease awareness (specifically regarding men and youth), self-care (including no standard possibility to track disease status, low adherence, missing follow-up medical appointments, and low motivation), difficulties of patients to engage in the care process, build an emotional connection to primary care teams, and lack of consistent early detection and standards of care. For healthcare professionals, needs in optimizing and clarifying guideline-based care, treatment and follow-up, improving information management (e.g. quality of medical record and completeness of documentation), enhancing standard continuous training programs on disease and treatment, and reinforcing team-based care were identified. From the health system perspective, potential was seen to define structured processes to upgrade efficiency, and establish defined treatment and care delivery goals with a focus on outcomes, action plans and applicable guidelines and tools on diagnosis, treatment and control. All the findings of this situational analysis were later confirmed during an expansion phase of the same methodology implemented in another 18 UBS in Itaquera and 18 UBS in Penha. Additionally, the results of this analysis are in line with roadblocks identified by entities such as the World Heart Federation [ 6 ] or the Organisation for Economic Co-operation and Development [ 44 ]. Hence, it is assumed that the identified challenges including primary care management, patient pathway/journey, and workforce up-skilling are transferable to other geographies and health systems.

To our knowledge, this work is the first that displays the health system in São Paulo or even Brazil, its team structures, responsibilities, and needs on a comprehensive patient journey map. This situational analysis found that, although aware of the complexity of the health system, the visualization of the journey map gave health system managers and healthcare professionals a new perspective on the system that they navigate daily. This provided valuable insights for discussion of opportunities and challenges to address latent and explicit needs, process optimization and task-shifting.

In the context of this urban population health initiative, we evaluated the existing gaps in the healthcare system by engaging with health professionals and patients. This situational analysis provided valuable insights that directly fed into the design of specific interventions and further informed the CARDIO4Cities approach. The CARDIO4Cities approach, which stands for Care, Access, Policy Reform, Data and Digital, Intersectoral Collaboration, and Local Ownership, as described by Aerts and Boufford [ 22 ], was developed based on these insights. This comprehensive situational analysis aided in identifying the specific needs and opportunities within the healthcare system, enabling the development of targeted interventions. The implementation of the CARDIO4Cities approach in São Paulo, guided by the São Paulo health authorities, has been proven to be impactful [ 45 , 46 ]. We believe that a precise understanding of the situation and the healthcare system’s needs is crucial for devising tailored strategies to improve cardiovascular health. During the diagnostic phase, the information gathered through this situational analysis was used to co-create a total of 14 solutions in collaboration with various stakeholders. The objective of these solutions was to reform hypertension management, optimize healthcare delivery, and increase cardiovascular population health.

This process described in the paper showed that despite being resource-intensive due to the assessment being embedded in the primary care context and its daily operation, the methodology led to findings that were perceived to be focused on core needs of the beneficiaries, namely the patients, healthcare professionals, managers and decision-makers and as such were meaningful, endorsed and accepted as appropriate. The findings allowed for the development of sustainable interventions, enabling local stakeholders to feel fully involved and empowered in the whole process. This focus on actual needs is a major strength of the approach, which was reinforced by the bottom-up analysis of the situation. Another strength is that this initiative was able to bring together all types of stakeholders in a participatory and inclusive manner making sure all voices were heard. Finally, the careful selection of the pilot UBSs, whereby every administration model was represented, was of great importance.

Limitations of this work include that the first version of the online form was too complex for respondents and, therefore, it needed to be adapted. Consequently, the composition of questions asked to UBS managers slightly differed between the two districts. Moreover, the team realized, at the start of the project, that some stakeholders felt they might be judged by what they mentioned, feeling observed and showing some discomfort when it came to sharing any bottlenecks in the system. This hesitancy was, most likely, a result of previous negative experiences where the same stakeholders participated in projects without ever seeing any outcomes or benefits. Thus, it was fundamental to clarify that the aim was to build a partnership offering a safe space to share any issues, in a constructive manner. Finally, it was not always easy to obtain consistent data on CVDs from the different stakeholders as there were several sources to collect the data from. Lastly, the rapid staff turnover at the SMS-SP was, at times, limiting the efficacious progress of the analysis.

Despite all the efforts the SMS-SP has put into reducing the burden of hypertension in São Paulo city, its prevalence remains high and its control remains low. This situational analysis, conducted in close collaboration with SMS-SP, allowed the Better Hearts Better Cities initiative to apply an innovative methodology to identify opportunities for improvement within the health system and established an operational baseline for boosting the diagnosis, treatment, and control of patients with hypertension living in low- and middle-income settings of São Paulo city. In doing so, it laid the foundation for the design of solutions and successful roll-out and expansion of the project. Based on the experience and results from both the pilot and expansion phases, the team recommends the use of this methodology in future studies that aim at identifying needs within a health system based on a well-defined focal area. Employing bottom-up, collaborative, inclusive and needs-focused approaches drives change management, reinforces sustainability and up-take of solutions in the implementation phase.

Data availability

The datasets used and/or analysed during the situational analysis are available from the corresponding author on reasonable request.

Abbreviations

Activities, Environments, Interactions, Objects, and Users

American Heart Association

Assistência Médica Ambulatorial (outpatient medical care centres)

Blood Pressure

Community Health Agents

Conselho Federal de Farmácia (federal pharmacy council)

Conselho Regional de Farmácia (regional pharmacy council)

Coordenadoria Geral de Saúde (regional health coordinator)

Cardiovascular Disease

Equipes de Atenção Básica (primary care teams)

Estratégia Saúde da Família (family health strategy)

Gestão de Sistemas de Saúde (health system management)

Inquérito de Saúde (health survey)

Núcleo Ampliado de Saúde da Família (expanded family health center)

Non-communicable Diseases

Non-governmental Organization

Organização Social de Sáude (health social organization)

Práticas Integrais de Promoção da Saúde e Nutrição na Atenção Básica (comprehensive health and nutrition promotion practices in primary healthcare)

Plano Municipal de Educação Permanente (municipal permanent education plan)

Sistema Integrado de Gestão de Assistência (integrated assistance management system)

Secretaria Municipal de Saúde (municipal health secretariat)

Sociedade de Cardiologia do Estado de São Paulo

Supervisão Técnica de Saúde (technical health supervision)

Sistema Único de Saúde (public health system)

Secretaria de Vigilância em Saúde/Ministério da Saúde (health surveillance secretariat/ministry of health)

Unidade Básica de Saúde (primary healthcare units)

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Acknowledgements

We specifically thank the municipal authorities from São Paulo, Brazil, for leading and owning this initiative; all healthcare professionals, managers, nurses, doctors, community agents and other healthcare professionals who participated in the initiatives co-creation and roll out; and all patients who participated in the implementation. We are grateful to the UMANE Foundation for the strategic partnership and co-funding as well as all local partners and stakeholders who contributed to the initiative, with a special thanks to the teams of the Instituto Tellus and IQVIA in Brazil. We would like to acknowledge Ariane Abreu for her support reviewing the manuscript.

The Better Hearts Better Cities initiative and the presented paper are funded by the Novartis Foundation. Novartis Foundation contributed to the design of the situational analysis and the collection and interpretation of data and in writing of the manuscript.

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Marta S. Palmeirim, Jasmina Saric & Peter Steinmann

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Yara C. Baxter, Theresa Reiker & Johannes Boch

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Hospital Alemão Oswaldo Cruz, São Paulo, Brazil

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World Heart Federation, Geneva, Switzerland

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Contributions

MSP, JB, MS and YCB conceived and planned the manuscript, collected and analyzed the data. MSP, JS, PS, AA, LFD, LAB, SMSR, MMCL, EPRA, RVM, BA, MS, LM, OJ, TR, JB, YCB contributed to interpreting the results and writing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Marta S. Palmeirim .

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Competing interests.

The Novartis Foundation funded the Better Hearts Better Cities initiative and the current manuscript. The American Heart Association is funded by the Novartis Foundation to provide technical assistance and resources to support professional education, quality improvement, monitoring, and evaluation. The views expressed in this manuscript are those of the authors and do not represent the views of the American Heart Association. The Swiss Tropical and Public Health Institute, the Sociedade de Cardiologia do Estado de São Paulo (SOCESP), the Instituto Tellus and IQVIA receive funding from the Novartis Foundation to contribute to the implementation and/or evaluation of the Better Hearts Better Cities initiative. None of the authors has declared any additional conflict of interest.

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Local approval agreements for data collection within the Better Hearts Better Cities initiative has been obtained from the Municipal Health Secretariat of São Paulo (CEP-SMS; 5.311.415). Consent was obtained from all study participants.

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Supplementary Material 1: Questionnaire used in the district of Itaquera.

Supplementary material 2: questionnaire used in the district of penha., supplementary material 3: shadowing of community health agent (cha) form., 12913_2024_10978_moesm4_esm.tif.

Supplementary Material 4: Figure 1. Patient care journey map with personas representing patients, community health agents, doctors, pharmacists and nurses. BP, blood pressure; CHA, community health agent; CFF, Conselho Federal de Farmácia (federal pharmacy council); CRF, Conselho Regional de Farmácia (regional pharmacy council); ISA, Inquérito de Saúde (health survey); PINAB, Práticas Integrais de Promoção da Saúde e Nutrição na Atenção Básica (comprehensive health and nutrition promotion practices in primary healthcare); SIGA, Sistema Integrado de Gestão de Assistência (integrated assistance management system); SO, health social organization; SVS/MS, Secretaria de Vigilância em Saúde/Ministério da Saúde (health surveillance secretariat/ministry of health); UBS, unidade básica de saúde (primary healthcare unit).

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Palmeirim, M.S., Baxter, Y.C., Silveira, M. et al. Situational analysis of hypertension management at primary health care level in São Paulo, Brazil: population, healthcare professional and health system perspectives. BMC Health Serv Res 24 , 668 (2024). https://doi.org/10.1186/s12913-024-10978-1

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Published : 28 May 2024

DOI : https://doi.org/10.1186/s12913-024-10978-1

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• Publications Podiatry Today Today's Wound Clinic Wound Management & Prevention Wounds

Research Perspectives on Quality of Life in Wound Care Patients

Featuring Caroline Fife, MD, and Marissa Carter, PhD

Welcome to Speaking of Wounds, a podcast by the Wound Care Learning Network. I'm Dr. Jennifer Spector, the Assistant Editorial Director for WoundSource, and we're happy to have you listening today.

Just as a reminder, this podcast is intended as an informational tool for medical professionals and is not intended to diagnose or treat any medical conditions, nor does it guarantee payment or reimbursement for any services rendered. I'll let our guests introduce themselves shortly, but we're so excited to have both of them with us today to speak on their expertise surrounding research perspectives on quality of life in wound care. The Wound Care Learning Network had the privilege of meeting with them during the Symposium on Advanced Wound Care Spring session in Orlando, Florida, and we're so excited to present this episode to you today.

I'm Dr. Caroline Fife. I'm the Clinical Editor of Today's Wound Clinic and a long-time wound care practitioner.

I'm Dr. Marissa Carter. I'm a health economic specialist and a clinical trial design specialist and a biostatistician, and I also and work for the WCCC.

So one of the things that I've been wanting to talk about is the research that we did looking at the numerous medical problems that patients with chronic wounds and ulcers have. And this came out of a project that I did in which I was trying to get a quality measure approved by CMS, briefly, managed to do that, to look at the quality of life of patients with chronic wounds and ulcers. And so we used the Wound QOL and gave it on a tablet to hundreds of patients and discovered that there was no relationship between their quality of life score and whether their wound healed. And so I contacted you to say, I think I have an idea about why this is not working.

And my concept was that it was because the patients had so many other problems. And then you took it from there, as you often do, a very elegant analysis of what the real barrier to measuring quality of life in relation to wound care is. So what we did, and Caroline's idea was a good one, and that is, we're asking the question, why are patients so sick? So let's establish the fact, how are patients sick? How do we measure it? And so we looked at two different ways.

The first thing was comorbidities. We did a massive look at all the comorbidities that each patient has. We divved them all up, categorized them, and so forth. Then we used a very novel different way of looking at patients' quality of life in terms of their comorbidities using what we call utility, where that's the scale of 0 to 1, where 0 is dead and 1 is perfect health. And we looked at each patient. We did some serious mathematical transformations. And we discovered something very interesting. And that is, when we looked at each patient's score, we found their utility numbers were pretty low. And why are they low? Because they have such awful things that are wrong with them. A lot of them have -- They're paralyzed.  They're in heart failure. They're immobile, they (have) anxiety. They're depressed. They have serious chronic heart failure and lots of other diseases. So their middle of the road score tells us that quality of life really is bad.

It's very low in the absence of a wound. And we finally, we validated our mathematical approach to this quality of life establishment using very specific EQ5D5L stories and data from several different countries. And lo and behold, our measurement approach and the numbers that came from those 12, 13 studies, are almost the same.

So one of the things that's hard for me is, you know, I'm a simple girl. I looked at these several hundred patients, the comorbid conditions they had, and I said, wow, they look really sick. And then you put numbers to that.

And the concept of utility score does not mean anything to me as a clinician. I confess that it's not a concept that seems important or logical to the average practicing clinician, although maybe I'm bringing the marks down of the average clinician because I struggle so much with it. So I'm going to rephrase in simple language what I think you said, which is that if you look at the severity of underlying conditions and just understand how much those affect a person's life and life expectancy, The underlying medical conditions that most people with chronic wounds had were worse than the wound itself.

And as a result, the incremental suffering caused by the wound turned out to be less important than we originally thought. The icing on the cake was, we see in so many studies that wound quality of life, whatever the instrument, doesn't change with healing. Healing a wound in the great scheme of things for most of our very sick patients is a small thing. It doesn't move the needle and that was a long-held suspicion I'd had and it was a hypothesis and in a sense we have started to prove that as true. 

I think maybe that's overstating. Every patient wants to be healed and when we ask patients what they want of their wound care, they will say, to be healed. But the fact is, many of the quality of life instruments ask questions like, how does this impact you walking upstairs? Well, (they say) I could never walk upstairs. How does this impact your ability to be mobile? Well, (they say) I'm not mobile. How does this impact your ability to go on vacation and enjoy your free time? Well, (they say) I can't do that either. So It becomes challenging to measure a piece of quality of life that's impacted, which means we're not asking the right questions.

So we may need to ask them questions about their out-of-pocket expenses or social embarrassment or the time factor in changing a dressing, but the big picture things in quality of life are so impacted by their breathlessness and their immobility and their other challenges that - the wound is less of a contributor. - So the answer to why are our patients so sick? It's because they have such a breadth of such very serious problems in their life. - Which is why they have a wound that doesn't heal.

Right, it's a circular thing in a sense. It's not always about their wounds. It's about the context of understanding the patients, how sick they are, and the wound is really just a small compartment in that entire problem.

So I think that's another thing. Clinicians will often say, oh, but my wound center is special because our patients are so sick, you just don't understand. And the answer I feel is, yes, they're all sick. All of our patients are like this. You're not special, but it is true. And this is a big problem from a survival standpoint in terms of running a clinic.

When the hospital administration wants you to get a patient in and out of a room in 15 or 20 minutes. And the patients are immobile, they need three people to assist them. That's not the problem of the wound.

That's just the fact that they're very frail, very compromised people. So I think we're going to have to have a new reality check on what it's like to care for these patients because it's not at all a simple thing. Yes, absolutely.

And it extends into so many areas. We run randomized controlled trials whose populations look nothing like these people we've been talking about. So how can you generalize some of those trials to the people we're talking about? And I think the result is that the FDA and CMS and other payers have no idea what a real patient looks like because they see these clinical trials of superficial singular wounds and the average patient has more than one wound, which by the way is the other reason that I forgot to mention why the quality of life factor sort of failed is that it never occurred to me when a patient has multiple wounds to tell them oh keep in your mind which wound it is that you're thinking about when you're answering these quality of life questions because that's a ridiculous idea isn't it like it's all of them and yet we do clinical trials where we look at just their left leg wound not their right leg wound or the third wound on their left leg not all of them.

So I'm very concerned as a clinician about the fact that we continue to do research at the level of the wound and not at the level of the patient who has multiple problems. But that's another barrier for quality of life working because there's not a one-to-one. And when we're all done, if the wound had healed, one wound healed, the other one didn't.

What do we do with the quality of life then? It's almost like when you're working in control trial land and you think of just one wound, so this idea sticks in your head, "Oh, the patient only has one wound." One to one. Well, in our real-world patients, they have lots of wounds. Yes.

So, in a sense, you need to get out of that protective umbrella of control trial land and get into the real world and understand there's a vast difference, guys. We're going to have to have a different tool. I think there might be ways to measure the things that matter to the patient, and I think that was my mistake going into it is thinking it's somehow a tool designed generally for wounds.

I think maybe that's the process going through with the wound cue is trying to figure out, okay, let's ask the patient what matters to them. And just to finish the concept about the CMS quality measure that could be reported under MIPS, CMS then rejected that measure because they said simply measuring quality of life is not a quality activity. What they expected was for us to be able to demonstrate a specific percentage, a measurable improvement in quality of life in relation to our treatment.

And clearly the QOL failed as a tool. I'm not trying to dismiss that, but conceptually for all the reasons we've said it failed. So if we're gonna be able to use quality of life as a surrogate endpoint, we'll have to first find out what aspect of quality of life is the thing that we should look at.

And to keep in mind that from the standpoint of CMS or reimbursement, simply asking people about quality of life is not something that the payers care about. They want to be able to measure in what way it's better, which is a completely different perspective than we had. So I'm always frustrated when a manufacturer or someone wants to know if their device, their treatment, their whatever has changed quality of life and I keep thinking you need to stand far enough back that I can't swing at you because it's expensive to measure, it's time consuming, there's no reimbursement for it and we have yet to find a way to do it in a way that is consistently related to outcome, so I want people to stop asking me about quality of life until these problems have been solved, and I haven't seen a lot of investment in trying to do that.

I mean, as a final wrap-up, I would say trying to figure out the quality of life in patients is not as simple as it seems. We have spent 30 years in utility work trying to discover, how do you measure that there are gazillion ways to do this and we're still arguing which way is right. So you can tell you the nature and the depth of the problem is going to be an on-topic research for the next 20-30 years.

And all patients with chronic wounds are very sick. We'd like to thank doctors Fife and Carter for taking the time to speak with us today at SAWC Spring. That wraps up the discussion for today but for more information on today's topic, we invite our listeners to explore all the resources available through the Wound Care Learning Network and at Woundsource.com.

Thank you again for joining us today on this episode of Speaking for Wounds and enjoy the rest of your day.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.

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