We carried out co-authorship and co-citation network analyses of authors and documents in VOSviewer. Results: We identified two main co-authorship and co-citation groupings. Our document co-citation analysis also identified four clusters with two major groups, the Defining HIA cluster and the Describing the fields cluster versus the Active transport quantitative HIA cluster, and the Quantitative modelling tools cluster. Conclusion: Our findings strongly suggest that there exist two groups of thought in the scholarly fields of HIA and health in EIA. Barriers to developing more methodologically integrated approaches to considering health within EIA are related more to disciplinary differences than field (HIA versus EIA)-based differences and we advocate for the development of transdisciplinary approaches to both HIA and EIA.Background: The fields of Health Impact Assessment (HIA) and Environmental Impact Assessment (EIA) have grown with increasing numbers of disciplines and sectors contributing to their advancements, but with it, perceived conflict over methodological and disciplinary approaches to integrate health in impact assessments. This study maps the current field of HIA and health in EIA to examine the scientific landscape of the field. Methods: We carried out a bibliometric analysis of HIA papers and EIA papers that included a health focus in peer-reviewed journals in the Web of Science Core Collection ( Recent legislative developments such as the European Union Environmental Impact Assessment (EIA) Directive (2011/92/EU amended by 2014/52/EU) requiring the consideration of health within EIAs have strengthening the need to integrate methodological and disciplinary approaches. Cave et al., in this Special Issue, argue that “Health in EIA requires a framework that applies to topics with different methodological and epistemological frameworks. A single assessment will present numerous findings on different topics and can, therefore, use both quantitative and qualitative approaches” [There is now a body of literature on the relationship between a health impact assessment (HIA) and EIA and how health is considered within EIA ,2,3,4. RImplicit (and sometimes explicit) within the literature are differences between disciplinary and paradigm perspectives—a so called paradigm war where paradigm and related epistemological and methodological differences are seen as incommensurate . ParadigBoth HIA and EIA are concerned with creating knowledge about the potential impacts of an activity . We (and others) believe that the dominant disciplines within EIA and HIA fields tend to have different paradigm perspectives ,5,11,12.Generally, fields that have tended to utilise a positivist or post positivist paradigm share a view that what is knowable is what can be observed and measured. These fields privilege certain methodologies and the methods used within research, with a greater focus on quantitative approaches (counting things) relying on empirical observation and measurement . WhereasThe reality is more complex and nuanced than presented here, with individual practitioners and researchers within the different fields having a mix of paradigm perspectives and not all quantitatively inclined researchers being positivists and qualitative, social constructivists. However, for the purpose of this paper, our focus is on identifying overarching tendencies and characteristics within the fields of HIA and EIA and our main point is that fields and the dominant disciplines within them tend to draw on particular paradigm positions and these paradigm positions tend to be associated with certain types of methodological approaches. This influences the questions asked, the methodological approaches used, and the value placed on different types of data.These differing paradigms are often not made explicit or, in some cases, practitioners may not even be aware of them. However, as Carter and Little  observedAre there any distinct clusters of literature and authors within the fields of HIA and health in EIA literature?(a)What is the nature of linkages between clusters?(b)Can we identify distinct paradigm and/or disciplinary boundaries between clusters?(c)Can we identify key themes and areas of focus within clusters?If there are clusters:In this paper we utilise bibliometric analysis techniques to investigate the broad fields of ‘health impact assessment’ and ‘health in environmental impact assessment’. The following questions guided our analysis:To collect the publications for the bibliometric analysis, we searched for articles in peer-reviewed journals in the Web of Science Core Collection of which the main topic of study was EIA with an explicit health component or HIAs. The search terms “health impact assessment*” OR “HIA” OR “HIAs” were applied in the title or author keyword fields to capture articles addressing health impact assessments and the search terms “health” AND  were applied to capture publications that address health in the context of environmental impact assessments and strategic environmental impact assessments. Additional limiters included language (English), years (2015–2020), and type of publication (article). Early access publications were excluded. Although our bibliometric analysis includes all the cited references that were listed in the reference list of the publications as the data source, we included only the years 2015–2020 to analyse the co-citation pattern in the current scientific literature.We used the Gothenburg definition of HIA:A combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of its effects within the population ;The IAIA definition of EIA:refers to a formal and systematic process that includes identifying, predicting, evaluating, and mitigating the biophysical, social, and other relevant effects of development proposals prior to major decisions being taken and commitments made .We purposely used the Web of Science as our sole bibliographic database because the visualisation software tool we used, VOSviewer, has maximum functionality for Web of Science and does not support mixed use of other databases. Limiting the search to Web of Science did not introduce any critical limitations to the study because Web of Science is a comprehensive scientific database, and we could assume saturation was achieved. Additionally, this was fit for purpose because the aim of the study was to examine the overall pattern of the two fields and not a comprehensive statistical analysis.The search retrieved a total of 556 items. We then imported the search results to Covidence to exclude irrelevant studies that did not address HIA as ‘procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population’ . We incl2, Cytoscape, CitNetExplorer, HistCite have been developed for analysing and visualising bibliometric and citation networks [Visualising bibliometric networks provide a powerful and efficient method to understanding the overall landscape of the topic area by quantifying and illustrating the relationships of publications. Several software tools such as Pajek, Gephi, VOSViewer, CiteSpace, Scinetworks . In our There are many different types of bibliometric mapping and analytical methods that can be performed of authors, journals, publications, countries, and institutions and can be applied at levels of titles, keywords, text, and even entire citation records ,24. In tCo-authorship relationships show scientific collaboration patterns of authors and visualise the existing research communities in the field ,23,24. WCo-citation relationships, on the other hand, visualise the intellectual structure of the scientific field ,23,24. TBecause co-citation relationships are based on the cited documents, external publications were added to the co-citation analysis. Furthermore, because co-citation is a relationship which is established by the citing authors, co-citation patterns can change over time. Changes in the co-citation patterns, when viewed over a period of years, may provide clues to understanding the mechanism of specialty development, or changes in the paradigm. In this paper, the co-citation map was produced on articles published during the years 2015–2020, which shows the current intellectual structure of the HIA and health in EIA fields.The findings are presented in two parts—we first identified two major groups of co-authorship clusters, which was further supported by an author co-citation analysis. To further confirm the pattern, we looked at the document level and found four distinct co-citation clusters. A content analysis of the top co-cited papers in each cluster is presented. Throughout the paper, we used the term clusters to describe the distinctive aggregation of closely related publications or authors that were represented in different colours. The term group represents closely related clusters.In the network of the 229 publications included in the analysis, there were 880 authors. The co-authorship network of these authors is depicted in A closer examination of the authors and their disciplinary backgrounds   showed tThe co-authorship pattern was consistent with the author co-citation network . The autThe document co-citation network showed four clusters of strong co-citation relationships . DocumenIt was difficult to distinguish the differences between the Defining HIA cluster (Green) and the Describing the fields cluster (Blue). It did seem to suggest that the Defining HIA cluster (Green) addressed HIA while the Describing the fields cluster (Blue) contained discussions about both HIA and Health in EIA. In the Defining HIA cluster (Green), there were two main types of papers: 1. large scale evaluations of HIA effectiveness and 2. papers defining and describing HIA. An examination of the disciplinary perspective of the (lead) authors identified an overarching public health disciplinary perspective with a tendency towards disciplines with an implicit social constructivist or interpretivist paradigm perspective. Meanwhile, the Describing the fields cluster (Blue) differentiated itself from the Defining HIA cluster (Green) in that it focussed on papers describing the field of HIA, Health in EIA and EIA, with the authors making recommendations to strengthen the fields. This cluster demonstrates a mix of disciplinary perspectives covering public health/medicine, environmental epidemiology, and social research with a tendency more towards positivist paradigm perspectives than the Defining HIA cluster (Green).The Active transport quantitative HIA cluster (Red) and the Quantitative modelling tools cluster (Yellow) tended to show characteristics of the positivist methodological aspects of HIAs or EIAs such as epidemiological evidence and quantification and modelling for the assessment of health impacts. The Active transport quantitative HIA cluster (Red) focussed on the relationship between the active transport and health with papers containing modelling and/or estimating health impacts of scenarios utilizing quantitative assessment methods. In comparison to the Defining HIA cluster (Green) and the Describing the fields cluster (Blue), the main disciplinary perspective was epidemiology with a clear positivist paradigm perspective. The Quantitative modelling tools cluster (Yellow) also shared a strong positivist paradigm perspective with environmental epidemiology being the dominant discipline. These papers either described quantitative HIA tools or their application.We also noted that, when we were screening papers for inclusion in the study, a number of papers with a strong quantitative modelling methodological focus used the term HIA differently than we as HIA practitioners and academics would. In the field of HIA, there is a very strong procedural element involving screening, scoping, identifications, assessment, and the development of recommendations ,13. In oWhen examining the geographic focus of the papers, we could see that the Defining HIA cluster (Green) and the Describing the fields cluster (Blue) had an international spread of papers, whereas the more technical Active transport quantitative HIA cluster (Red) and the Quantitative modelling tools cluster (Yellow) were predominantly European in focus.When examining the co-citation map , it was Each circle denotes a cited publication, and the lines indicate co-citation relationships. The size of the circle represents the number of citations. The larger the circle, the more frequently the publication was cited. The colours indicate clusters of publications with strong co-citation relationships.Our findings showed the current overall landscape of the field of Health in EIA and HIA and two major groups of research traditions (or paradigms) within the fields could be identified. The two research traditions were not defined by differences of the field, (EIA versus HIA), but by disciplinary, methodological, or paradigmatic differences.The bibliometric networks showed a clear cluster of quantitative, environmental health focused publications and authors (shown in red) sitting separately from the other main clusters (green and blue) in terms of co-citation and co-authorship. This does not necessarily mean that the authors and papers were not engaging with each in other ways, but this did not show up in the bibliometric analysis. Interestingly, although the focus of the papers was environmental health, they were within the context of HIA. We were unable to tell from our analysis whether this was linked to environmental determinants being more amenable to quantification than social determinants or whether the field and discipline interest drove the focus on environmental health pathways. Environmental health determinants are of particular relevance to health within EIA projects, given the material physical nature of those projects; however, we also saw these quantitative methodologies being applied within the HIA papers. These methodological differences could be linked to implicit paradigm differences, with quantitative methods being more strongly linked to positivist paradigm perspectives and qualitative or mixed methods being linked to social constructivist/interpretivist paradigm positions.Furthermore, and more importantly, our analysis showed that there was crossover between HIA and Health in EIA in terms of co-authorship and co-citation, with some authors acting as boundary spanners bringing together the fields of HIA and EIA . Where we did see separation was in the discipline, methodology, and paradigm. The two groups that appeared in the document co-citation clusters demonstrated this with public health and mixed methods focused as a distinctive group, and quantitative methods focused and environmental and social epidemiology as the other. The fields of HIA and health in EIA were not separate; rather, they were represented in both groups. In conclusion, these findings suggested that barriers to developing more methodologically integrated approaches to considering health within EIA were related more to disciplinary, methodological, and paradigmatic differences than field (HIA versus EIA)-based differences. Or, in other words, it’s not so much that HIA and EIA are not integrated but rather that the core disciplines  within the fields are not integrated. This suggests that if we wanted to strengthen the consideration of health in impact assessments through a greater methodological integration, we should focus on ways of bringing the actors from different disciplines who work within HIA and EIA together.We, the authors of this paper, both drew on the critical realist paradigm to inform our work. From our paradigm perspective, it was not an either-or question to answer when determining what methodological approach is best suited to assess health impacts within an EIA. From a critical realist perspective, our environment is layered, ranging from the sub molecular to planetary level and there is interplay and emergence between those layers . This meThe value of HIAs is maximized by bringing together concepts, methodologies, and solutions from diverse backgrounds and disciplines. In doing so, a transdisciplinary approach that addresses both the overlapping and non-overlapping areas of the disciplines is required. This differs from multidisciplinary or interdisciplinary approaches as these approaches seek collaboration in the intersections of consensus or avoid areas that are in conflict . ArticulA bibliometric analysis is a powerful tool that visualises the overall landscape of a scientific field and presents a descriptive overview of the relationships of the selected publications in an efficient way. However, caution is required in the interpretation and replication of the results. Results from bibliometric analyses vary depending on the search and inclusion criteria and the clustering parameters. The parameters are selected based on the research question which, in this case, was influenced by the researchers’ underlying beliefs and paradigms in relation to HIA. For example, both researchers in this review are HIA practitioners and researchers and both hold a critical realist paradigm position that influences our understanding of the determinants of health and the function of HIA as a tool in the policymaking process. As such, we drew on a broad social model of health, participatory methods, and mixed methods. The positions of the researchers not only prompted the overall research question but were reflected in the execution of the bibliometric review. Firstly, in screening the publications, we applied a set of inclusion criteria that would include HIAs that addressed the broader social concept of health and a wider range of methodologies applied in assessing health impacts. A search, filtering, and analysis by reviewers who follow positivist paradigm or come from biomedical fields may produce different results and interpretation than reviewers who embrace constructivist or the social model of health paradigms by setting a different set of inclusion criteria. Secondly, in determining the patterns of clusters, what we identify and interpret as unique clusters may be different to what others may find as clusters of significance.Some limitation should be considered in understanding the findings of our review. The publications were searched from one multidisciplinary database, a decision determined due to technical reasons. While searching from only one database may be criticized for a systematic literature review that emphasizes comprehensive and exhaustive searches, this method was adequate as the database is one of the largest multidisciplinary and comprehensive academic databases. We limited our search to English language publications but were aware of significant French and Spanish and other localized non-English fields of work that we did not include. We limited our search to papers that were identified as either HIA or EIA. We did not explicitly search for other forms of impact assessment that may include health such as the Integrated Environmental Health Impact assessment, or the Strategic Health Impact Assessment or Social Impact Assessment. Future research could consider health in all forms of impact assessment; however, this was beyond the scope of our paper. In our analysis of disciplinary backgrounds of authors within clusters, we based our assumptions on the job title and publicly available information of degrees held. This may not align with how the authors identify their disciplinary perspective. We included peer-reviewed journal publications from the recent 5 years as we believe they will be sufficient to demonstrate the current landscape of the field of HIA. Future work would look at other time frames to examine how the field has changed over time. Despite the limitations of bibliometric analyses, this methodology is fit-for-purpose.Our study was the first bibliometric analysis carried out in the fields of HIA and EIA. By providing an overview of the current leading clusters of publications and authors our paper provides an introduction and synopsis of the current state of play in academic literature. Future research could build on our work through, for example, examining how the field has developed and changed over time and also considering how different clusters assess health impacts. We would also welcome and encourage researchers with differing disciplinary perspectives to engage with and offer alternative interpretations of our data.A bibliometric analysis of the fields of HIA and Health in EIA demonstrated that there are existing linkages between the fields of HIA and EIA. In a sense, the fields are already talking to each other. However, there were also groupings of authors and their publications that sat in isolation from the broader fields.We argue that understanding the full range of potential health impacts requires more than multiple disciplines working in parallel. In a health and environmental impact assessment, multiple causal mechanisms operate at multiple levels. This requires multi-disciplinarity to understand different levels, inter-disciplinarity to understand multi causality and emergence and transdisciplinary work that goes beyond disciplines working in parallel or sequence to utilise integrative approaches ,49. FromIn terms of next steps, we call on our colleagues to work with us to find a way to bring the different clusters and disciplinary actors together in a conversation where we can learn from each other’s perspectives and identify ways to collaborate and engage in transdisciplinary work. For effective transdisciplinary collaboration to occur, it is important that researchers and practitioners understand the epistemological and ontological differences that underpin the knowledge and ideas that are generated. Furthermore, researchers and practitioners should actively apply transdisciplinary knowledge to draw a more coherent and comprehensive approach to HIA. By doing so, we will be able to attempt collaboration in the non-overlapping or marginal areas between the diverse disciplines rather than limiting collaboration to those overlapping areas. In doing so, as O’Campo reminds us “the ultimate goal of transdisciplinary approaches is to achieve social change by generating knowledge about real-world problems and solutions” .


Purpose.Epilepsy is one of the main brain disorders in the world and should be considered a priority for healthcare in Africa. Internet is a growing source of health information for healthcare and patients with epilepsy (PWEs). In this short communication, we tried to describe the status of websites on epilepsy in Africa in terms of availability and pertinence, and to suggest ideas on how to make them more effectiveMethodsThe existence of epilepsy websites and their distribution in Africa were acquired using a questionnaire sent to different neurologists in the African continent.ResultsBased on the survey answers and the web search, our results show that out of 54 African countries, only 16 countries (≈30%) have an active epilepsy website.ConclusionThe need for reliable, clearly written, and easily comprehended information about epilepsy is considered as an important element to enhance the quality of care, for this all African countries should create and improve their epilepsy websites in order to promote education and awareness. It affects people of all ages and is characterized by unpredictable recurrent seizures . The Afrpulation . Prevalepulation .Epilepsy is not only a medical condition; it also includes sociological and cultural dimensions. Africa has more than 24% of all illiterate adults in the world . So it iThe high rate of illiteracy and the lack of resources within the health system with a low doctors/population ratio are factors that allow epilepsy to affect the physical, psychological, and social functioning of patients and their families . In ordeTo obtain information on the existence of websites specializing in epilepsy and their contribution in African countries, a questionnaire was designed using a Google Forms survey application. The questionnaire was displayed on a single webpage with a submit button at the end of the page. The Google Forms uniform resource locator (URL) was distributed as a link by email sent to all neurologists in the African countries. Respondents entered and submitted answers directly via Google Forms URL. Each respondent was restricted to only one possible response in order to avoid duplicate response errors. Information collected includes the title, the country, and the number of neurologists, affiliation to the International Bureau for Epilepsy (IBE) and International League Against Epilepsy (ILAE), and the existence of epilepsy website.The questionnaire was distributed between March 2020 and August 2020. Data were stored by Google Forms. About the countries for which we didn’t get answers by the questionnaire, we proceed to a web search using Google search engine, which is the most used search engine in Africa. The keyword combinations used were the epilepsy website and each African country (in French and English). The list of web pages was included if they give educational, medical, or health information about any aspect of epilepsy. The results of the web research which does not serve to achieve our objectives have been eliminated. Statistical analyses were carried out with the software Microsoft Excel for Windows version 2007.The questionnaire was sent to more than 54 neurologists from 33 different African countries. A total of 27 answer forms from 22 different countries were received . The response rate varied substantially between different countries. The analysis of the questionnaire results found that the majority of respondents were neurologists in 76%, mainly working in public teaching hospitals (77%). From the 22 countries, the affiliation to ILAE was over 61%, while affiliation to IBE was about 50%  have an epilepsy website. While some countries excel in virtual epilepsy education and support, others don’t even own a local center or association for this matter, let alone a website, despite the high prevalence of this disease among African countries. Countries of North and South Africa come first in the availability of epilepsy websites compared to other regions of the African continent. Morocco, Algeria, Namibia, Swaziland, and South Africa have specific websites, dedicated to improving the epilepsy practice field and its neurophysiologic exploration. As for Egypt, Libya, and Tunisia, they have Facebook pages where they share useful information and updates with their followers. While Cameroon and the Democratic Republic of the Congo are an example for the countries of Central Africa which have an online platform; where people can get all information and instructions regarding epilepsy and its different aspects. They even pay home visits and share inspiring stories despite the huge pressure these countries are facing. In the East part of Africa, Kenya and Uganda established an online source, where they strongly defend quality care and equal opportunities, as well as empowering patients with epilepsy (PWEs) through awareness and second chances, by disseminating correct medical explanations and eradicating misconceptions.Epilepsy is the fourth most common neurological disorder worldwide . It affeThe results revealed that 2/3 of the African countries don’t have web pages dedicated to epilepsy. This lead to many African patients claiming information from incredible sources. The low number of epilepsy websites in Africa besides other socioeconomic and healthcare factors, keeps epilepsy greatly misunderstood, deeply stigmatized, severely underfunded, and most often, ignored by the healthcare system. Relatively some web pages displayed non-scientific information, while more accurate information was provided by websites of medical institutions and general health websites.With changing times, people are becoming more and more aware of the need to seek scientifically founded information. The world today is too conscious of the impact of epilepsy, but many people in African countries keep a sort of transition between non-scientific and scientific practices. This transition does not automatically embrace the full tenets of medical understanding. It appears that even with the presence of websites in some countries, the rate of epileptic patients properly treated is very low. It can be expounded by either the malfunctioning of the site, the inadequate and disproportionate proposal of the information within the website, or the socio-economic status of the African population. For that not only websites should be built; they must contain simple and significant information serving as a guide to people in need. Furthermore, websites should be supervised by the local health authority centers. These centers are obliged to check the utility and the value of giving information in order to build trusted websites concurrently with reputed sources. Websites alone aren’t enough, but the use of full technological advancements could help the African continent to improve medical knowledge and care to underserved populations.Despite the efforts made by the African countries in the fight against epilepsy, they should expand more South-South collaborations, along with establishing local African guidelines for epilepsy management and advocacy through websites and telecommunication ways. Developing electronic platforms with databases in Africa will promote epilepsy care and provide credible sources.


The traditional Japanese dietary pattern, “Washoku,” is considered to provide an ideal nutritional balance. However, it tends to have a high salt intake. To reduce population-level salt intake, it is important to review the overall dietary patterns over a wide area.  To identify dietary patterns with high salt intake, partial least squares regression analysis was conducted using population-based household survey data from 52 cities. Annual salt consumption was set as the target variable, and the annual purchase weight of 109 foods was set as the explanatory variable.  At least three dietary patterns  accounted for more than 90% of the variation in salt consumption and 29% of the explanatory variables (food purchases). Traditional patterns explained the salt consumption and regional differences in energy and protein consumption; however, their relationship to fat consumption was weak. The results reconfirmed that “Washoku” has an ideal nutritional balance but has high salt intake. The distribution of scores for traditional Japanese food patterns was high in northeast Japan and low in southwest Japan, with a geographical gradient. This pattern is thought to have formed over a long period of time because of the influence of environmental factors, such as local climate. In 2018, the traditional Japanese dietary pattern, “Washoku,” was registered as a UNESCO World Intangible Cultural Heritage. The Japanese eating style based on “Ichiju Sansai” (one soup and three side dishes) is considered to provide an ideal nutritional balance. By using “Umami” (dashi stock) skillfully, those who consume this diet ingest low levels of animal fats and oils, which is beneficial for longevity and for the prevention of obesity in Japanese people [In contrast, Japanese dietary patterns tend to have high salt content , 10. TheThe levels of salt intake in Japanese people are high in the northeast region, which may be due to differences in eating habits, food culture, and food availability, depending on the region . To reduHowever, there are challenges in conducting a national survey to understand the differences in eating habits and food culture in different regions. For example, in Japan, there is an annual National Health and Nutrition Examination Survey . HoweverHowever, household budget surveys are conducted in many countries to monitor the economic situation of the population, including the Family Income and Expenditure Survey (FIES) in Japan . The FIESince this survey is not nutritional, it is not possible to determine the exact amount of nutrient intake, but it is possible to identify an overall dietary pattern with a degree of validity. Previous studies that have derived dietary patterns from household survey data have been conducted in Europe and South America , 18.Empirical methods frequently used to derive dietary patterns include principal component analysis (PCA), reduced rank regression (RRR), and partial least squares (PLS) regression analysis. The dietary patterns obtained using PCA tended to explain the high variation in dietary intake, thus the dietary patterns of real populations. However, these patterns may not be relevant to variables of interest, such as disease risk or nutrient intake , 20. RRRTherefore, in this study, we attempted to derive the dietary pattern of high salt intake using PLS regression analysis using population-level food purchase data based on a household survey in 52 prefectural offices and ordinance-designated cities in Japan. In addition, we compared the results of the analysis in two different statistical years and examined the validity and reproducibility of pattern extraction.In this population-based study, we obtained annual mean food consumption data of households with two or more people in 47 prefectural capitals and five ordinance-designated cities from the results of the 2013 and 2018 Family Income and Expenditure Survey (FIES) as basic data. The data scale and sampling method are available on the homepage of the Statistics Bureau, Ministry of Internal Affairs and Communications . From thBased on the annual food consumption of 47 prefectural capitals and five ordinance-designated cities , we selected 109 foods with a record of purchase weight and calculated their basic nutritional value, including annual total calories, salt, protein, fat, and carbohydrates per household in each city. Nutritional values were calculated according to the 2015 Japanese Dietary Intake Standard . The anaTo identify the dietary patterns of high salt intake, PLS regression analysis was conducted using the annual total salt purchase weight from all foods  in 52 prefectural capitals and ordinance-designated cities as the objective variable and the annual purchase weight of 109 foods as the explanatory variable. PLS calculations were performed using the PLS package in R. The calculation was based on a correlation matrix –25. PLS We compared the 2013 and 2018 purchases for each of the 109 food products for each prefectural capital and ordinance-designated city and used Spearman's correlation coefficients to assess the reproducibility of the 109 food purchase patterns. In the comparisons, we did not adjust the amount purchased in each year by the total calories purchased, average income, or any other criteria.The loading vectors of 109 foods and 52 city factor scores obtained for each dietary pattern in each year were also compared to the 2013 and 2018 values, and their reproducibility was assessed using Spearman's correlation coefficient. In addition, the factor scores of the prefectural capitals obtained for each dietary pattern were displayed on a map to investigate the continuity and validity of the distribution.To compare food purchase trends in 2013 and 2018, we ranked the cities for each of the 109 foods in descending order based on purchase weight, and Spearman's correlation coefficients of the purchase rankings between 2015 and 2018 were calculated . The higPLS regression analysis was used to identify dietary patterns with high salt consumption from the 2013 and 2018 food purchase records. At least three factors (dietary patterns) accounted for more than 90% of variations in salt consumption and 29% of variations in explanatory variables (food purchases). In particular, the influence of the first factor was large, and more than half of the fluctuations in salt consumption were explained .In The first loading factor showed that the purchase of vegetables, seafood, and seasonings, such as salt and miso, was high. This may represent the aforementioned typical Japanese food pattern; thus, it was named the traditional Japanese pattern. The score of the traditional Japanese pattern was higher in the northern region than in the southern region; thus, a geographical gradient exists . The corContrary to the first loading factor, the second loading factor indicated that salt intake was suppressed when the purchase of vegetables, fruits, and dairy products increased . These sThe third factor showed that the purchase of seafood, such as shrimp and crab, resulted in a decrease in the amount of salt and the purchase of dairy products resulted in an increase in the amount of salt. These scores were low in coastal cities, such as Tottori and Akita, and high in inland cities, such as Nagano, Kofu, and Yamagata. Although it was not possible to associate a simple dietary pattern among the localities, local patterns were identified at a smaller scale than those captured by the first and second loading factors; thus, it was named the local Japanese pattern.We identified three major salt-rich dietary patterns  from food purchase records in 52 cities across Japan from the FIES using PLS regression analysis. Three dietary patterns accounted for more than 90% of the variation in salt consumption .The reproducibility of the dietary patterns from the FIES was acceptable. Spearman's correlation coefficient of the loadings of dietary patterns between 2013 and 2018 ranged from 0.88 to 0.63 . In addiThe major dietary patterns identified may have been reported in previous Japanese studies. Most Japanese studies have identified dietary patterns that are similar to the traditional Japanese patterns in this study; namely, this dietary pattern is characterized by a large intake of typical Japanese foods, such as vegetables, seafood, soy products, seaweed, mushrooms, fruits, and green tea , 26, 27.The distribution of the scores for the traditional Japanese food patterns was high in northeast Japan and low in southwest Japan, and a geographical gradient existed. Japanese food is characterized by seasonal ingredients, and this distribution may be closely related to climatic factors . For exaIn recent years, it has become clear that salt intake plays an important role in maintaining body temperature. Animal studies have suggested that the physiological need for salt intake may be increased in cold environments –30. It iA number of Japanese studies have also observed dietary patterns similar to those of the urban Japanese patterns observed in the present study, namely, patterns with high intake of meat, processed meat, dairy products, and raw vegetables. Other studies may have named these diets differently, for example, as westernized food patterns , 26, 27.Dietary patterns tend to vary widely between generations , 32–34. Urban households have high incomes and a high rate of food externalization . Due to In this study, bread was not detected as a representative ingredient in urban Japanese patterns. Unlike rice, bread can be eaten immediately, and no further preparation is required. In recent years, the consumption expenditure of bread has exceeded that of rice in Japan . Bread sTraditional and urban Japanese patterns have been observed in many other studies, but most of these are studies on individuals , 27. TheThe distribution of the score of the local Japanese pattern was dispersed, and there was no geographical continuity. It was not possible to associate the previously reported dietary pattern with the local Japanese pattern, but considering the distribution of scores for the first  and second (urban Japanese pattern) factors showed a degree of geographical continuity, and the third factor is thought to reflect a more local dietary pattern.The Japanese archipelago is made up of islands that stretch to the north and south. Japan is a volcanic country; thus, it is very mountainous with a wide range of altitudes, resulting in extreme variations in climate. In addition, the Japanese archipelago is influenced by the monsoon and has four distinct seasons. Such an environment becomes a factor that emphasizes regional characteristics, resulting in the development of various local dishes and unique food cultures in different regions. However, factor 3 was inferior to factors 1 and 2 in terms of reproducibility, and Spearman's correlation coefficient was 0.63, in the comparison between loading 2013 and 2018 , and wasIn this study, PLS regression analysis was performed using the average values of household surveys taken in 52 cities to identify dietary intake patterns with high salt intake. Some food purchase patterns were regionally specific, and the geospatial distribution of scores over a wide macroregion provided insights into the factors involved in the establishment of the food pattern. In this respect, it was considered to be sufficiently effective and thus suitable for extracting dietary patterns. In this study, to avoid becoming arbitrary, we directly used the food purchase weight from the FIES for analysis. However, with respect to foodstuffs purchased in small quantities, purchase weights tend to fluctuate year by year; thus, it may be possible to obtain a more stable pattern by excluding such foodstuffs.On the other hand, the FIES includes a limited number of purchased food items, and there are discrepancies in the dietary survey items targeted at individuals. For example, regarding the intake of beans, which are characteristic of Japanese food, only “tofu” is subject to a weight survey. In addition, foods such as tea and alcohol are often purchased as gifts; thus, the values obtained may not reflect intake.In addition, in the analysis using the average value for each city, the purchase pattern at the individual level was smoothed, and the food pattern phenomenon occurring at the microlevel was offset. Therefore, while household surveys can help develop data that are representative of dietary choices across a wide range of countries, the insights derived from them do not directly apply to individuals.In conclusion, we used the FIES data to identify three Japanese dietary patterns with high salt intake  and confirmed that this method was effective and reproducible. While household survey data represent food availability rather than consumption, this method is useful for the long-term representation of dietary options across a wide region of the country. Therefore, FIES data could help to identify a variety of food choices and allow the appropriate planning of broad-based nutrition advisory activities .The salt intake of Japanese people is decreasing annually. It is also considered that the dietary patterns of Japanese people are gradually changing. However, the traditional dietary pattern is still the main dietary pattern of the Japanese, and it is expected that it will be inherited in the future. This pattern is thought to have formed over a long period of time because of the influence of environmental factors, such as local climate. In the future, in order to achieve further salt reduction, it will be important to consider these characteristics and provide nutritional advice while taking advantage of traditional dietary patterns. The results of this study suggest that Japanese salt intake is high due to regionally specific factors. Therefore, FIES data could help to identify a variety of food choices and allow the appropriate planning of broad-based nutrition advisory activities.


Informed by different grassroots learning and educational practices engaged in waste management, and drawing from the concepts of insurgent citizenship and environmental stewardship, we examine the role of waste picker organizations and movements in creating new pathways towards more sustainable environmental waste governance. Two case studies (Argentina and Brazil) demonstrate how waste pickers inform and educate the general public and raise the awareness of socio-environmental questions related to waste management. Different educational practices are used as strategies to confront citizens with their waste: to see waste as a consumption problem, resource, and income source. Our paper draws on grassroots learning  and education (stewardship) aimed at the transformation of waste practices. We argue that waste pickers play an important role in knowledge production promoting recycling, in landfilling less and recovering more resources. We conclude that waste pickers act as insurgent citizens and also are environmental stewards. Solid waste is a significant urban problem, receiving increasing attention by the public and government. In many cities in the global South, municipal waste is still primarily landfilled or dumped. Often, peripheral neighborhoods do not have regular garbage collection and the locals dump or burn their waste, if it is not collected by informal or small-scale waste entrepreneurs and waste pickers , 2017. MGrassroots initiatives in the global South are challenging the current waste regime by rising socio-environmental concerns in waste management . RecycliWaste pickers organize in cooperatives, associations, or unions to participate in waste management, providing different services, for which they want to be recognized and remunerated. Organized waste pickers are part of a community of practice. They meet regularly in cooperative assemblies, network meetings or other meetings, workshops, or conferences, where they can share their work experiences, expand their capacities and use their agency for advocacy. They promote recycling in their communities, sometimes by engaging in educational tasks, such as informal conversations with households, presentations at schools or community centers, or through participating in formal programs linked to environmental education. Some scholars argue that these grassroot initiatives and networks have turned into the new social movements of the urban poor that, intentionally or not, challenge the nature of the state, local governments, and civil society . We agreWaste pickers benefit from what This paper connects the literature on social movement learning with the work on environmental stewardship, to be introduced in the next section of this paper, by examining the role of organized waste pickers, part of a social movement, in creating new pathways towards more sustainable environmental governance and a more just society.The paper is informed by the educational practices of waste picker organizations in Brazil and in Argentina, which the authors have accompanied for more than 10 years. These initiatives constitute important innovation spaces for sustainability and social justice . AddressIn the next section, we introduce the theoretical framework bringing together ideas on social movement learning  and enviDiscourses on waste vary significantly, with narratives drawing from landfilling as the solution in the past, to presently landfilling less and recovering more . IncreasPeople have always found a way to extract value from specific waste . ParticuOrganizing collectively, for example, into cooperatives, associations, networks, or social movements provides opportunities for empowerment and use of agency. In the case of waste pickers, their level of organization has allowed them to expand their knowledge and has already created significant changes and successes for the waste pickers. We discuss learning as “social movement learning,” describing how the organization of waste pickers contributes to social learning, which then frames educational processes to improve recycling.Waste management education has been portrayed for the global North as a governmental tool used to discipline and normalize citizens into the dominant waste narrative of the prevailing waste regime, which currently worldwide depends on consumerism and throw away practices . From thIn the global South, the absence of waste collection and poor waste management practices as well as the lack of education often cause severe environmental and public health problems. Informal neighborhoods, which often expand over large areas, are not serviced by formal waste collection . When loIn Brazil and Argentina, part of the waste pickers organize in cooperatives, associations, unions, federations, and networks and form social movements which provides new formulations on how to deal with waste and how to promote participatory waste management, disrupting existing assumptions about them that have sustained stigma and marginalization. The struggles of waste pickers, usually the most impoverished and socially excluded citizens, have also generated new movements of insurgent citizenship based on their claims to have a right to resources and spaces in the city as commons . HolstonSão Paulo Recycling Forum, and, in 2001, waste pickers formalized the organization of the National Recyclers’ Movement (MNCR) (Redes) and inter-networks (Inter-Redes). In the case of Argentina, in 2011, the Argentine Federation of Waste Pickers  was created, which is now part of the Confederation of Workers of the Popular Economy (Confederación de Trabajadores de la Economía Popular). The Confederation brings together waste pickers, street vendors, small farmers, workers in recovered factories, and textile workers.The idea of resistance and manifestation is central to the organized waste pickers whom we identify as “insurgent citizens.” Waste pickers and their allies create new spaces of active citizenship, according to t (MNCR) . The mosThrough these organizations waste pickers have become forces and a movement acting outside the state. Learning is a cognitive process that can take place in informal or incidental ways, in specific social contexts and can occur purely through observation or direct instruction. The learning can be enhanced when controversies are viewed and engaged in. The different world views of the collaborating actors then become assets in the process of transformation. Often starting out with conflicting world views and experiences, over time the different parties reach mutually agreeable problem definitions and develop solutions to questions and new products, or they develop practices based on reordered priorities and alternative values. These knowledge sharing interventions among members of the social movement  or with other interlocutors  can be intensive and empowering for the participants.The spaces where waste pickers act had to be conquered over many years and with persistent struggle. In some cases, waste picker organizations have a close dialogue with local politicians, advancing the movements’ agenda of inclusive waste management. Yet, as Holston notes, “the result is an entanglement of democracy with its counters, in which new kinds of urban citizens arise to expand democratic citizenships and new forms of urban violence and inequality erode them” , p. 246.Often waste pickers actively engage in environmental stewardship practices, through which they seek to transform the politics of waste management, granting them fair remuneration for their services. Different circumstances define whether and how individuals or groups become involved in stewardship activities. In these cases, the individuals or groups make use of their agency and the existing structure to act as socio-environmental stewards. We take the definition provided by Bennett, et al. for local environmental stewardship, as “…the actions taken by individuals, groups or networks of actors, with various motivations and levels of capacity, to protect, care for or responsibly use the environment in pursuit of environmental and/or social outcomes in diverse social–ecological contexts” , p. 597.This article builds on research which was conducted by the authors in São Paulo and in Buenos Aires. Three of the authors have a long standing relationship with the waste pickers in the region and can draw on many years of participatory research with waste pickers. In both cases, the authors work with participatory and action oriented research frameworks, embedded in an epistemological understanding of knowledge being co-generated with the participants during the research process. The authors were only instrumental in helping organize and facilitate the meeting space, and systematize the observations, voice recordings, and additional information collected during the research. In both cases, waste pickers were involved from the beginning in the design and implementation of the interventions. It is the authors’ understanding that participatory research is praxis oriented and transformative. Early on in the research process, during meetings with waste pickers and informal conversations during visits to the cooperatives, waste pickers identified the need to work on interventions or actions that would support the de-stigmatization of waste pickers, and improve the work in selective waste collection programs, advancing the level of knowledge amongst waste pickers and in general in the community.This grassroots–academic collaboration  is basedParticipatory action research (PAR) promotes mutual involvement, personal growth, and empowerment of the participants through the research process . ResearcParticipatory and empowering approaches are becoming more widespread in environmental and social studies, involving citizens as scientists, co-generating knowledge . ParticiAn emphasis on emancipatory transformation is often implicit in the tools applied in PAR, and interventions can transform the lives of the participants. We have used workshops, general assemblies, participant observation, and citizen scientists approaches to work through the interventions. Throughout the application of these tools, we documented, transcribed, and systematized the information for data analysis, making sure to incorporate the feedback received from the participants. The specific approach and methods applied will be introduced for each of the two case studies in the following sections.Next, we will introduce the empirical studies, conducted in Argentina and Brazil, focusing on the similarities in terms of structure and agency of the main protagonists involved in the activity of insurgent citizens, educating for environmental stewardship.This case draws on ethnographical research, based on PAR, that one of the researchers conducted with the National Waste Picker Federation  since August 2016. The key objective of this research was to develop systematized data that shows the developments of the federation that let the cooperatives to become part of the Integrated Solid Waste Management program. In Argentina, waste management is organized by the local governments, and waste picker cooperatives in Argentinian municipalities often struggle to be part of the local waste management system, managing the recyclables materials.Anuillan  is a recycling cooperative composed mostly of women. The cooperative is also a member of the excluded workers movement (Movimiento de TrabajadoresExcluidos—MTE) and of the FACCyR, which is affiliated to the Workers Confederation of the Popular Economy (Confederación de Trabajadores de la Economía Popular—CTEP), in Argentina.Anuillan and the Recycling Board of the city of Buenos Aires (DGREC) decided to start an environmental stewardship program. Even though, waste separation is mandatory in the city of Buenos Aires since 2002, there was no state program in place to introduce or to reinforce the recycling program as a form of household waste management. The government did not encourage resource separation, while the waste pickers continued to access open curbside garbage bags containing mixed waste, in order to find the recyclables amongst the discarded materials. Under the environmental stewardship program, information about waste separation at the source is collected and the program teaches households about recycling and brings them in contact with the waste pickers that work in their neighborhood, in order to start waste separation at the source. The women involved in this program developed a pedagogical approach, where they conducted a survey and, at the same time, hold informative conversations with household members, they speak at schools and other community institutions, and they promote the idea about source separation during recreational activities in parks and at public recycling centers, where the community can deliver their recyclable materials.In 2014, In September 2016, FACCyR who is committed to improving the livelihood conditions for all waste pickers in the country understood the importance of the role of the cooperative members as being the first link of the chain in a model of waste recovery, and they decided to replicate this experience with other cooperatives. In 2016, the researcher began working with FACCyR in two cooperatives, to whom the researcher established a trustful relationship, which reflects inconsistency in the support provided to the groups, the development of projects, and the stimulation of joint discussions and workshops to address the problems the cooperatives are facing . Based o• Introduction to the program of environmental stewards• The challenge to separate waste at the source• General concepts related to waste management systems• Laws and regulations in waste managementThen, the researcher collaborated with many other courses to adapt these to the needs of the waste pickers in other cooperatives, also associated to FACCyR. The researcher took notes on key learnings, concepts, and methods from the course and passed them to the promoters as text. These notes allowed the systematization and the reformulation of the workshops and finally led to the development of the course material. The content of the courses is focused on four key themes:The content was then discussed and collectively adjusted during follow-up meetings. Based on these courses, a guide was created, together with the development of a program for these courses. By doing so, not only the materials were developed but FACCyR also created a policy to set up these courses throughout the country with all cooperatives that are members of FACCyR. This social learning experience then also contributed to the creation of the training program itself.Being a policy “made by women for women,” oriented towards waste pickers with a specific gender perspective and recognizing the work of women as a central part of the relationship between households and waste pickers, makes this program one of the foundational proposals for an Integrated Solid Waste Management Model with social inclusion, as part of the main demand of FACCyR’s platform, nationwide. Women were generally the ones who, during the door-to-door collection in the streets, established the links with the merchants and households. Being a woman made the communication easier, and strangers felt less intimidated than being contacted by men. The policy seeks to recognize the specific role of women and, at the same time, re-signifies their place in the work of collection and classification of recyclables. This Integrated Waste Management Model, where the promotion of source separation is a key issue, is being proposed in different places all around the country and, at the moment, it has been adopted by all members of the federation, as a central aspect of the work of waste pickers, not only to support their livelihoods through waste diversion but also as a way of rendering visible their work in the streets, in schools, sport clubs, and government offices.Fundação Centro Universitário Santo André(FSA), where waste pickers have been invited to present in lectures and to participate in the dialogue with students and staff during the ‘Environment Week’ (Semanas Integradas do Meio Ambiente). The interventions of these waste pickers have challenged the everyday academic space and practices, traditionally perceived as symbol for authorized and legitimate knowledge development and expertise. This case study describes experiences invovlving two of the authors engaging with environmental education carried out by waste pickers in collaboration with academics from the University of Saaaaaa.The São Paulo case study, focuses on environmental education activities at the University Participatory Sustainable Waste Management (PSWM) was developed using a PAR approach. Throughout the Project, exchanges of experiences and actions were developed in collaboration with waste pickers, contributing to their personal development, self-worth, internalization of cooperative values, and solidarity economy, and also with the appropriation of sociopolitical and environmental contexts  aimed at strengthening waste pickers and public policies for waste management with social inclusion, a partnership between the University of Victoria – CA, the Faculty of Education at the University of São Paulo (USP) and is FEUSP, the Foundation, supporting USP, with a grant from the Canadian International Development Agency (CIDA). This partnership project called contexts . In 2006Furthermore, since 2011, waste pickers have been involved in giving talks and engaging in educational activities on recycling and related socio-environmental issues, specifically touching on waste challenges in the metropolitan region of São Paulo. During the lectures, the waste pickers’ stories highlight their origins and their everyday work experiences, pointing towards their struggles and difficulties to survive as well as their advances in organizing and creating new spaces as cooperatives, networks, and as a social movement.The knowledge shared by these waste pickers include insights into technical aspects of the collection and separation of recyclable materials and their transportation, the organization and governance of work in cooperatives, the socio-environmental impacts caused by waste, as well as the necessity to prioritize waste avoidance and reduction. The waste pickers bring technical information with a critical positioning regarding the interests of their professional category and regarding the environmental impacts from waste which are a collective concern. Even given all the differences between the various speakers, over the years, their discourses emphasize the need for change in consumption behavior and the struggles to design public policies that are inclusive and tackle the social and environmental issues related to waste.In 2013, the Environment Week was carried out slightly different. The event was aimed at highlighting the need to implement selective waste collection and this intervention should help raise awareness among students, teachers, and employees on waste issues and the role of waste pickers. Piles of waste accumulated during the previous day was displayed in the universitys courtyard. The dialogue between waste pickers and the public developed as soon as the students left the classrooms and, along with their teachers and staff, visited the exhibit showing the garbage pile These lectures and critical dialogues around the topic waste at the university have developed follow-up interventions. The waste pickers involved were able to sensitize those who were present, by their special way of approaching the topic and by their communication filled with lived knowledge, emotions, and meanings. The work and struggles of the waste pickers, hitherto ignored by the academic community, were thus revealed. In this interaction, the waste pickers themselves were also challenged by entering new spaces and speaking in these spaces from which they were previously excluded.The agility performed by the waste pickers during these lectures indicates a possible contribution of the PSWM to their empowerment , which was later expanded throughout the networks of interactions between groups in the region as well as their participation in the National Waste Pickers Movement (MNCR), which they helped to strengthen. In parallel, the exchange of experience has supported the empowerment of waste pickers but has also helped make these organizations stronger. At the beginning of the PSWM project, a long process was required until the waste pickers felt at ease in the physical space of the university, which they never dreamed of having access to. Then during the events, they appeared as protagonists in the teaching of various types of knowledge. Our long term contact with waste pickers, dating to the beginning of 2005, allow us to perceive such changes.Since then, the waste pickers have also been lecturing in different elementary schools, bringing to these spaces a reflection and awareness through the encounters with their real world, giving new meanings to the knowledge usually stripped of the historical complexity that engenders socioenvironmental problems.The approach by the waste pickers to socioenvironmental themes at the university has instigated yet another important dimension, impregnated with meanings and social representations : regardiWaste pickers' voices are usually not recognized within the Social Sciences, but through their narratives, the social, economic, cultural, political, and human dimensions of their exclusion becomes evident. In interactions, they demonstrate that beyond the work they do, they are also people, social subjects. This was a more frequent and relevant aspect that emerged out of the reports from the students delivered after the lectures. Since the first intervention, the awareness among students and faculty had increased and particularly students showed a higher level of interest and sensitivity to selective waste collection issues, attested by the surveys conducted after these Environment Weeks. In addition, the community’s response to institutional debates on the implementation of selective waste collection was greater which, in 2017, resulted in the implementation of the Selective Waste Collection Program at FSA. This accomplishment was not only the result of the lectures given by the waste pickers, but also of the reports and research confirming the importance of their contributions.The following table  summarizThe collective impact of waste actors such as the waste pickers in Argentina and Brazil on improving the environment goes beyond the environmental and sanitation measures mandated by the government , and theOur research also shows efforts to diffuse and institutionalize these knowledges towards mainstream institutions. In Argentina, a collaboration with FACCyR works towards the development of a training manual and the systematization and programming of a course that can be replicated in different cooperatives throughout the country, thus expanding the impact of waste pickers’ environmental stewardship education. This process is also essential for the construction and consolidation of new paradigms. In the two cities, the institutionalization of these knowledges encountered a “porous” and receptive public administration (be it the city or the university administration)  that facIn the case of the environmental stewards in Buenos Aires, it was a bottom-up approach, with the waste pickers themselves being the ones that implemented the training with waste pickers, and not people from the outside, contracted by the government. In this way, they were able to fight for recognition, both of their work and of their specific knowledge regarding recycling. In the case of Brazil, while initiated with support from the university, waste pickers continued on their own, promoting environmental education at schools and among clients , giving presentations and engaging in meetings, often involving struggles and disputes in order to access new spaces and to de-stigmatize their activity.Ultimately these interventions, such as the waste related activities with waste pickers during the Environment Week at the university FSA in São Paulo have created the potential for generating more sustainable ways of producing, consuming, and living. Same results are achieved by the environmental stewardship of informed waste pickers in Buenos Aires who have been trained and educated to disseminate best material separation practices at the source. In the case of Buenos Aires, in buildings where only 20% of the housing units separated their waste, the number rose to 80% after the intervention of the environmental stewards. The interactions between waste pickers and university students, schools, ordinary citizens, politicians, and public officers, as well as with members from other organized waste picker cooperatives and networks are geared towards endurable changes in relation to solid waste and related socioenvironmental aspects, facilitating the transition between local scale and more structural societal changes . In bothcapillarization, the rooting of these learnings, reflecting in general perceptions and public policies related to environmental education  holds a place at the end of the pipeline in our society. In addition to the new knowledge produced, the studies reveal a change in attitude of these waste pickers in the direction of personal transformations, as evidenced by the very fact that they took responsibility for the performance of lectures and actions in which they became protagonists.In this paper, we argue for the expansion of the concept of local environmental stewardship to include the insurgent perspective of grassroots initiatives who get involved in diverse innovative, educational contributions. Insurgent citizenship involves those that manage to innovate amid the necessity of coping with urban inequalities . The intThe examples from Argentina and Brazil demonstrate how individuals who have historically been excluded and stigmatized, are speaking up, reinventing themselves as insurgent citizens and environmental stewards, making themselves heard in spaces they were previously not invited to, as, for example, the university. The cases serve to illustrate how knowledge production can be insurgent being co-created from the periphery of the systems by questioning the current culture of consumption and discard, giving the power to recover resources by ordinary people.Insurgent citizenship challenges established knowledges, questions technology assumptions linked to modernity, and critiques the concept of “the expert,” sometimes creating clashes with more powerful actors  in these newly occupied spaces. The learning that stems from these grassroots processes is insurgent. Insurgent learning is experiential and validated by everyday experiences of subaltern populations.In the case study from São Paulo, Brazil, the lectures allowed for the creation of a bond between students, teachers, and staff with the socio-environmental situation experienced by waste pickers, a social group largely excluded in all dimensions of life. In part, the lectures filled the frequent "void" between academia and reality, as observed in traditional research and even extension work, which often acts as "deposition of knowledge in communities" and understands social subjects as simple “study goals” . IdeallyThe knowledge of waste pickers allows for policy recommendations supporting other forms of interventions in waste management that have the potential to be most beneficial to the urban context. Their suggestions to the government include the need to commit to capacity building of waste pickers to implement door-to-door separate material collection and household education for recycling on an extensive scale. Anchored in public policies that guarantee continuous environmental education and awareness building, the quality of source separation and the recycling rates can be improved. Waste pickers also request to participate in reverse logistics schemes. EPR policies need to recognize waste picker organization as important actors in the circular economy. Finally, waste pickers require resources, technology, and access to knowledge to further improve their capacity to work in formal waste management and environmental education using their real life experiences with waste to leverage for greater awareness of the general public. From a socioecological perspective, waste pickers are important actors with the potential to address some of the most pressing waste related issues in the city, reducing waste leakage into the environment, increasing the circular economy, and promoting social inclusion.We agree with In this article, we have discussed the emergent spaces of invention and agency where waste pickers become active. New kinds of active citizens and citizenships emerge in global peripheral urbanization, as suggested by Finally, the interaction between knowledge produced in academia and local knowledge is always a reason for reflection, especially when the aim is to empower and expand the autonomy of exploited community social actors . Access


Objectives: Digital technologies in public health are primarily used in medical settings and mostly on an individual and passive way of use. There are research gaps on digital media facilitating participation, empowerment, community engagement, and participatory research in community settings. This scoping review aims to map existing literature on digital formats that enable participation in the field of health promotion and prevention in community settings.Design: The databases Medline, EMBASE, and PsycINFO were used to identify studies published from 2010 up to date (date of literature search) onward that used digital formats in all or in the main sequences of the process to enable high levels of participation in health promotion and prevention activities in community settings.Results: This review identified nine out of 11 included studies relevant to the research question. We found five studies that applied qualitative participatory research, two studies on peer support and one study each on empowerment and crowdsourcing. The digital technologies used varied widely and included social media platforms, bulletin boards, online forum webpages, and customized web providers and programs. Most studies mentioned anonymity, flexibility, and convenience as benefits of digital interventions. Some papers reported limitations such as difficulties by interpreting written-only data or the possibility of selection bias due to the digital divide.Conclusion: This scoping review identified only few studies relevant to our objective, indicating an existing gap in research on this topic. Digital formats were found to be particularly suitable for purposes where anonymity and flexibility are beneficial, such as for online peer exchange and peer support programs. The Ottawa Charta and the Alma Ata Declaration defined community participation as a basic element and key principle for health-promoting activities and programs , 2. The Communities can be defined as geographic entities ranging from neighborhoods to towns or cities, as well as larger geographic areas . IrrespeAdvancing digitalization offers opportunities to exploit new possibilities in the implementation of health promotion and prevention programs . Many diTo our best knowledge, there is no review identifying existing studies on digital formats for community participation, irrespective of a specific group or a specific type of community participation. For this reason, we conducted a scoping review to systematically map the research in this area on a broader level and identify core concepts.This scoping review aims to map existing literature on digital formats that enable participation in the field of health promotion and prevention in community settings to provide a better and more comprehensive understanding of the research area. This review will focus only on interventions with a true level of participation according stage model of participation by Wright et al., meaning that participants had at least to be involved in the decision-making process, and interventions that follow a digital approach at all stages of the participative elements. Specific aims are to describe (1) the participatory elements that were used in the interventions, (2) how the digital formats were used to conduct health promotion and prevention activities ensuring participatory approaches, and (3) benefits and limitations mentioned in relation to the digital format.We conducted a scoping review to identify existing literature on digital formats that enable participation in the field of health promotion and prevention in community settings. The aim of a scoping review is to map existing literature on a specific topic and to identify characteristics and concepts behind it . In contThis scoping review was based on the framework of Arksey and O'Malley  and incoThe following steps were conducted:Step 1: Identifying the research questionStep 2: Identifying relevant studiesStep 3: Study selectionStep 4: Charting dataStep 5: Collating, summarizing and reporting resultsArksey and O'Malley suggest an optional Step 6 where practitioners and consumers can be consulted . This sthttps://osf.io/v9jfc/).A protocol was developed a priori by the author team, following the same guidelines as described in this scoping review. The final protocol was registered with the Open Science Framework on February 21, 2021  Which participatory elements were used in the intervention? (2) How were digital formats used to conduct health promotion and prevention activities ensuring a participatory approach? (3) What benefits and limitations were mentioned related to the digital format?We focused on the participation levels six to nine, according to the stage model of participation by Wright et al. . It defi* OR municipal* OR citi* OR city OR local OR neighborhood OR rural OR urban AND community participation OR participatory research OR participat* OR empower* OR involve* OR engage* OR partnership AND internet OR mobile applications OR social media OR smartphone OR mobile OR online OR digital OR photo* OR video* AND health promotion OR public health OR prevention OR health education.Literature searches were conducted in the databases Medline, EMBASE, and PsycINFO. The search strategy for the database search included database-controlled vocabulary and additional keywords, using truncations to search by title and abstract. The search strategy was identical for all three databases, adapted to the respective subheadings of the database and contained the following terms: communitGiven the rapidly changing technological developments over the last decade, the search was limited to publications from 2010 to current studies (up to date when search was performed: 11/13/2020). Only studies in English were included.EndNote citation management software.Hand searches were additionally performed from the reference list of relevant reviews identified during the title and abstract screening to search for literature that may not have been captured by the databases used. After the search, duplicates were removed in the The third stage of Arksey and O'Malley's framework aims to identify the studies to be included in the scoping review. To maintain clear congruence between title, objectives, and research question, we based the inclusion and exclusion criteria on a PCC framework, consisting of the categories: population, concept, and context. “Study design” was added as an additional category .We searched for members of a community, including geographically defined communities, communities connected through common interests or lifestyles or virtual communities. We focused on intervention or research concepts that used digital formats in all, or in the main sequences of the process for enabling participation or empowerment in the context of health promotion or prevention. Any empirical study designs except reviews or meta-analysis were included. The inclusion and exclusion criteria are shown in Rayyan was used. Conflicting reviewer decisions whether a study met the inclusion criteria were discussed and resolved in the team.An iterative team approach was used for the screening process, which was conducted in two phases: first a title and abstract screening and second a full text screening with all included studies from the first phase. Prior to the initial title and abstract screening, an iterative process was used to screen the first 100 citations and discussed by the research team  until inclusion and exclusion criteria were sufficiently specified. For the screening of records, one author (CS) screened 100% of the citations. The other authors divided 50% of the citations among each other, resulting in half of the records being double-screened independently. For the screening process, the web-based literature management program In the following full-text screening, a similar approach was used, resulting in 100% of the records being double-screened independently. Again, all conflicting classifications were discussed and resolved within the team. To ensure that no articles were missing, reference lists of relevant reviews were screened by the first author by title and abstract, and in full-text where appropriate.The selection process is illustrated by a PRISMA flow chart displaying the results of the screening steps.Excel spreadsheet. Following the recommendations from Levac et al. , type and description of intervention, recruitment methods, data collection, sample size, analysis method, and findings.The data extracted for the specific information section were type of digital elements and further detailed description of these elements, type of participatory activities and further description (such as level of participation) and benefits, limitations and conclusions related to the use of the digital formats.The results were collated and summarized based on relevance to the research questions and reported in three tables. The first and second table focus on general information about each study, with the first table providing preliminary information and the second table presenting details about the methodology and results. The third table focuses on answering the three specific research questions. It contains information about the interventions related to the participatory aspect, the digital format, and the experiences made with it. The presented tabular results are accompanied by a narrative summary.Endnote, 3,735 articles remained for title and abstract screening. The reference lists of eight relevant reviews (n = 28), mostly because only abstracts were available, and “wrong concept in relation to the digital format” (n = 29). Of the included 11 studies, three reported on the same intervention ..Endnote,n = 6) followed a qualitative study design . There were also a high number of studies that had to be excluded because the full texts were not available. In addition, we conducted the database search in November 2020, which may have been too early to find relevant studies related to the COVID-19 pandemic. Second, we did not perform a quality assessment of the included studies and did not focus on ethical and data protection aspects of using digital formats. However, this was not considered relevant to the objective of this study, which was to collect existing literature on this topic and examine it for key concepts. Considering the relatively low number of included studies compared to the number of papers found by the literature search, this might be explained by the clearly defined and specific inclusion criteria, as we were looking for interventions with a high level of participation for communities and a high proportion of digital implementation in the intervention. This focus was also reflected in the search strategy, where we searched specifically for community, participation and their synonymous terms. These criteria were needed for narrowing the amount of publications found at the initial search. However, this may have led to the omission of publications that might have been of interest for our work. Despite these limitations, we do consider this clear focus to be a strength and a quality criterion of this paper.Other strengths of this review were the sound methodology based on recommended frameworks of Arksey and O'Malley and the PRISMA checklist for preferred reporting items.This scoping review only found a few studies following a consequent digital format to enable a high level of community participation in health promotion and prevention, indicating an existing gap in research on this topic. Digital formats were found to be suitable for purposes where anonymity is helpful. In the included studies, this was apparent in qualitative participatory research studies, particularly in online focus groups that required participants to talk about sensitive subjects. Furthermore, the aspects of anonymity and easy accessibility appeared to be beneficial in supporting vulnerable and stigmatized communities, such as through peer exchanges and peer support programs. Further research should be conducted on the purposes for which digital formats can be more effective than traditional formats in enabling participation, in order to make more targeted use of the potential of digital technologies and social media. Disadvantages of digital formats, such as possible selection bias due to the digital divide and difficulties in interpreting written-only data, have to be weighed against the benefits. The consequences of social distancing due to the COVID-19 pandemic and the unpredictability of similar exceptional circumstances in the future stress the need to further develop and implement digital formats in health promotion and prevention activities in community settings.CS conducted the database search. During the screening process, CS screened all records in the title/abstract and in the full-text screening stage. MC, SV, and CJ-S divided half of the records among each other during the title/abstract screening. In the full-text screening phase, MC and SV screened half of the records each. CS, SV, and MC were involved in the data extraction process. CS drafted the first version of this manuscript and developed it further based on feedback from SV and MC. CS, SV, CJ-S, and MC all read, reviewed, and approved of the final version of the manuscript. All authors contributed to the conception of the study and the development of the search strategy.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.