Background
Intensive care units (ICUs) contribute significantly to healthcare's environmental footprint, with medications playing a major role. This study performed a comprehensive Material Flow Analysis (MFA) of medications in a large academic ICU to quantify material flows and identify opportunities for sustainability.

Methods
A single-center MFA was conducted at a 50-bed ICU, analyzing all medications delivered in 2023. Medication and packaging components were weighed and categorized by active pharmaceutical ingredients (APIs), excipients, and packaging type. Total annual mass as well as daily medication and packaging waste per patient were calculated.

Results
The annual medication inflow totaled 234,337 kg, including 194,411 kg of medication content (5287 kg APIs, 189,124 kg excipients) and 39,923 kg of packaging. APIs constituted only 2.3% of the total medication mass. On average, patients received 89.5 medication units daily, totaling 5.0 kg of medication and generating 1.7 kg of packaging waste. Waste outflow comprised 194,413 kg to the sewage system, 21,894 kg for incineration, and 18,030 kg recycled, consisting primarily of continuous renal replacement therapy (CRRT) bags.

Conclusions
This MFA highlights significant opportunities to enhance ICU medication sustainability by targeting CRRT-related waste, optimizing fluid formulations to reduce excipient use, and minimizing packaging. These findings support the development of targeted interventions to reduce the environmental footprint of critical care.

Negative Pressure Wound Therapy (NPWT) is a treatment that promotes healing of chronic wounds. Despite high prevalence of chronic wounds in Low- and Middle-Income Countries (LMICs), NPWT devices are not available nor affordable. This study aims to improve chronic wound care in LMICs by presenting the Wound Care (WOCA) system, designed for building, testing and use in LMICs. Design requirements were formulated using input from literature, ISO standards, and wound care experts. The WOCA design was developed to provide safe, portable, user-friendly and affordable NPWT to patients in LMICs. The design features an adjustable operating pressure ranging from −75 to −125 mmHg, a battery for portability, a 300 ml canister, overflow protection, and system state alarms. An Arduino controls the pressure and monitors the system state. Three prototypes were developed and built in Nepal, and their performance was evaluated. Pressure control was 125 ± 10 % mmHg, internal leakage was 7.5 ± 4.3 mmHg/min, reserve capacity was 189 ± 16.9 ml/min, and overflow protection and alarm systems were effectively working. Prototype cost was approximately 280 USD. The WOCA demonstrates to be a locally producible NPWT device that can safely generate a stable vacuum. Future research will include clinical trials situated in LMICs.

Integrating hydrogen into energy systems presents challenges involving social dynamics among stakeholders beyond technical considerations. A gap exists in understanding how these dynamics influence the deployment of hydrogen technologies and infrastructure, particularly in infrastructure development and market demand for widespread adoption. In the Netherlands, despite ambitious strategies and investments, comprehensive explanations of social dynamics' impact on integration processes and market development are lacking. This study addresses this gap by analyzing the hydrogen value chain and stakeholder interactions in the Dutch hydrogen sector. A literature review highlights system integration challenges and the need for decentralized coordination and cross-sector collaboration. Using the Dutch energy grid and its hydrogen initiatives as a case study, social network analysis and semi-structured interviews are applied to analyze over 60 hydrogen initiatives involving more than 340 stakeholders. Initiatives are categorized into large-scale centralized and decentralized local types based on scale and stakeholder involvement, allowing targeted analysis of stakeholder interactions in different contexts. Findings reveal that centralized networks may limit innovation due to concentrated influence, while decentralized networks encourage innovation but require better coordination. These insights guide strategic planning and policymaking in hydrogen energy initiatives, aiming to enhance scalability and efficiency of hydrogen technologies for sustainable energy solutions.

Background
The health care sector is among the most carbon-intensive sectors, contributing to societal problems like climate change. Previous research demonstrated that especially the use of personal protective equipment (e.g., aprons) in critical care contributes to this problem. To reduce personal protective equipment waste, new sustainable policies are needed.

Aims
Policies are only effective if people comply. Our aim is to examine whether compliance with sustainable policies in critical care can be increased through behavioural influencing. Specifically, we examined the effectiveness of two sets of nudges (i.e., a Prime + Visual prompt nudge and a Social norm nudge) on decreasing apron usage in an intensive care unit (ICU).

Study Design
We conducted a field experiment with a pre- and post-intervention measurement. Upon the introduction of the new sustainable policy, apron usage data were collected for 9 days before (132 observations) and 9 days after (114 observations) the nudge interventions were implemented.

Results
Neither the Prime + Visual prompt nudge, nor the Social norm nudge decreased apron usage.

Conclusions
While previous studies have found that primes, visual nudges and social norm nudges can increase sustainable behaviour, we did not find evidence for this in our ICU field experiment. Future research is needed to determine whether this null finding reflects reality, or whether it was due to methodological decisions and limitations of the presented experiment.

Relevance to Clinical Practice
The presented study highlights the importance of studying behavioural interventions that were previously proven successful in the lab and in other field contexts, in the complex setting of critical care. Results previously found in other contexts may not generalize directly to a critical care context. The unique characteristics of the critical care context also pose methodological challenges that may have affected the outcomes of this experiment.

Due to the significant environmental impact of healthcare, there is an urgent need to accelerate its circular transition. We provide an overview of the ESCH-R project study design and methodology for accelerating the transition from a linear to a circular healthcare sector through the development and implementation of circular interventions in the Netherlands. Using a transdisciplinary approach, we will apply the 10-R ladder framework for a circular economy to hospitals. Methods are presented to analyze current clinical practices, policies and requirements for sustainable behavioral change, from material flows and operations to policy and regulations. We describe methods for the development of circular interventions, including business models, contract templates, and product redesigns. Finally, our approach to dissemination and education is presented. The described study design and methods can be used by other hospital (settings) to identify environmental hotspots for circular interventions in their own healthcare practice and for the cross-transfer of knowledge and anticipated challenges in implementing circular strategies. Ultimately, the ESCH-R project will deliver innovative, scalable approaches for hospitals to reduce procurement of raw materials, retain value of medical products, and reduce waste streams, CO2 emissions and pollution.

Background: Schistosomiasis (SCH) and soil transmitted helminthiasis (STH) have been targeted for elimination as a public health problem (EPHP) within the World Health Organization (WHO)’s Roadmap for Neglected Tropical Diseases (NTDs) 2021–2030. One of the global strategies for the control and elimination of these diseases is the mass administration of praziquantel and albendazole/mebendazole without prior individual diagnosis. To measure the progress towards the 2030 target, we conducted an assessment to determine the impact of the 3–5 rounds of annual mass drug administration among school age children in Ekiti State. Such scientific insights into the impact of these treatments will facilitate improved planning and targeting of resources towards reaching the last mile. Methodology: This assessment was conducted in 16 local government areas (LGAs) of Ekiti State between October and November 2023. Samples were collected from pupils in 166 primary and junior secondary schools across 166 wards of the State. Urine and stool samples were collected from 7670 pupils of ages 5 to 14 years, following standard laboratory procedures. Urine membrane filtration techniques were used for urine preparation while the Kato–Katz technique was used for stool preparation. A novel AiDx digital microscope was used to examine the presence of any ova in the prepared specimen. Parasite ova in urine were reported as the number of ova/10 mL of urine, and were categorized as light infection (˂50 ova/10 mL of urine) or heavy infection (>50 ova/10 mL of urine) while ova of parasites in stool samples were reported as eggs per gram of stool (EPG) and categorized into light, moderate and heavy infection. Results: Overall, 0.76% (0.56–0.95) at 95% CI of the 7670 respondents were infected with Schistosomia haematobium. No Schistosoma mansoni infection was recorded in the study. Similarly, 3.9% (3.43–4.29) at 95% CI were infected with STHs. The overall prevalence of schistosomiasis had significantly reduced from 8.2% in 2008 to 0.8%, while the overall prevalence of STHs significantly reduced from 30.9% to 3.9% with Ascaris lumbricoides being the dominant species of STH. In the 16 LGAs assessed, Ekiti West had the highest S. haematobium prevalence of 4.26%. Ise/Orun and Oye ranked second and third with a prevalence of 3.48% and 2.40% respectively, while all other LGAs had <1% prevalence. The prevalence of STHs was highest in Ekiti-West with a prevalence of 10.45% while Emure and Ikole Local Governments had the lowest prevalence of 0.31% and 0.38%, respectively. There was no significant difference in the prevalence of schistosomiasis between male (0.76%) and female (0.75%) as p ≥ 0.05. Similarly, the difference in prevalence for STH among males (3.95%) was not significantly different from their female counterparts (3.77%), p ≥ 0.05. Conclusions: Based on the WHO guidelines, this study demonstrated that only three LGAs require continued MDA every 2/3 years, seven require only surveillance while six are now non-endemic for schistosomiasis. Similarly, two of the LGAs require one round of MDA yearly, eight LGAs need one round of MDA every two to three years and six LGAs are now below the treatment threshold and no longer require treatment for STH.

Introduction: Schistosomiasis is a public health concern and there is a need for reliable field-compatible diagnostic methods in endemic settings. The AiDx Assist, an artificial intelligence (AI)-based automated microscope, has shown promising results for the detection of Schistosoma haematobium eggs in urine. It has been further developed to detect Schistosoma mansoni eggs in stool.

Methods: In this study, we evaluated the performance of the AiDx Assist for the detection of S. mansoni eggs in stool samples and further validated the performance of the AiDx Assist for the detection of S. haematobium eggs in urine samples. Additionally, the potential of the AiDx Assist for the detection of other helminths in stool samples was explored. In total, 405 participants from an area endemic for both S. mansoni and S. haematobium provided stool and urine samples which were subjected to AiDx Assist (semi- and fully automated), while conventional microscopy was used as the diagnostic reference.

Results: Only samples with complete test results were included in the final analysis, resulting in 375 stool and 398 urine samples, of which 38.4% and 65.3% showed Schistosoma eggs by conventional microscopy. The collected images of the stool samples were retrospectively examined for other helminth eggs via manual analysis. For the detection of S. mansoni eggs, the sensitivity of the semi-automated AiDx Assist (86.8%) was significantly higher compared to the fully automated AiDx Assist (56.9%) while the specificity was comparable, with 81.4% and 86.8%, respectively. Retrospectively, eggs of Ascaris lumbricoides and Trichuris trichiura were visualized. For the examination of urine samples, a comparable sensitivity in the detection of S. haematobium eggs was found between the semi-and the fully automated modes of the AiDx Assist, showing 94.6% and 91.9%, respectively. Furthermore, the specificity was comparable, with 90.6%and 91.3% respectively.

Discussion: The AiDx Assist met the World Health Organization Target Product Profile criteria in terms of diagnostic accuracy for the detection of S. haematobium eggs in urine samples and performed modestly in the detection of S. mansoni eggs in stool samples. With some further improvements, it has the potential to become a valuable diagnostic tool for screening multiple helminth parasites in stool and urine samples.

Purpose
Properly functioning health systems globally require medical devices and equipment for vital care. Despite promising innovations, many medical devices face adoption barriers such as regulatory issues, interoperability and data exchange challenges. In low-resource settings, contextual factors influencing adoption and diffusion have not been synthesized into an overview to guide future medical device and equipment suppliers. Our study provides a scientific inventory of frameworks, theories, models, and guidelines describing the adoption and diffusion of medical devices and equipment in low-resource settings.

Methods
We searched both the PubMed and Scopus databases to identify studies within the health and broader non-health domains. Our search yielded 2.124 results after de-duplication. Extended attributes on the type of the paper, adoption and diffusion focus, medical devices and equipment use cases, and country settings revealed patterns of underpinning and emerging frameworks for adoption and diffusion.

Results
We included 28 studies in our review. The most researched device types were telemedicine, telehealth, m-health, and e-health. Among a larger variety, the most utilized underpinning frameworks were the Diffusion of Innovation Framework, and the Technology Acceptance Model. These frameworks led to the development of emerging models, such as a modified version based on Kifle’s Adoption Model or the Intervention-Context-Actors-Mechanism-Outcome Model.

Conclusions
Our findings offer initial insights for further research in identifying mechanisms for improving access to and utilization of medical devices and equipment in low-resource settings. Researchers can use this comprehensive review to guide continued research, addressing gaps in theoretical understanding and empirical evidence on medical device adoption and diffusion in low-resource settings.

Mitigating environmental impacts is an urgent challenge supported by (scientific) intensive care societies worldwide. However, making green choices without compromising high-quality care for critically ill patients may be challenging. The current paper describes a three-step approach towards green intensive care units. Starting with the measurement of environmental sustainability, intensive care units can identify hotspots, quantify the environmental impacts of products and procedures, and monitor sustainable progress. Subsequently, a multidisciplinary approach is proposed to improve environmental sustainability, including a collaboration of procurement specialists and healthcare professionals, using co-creation and green teams as efficient grassroots change agents. A context-specific approach for enhancing sustainable healthcare practices is key in order to fit local regulatory requirements and create support of professionals. A final step is to share results and create momentum, including publishing initiatives and participating in online (inter)national networks. Based on the core sustainability principles, this three-step approach towards green ICUs provides a valuable tool to professionals worldwide to facilitate change towards environmentally responsible intensive care units.

Introduction: One of the global strategies for the elimination of schistosomiasis is by Mass Drug Administration (MDA) of a single oral dose of praziquantel (40 mg/kg) without a prior individual diagnosis, with a target of >75% treatment coverage among school-aged children. This study was conducted to determine the endemicity of schistosomiasis among school-aged children and adults in Abuja, Nigeria. Methods: A total of 1370 participants were recruited, which consisted of 667 (48.67%) males and 703 (51.31%) females. Urine and stool specimens were collected from each participant and analyzed using standard procedures. Results: The overall prevalence of schistosomiasis was 27.5% in this study with Abuja Municipal having the highest prevalence of 49%, while the least (6.1%) was reported in Bwari LAC. The prevalence of schistosomiasis significantly differs (p < 0.05) between the area councils. The location of communities significantly affected the prevalence of schistosomiasis in Abaji, AMAC, and Gwagwalada LACs (p < 0.005). The Schistosoma recovered in this study were S. haematobium and S. mansoni. The prevalence of schistosomiasis increased from the baseline of 21.1% to 49% in Gwagwalada LAC. Gender significantly affected the prevalence of schistosomiasis as more males were infected (33.1%) than their female counterparts (22.2%) (p < 0.05). The prevalence of schistosomiasis was 31% and 23.9% among SAC and adults, respectively. The participants’ activities in the river significantly affected the prevalence of schistosomiasis in this study (p < 0.05). Conclusions: The clamour for urgent government and non-government intervention through alternate sources of water like boreholes or pipe-borne water, as well as implementing a behavioural change campaign across the communities to prevent the recurrence, are advocated.

This research and design project is part of the Green ICU initiative and focused on reducing the environmental impact of gloves at the Intensive Care Unit (ICU) of the Erasmus Medical Center (EMC). At the ICU of the EMC around 108 gloves are used per patient per day; to protect the user (healthcare staff) from infections. The high frequency of use and the resource-intensive production define disposable nitrile gloves as one of the ‘hotspots’ contributing to the environmental impact created by the ICU. This research and design project addressed the problem from three different perspectives: user-centred, product-centred and supply-centred. The extensive research resulted in three design directions on how to reduce the environmental impact of gloves. Subsequently, all insights from the research were brought together into five design building blocks. These design building blocks provided guidance for the design phase of the project. The project resulted in a redesign of the current glove dispensers. The final design is named ‘GloVe’, a vertical dispense system. By incorporating the five building blocks, the design can provide benefits for multiple stakeholders within the healthcare system. It reduces the environmental impact of gloves in the ICU by dispensing one glove at a time. Furthermore, the gloves are dispensed at the cuff, which comes in little contact with the patient. The vertical movement is pleasant to the user. The use of colour for different sizes makes it clear to the care assistant which box should go in which holder. Also, nurses will see at a glance, which size gloves they are dispensing. The small V-shaped opening makes the undesirable behaviour, of placing gloves back, almost impossible.

Traditionally, automated slide scanning involves capturing a rectangular grid of field-of-view (FoV) images which can be stitched together to create whole slide images, while the autofocusing algorithm captures a focal stack of images
to determine the best in-focus image. However, these methods can be timeconsuming due to the need for X-, Y- and Z-axis movements of the digital microscope while capturing multiple FoV images. In this paper, we propose a solution to minimise these redundancies by presenting an optimal procedure for automated slide scanning of circular membrane filters on a glass slide. We achieve this by following an optimal path in the sample plane, ensuring that only FoVs overlapping the filter membrane are captured. To capture the best infocus FoV image, we utilise a hill-climbing approach that tracks the peak of the mean of Gaussian gradient of the captured FoVs images along the Z-axis. We implemented this procedure to optimise the efficiency of the Schistoscope, an automated digital microscope developed to diagnose urogenital schistosomiasis by imaging Schistosoma haematobium eggs on 13 or 25 mm membrane filters. Our improved method reduces the automated slide scanning time by 63.18%and 72.52% for the respective filter sizes. This advancement greatly supportsthe practicality of the Schistoscope in large-scale schistosomiasis monitoringand evaluation programs in endemic regions. This will save time, resources andalso accelerate generation of data that is critical in achieving the targets for schistosomiasis elimination.

This project aims to reduce the environmental impact of the Intensive Care Unit (ICU) of the Erasmus Medical Center (EMC). Systemic design research was executed to map the current waste flow created by the ICU. Literature review, interviews and observations were performed to gather information about the healthcare protocols, hospital procurement process, intubation practices and used devices and consumables. This resulted in a set of challenges which were used to ideate from different perspectives to improve the sustainability of the ICU. A set of opportunities to introduce circularity within the ICU were defined. These opportunities ranged from waste separation to the reduction of the disposal of unused products. The selected circular opportunity was intubation, needed when patients cannot breathe by themselves. For this, a video laryngoscope, which is composed of various plastics, a video camera, and a led light, is used for only a few minutes and disposed of (and incinerated) directly afterwards. The aim of the second part of this research project was: Can we design a circular intubation procedure as a catalyzer for systemic change towards circular ICUs? One of the proposed circular strategies for the video laryngoscope is the reprocessing of intubation devices used at the ICU itself. A transition model toward reprocessing using UV-C radiation technique was further developed. Compared to current reprocessing procedures, UV-C disinfection consumes no water and less electricity and offers the possibility of decentralized reprocessing within the ICU department itself. This project aims to provoke conversations between the hospital, manufacturers and other stakeholders about how the healthcare sector could start reprocessing valuable medical devices towards a circular ICU.

Introduction: Millions of women worldwide annually undergo manual vacuum aspiration (MVA) with no pain medication, which is a violation of their basic human dignity. We designed a novel device (Chloe SED®) to administer paracervical block (PCB) during MVA in countries where pain medication is not typically given due to the high cost of the necessary tools.

Methods: We conducted a single-blinded, randomized controlled non-inferiority trial including 61 patients at two hospitals in Kisumu, Kenya, to validate Chloe SED® for administration of PCB during MVA. PCB administered with Chloe SED® was compared to PCB administered with a standard spinal needle. Patients requiring MVA were block randomized in blocks of six, each provider completing six PCBs—three with the Chloe SED® and three with the standard spinal needle. The trial was registered with the Kenya Pharmacy and Poisons Board, ECCT/19/03/01 (https://ctr.pharmacyboardkenya.org/applications/index/protocol_no:RUNDVC8xOS8wMy8wMQ__/filter:/investigator:/sites:/pages:5/start_date:/end_date:/disease_condition:/users:/ercs:/stages). An intention-to-treat analysis was completed. The primary outcome was the non-inferiority of the pain score during uterine evacuation with a non-inferiority margin of 2 points on an 11-point numerical rating scale. Secondary outcomes included the non-inferiority of the pain score at four other time points and patient satisfaction.

Results: Chloe SED® showed non-inferiority of the primary outcome with a mean pain score during evacuation of 3.8 [90% confidence interval (CI): 3.1–4.6] compared with the spinal needle at 4.1 (90% CI: 3.5–4.7). Non-inferiority of the pain score was shown at all time points. Most patients expressed a desire for the continued use of the device to administer PCB for MVA. No adverse events were noted.

Conclusion: In summary, the Chloe SED® appears non-inferior to the spinal needle and desirable for the administration of PCB during MVA.

This research project, part of the Green Intensive Care Unit (ICU) initiative at the Erasmus University Medical Center (EMC), is focused on reducing the environmental impact of syringes at the ICU by designing solutions based on circular economy principles. Based on a Material Flow Analysis of the EMC ICU, syringes and their packaging have been identified as one of the main environmental impact hotspots. Therefore, this project aimed to redesign the syringes, their packaging, and their use, according to circular design strategies suitable for medical products to decrease their environmental impact, while remaining convenient and safe in use for the healthcare staff and patients. Research was executed to understand the context from multiple perspectives. The outcomes demonstrated that decreasing the impact of syringes is not only related to the design of the syringe itself. Manufacturing, preparation, use and disposal, all contribute to the environmental impact of the syringe. Various possible interventions were derived to reduce its impact:

1.
Adapting the infection prevention protocol and behaviour of the staff;

2.
Separating infectious waste from general hospital waste;

3.
Redesigning the syringe itself;

4.
Optimising the filling process of syringes.

The final design is an optimised filling process for prefilled sterilised syringes (PFSs), based on circular strategies such as reduce, reuse, rethink and repurpose. Interventions include: eliminating a redundant sterilisation phase, reducing residual medication and changing from steam to gamma sterilisation. This resulted in decreasing the amount of waste, material, energy and water consumption, while offering similar convenience and safety for the staff and patients of the ICU.

Community mobilisation is a vital process for raising awareness and increasing participation in healthcare interventions, research, and programmes that require human sample collection and mass management. In this report, we present the community mobilisation approach undertaken for the implementation of the operational mapping and assessment of granular schistosomiasis and soil-transmitted helminths in Ekiti State, Nigeria. The mobilisation was conducted in 177 communities/wards of the 16 local government areas. A total of 15,340 urine and stool samples were collected in 34 days. The efficacy and success of the strategy were evaluated through the following three performance metrics: community compliance rate, the participant response rate at the community level, and the overall compliance response rate of the four most sensitive LGAs. Community compliance was 93.7% as sample collection was denied in nine communities and two other communities demanded the return of the collected samples despite our mobilisation effort because of cultural bias and myths that connect the collection of stool and urine samples to ritual activities in the local context. The participant response rate at the community level was 86.7%. Three of the four sensitive LGAs (based on previous assessment programmes) demonstrated satisfactory compliance rates of 100%, while a response rate of 64.0% was computed for one of the LGAs. We believe our approach contributed to effective community mobilisation and awareness and that the developed model has the potential to improve participation rates in large healthcare assessments and intervention programmes.

Introduction
Schistosomiasis is a significant public health concern, especially in Sub-Saharan Africa. Conventional microscopy is the standard diagnostic method in resource-limited settings, but with limitations, such as the need for expert microscopists. An automated digital microscope with artificial intelligence (Schistoscope), offers a potential solution. This field study aimed to validate the diagnostic performance of the Schistoscope for detecting and quantifying Schistosoma haematobium eggs in urine compared to conventional microscopy and to a composite reference standard (CRS) consisting of real-time PCR and the up-converting particle (UCP) lateral flow (LF) test for the detection of schistosome circulating anodic antigen (CAA).

Methods
Based on a non-inferiority concept, the Schistoscope was evaluated in two parts: study A, consisting of 339 freshly collected urine samples and study B, consisting of 798 fresh urine samples that were also banked as slides for analysis with the Schistoscope. In both studies, the Schistoscope, conventional microscopy, real-time PCR and UCP-LF CAA were performed and samples with all the diagnostic test results were included in the analysis. All diagnostic procedures were performed in a laboratory located in a rural area of Gabon, endemic for S. haematobium.

Results
In study A and B, the Schistoscope demonstrated a sensitivity of 83.1% and 96.3% compared to conventional microscopy, and 62.9% and 78.0% compared to the CRS. The sensitivity of conventional microscopy in study A and B compared to the CRS was 61.9% and 75.2%, respectively, comparable to the Schistoscope. The specificity of the Schistoscope in study A (78.8%) was significantly lower than that of conventional microscopy (96.4%) based on the CRS but comparable in study B (90.9% and 98.0%, respectively).

Conclusion
Overall, the performance of the Schistoscope was non-inferior to conventional microscopy with a comparable sensitivity, although the specificity varied. The Schistoscope shows promising diagnostic accuracy, particularly for samples with moderate to higher infection intensities as well as for banked sample slides, highlighting the potential for retrospective analysis in resource-limited settings.

The accomplishment of Sustainable Development Goals (SDGs) is intrinsically connected to improving livelihoods in the Rural Global South (RGS). RGS livelihoods are complex, showing multiple dimensions beyond mere economic considerations. However, many related development policies (over)simplify livelihoods to income thresholds, leading to flawed interventions. Adequate strategies to address RGS livelihoods require a much deeper understanding of their various dimensions and complexities. Q methodology (Q) is a powerful participatory research technique that enables the systematic study of different viewpoints on subjective topics. Moreover, it has the potential to identify and reveal previously unheard narratives, thus allowing us to question the traditional understandings of RGS livelihoods. Yet, as a time- and assistance-intensive technique, its implementation faces methodological challenges that are currently overlooked and ought to be considered. We selected and reviewed 50 Q studies applied to different forms of RGS livelihoods. First, we discuss several on-field Q limitations associated with the physical, logistical, social, and cultural constraints. Second, we draw on good practices and strategies to cope with these limitations. Notwithstanding the limitations and strategies, we advocate building Q capacities and the gender-balanced empowerment of local researchers. This may contribute to a better understanding of the nuances and challenges of RGS livelihoods.

Manual vacuum aspiration (MVA) is a painful procedure often conducted without analgesia. The World Health Organization (WHO) recommends a paracervical block (PCB) as the mode of pain relief during MVA. Few studies have assessed patient perspectives on pain control during MVA. We investigated the perspectives of health workers and patients on MVA under PCB. This study was nested within a pilot randomized controlled trial (RCT) evaluating the Chloe SED (syringe extension device) for PCB provision. Eleven providers and 61 patients were enrolled. All providers had MVA experience. They had not provided pain relief on 20% of occasions, and only one had previously administered PCB for MVA. Both patients and providers indicated MVA was painful and deserving of analgesia. Pain was the most common reason for difficulty completing an MVA. Providers noted that PCB made the procedure more tolerable. For patients, efficacy, remaining conscious, and same-day discharge were key considerations when selecting pain relief. Notably, 84% of patients expressed satisfaction with MVA under PCB. PCB is a vital component of the MVA care package. Considering patient and provider perspectives is essential to optimizing a humane and effective procedural experience.

As the transition to sustainable energy intensifies, hydrogen emerges as a pivotal medium in mitigating climate change and improving energy security. While its applicability across various sectors is undeniable, its integration into established energy systems presents multifaceted challenges. This study investigates the complexities of integrating hydrogen into the Netherlands' energy systems. Beyond technological advancements, the successful design and rollout of a hydrogen supply chain require coordination and collaboration among a myriad of stakeholders. Through a mixed-methods approach, this study combines findings from a broad literature review, policy document analyses, evaluation of 59 field projects, and engaging dialogues with 33 key stakeholders from different sectors. This investigation led to the identification and categorization of key players in the Dutch hydrogen sector, revealing their interconnected roles and the challenges encountered in the hydrogen integration process. The study further categorized the identified challenges faced by stakeholders into five core domains: technical, infrastructural (including supply chain), socioeconomic, environmental, and institutional, with associated factors. Prominent challenges include transportation infrastructure upgrades, high initial costs and scalability, effective storage methods, safety and cybersecurity measures, storage and distribution infrastructure, security of supply, and public acceptance. This study contributes to the hydrogen integration discourse, offering insights for academics, industry, and policymakers. Its detailed stakeholder analysis, holistic categorization of challenges across five domains, and a stakeholder-centric approach grounded in real-world dialogues offer applicable frameworks beyond its primary context. In this vein, it guides future research and decisions, and its approach is adaptable for different regions or sectors, emphasizing comprehensive transition strategies.