Navigating University Openness in Research Policy Inconsistent with Indigenous Data Sovereignty: A Case Analysis.

Indigenous nations and communities in the United States have rights as sovereign governments to exercise control and ownership over all data and information generated by or from the tribes, tribal members, or tribal resources. Indigenous nations exercise these rights through data ownership policies established in response to unethical research practices in research involving Indigenous communities. Most universities in the U.S. have "openness in research" policies to ensure academic freedom to publish freely, exercised by retaining university control of data. Here, we describe our study of cultural ecosystem services in the St. Louis River estuary region (Nagaajiwanaang in the language Ojibwemowin) in Duluth, Minnesota, and Superior, Wisconsin, U.S., an area that includes portions of the 1854 and 1842 Ceded Territories and reservation lands of a local band of Ojibwe (hereafter referred to as "the Band"). In this university-led, Band-supported study, both the university and the Band sought ownership of data collected based on their respective policies, resulting in a research delay of nearly a year. We found that open research policies that do not consider Indigenous sovereignty can hamper collaboration between university researchers and tribal nations, even when there is broad agreement on research goals and objectives. University open research policies that do not explicitly address Indigenous sovereignty fall short of the open research principles they intend to support and should be revised. Formal adoption of principles for ethical research with sovereign tribal governments by universities is needed to improve coordination and trust among university and tribal researchers and members.

Cross-sectional analysis of primary care clinics' policies, practices, and availability of patient support services during the COVID-19 pandemic.

BACKGROUND: Healthcare accessibility and utilization are important social determinants of health. Lack of access to healthcare, including missed or no-show appointments, can have negative health effects and be costly to patients and providers. Various office-based approaches and community partnerships can address patient access barriers. OBJECTIVES: (1) To understand provider perceptions of patient barriers; (2) to describe the policies and practices used to address late or missed appointments, and (3) to evaluate access to patient support services, both in-clinic and with community partners. METHODS: Mailed cross-sectional survey with online response option, sent to all Nebraska primary care clinics (n = 577) conducted April 2020 and January through April 2021. Chi-square tests compared rural-urban differences; logistic regression of clinical factors associated with policies and support services computed odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Response rate was 20.3% (n = 117), with 49 returns in 2020. Perceived patient barriers included finances, higher among rural versus urban clinics (81.6% vs. 56.1%, p =.009), and time (overall 52.3%). Welcoming environment (95.5%), telephone appointment reminders (74.8%) and streamlined admissions (69.4%) were the top three clinic practices to reduce missed appointments. Telehealth was the most commonly available patient support service in rural (79.6%) and urban (81.8%, p =.90) clinics. Number of providers was positively associated with having a patient navigator/care coordinator (OR = 1.20, CI = 1.02-1.40). For each percent increase in the number of privately insured patients, the odds of providing legal aid decreased by 4% (OR = 0.96, CI = 0.92-1.00). Urban clinics were less likely than rural clinics to provide social work services (OR = 0.16, CI = 0.04-0.67) or assist with applications for government aid (OR = 0.22, CI = 0.06-0.90). CONCLUSIONS: Practices to reduce missed appointments included a variety of reminders. Although finances and inability to take time off work were the most frequently reported perceived barriers for patients' access to timely healthcare, most clinics did not directly address them. Rural clinics appeared to have more community partnerships to address underlying social determinants of health, such as transportation and assistance applying for government aid. Taking such a wholistic partnership approach is an area for future study to improve patient access.

Associations between cannabis policies and state-level specialty cannabis use disorder treatment in the United States, 2004-2019.

BACKGROUND: Cannabis use disorder (CUD) treatment prevalence decreased in the US between 2002 and 2019, yet structural mechanisms for this decrease are poorly understood. We tested associations between cannabis laws becoming effective and self-reported CUD treatment. METHODS: Restricted-use 2004-2019 National Surveys on Drug Use and Health included people ages 12+ classified as needing CUD treatment (i.e., past-year DSM-5-proxy CUD or last/current specialty treatment for cannabis). Time-varying indicators of medical cannabis laws (MCL) with/without cannabis dispensary provisions differentiated state-years before/after laws using effective dates. Multi-level logistic regressions with random state intercepts estimated individual- and state-adjusted CUD treatment odds by MCLs and model-based changes in specialty CUD treatment state-level prevalence. Secondary analyses tested associations between CUD treatment and MCL or recreational cannabis laws (RCL). RESULTS: Using a broad treatment need sample definition in 2004-2014, specialty CUD treatment prevalence decreased by 1.35 (95 % CI = -2.51, -0.18) points after MCL without dispensaries and by 2.15 points (95 % CI = -3.29, -1.00) after MCL with dispensaries provisions became effective, compared to before MCL. Among people with CUD in 2004-2014, specialty treatment decreased only in MCL states with dispensary provisions (aPD = -0.91, 95 % CI = -1.68, -0.13). MCL were not associated with CUD treatment use in 2015-2019. RCL were associated with lower CUD treatment among people classified as needing CUD treatment, but not among people with past-year CUD. CONCLUSIONS: Policy-related reductions in specialty CUD treatment were concentrated in states with cannabis dispensary provisions in 2004-2014, but not 2015-2019, and partly driven by reductions among people without past-year CUD. Other mechanisms (e.g., CUD symptom identification, criminal-legal referrals) could contribute to decreasing treatment trends.

How is who: evidence as clues for action in participatory sustainability science and public health research.

Participatory and collaborative approaches in sustainability science and public health research contribute to co-producing evidence that can support interventions by involving diverse societal actors that range from individual citizens to entire communities. However, existing philosophical accounts of evidence are not adequate to deal with the kind of evidence generated and used in such approaches. In this paper, we present an account of evidence as clues for action through participatory and collaborative research inspired by philosopher Susan Haack's theory of evidence. Differently from most accounts of evidence for use in policies and interventions, our account combines action-oriented (the how) and actors-oriented (the who) considerations. We build on Haack's theory and on the analysis of examples of participatory and collaborative research in sustainability science and public health research to flesh out six procedural criteria for the generation and mobilization of evidence in and from participatory research. Action-oriented criteria invite to look at evidence from a (a) foundherentist, (b) gradational and (c) quasi-holistic perspective. Actors-oriented criteria point out that evidence generation and utilization are (d) social, (e) personal, and (f) embedded. We suggest that these criteria may reinforce participatory and collaborative approaches to evidence co-production when addressing complex problems in sustainability science and public health allowing for the generation of a kind of practical objectivity.

Towards a more integrated research framework for heat-related health risks and adaptation.

Advances in research on current and projected heat-related risks from climate change and the associated responses have rapidly developed over the past decade. Modelling architectures of climate impacts and heat-related health risks have become increasingly sophisticated alongside a growing number of experiments and socioeconomic studies, and possible options for heat-related health adaptation are increasingly being catalogued and assessed. However, despite this progress, these efforts often remain isolated streams of research, substantially hampering our ability to contribute to evidence-informed decision making on responding to heat-related health risks. We argue that the integration of scientific efforts towards more holistic research is urgently needed to tackle fragmented evidence and identify crucial knowledge gaps, so that health research can better anticipate and respond to heat-related health risks in the context of a changing climate. In this Personal View, we outline six building blocks, each constituting a research stream, but each needed as part of a more integrated research framework-namely, projected heat-related health risks; adaptation options; the feasibility and effectiveness of adaptation; synergies, trade-offs, and co-benefits of adaptation; adaptation limits and residual risks; and adaptation pathways. We outline their respective importance and discuss their benefits for health-related research and policy.

Modelling policies to improve affordability and consumption of nutritious foods for complementary feeding in Kenya.

In Kenya 26% of children under age 5 experience stunted growth, 4% are wasted and 11% are underweight. In pregnant women, the prevalence of iron deficiency is 36% and iron-deficiency anaemia prevalence is 26%. Previous studies have identified affordability as a key barrier to the intake of nutrients, particularly from animal-source foods (ASFs). Thus, this study analyzes to what extent the affordability of ASF in Kenya can be improved. It focuses on four ASFs: eggs, milk, chicken and beef. Using a computable general equilibrium model, three policy simulations were undertaken to establish the impact of potential changes on nutritious ASF availability and affordability: a 20% increase in total factor productivity (TFP) for the four products; a 20% TFP increase plus a 25% reduction in trade and transportation margins; and a 20% TFP increase for ASF and maize (a key input in animal feed). Simulations suggest increasing the productivity of the four ASF products would increase their availability and lower consumer prices (up to 17% lower). Household consumption of the four commodities would increase, resulting in improved household dietary diversity. Rural households would gain more compared with urban households. Poor households (the lowest 40%) would register larger welfare (Equivalent Variation) gains than other households in both urban and rural areas. The richest 20% of the population would neither lose nor gain following the policy changes. Reducing transportation costs and trade margins and increasing maize productivity could further reduce the price of ASFs through lower production costs and increased consumption.

Improving complementary feeding practices, programs and policies for optimal early childhood nutrition in Kenya: What would work?

Complementary feeding practices are greatly influenced by local contexts. Therefore, national home-grown evidence, policies and guidelines are critical to improving infant and young children's diets. This Special Issue has provided a comprehensive, evidence-based analysis of the situation, gaps and context-specific opportunities for improving young children's diets in Kenya. The primary research findings of the Special Issue supported the identification of a set of recommendations articulated across the four systems (food, health, water, sanitation and hygiene [WASH] and social protection) to improve food availability and accessibility in Kenya at the national and subnational levels. It is anticipated that the decentralised government functions seen in Kenya provide a strong opportunity to develop and mainstream context-specific recommendations into action. This Special Issue recommends adopting a multi-sectoral systems approach, including a shared vision, joint planning, implementation and monitoring, towards improving young children's diets with a focus on service delivery as well as scaled-up community social behaviour change interventions. In particular, the approach should entail advocacy for policy revisions for service delivery that support complementary feeding and development of costed implementation strategies in support of the same, across four critical systems-food, health, WASH and social protection, along with, the strengthening of national coordination, monitoring and accountability structures as per the Kenya Nutrition Action Plan. Finally, the development of a legal framework for enhanced accountability from all relevant sectors towards sustainable, nutritious, safe and affordable children's diets. These recommendations provide a clear direction in addressing the complementary feeding challenges, which the primary research of this Special Issue has presented.

Monitoring to detect changes in water quality to meet policy objectives.

Detecting change in water quality is key to providing evidence of progress towards meeting water quality objectives. A key measure for detecting change is statistical power. Here we calculate statistical power for all regularly (monthly) monitored streams in New Zealand to test the effectiveness of monitoring for policy that aims to decrease contaminant (phosphorus and nitrogen species, E. coli and visual clarity) concentrations to threshold levels in 5 or 20 years. While > 95% of all monitored sites had sufficient power and samples to detect change in nutrients and clarity over 20 years, on average, sampling frequency would have to double to detect changes in E. coli. Furthermore, to detect changes in 5 years, sampling for clarity, dissolved reactive phosphorus and E. coli would have to increase up to fivefold. The cost of sampling was predicted to increase 5.3 and 4.1 times for 5 and 20 years, respectively. A national model of statistical power was used to demonstrate that a similar number of samples (and cost) would be required for any new monitoring sites. Our work suggests that demonstrating the outcomes of implementing policy for water quality improvement may not occur without a step change in investment into monitoring systems. Emerging sampling technologies have potential to reduce the cost, but existing monitoring networks may also have to be rationalised to provide evidence that water quality is meeting objectives. Our study has important implications for investment decisions involving balancing the need for intensively sampled sites where changes in water quality occur rapidly versus other sites which provide long-term time series.

Scoping review: mapping clinical guidelines and policy documents that address the needs of women who are dependent on drugs during the perinatal period.

BACKGROUND: Women who use or are in treatment for drug use during the perinatal period often have complex needs and presenting comorbidity. Women who use opioids during pregnancy, and their infants, experience poor outcomes. Drug use by women during pregnancy is a public health priority. This scoping review aimed to (1) map clinical guidelines, treatment protocols and good practice guidance across the UK for women who use or are in treatment for drug use during the perinatal period, (2) identify recommended best practice across health and social care for optimising outcomes and reducing inequalities for these women and (3) identify potential gaps within guidance. METHODS: We followed the Joanna Briggs International (JBI) guidance on scoping reviews and PRISMA Scr extension. A registered protocol, containing a clear search strategy, inclusion, and exclusion criteria was adhered to. Reviewers double screened 25%, discussing disagreements. Data were extracted using a predefined template and charted in tables. Recommendations for best practice were organised around agreed categories. RESULTS: Of 968 documents screened, 111 met the inclusion criteria. The documents included UK-wide, national, regional, and organisational policy documents. They varied in the degree they were relevant to women who use or are in treatment for drug use during the perinatal period, the settings to which they applied, and their intended users. Most were created without patient or public involvement and lacked any clear evidence base. Overall, documents recommended an integrated model of care with a lead professional, clear referral pathways and information sharing between agencies. Guidance suggested referrals should be made to specialist midwives, drug, and social care services. A holistic assessment, inclusive of fathers / partners was suggested. Recent documents advocated a trauma-informed care approach. Opioid substitution therapy (OST) was recommended throughout pregnancy where required. Potential gaps were identified around provision of support for women postnatally, especially when their baby is removed from their care. CONCLUSIONS: This synthesis of recommended practice provides key information for practitioners, service providers and policy makers. It also highlights the need for guidelines to be evidence-based, informed by the experiences of women who use or are in treatment for drug use during the perinatal period, and to address the support needs of postnatal women who have their babies removed from their care.

Financing Policy Considerations From Texas to Optimize Care for Children With Medical Complexity.

Texas has a tremendous opportunity and momentum to build a more effective system of care for children with medical complexity (CMC) and their families. This is evidenced by growing collaboration among many committed partners since implementation of the Medicaid STAR Kids managed care program in 2016 and Texas' participation in a US Health Resources and Services Administration-funded, 10-state Collaborative Improvement and Innovation Network to Advance Care for CMC from 2017 to 2022. Texas has several comprehensive health homes for CMC that position the state to serve as a national model of integrated, family-centered care for CMC and ensure high-quality care to an exceedingly vulnerable population. Further, Texas' elected leaders demonstrated their interest in system innovation in 2019 and 2021 by enacting state legislation to explore alternative care models and conduct a health home pilot for CMC. Much more must be done to sustain the work underway and bring the promise of care transformation to reality. To this point, we recommend that care planning and coordination be delegated to provider-led, integrated health homes for CMC with alternative payment structures that appropriately reimburse and align incentives with optimal care delivery. To realize the policy aspirations of an effective system of care for CMC, regulatory oversight, payment models, and outcome measures need to be improved to align with the vision articulated in Texas legislation and agency guidance. Although each state's Medicaid program is different, we believe each state can take away policy lessons from those learned by Texas.

How do people who smoke perceive a tobacco retail outlet reduction policy in Aotearoa New Zealand? A qualitative analysis.

BACKGROUND: Aotearoa New Zealand plans to greatly reduce tobacco retail outlets, which are concentrated in areas of higher deprivation and perpetuate health inequities caused by smoking and borne particularly by Maori. However, we lack in-depth analyses of how this measure could affect people who smoke. METHODS: We undertook in-depth interviews with 24 adults from two urban areas who smoke. We used a novel interactive mapping approach to examine participants' current retail outlets and their views on a scenario where very few outlets would sell tobacco. To inform policy implementation, we probed participants' anticipated responses and explored the measure's wider implications, including unintended impacts. We used qualitative description to interpret the data. RESULTS: Most participants anticipated accommodating the changes easily, by using alternative outlets or bulk-purchasing tobacco; however, they felt others would face access problems and increased costs, and greater stress. They thought the policy would spur quit attempts, reduce relapse among people who had quit and protect young people from smoking uptake, and expected more people to switch to alternative nicotine products. However, most foresaw unintended social outcomes, such as increased crime and reduced viability of local businesses. CONCLUSIONS: Many participants hoped to become smoke-free and thought retail reduction measures would prompt quit attempts and reduce relapse. Adopting a holistic well-being perspective, such as those developed by Maori, could address concerns about unintended adverse outcomes and provide comprehensive support to people who smoke as they adjust to a fundamental change in tobacco availability.

Traumatic birth and childbirth-related post-traumatic stress disorder: International expert consensus recommendations for practice, policy, and research.

BACKGROUND: Research suggests 1 in 3 births are experienced as psychologically traumatic and about 4% of women and 1% of their partners develop post-traumatic stress disorder (PTSD) as a result. AIM: To provide expert consensus recommendations for practice, policy, and research and theory. METHOD: Two consultations (n = 65 and n = 43) with an international group of expert researchers and clinicians from 33 countries involved in COST Action CA18211; three meetings with CA18211 group leaders and stakeholders; followed by review and feedback from people with lived experience and CA18211 members (n = 238). FINDINGS: Recommendations for practice include that care for women and birth partners must be given in ways that minimise negative birth experiences. This includes respecting women's rights before, during, and after childbirth; and preventing maltreatment and obstetric violence. Principles of trauma-informed care need to be integrated across maternity settings. Recommendations for policy include that national and international guidelines are needed to increase awareness of perinatal mental health problems, including traumatic birth and childbirth-related PTSD, and outline evidence-based, practical strategies for detection, prevention, and treatment. Recommendations for research and theory include that birth needs to be understood through a neuro-biopsychosocial framework. Longitudinal studies with representative and global samples are warranted; and research on prevention, intervention and cost to society is essential. CONCLUSION: Implementation of these recommendations could potentially reduce traumatic births and childbirth-related PTSD worldwide and improve outcomes for women and families. Recommendations should ideally be incorporated into a comprehensive, holistic approach to mental health support for all involved in the childbirth process.

The indispensable whole of work and population health: How the working life exposome can advance empirical research, policy, and action.

OBJECTIVES: The thesis of this paper is that health and safety challenges of working people can only be fully understood by examining them as wholes with interacting parts. This paper unravels this indispensable whole by introducing the working life exposome and elucidating how associated epistemologies and methodologies can enhance empirical research. METHODS: Network and population health scientists have initiated an ongoing discourse on the state of empirical work-health-safety-well-being research. RESULTS: Empirical research has not fully captured the totality and complexity of multiple and interacting work and nonwork factors defining the health of working people over their life course. We challenge the prevailing paradigm by proposing to expand it from narrow work-related exposures and associated monocausal frameworks to the holistic study of work and population health grounded in complexity and exposome sciences. Health challenges of working people are determined by, embedded in, and/or operate as complex systems comprised of multilayered and interdependent components. One can identify many potentially causal factors as sufficient and component causes where removal of one or more of these can impact disease progression. We, therefore, cannot effectively study them by an a priori determination of a set of components and/or properties to be examined separately and then recombine partial approaches, attempting to form a picture of the whole. Instead, we must examine these challenges as wholes from the start, with an emphasis on interactions among their multifactorial components and their emergent properties. Despite various challenges, working-life-exposome-grounded frameworks and associated innovations have the potential to accomplish that. CONCLUSIONS: This emerging paradigm shift can move empirical work-health-safety-well-being research to cutting-edge science and enable more impactful policies and actions.

Sustaining an Aboriginal wellbeing program: Informing health promotion practice and policy.

ISSUE ADDRESSED: Aboriginal and Torres Strait Islander Peoples' holistic concepts of wellbeing are inadequately represented in the health promotion discourse. The aim of this article was to explore what sustains an Aboriginal wellbeing program, to inform critical reflection and reorientation to empower Aboriginal wellbeing approaches in health promotion practice and policy. METHODS: Aboriginal and non-Indigenous researchers collaboratively designed a critically framed, strengths-based research approach with Aboriginal Community Controlled Health Service staff and wellbeing program participants. Data from Individual Yarning (n = 15) with program participants and staff inspired co-researchers to co-develop interpretations over two half-day Collaborative Yarning sessions (n = 9). RESULTS: Co-researchers depicted five lifeworld qualities that sustain an Aboriginal wellbeing program: love, connection, respect, culture and belonging. The lifeworld qualities are relational, communicative and involve the dynamics of identity, power and self-determination. CONCLUSIONS: The five qualities support a lifeworld approach to an Aboriginal wellbeing program, opening communicative and relational opportunities to mediate culturally responsive interactions. The qualities mediated interactions between people in the lifeworld including program participants and coordinators, and systems representatives including health service providers. A lifeworld approach provides a way to empower Aboriginal self-determination and leadership through embedment of cultural determinants of health in wellbeing programs. SO WHAT?: Health service providers and policy makers can use lifeworld approaches to guide critical reflection and reorient practice and policy related to Aboriginal health. The lifeworld qualities that encompass this approach in wellbeing programs are communicative and relational, centred on local community voices and co-produced with community for Aboriginal identity, empowerment and self-determination.

Revision of Malawi's Health Benefits Package: A Critical Analysis of Policy Formulation and Implementation.

OBJECTIVES: Health benefits packages (HBPs), which define specific health services that can be offered for free or at a reduced cost to fit within public revenues, have been recommended for over 30 years to maximize population health in resource-limited settings. However, there remain gaps in defining and operationalizing HBPs. We propose a combination of design and prioritization methods along with practical strategies to improve the implementation of future iterations of the HBP in Malawi. METHODS: For HBP development for Malawi's Third Health Sector Strategic Plan, we combined cost-effectiveness analysis with a quantitative, consultative multicriteria decision analysis. Throughout the process of development, we documented challenges and opportunities to improve HBP design and application. RESULTS: The primary and secondary HBP included 115 interventions. However, the definition of an HBP is just one step toward focusing limited resources, with functional operationalization as the most critical component. Full implementation of previous HBPs has been limited by challenges in aid coordination with the misalignment of nonfungible vertical donor funding for the HBP without accounting for the complexity and interconnectedness of the health system. Opportunities for improved application include creation of a complementary minimum health service package to guide overall resource inputs through an integrative approach. CONCLUSIONS: We believe that expanded participatory HBP methods that consider value, equity, and social considerations, along with a shift to providing integrated health service packages at all levels of care, will improve the efficiency of using scarce resources along the journey to universal health coverage.

Assessing the Value of Provider-Facing Digital Health Technologies Used in Chronic Disease Management: Toward a Value Framework Based on Multistakeholder Perceptions.

OBJECTIVES: Hardly any value frameworks exist that are focused on provider-facing digital health technologies (DHTs) for managing chronic disease with diverse stakeholder participation in their creation. Our study aimed to 1) understanding different stakeholder opinions on where value lies in provider-facing technologies and 2) create a comprehensive value assessment framework for DHT assessment. METHODS: Mixed-methods comprising both primary and secondary evidence were used. A scoping review enabled a greater understanding of the evidence base and generated the initial indicators. Thirty-four indicators were proposed within 6 value domains: health inequalities (3), data rights and governance (6), technical and security characteristics (6), clinical characteristics (7), economic characteristics (9), and user preferences (3). Subsequently, a 3-round Web-Delphi was conducted to rate the indicators' importance in the context of technology assessment and determine whether there was consensus. RESULTS: The framework was adapted to 45 indicators based on participant contributions in round 1 and delivered 16 stable indicators with consensus after rounds 2 and 3. Twenty-nine indicators showed instability and/or dissensus, particularly the data rights domain, in which all 5 indicators were unstable, showcasing the novelty of the concept of data rights. Significant instability between important and very important ratings was present within stakeholder groups, particularly clinicians and policy experts, indicating they were unsure how different aspects should be valued. CONCLUSIONS: Our study provides a comprehensive value assessment framework for assessing provider-facing DHTs incorporating diverse stakeholder perspectives. Instability for specific indicators was expected due to the novelty of data and analytics integration in health technologies and their assessment. Further work is needed to ensure that, across all types of stakeholders, there is a clear understanding of the potential impacts of provider-facing DHTs. HIGHLIGHTS: Current health technology assessment (HTA) methods may not be well suited for evaluating digital health technologies (DHTs) because of their complexity and wide-ranging impact on the health system.This article adds to the literature by exploring a wide range of stakeholder opinions on the value of provider-facing DHTs, creating a holistic value framework for these technologies, and highlighting areas in which further discussions are needed to align stakeholders on DHTs' value attributes.A Web-based Delphi co-creation approach was used involving key stakeholders from throughout the digital health space to generate a widely applicable value framework for assessing provider-facing DHTs. The stakeholders include patients, health care professionals, supply-side actors, decision makers, and academia from the United States, United Kingdom, and Germany.High levels of instability among stakeholders and value domains are demonstrated, indicating the novelty of assessing provider-facing DHTs and their impact on the health system.

Phosphorus recovery from domestic wastewater: A review of the institutional framework.

Phosphorus (P) is an essential element for life that must be managed sustainably. The institutional framework for P recovery from wastewater includes policies, regulations, plans, and actions that promote the recovery, recycling, and safe use of this element, aimed at moving toward more sustainable nutrient management and environmental protection. This review analyzes the status of the institutional framework for P recovery from wastewater in different countries around the world. Europe is the continent where the most progress has been made in terms of legislation. Countries such as Germany, the Netherlands, Austria, and Denmark have already implemented policies and regulations that promote environmental protection, as well as P recovery and reuse. In other parts of the world, such as the United States, China, and Japan, there have also been significant advances in promoting the closure of the P cycle, with the implementation of advanced recovery technologies in wastewater treatment plants and regional/national action plans. By contrast, in Latin America there has been little progress in P treatment and recovery, with a weak regulatory framework, unclear goals, and insufficient allocation of techno-economic resources. In this context, it is necessary to reinforce the comprehensive institutional framework, which covers technological aspects, economic incentives, political agreements, and regulations, to promote the sustainable management of this valuable resource.