Measurement, Reporting, and Verification (MRV) systems are thought to be essential for effective carbon accounting and joint REDD+ carbon, conservation, and social development goals. Community participation in MRV (PMRV) has been shown to be both cost effective and accurate, as well as a method to potentially advance stakeholder empowerment and perceptions of legitimacy. Recognizing land tenure as a long-standing point of tension in REDD+ planning, we argue that its engagement also has a key role to play in developing a legitimate PMRV. Using household surveys, key informant interviews, and participatory mapping exercises, we present three ‘lived’ land tenure contexts in Indonesia to highlight their socially and ecologically situated natures and to consider the role of tenure pluralism in shaping PMRV. We then raise and interrogate three questions for incorporating lived land tenure contexts into a legitimate PMRV system: 1) Who holds the right to conduct PMRV activities?; 2) How are the impacts of PMRV differentially distributed within local communities?; and 3) What is the relationship between tenure security and motivation to participate in PMRV? We conclude with implementation lessons for REDD+ practitioners, including the benefits of collaborative practices, and point to critical areas for further research. Current international efforts to mitigate climate change include actions targeting the sustainable conservation and management of tropical forested landscapes. First proposed at the UN Framework Convention on Climate Change (UNFCCC) in 2005, Reducing Emissions from Deforestation and Forest Degradation (REDD+) policy aims to compensate developing countries for their avoided carbon emissions through reduced deforestation and forest degradation in addition to the conservation, sustainable management, and enhancement of forest carbon stocks .As currently envisioned, REDD+ requires a standardized unit of carbon, representing reduced carbon emissions, to be calculated, monitored, and monetized for global exchange ,3. MeasuTogether such concerns led to the inclusion of social and environmental ‘safeguards’ in the 2010 UNFCCC Cancun Agreements. In policy and planning circles, community-centered safeguards have focused on questions of tenure security, stakeholder participation, and the need for free, prior, and informed consent (FPIC) . Tenure by and for whom forests are taken into account” .Research on participatory MRV (PMRV) has shown community involvement to be both cost effective and accurate ,18, as wThe rise of global environmental governance showcases the growing role of non-state actors, whether multi-national companies, non-governmental organizations, or indigenous communities, in determining the effectiveness of environmental mechanisms and institutions ,21. FromLand tenure in tropical forested countries has been highlighted as a driving factor limiting REDD+ outcomes ,24,25. ASpecifically, we argue for more attention by REDD+ practitioners and policymakers to how legal pluralism manifests on the ground , especiaIndonesia, with its diversity of socio-ecological contexts, co-existing legal systems, and minimal statutory recognition of community rights –36 provilegitimate PMRV.We begin this paper with a short review of forest governance in Indonesia, a presentation of our methods, and a description of our study sites. We then present results depicting three lived tenure contexts seen in the Indonesian provinces of Central Java, West Kalimantan, and Papua . The folLegal pluralism in Indonesia stretches from the colonial period to the transnational governance regimes of today . In Indoadat) and religious systems as practiced throughout Indonesia. In 1945, the newly independent Indonesian government then replaced colonial law with ‘national law,’ which sought to incorporate these systems of customary and religious law into a single legal system [State law, as established by Dutch colonial administrators, explicitly differentiated between systems of ‘colonial law’ and the ‘people’s law,’ which included customary . District governments thus gained the right to manage Non-Forest Estate land , though the Forest Estate remained under the Ministry of Forestry’s purview . DistricAt the provincial level, there was a separate push towards decentralization with the granting of special autonomy status to the provinces of Aceh and Papua in 2001 . This stadat) legal systems disenfranchised and their options for claiming additional rights limited [Hutan Kemitraan) (Basic Forestry Law No 41/1999 and Government Regulation No 6/2007 Article 99) and the Village Forest program (Hutan Desa) (Basic Forestry Law No 41/1999 and Government Regulation No 6/2007 Article 99). Forest Partnerships provide rights to local communities on a case-by-case basis according to a formal agreement between a private land holder and a community [Though decentralization has led to greater empowerment of community management regimes, these rights are narrowly supported in national statutory law. Local communities living within or near National Forest Estates often find their customary ( limited . Nationaommunity . The Vilommunity .Hutan Masyarakat Adat) within the National Forest Estate is unconstitutional (Customary Court Case 35/PUU-X/2012). By removing these lands from the National Forest Estate, the decision provides indigenous communities with full rights to these forest areas. Though it has yet to be implemented on the ground, this is the first time the Indonesian government has devolved full land rights to communities [Recent changes in forest governance at the national level highlight the fluidity of legal pluralism in Indonesia. In a promising advancement for community rights recognition, the Indonesian Constitutional Court ruled in 2013 that the classification of Indigenous Community Forests  conducted by researchers at the Center for International Forestry Research (CIFOR) . The stuFor this paper, a common set of research methods was designed to examine land tenure contexts shared across research site villages, as well as variations between them. The methods include focus group discussions (FGD), key informant interviews (KII), and household surveys (HHS).For each research village, 8–10 community members, with a team of facilitating researchers and the aid of satellite imagery, created a participatory map of past and present land cover and land use. While the FGD was open for all to attend, primary participants comprised both male and female adults and were selected by community members at an opening community meeting for their knowledge of area land uses, land cover changes, and land tenure arrangements.We conducted 4–6 key informant interviews per village for a total of 30 interviews across research sites. Informants were selected by community members in the opening community meeting based on relevant knowledge and included knowledgeable community members, customary leaders, and village heads. Some key informants also participated in the participatory mapping FGD, but identical participant sets were not required.During the interview we used the participatory map produced previously as a visual aid. Key informants were asked a series of questions for each land cover category identified in the mapping FGD, including who uses and manages the area, for what purpose, and according to what arrangement. Terms for access, use, management, and exclusion rights were adapted from Larson (2012) .Responses were then coded by land user, which included individuals (often households), groups , the entire village, or a user group extending beyond the village scale. Combining remote sensing and participatory mapping data, spatial areas were coded based on this typology of user group.While the larger data set includes valuable nuances regarding diversities of land uses, resources, temporalities, and user groups, for this paper we focus on spatially distinct areas, identified by key informants, that more specifically hold individual claims , group uses (for example a hereditary fruit tree grove), village-level claims, or otherwise. Key informants were also asked for their perceptions of villages’ ability to access land and resources in the past, present, and future, with responses coded according to whether access for each land category was considered relatively difficult, easy, or conditional. These responses are summarized and presented in site-specific Results sections entitled “Perceptions of Land and Resource Access.”We conducted 62 household surveys in Papua, 171 in Central Java, and 185 in West Kalimantan. The sample size in each village was defined by a function of population size, a confidence level of 95%, a margin error of 0.1, and a variance of estimated change. We used a simple random sample stratified by sub-villages to determine the sample size and randomly selected via lottery method. In the household survey, we asked multiple questions to assess household human capital; socio-economic conditions and trends; land uses; proximity to forest and mobility; and participation and motivation involving in local organizations. One section of direct relevance for our tenure analysis concerned respondents’ land uses, household rights over those land uses , land right claiming processes, and particular land right agreements.Combining these methods with an analysis of Indonesian statutory forest policy and Ministry of Forestry land classifications , we presnegotiated partnerships in Central Java between local communities and private timber companies; tenure mosaics in West Kalimantan comprised of simultaneous, overlapping statutory and customary claims to land and resources; and customary authorities in Papua comprised of overlapping and flexible claims based on the settlement history of the area.With attention to both similarities within research sites and differences across site villages, the results below illustrate three distinct lived tenure contexts across our research sites in Central Java, West Kalimantan, and Papua provinces. The tenure contexts include: Interesting similarities and differences in household perceptions of land rights are seen across research sites, captured in the HHS using categories of ownership, rental, and use rights ).As described by key informants and FGD participants, PHBM is a negotiated partnership resulting from a history of conflict and compromise involving area communities, Perhutani, local NGOs, and the sub-district government. Following Indonesia’s national decentralization movement, in the late 1990s 30 villages in Wonosobo, including Lebak and Karanganyar, negotiated for rights to Perhutani forest. Leading up to this agreement, members of surrounding communities had logged much of Perhutani forest without the company’s authorization. Through the establishment of PHBM in 2001, Perhutani land was divided and distributed to those communities Perhutani categorized as a forest village community, meaning villages bordering their plantation stands whose livelihoods are to some extent related to forests. All households of Lebak and a portion of Karanganyar, whose area borders the plantation, were granted individually-based use rights to Perhutani forest land See . Key infBadan Pertanahan Nasional).Participatory maps show that agroforest and agricultural lands, held as individual properties, account for 66% and 68% of land in Karanganyar and Lebak, respectively. These lands are legally classified as Non-Forest Estate and individuals hold legal land titles issued by the National Land Agency  agreement with Perhutani and decreasing agricultural land availability due to a fixed amount of land for an increasing population. Key informants reflected that prior to the establishment of PHBM in 2012, villagers were restricted from accessing Perhutani land or collecting any forest products. The area was tightly patrolled and if caught all resources were confiscated. Informants find future access conditional on Perhutani’s willingness to continue the Partnership agreement. Furthermore, villagers are unclear as to the time frame of the PHBM contract: time frames mentioned range from between 30–50 years to indefinite. However, the villagers feel they have a certain amount of leverage to maintain access, recognizing that Perhutani needs their help to maintain the village stands and protect them from unwanted logging.Land and resources in the villages of Hulu Pengkadan, Sri Wangi, and Nanga Jemah in West Kalimantan interact across a weaving of individual, family, group, and village claims. The means to make and defend these claims rely on sources of legitimacy granted at the village, sub-district, or national level, creating a mosaic of overlapping and simultaneous land and resource claims.rimba, as managed and regulated by the village government. They likewise explain that customary rules grant villagers the right to harvest forest resources according to their needs, a right that can be granted to outsiders with permission from the village government. Household surveys show that within the rimba villagers collect NTFPs, including rattan for weaving and wild vegetables, as well as timber for personal use.Key informants describe forest land never cleared for agriculture, locally known as rimba accounting for 90% of land in Nanga Jemah, while only 12% in both Hulu Pengkadan and Sri Wangi. Such disparities might account for why some households in Nanga Jemah, due to a substantially larger forest area, also cut timber for commercial purposes. Without a business license required to sell timber and non-timber forest products, however, all products sold are limited to the informal market. All told, household surveys show that 77% of households in Nanga Jemah (more than any other village in our study) collect forest resources to sell.Participatory maps show Durio sp.), tengkawang (Shorea sp.), or tapang honey trees (Koompassia excels), belong to the person who planted the tree or their descendants. Depending on when the tree was planted, the descendants may be recognized today to include a single family, a neighborhood, the entire village, or outside communities with hereditary ties. These tree resource claims overlap and coexist with the private land claims made in clearing land.FGD participants and key informants explain that many land and resource rights derive from the practice of rotating agriculture, in which the act of clearing forest establishes a largely private land claim. We categorize this as ownership in Participatory maps display that individually claimed land accounts for 84%, 38%, and 10% of the total land area in Hulu Pengkadan, Sri Wangi, and Nanga Jemah, respectively. The majority of households (66%) in Hulu Pengkadan rely on cash income and subsistence from agricultural lands, while far fewer (31% and 37%) do so in Sri Wangi and Nanga Jemah, respectively. This is in contrast to the high degree of subsistence and cash income earned from agroforests, primarily rubber and tengkawang, by 94%, 93%, and 78% of households in Hulu Pengkadan, Sri Wangi, and Nanga Jemah, respectively.Key informants describe that within all villages most claims are known by word of mouth; however, some individuals do hold written land deeds, issued and recognized by the village government to be used in land dispute cases. The village land boundaries are currently under negotiation between village leaders, which will be written down and approved by the sub-district government.hak mutlak (absolute rights) and are defendable in customary court. Yet when people move to the village or desire additional gardens, it is difficult today to find land. Villagers are not allowed to open new forest land in Hulu Pengkadan or Sri Wangi due to rules established and enforced by the village government. These limitations do not exist in Nanga Jemah where villagers are still allowed to open new land; however, informants noted that finding an area that is not already claimed is challenging and will be far from the village settlement.In West Kalimantan, key informants’ perceptions of access to land rights from the past to the present focus on the villagers’ ability to access enough agroforestry and agriculture land to support their livelihoods. The informants agreed that in the past accessing lands for agricultural and agroforestry production was not difficult; there were large forested areas to be converted, low land prices, and less people seeking land. Pre-established land rights, from opening their own land or inheriting it, are considered rights in perpetuity or The ability to access forest resources in the future is perceived to be uncertain. The respondents agreed that villagers will respect and follow the village’s management rules, including not being allowed to open new land in two of the villages. Yet some respondents question if the rules will be enough to sustain resources as villagers are still allowed to harvest timber and non-timber resources as they need. Despite local respect for village rules, other forest user groups threaten future land and resource access. The primary threats our informants mentioned included restrictions on community land use enforced by the national government, based on statutory forest classifications, and/or from companies with a forest concession.Hutan Desa), which recognizes certain statutory legal rights to the forest. The official permit from the district remains incomplete, however, and it is not yet clear to key informants what legal rights will be recognized through the designation. Recent negotiations to establish the Village Forest boundaries in Sri Wangi led to confusion over statutory forest classifications in their village areas. This raised concerns over the potential restrictions on community land use, such as prohibiting forest resource extraction due to a lack of community statutory rights. Our respondents ultimately hope that the statutory rights gained in establishing the Village Forest will allow them to maintain their management systems and land access into the future.Notably, over the span of this research, Sri Wangi and Nanga Jemah were granted approval for a Village Forest (adat) systems, organized along family lineages and shaped by ongoing social relationships. The Mamberamo Raya Regency where Bagusa and Yoke are located encompasses 59 villages found along the Mamberamo River. Yoke is comprised of two settlements, one along the coast and the other in the mangrove forest. Bagusa is a single settlement located in the swamp forest further upstream along the Mamberamo river. Villages are connected by ethnic lineages (suku), creating an interconnected adat system in which village boundaries are not strictly separated. Village territories are defined as the furthest area in which villagers have the right to hunt, fish, and collect resources. However, such tenure rights, whether it is to use rivers, lakes, or forests, often overlap between villages and across village boundaries.Key informants describe land tenure claims within Bagusa and Yoke as governed through customary (Ondoafi), whose authority is hierarchically nested, following this same settlement history. Individuals and groups outside this shared ethnic lineage, unless joined by marriage, must first ask the appropriate Ondoafi for permission to collect resources or cultivate land within any particular village territory or territories.Village-level claims to access, use, and manage land follow a historically-based hierarchy of settlement, with Yoke and Bagusa recognized as the first settlers and thus the oldest villages in Mamberamo Hilir District. Tenure disputes, both within and between villages, are mediated through customary leaders  to annual crops such as cassava. Sago (Metroxylon sagu), the regional staple food, is gathered from separate sago groves, which may be both wild and domesticated. At the time of our surveys, 65% of respondents in Bagusa and 75% in Yoke use gardens or groves for personal or commercial purposes. Households derive cash-based income from selling forest products and fish, as well as subsistence from myriad forest activities, whether hunting pig, harvesting eggs, or collecting sago. Only 7% of households in Yoke and 21% in Bagusa do not draw either cash income or subsistence needs from the forest. This figure excludes income and subsistence needs from collecting fish, which may come from both the sea and fresh water areas located within the forest. Timber extraction, as described by informants and confirmed in surveys, is minimal in both villages, with timber harvested as needed for housing, boating, and construction, and neither selling it commercially.Villagers’ gardens, cultivated as agroforests, include a variety of species, from banana, coconut, and areca nut palm  A primary benefit of local participation in MRV discussed in the literature is its capacity to adapt MRV standards and methods to particular social and environmental conditions due to the inclusion of local communities and their situated and specialized knowledges . With thwho can measure forest carbon where across a particular forest landscape. Studies on participatory monitoring provide a series of considerations for how to select who should measure forest carbon. Community-driven participant selection is thought to enable measurement and monitoring activities that operate within, and respect, existing sociocultural relationships [The success of PMRV in some sense rests on answering a deceptively simple question, namely ionships . Such acionships , pushingionships .Lived land tenure contexts present additional complexities regarding who can measure forest carbon and where. As presently envisioned, MRV involves the establishment of long-term monitoring plots to effectively measure forest carbon and its fluctuations over time. Our results raise considerations for the identification of who has the right to measure within those plots, as well as who has the authority to grant permission for that measurement. Indeed the desired plots may include not only multiple actor groups holding a variety of statutory and customary resource claims but additional nuances of how and when such claims are enforced.Our sites in West Kalimantan display the risk of complications due to an absent legal right holder, according to national concessions. The logging company is still considered the legal right holder of the majority of forest land despite being inactive on the ground for more than 10 years. When working through a national legal framework the existing logging concession’s rights prevents the possibility for local people to participate in and benefit from REDD+ and MRV in this forest.Yet another challenge to this question of who measures where concerns the heterogeneity of local communities within particular lived land tenure contexts. Previous scholars’ work interrogates the concept of a community to extend beyond a small spatial area, a homogeneous social group, and a set of culturally shared norms . InsteadIn the negotiated partnerships in Central Java, the formal and individualized nature of claims will shape who has authority to measure particular designated MRV plots. Interestingly, while such a system could bring welcome clarity to questions of participant selection and authority, this same system could pose a potential obstacle for reaching a consensus to participate in MRV across private landholders. Additionally, measurements in land under a Forest Partnership agreement will require renewed negotiations of rights and benefits across Perhutani and village stakeholders and raises substantive concerns regarding who can claim the right and authority to both measure and choose where to measure on Partnership land.The local tenure system seen in the Papua sites offers its own set of complications regarding PMRV participant selection and authority. The customary system is one that is fundamentally interconnected and flexibly grants overlapping resource access, use, and management rights across multiple communities. The lived land tenure context as described by key informants can thus be viewed as not simply about relationships between people and resources but rather as complex relationships between people themselves ,30. The Whether the social, economic, and political differences across Forest Partnership stakeholders in Central Java or the filially-connected and flexible nature of customary tenure in Papua, we see contexts that confound traditional understandings of community and highlight heterogeneities that will need to be negotiated for the design and enactment of equitable and effective PMRV.The uncertainty of how REDD+ carbon rights will be defined in Indonesia complicates efforts to design PMRV-related compensation and benefit-sharing mechanisms. It is as yet unclear how assigning carbon rights in REDD+ relates to pre-existing systems of land or resource rights . Carbon Right now participation in MRV does not equate to benefiting from carbon rights; however, Larrazábal, et al.  argue thNavigating carbon rights is only more complicated when placed in conversation with lived land tenure contexts. In Central Java’s Forest Partnership there is a need to clarify how local communities’ use rights to Perhutani land relate (or not) to carbon rights and related benefits. The mosaic of tenure rights in West Kalimantan raises the important question of which legal scale–national, sub-national, or village–will hold the authority to determine the connection between tenure claims and carbon rights. Key informants in Papua, meanwhile, suggest that carbon benefit distribution would be most clear and culturally attentive if it operated according to the existing customary village hierarchy. The overlapping tenure system across village territories there, however, potentially opens up substantial space for confusion in tracking causation of forest carbon fluctuations across forest user groups.Our results reveal the potential for high variation both between and within villages regarding the amount and type of land claimed, as well as the way that land is used. Our West Kalimantan sites offer a powerful example of how such variation may complicate PMRV activities and have differential community impacts. This is particularly seen in the potential of monitoring forest carbon and forest carbon change to highlight certain commercial forest uses considered illegal under statutory law. While such activities might complicate or compromise the accuracy of relevant forest carbon measurement, alternatively, efforts to mitigate these activities will have varied effects across individuals in the village, as people are seen to be dependent on forests to varying extents and for varying needs. Such costs show that any PMRV system will have varied economic, social, and political impacts within a community. These variations should be considered when designing and implementing PMRV in order to identify culturally appropriate incentives and benefit-sharing distributions for PMRV. This foresight may help to recognize potential arenas of conflict and negative impact for those village groups and individuals without decision-making power.Securing tenure is seen to act as a significant incentive for local participation in community conservation efforts and potentially extends to REDD+ and PMRV engagements . Tenure Local perceptions of access to land and resources serve as an indicator for villages’ desire to increase tenure security and, if so, through what means. Despite recognition that there is not necessarily a link between tenure security and statutory land titles , discussIn examining tenure security across our three research sites, we detected noticeable differences in the relationship between perceived security and statutory rights. Specifically, when looking at local perceptions of future land access, we found that tenure security does not always correlate with the extent to which practiced tenure arrangements are recognized in statutory law. Rather we find that perceptions of tenure security are dependent upon by whom actors feel threatened and in need of defending their tenure claims against.We see across all three sites the presence of lived tenure contexts that have clear and robust methods for claiming and defending rights within and between neighboring villages. Yet, importantly for the consideration of PMRV, the basis of these claims varies across sites: in Java defending claims depends on statutory land titles; in Kalimantan on a combination of verbal and written claims upheld by the village or sub-district governments; and in Papua on understood ethnic and clan claim histories.The negotiated partnerships in Central Java offer an example of where increased tenure security has already been used as a tool to motivate community members to participate in forest monitoring activities. The PHBM Forest Partnership provides forest-adjacent households limited use rights in exchange for managing the land and monitoring unapproved extraction. In this example, the incentive of tenure security was directly related to how increased forest and resource access enabled additional, non-monitoring related livelihood benefits. Despite legal recognition, Central Java key informants note that future access to land and resources is uncertain.Hutan Desa). According to national law, the legal Forest designations shape which land uses will gain this statutory recognition. A Village Forest can only be located in the absence of exiting statutory resource or land concessions. With most of the Production Forest land within the villages still under the forest concession from the 1980s Click here for additional data file.S2 Fig(PDF)Click here for additional data file.S3 Fig(PDF)Click here for additional data file.S4 Fig(PDF)Click here for additional data file.S5 Fig(PDF)Click here for additional data file.


Road and railway networks are pervasive elements of all environments, which have expanded intensively over the last century in all European countries. These transportation infrastructures have major impacts on the surrounding landscape, representing a threat to biodiversity. Roadsides and railways may function as corridors for dispersal of alien species in fragmented landscapes. However, only few studies have explored the spread of invasive species in relationship to transport network at large spatial scales. We performed a spatial mismatch analysis, based on a spatially explicit correlation test, to investigate whether alien plant species hotspots in Germany and Austria correspond to areas of high density of roads and railways. We tested this independently of the effects of dominant environments in each spatial unit, in order to focus just on the correlation between occurrence of alien species and density of linear transportation infrastructures. We found a significant spatial association between alien plant species hotspots distribution and roads and railways density in both countries. As expected, anthropogenic landscapes, such as urban areas, harbored more alien plant species, followed by water bodies. However, our findings suggested that the distribution of neobiota is strongest correlated to road/railways density than to land use composition. This study provides new evidence, from a transnational scale, that alien plants can use roadsides and rail networks as colonization corridors. Furthermore, our approach contributes to the understanding on alien plant species distribution at large spatial scale by the combination with spatial modeling procedures. During the last century, linear human related infrastructures such as roads and railways have become a conspicuous part of the anthropogenic landscape ,2. In EuRoads threaten biodiversity in at least three different ways: 1) fragment and modify landscapes directly, 2) modify landscapes indirectly by promoting urbanization and, 3) modify landscapes by facilitating the movement of people and goods, thereby increases the risk of biological invasions . Then, eRoads and railways therefore serve as dispersal corridors for many plant species, particularly invasive ones ,10–16. TAbiotic and biotic variables together with dispersal mechanism strongly influence spatial pattern and invasion rate of invasive species –25. The Understanding the factors which facilitate and drive the spread of invasive species is necessary for developing appropriate strategies for preventing and limiting ecological invasions. Considering that: a) road and railways networks are among the most pervasive landscape features accompanying the urbanization process; b) most of the studies which verifyied that these infrastructures provide a vector of diffusion for neobiota were performed at local spatial scale; and c) plant invaders are more frequently found in highly disturbed anthropogenic habitats; we can expect a positive spatially association between the road/railways density and number of aliens plant species at large spatial scale. Thus, an eco-informatic approach, based on a large set of spatially explicit data focusing the pattern of alien plants, can provide new insights on invasion ecology.In according to this, the aim of our study is to provide a spatially explicit correlation analysis at large spatial scale, in order to assess the congruence between hotspots of invasive plant species and density of linear transports elements in two countries of central Europe. Furthermore, by modeling, to assess the relative role of road/railway density and land use composition on the distribution of alien plant species. Then, our approach can contribute to improve the knowledge on alien plant distribution by the combination with spatial modeling, to obtain more accurate predictive frameworks at large or regional spatial scale.https://www.eea.europa.eu/data-and-maps. This report provided a dataset with 13,373 records, with number of alien plant species per spatial unit, quantified following the methods of Kleinbauer et al. [2) of the Floristic Mapping Project of Central Europe . Each record presents the frequencies of 30 invasive alien vascular plant species in Austria and Germany . In this study, each FMA square was defined as the spatial unit for the further statistical and spatial analysis.We used the available records of hotspots of alien vascular plant species using the database of “Actual and potential future alien plant invasion hotspots under two emissions scenarios” , a reporr et al. . Each rehttp://www.openstreetmap.org/copyright. The following layers were used: road network and railways network from Germany and Austria. Roads term included both motorways and residential roads. The vector data is derived from CORINE land-cover (25-m resolution) [2 in each spatial unit.The maps were generated with GIS soſtware (ArcGIS 10.1)  with geoolution) . Road deolution) . The linolution) . In thisEach spatial unit was classified on the basis of the percentages of the different land uses types within each square. Land-use types considered here were based on the CORINE land-cover vector data derived from 25-m resolution satellite data from 2006. CORINE is a national georeferenced land-cover database available for the European Union, based on satellite digital images . The CORM varies between −1 and +1 and behaves like a correlation coefficient [A preliminary exploration of the correlation among variables was performed using the Pearson correlation coefficient  S1 Fig)S1 Fig). fficient ; it evalfficient . Mantel fficient , comparifficient .The relationship between hotspots of alien plant species and road and railway density in each spatial unit was examined using Generalized Linear Mixed Models (GLMMs), with the package ‘lme4’ ,57. NumbIn order to focus separately the role of road / railways density and land use composition on the hotspots of neobiota, we adopted a double approach. First, a new series of Generalized Linear Models (GLM) was ran using the number of alien plant species as response variable, introducing road density and country as predictors (model 2), and then the land use composition (measured as the percentage of each land use type) and country as predictors (model 3). Country was added in the model to explore if some variation in neobiota occurrence is due to intrinsic differences of each country. For example, considering that Germany is biggest country than Austria, we can expect also more linear structures in terms of absolute values, and then a potential increase in number of neobiota. Moreover, these differences can also mirror the higher population density in Germany , and a sSecond, a variation partitioning by partial regression analysis was used to isolate the proportion of the variation on neobiota explained by each of the two sets of factors exclusively (road / railways density and land use composition), and the proportions attributable to interactions between factors ,68. To tAll statistical tests were performed with R software .2) was 28 for Austria and 30 for Germany. On average, grid units contained 6.86 species in Austria and 12.09 in Germany. In both countries, the hotspots of alien plant species were more related to anthropogenic landscapes, such as urban habitat types  [M = 0.330, permutations = 9999, p < 0.01) and railways network  in Germany and Austria, indicating that grid units that differed more in number of alien plant species also differed more in density of linear transport features  . Spatialfeatures .The mixed models evaluate the association between number of alien plant species and road density and railways density, independently from country and dominant environment. The results confirmed that grid units with higher road density and with higher railways density (model 1) contained more number alien plant species , Fig 3. The last two models, including separately road density and land use composition on each spatial unit as potential predictors, showed a positive association between number of alien plant species and road density and country Germany model 2, . The strThe results of variation partitioning analysis provided additional confirmation that number of alien plant species is significantly correlated with road/railways density and land use composition. However, the large effect was found for road/railways density, followed by the intersection between road/railways density and land sue composition, and then land use composition in each spatial unit .Historical and current interactions between abiotic and biotic variables, including anthropogenic influences to natural communities and landscapes, determines invasion rate and distribution pattern of all alien species throughout the world –25,39,71Only spatially explicit information based on large dataset can be used to elaborate accurate macroecological patterns of plant invasions, suitable to predict or identify the areas of potential risk of invasions in future scenarios, as well as to elaborate adequate conservation strategies . In thisIn this study, we provide new evidence highlighting the spatial congruence between the pattern of hotspots of alien plant species and the pattern of road and railway density at large spatial scales in two European countries. This approach remains descriptive, and cannot truly demonstrate causality between alien plant species and modern transportation infrastructures. However, other studies provide additional compelling evidence for how roads and railways are instrumental in spreading of invasive species  were similar between countries, the average values of neobiota was higher in Germany. This difference could be partially due to differences on the gradient of elevation between both countries .The distribution and expansion of alien plants depends on roads as a main driver, but is also related to the land use composition around the roads . The urbBacaro et al. , highligThe importance of transport networks on alien plant species is particularly important, since the accumulation of alien species across all taxonomic groups shows no sign of saturation, worldwide . InvasivS1 FigThe diagonal shows the name of variables using the following codes: URB, urban; AGRI, agricultural, FOR, forest and semi-natural areas; WET, wetlands; WAT, waterbodies; ROAD, road density; RAIL, railways density. The squares below the diagonal show the bivariate plots and the squares above the diagonal the corresponding correlation coefficients, with level of significance indicated by symbols .(DOC)Click here for additional data file.


Kangaroo Mother Care (KMC) is an evidence-based intervention that reduces neonatal morbidity and mortality. However, adoption among health systems has varied. Understanding the interaction between health system functions—leadership, financing, healthcare workers (HCWs), technologies, information and research, and service delivery—and KMC is essential to understanding KMC adoption. We present a systematic review of the barriers and enablers of KMC implementation from the perspective of health systems, with a focus on HCWs and health facilities. Using the search terms ‘kangaroo mother care’, ‘skin to skin (STS) care’ and ‘kangaroo care’, we searched Embase, Scopus, Web of Science, Pubmed, and World Health Organization Regional Databases. Reports and hand searched references from publications were also included. Screening and data abstraction were conducted by two independent reviewers using standardized forms. A conceptual model to assess KMC adoption themes was developed using NVivo software. Our search strategy yielded 2875 studies. We included 86 studies with qualitative data on KMC implementation from the perspective of HCWs and/or facilities. Six themes emerged on barriers and enablers to KMC adoption: buy-in and bonding; social support; time; medical concerns; training; and cultural norms. Analysis of interactions between HCWs and facilities yielded further barriers and enablers in the areas of training, communication, and support. HCWs and health facilities serve as two important adopters of Kangaroo Mother Care within a health system. The complex components of KMC lead to multifaceted barriers and enablers to integration, which inform facility, regional, and country-level recommendations for increasing adoption. Further research of methods to promote context-specific adoption of KMC at the health systems level is needed. Key MessagesKangaroo mother care (KMC) is an effective, evidence-based intervention to reduce neonatal morbidity and mortality, and the health system plays an essential role in the scale up and adoption of KMC.Healthcare workers (HCWs) and health facilities face unique barriers to implementing KMC, especially in areas of social support, leadership buy-in, and access to training.Clear and consistent communication between HCWs and health facility leadership is an important enabler of successful KMC adoption.Analysis of KMC adoption through a health system perspective, with a focus on HCWs and health facilities, should inform strategies for health system adoption of KMC at the facility, regional, and national levels.The scale up of evidence-based newborn interventions such as kangaroo mother care (KMC) is often influenced by the strength of health systems. KMC includes early and continuous skin-to-skin contact (SSC) between the newborn and caregiver, exclusive breastfeeding, early discharge from health facilities, and supportive care and follow up . Among pTo maximize the effectiveness of a health system, all components of the system—leadership and governance, financing, health workforce, technologies, information and research, and service delivery—must function in an integrated manner that recognizes the inter-dependence of each part of the system . ImplemeUsing the search terms ‘KMC’ or ‘kangaroo care’ or ‘STS care’, we searched Pubmed, Embase, Web of Science, Scopus and World Health Organization Regional Databases from January 1, 1960 to August 19, 2015. In addition, we hand searched reference lists of included articles, published systematic reviews, and requested data from programmes implementing KMC such as Save the Children. Studies were included if they contained primary data on barriers or enablers of KMC implementation. Studies were excluded if they did not specifically discuss barriers or enablers from a HCW or health facility perspective .Screening and data abstraction were conducted by two independent reviewers using standardized forms to identify factors of KMC implementation. Study quality was evaluated based on selection bias, data collection and analysis methodology, generalizability, and ethics  were published in 2010–15, 53 (61.6%) had a sample size of <50, nearly half of the studies were based on interview or survey data (47.7%) and approximately one-third of the studies occurred in the Americas (32.6%). Most studies were based in a Neonatal Intensive Care Unit (NICU) (32.6%), and 9.3% of studies were community or population-based . The characteristics of the included studies are provided in We visualize a health system as a complex system with key components  with unique interests and values that contribute to the uptake of health interventions       ( (Nurse) Shortage of staff nurses, limited parental access, and shortened visitation time presented an obstacle to KMC uptake. Specifically, communication between staff and parents was strained in facilities with limited visitation hours. Parents were unhappy with shorter visitation times, as were staff, who found parents to be a greater interference when visitation was limited .… visitoThus, some studies showed that visitation time negatively impacted KMC implementation from both a health provider and parent standpoint.Conversely, some nurses and healthcare staff thought that long visitation hours facilitated KMC implementation because it would allow for fathers and other family to come in and support the mothers (being afraid something will go wrong and I will be blamed for it” and “…not [being] sure KC is safe” (Nursing Staff Members)   when there are other people coming in. Private rooms will help. (Mother) ((Mother) In some cases, lack of ambulatory services needed to transport mothers was considered to be barriers to accessing as well as conducting follow-up at the facility    babies was strengthened. Statistics and success stories on KMC were used for advocacy at different levels  guidelines provided an overarching outline of KMC , nationaThis is one of the first systematic reviews to analyse qualitative research and program evaluations regarding KMC adoption from the health systems perspective. A major strength of our study lies in the comprehensive collection of studies from KMC research studies and implementation programmes. However, the generalizability of the results may be somewhat limited as the majority of studies came from areas with neonatal mortality rates (NMRs) <15 per 1000 live births. Although KMC is beneficial for all LBW or preterm infants, the intervention would be especially be impactful in low- and middle-income countries with high NMRs. Furthermore, we recognize that KMC protocols are distinct depending on the infant population, including preterm and LBW infants. The recommendations provided in our study will need to take into account context-specific limitations. Our review study summarizes the evidence and provides recommendations to support KMC implementation within health systems on a global level.KMC is a complex intervention, with unique barriers and enablers encountered at the HCW and facility levels within a health system. Understanding the challenges to implement KMC at each level of the health system and the interactions between levels of the health system provides recommendations for critical changes within a health system. Further research is needed to test models that address the barriers and support facilitators in order to promote and implement context-specific health system changes for greater KMC adoption.HEAPOL online.Supplementary Table S1Click here for additional data file.Supplementary Table S2Click here for additional data file.


Noncommunicable diseases (NCDs) account for two-thirds of all deaths globally, with 75% of these occurring in low- and middle-income countries (LMICs). Many LMICs seek cost-effective methods to obtain timely and quality NCD risk factor data that could inform resource allocation, policy development, and assist evaluation of NCD trends over time. Over the last decade, there has been a proliferation of mobile phone ownership and access in LMICs, which, if properly harnessed, has great potential to support risk factor data collection. As a supplement to traditional face-to-face surveys, the ubiquity of phone ownership has made large proportions of most populations reachable through cellular networks. However, critical gaps remain in understanding the ways by which mobile phone surveys (MPS) could aid in collection of NCD data in LMICs. Specifically, limited information exists on the optimization of these surveys with regard to incentives and structure, comparative effectiveness of different MPS modalities, and key ethical, legal, and societal issues (ELSI) in the development, conduct, and analysis of these surveys in LMIC settings. We propose a research agenda that could address important knowledge gaps in optimizing MPS for the collection of NCD risk factor data in LMICs and provide an example of a multicountry project where elements of that agenda aim to be integrated over the next two years. The World Health Organization (WHO) estimates that 67% of the 56 million deaths that took place globally in 2012 were due to noncommunicable diseases (NCDs), in particular, cardiovascular diseases 42.6%), cancers (21.7%), chronic respiratory diseases (10.7%), and diabetes (4.0%) . Four ke2.6%, canKey to global efforts to prevent and control NCDs is national surveillance. At the national level, surveillance has three primary components: exposures , outcomes , and health system capacity and response  . The WHOIn 2013, the WHO developed an NCD global action plan and monitoring framework, establishing 9 voluntary targets and 25 indicators that have to be achieved to attain a 25% reduction in premature mortality from the four major NCDs  by 2025 . A summaOne promising approach increasingly being explored for public health surveillance involves mobile phones. An emergent field, mobile health , describes medical and public health activities that leverage the global proliferation of cellular networks and mobile phone ownership (or access) to improve population and clinical health outcomes. Device functionalities such as voice calls and short message services (SMS)—often referred to as text messages—global positioning system (GPS), as well as other wearable and connected devices may be harnessed to provide data and insight on individuals and populations ,9. CurreIn view of the increasing disease burden, the intersecting need for NCD data in LMICs and the near-universal population access to mobile phones in a growing number of countries presents an opportunity for public health. As cellular technologies leapfrog the need for traditional landline infrastructure, public health programs could conduct remote, population-level surveys by reaching out to community members through their own cell phones. Can such a widely dispersed technology have the potential to assist in the achievement of the WHO NCD global action plan targets? How can mobile phone surveys (MPS) be used for population-level NCD risk factor surveillance? What critical technology, sampling, and methodological questions need to be addressed before leveraging this potential? In this paper, we present the potential for MPS to collect such data, review key research issues, and introduce a multicountry effort that seeks to partly respond to this public health challenge. We draw on a selected review of literature, key global reports, and experience of the authors to propose a research agenda and report on efforts underway to address it. It is believed that this paper will facilitate a global dialog and action to enhance the use of MPS for NCD, and potentially other public health risk factor surveillance.Access to mobile phones has increased globally, reaching more than 100% saturation in some LMICs . For theIt was found that 83% of the 112 WHO member states responding to a 2014 survey reported having one or more mHealth initiatives; the most frequently reported categories were call centers or helplines, emergency toll free telephone services, and mobile telemedicine (reported by 49-59% of countries). Least frequent uses of mHealth were health surveys, surveillance, awareness, and decision support (reported by 19-26% of countries) ,14. To pLimited evidence exists on the comparative effectiveness of MPS modalities in LMICs though a variety of options are available. Three frequently employed modalities are interactive voice response (IVR), SMS, and computer-assisted telephone interview (CATI). IVR involves prerecorded audio messages or instructions given over the phone by a computer application; CATI involves one person interviewing another via the phone; and SMS involves communication between devices using short text messages . AlthougIn one comparative study, 630 Lebanese adults selected through multistage stratified cluster sampling were respondents for a face-to-face (40-min) survey adapted from the WHO STEPS, and a mobile phone interview (abridged version of NCD questions). The study reported high percent agreements (89.5-95.6%) and kappa statistics (κ=.79 to .91) for past-year alcohol consumption, ever smoking, and current cigarette smoking; and over 90% agreement for diagnoses of hypertension, diabetes, hyperlipidemia, and heart disease . Mobile phone interviews also saved about US $14 per person interviewed, when compared with face-to-face methods . The WorThe evidence base around the efficacy and impact of mHealth programs is growing rapidly, with increasing numbers of projects being evaluated with methodological rigor ,21. HoweThe proliferation of mobile phones, and the critical gaps raised by WHO and the literature highlight both the potential for MPS and the need for rigorous investigations of the feasibility, validity, and comparative effectiveness of different MPS modalities. In addition, there is a need to understand the ethical, legal, and societal issues (ELSI) around use of mobile phones for collecting NCD risk factors. These issues give rise to a rich research and development agenda proposed below.We propose a research and development agenda for NCD risk factors and MPS. The eventual purpose of the proposed agenda is to help standardize operating procedures for MPS, which will allow for comparisons of NCD risk factors within and across sites, and over time. Within this overall purpose, we propose specific goals. First, to answer key questions on how to design and deliver robust MPS to collect NCD risk factors; second, to assess the comparative effectiveness and costs of MPS modalities ; and third, to determine key ELSI in the development, in conduct, analysis, and reporting of MPS in LMICs. Each is further described below with proposed research objectives. These goals and specific objectives are also summarized in first goal (to answer key questions on how to design and deliver robust MPS on NCDs), one research objective is to assess the usability of different ways of delivering MPS —or by text message) and community perceptions and willingness to complete MPS. This will probably require qualitative methods such as key informant interviews, focus group discussions, and user-group testing. Participants’ perceptions and willingness to complete and ability to navigate MPS delivery modalities such as IVR, SMS, and CATI can be assessed in order to provide a user-designed MPS [Under the gned MPS . These fA second objective is to assess the role of different incentive amounts in MPS. Quasi-experimental or randomized controlled trial designs can be used to assess the effect of incentives on standardized contact, response, completion, and refusal rates in a MPS . StudiesA third objective will be to assess the impact of MPS introductory messages. This will, for example, necessitate studies that assess the effect of MPS introductory message on contact, response, completion, refusal, and attrition rates. Research could further examine the introduction content , voice type , and the introduction’s character  on key survey metrics by demographic characteristics. Exploring different sampling frames of mobile phone numbers is a fourth objective to assess the effect of the sampling frame on representativeness, response rate, completion rate, and costs of MPS. For example, the benefit of using random digit dialing (RDD) compared with a list of preexisting phone numbers, for example, from mobile network operators or previous surveys has not been characterized. Finally, the impact of NCD-specific questions (in modules) on survey attrition needs to be studied. NCD modules in existing surveys are groups of common-themed risk factor questions, such as diet and alcohol, and can be delivered in different order (or randomized) to assess survey impact by question number and content  by key demographics. The research agenda under this first goal will help optimize the delivery of MPS.second goal , it is important to understand the role and impact of different channels of communication with phone owners. One objective is to assess the effect of MPS modalities  on key metrics and performance indicators, for example, by administering the same survey content to a list of participants using two or more modalities. The costs of modality setup, deployment, and maintenance also need to be assessed to perform intermodal cost-comparisons. A second objective is to compare national or subnational estimates of NCD risk factor indicators between MPS modalities—this could be done by comparing NCD risk factor distributions captured using different MPS modalities. Variability in response to different questions, modules and risk factor prevalence captured by multiple modalities can be ascertained.Under the A third objective is to document MPS intermodal reliability and response consistency for NCD risk factors. This could be done by allocating (or randomizing) participants into two or more arms  to establish congruency in responses for the same questions. Participants in one arm could receive one modality followed by another modality a few days later. Crossover designs might also be possible for an assessment of response consistency, adjusted for the risk of priming after exposure to the prior modality. Differences in the reported prevalence of NCD risk factors can also be evaluated to quantify possible incongruences in responses between MPS modalities. These objectives under the second research goal will answer questions on comparative effectiveness assessment in MPS in LMIC settings, as well as questions as to which modality provides better information on key survey metrics.third goal (determine key ELSI) relevant issues need to be explored in the development, conduct, analysis, and reporting of MPS in LMICs. Objectives under this goal are to (1) determine key ethical issues encountered in the conduct of MPS; (2) identify common and preferred practices for obtaining individual consent or permission for MPS to ensure voluntary, informed data collection; (3) document commonly encountered regulatory complexities and challenges that arise when conducting MPS and how they have been addressed; and (4) identify key societal goals and values that are supportive of MPS and how these are balanced against other important interests .Under the A systematic review of the literature is needed to collect the most common ELSI and collate them according to broad themes. Data collection with researchers, public health practitioners, programmers, policymakers, and other stakeholders of MPS may help define and assess the key ELSI, how they have been addressed in practice, and how well they are reflected in existing reports and theoretical frameworks identified by global stakeholders. Additional conceptual work may be required in this space to understand which ethics principles and values are being satisfied and which may be tested using MPS. Equally important is the critical examination of factors that influence whether, and to what extent, various ELSI apply across different types of mHealth and digital health activities. This research goal will provide crucial perspectives and data to inform the responsible implementation of MPS in, by and for LMICs. The three research goals and possible objectives described above comprise an initial proposed research agenda for MPS and NCD risk factor data collection with a special focus on LMICs .Implementing the proposed research agenda will require both resources and creativity, either as standalone activities or integrated into other agendas. As such, we introduce in this section, an opportunity for integrating this agenda into a stream of work around data for health and NCD. The Bloomberg Data for Health Initiative (BD4HI) is supported by Bloomberg Philanthropies and the Australian Government’s InnovationXchange to improve the health of populations through strengthening public health data . It invoIt is in the context of this project that we proposed to integrate an initial research agenda for MPS . Key to Currently, there are over 7 billion mobile phone subscriptions around the globe . The majDespite the many advantages they present, it is important to note that NCD risk factor MPS probably would not obviate the need for in-person data collection. Physical measurements such as blood pressure, weight or height, and waist circumference, or obtaining blood samples for analyses , need to be conducted in-person. The MPS can complement an NCD surveillance system that includes a STEPS or similar survey done less frequently, which together can inform prevention and policy decisions . The surThe BD4HI offers a unique opportunity to test MPS technology and delivery options in real world settings, while enhancing our understanding of the norms and values that are likely to influence global implementation. Proof of concept on the use of this technology for NCD risk factor data collection could help countries to complement existing mechanisms for monitoring progress in their interventions toward achieving commitments for NCD global targets. We welcome the global NCD and mHealth communities to provide further input on the proposed research agenda and hope it will inform research projects in the coming years.


On August 16, 2015, a case of parotitis in a resident of the Rockaways neighborhood of Queens, New York City (NYC), was reported to the NYC Department of Health and Mental Hygiene (DOHMH) as a suspected mumps case. Subsequent investigations by DOHMH discovered an outbreak of mumps in the Rockaways, with 52 confirmed and probable mumps cases. DOHMH conducted a Facebook advertisement campaign providing information about mumps and the outbreak, which was targeted to Facebook users in the Rockaways neighborhood. The advertisement was shown to 86,111 persons during an approximately 2-week period and provided a timely and inexpensive means of effectively communicating with a large, targeted population.After the case of parotitis was reported on August 16, 2015, DOHMH identified two additional cases through investigation of the patient’s close contacts. These cases were the first indication to DOHMH of a mumps outbreak in the Rockaways. Because the first patient mentioned other persons in the neighborhood with parotitis, DOHMH contacted health care providers in the Rockaways for information about other patients with parotitis and any mumps laboratory testing not previously reported.DOHMH conducted investigations through interviews and review of medical records. Diagnostic testing included identification of mumps immunoglobulin M (IgM) in serum and detection of mumps virus RNA by real-time reverse–transcription polymerase chain reaction (rRT-PCR) of buccal swabs. DOHMH used criteria from the Council of State and Territorial Epidemiologists to classify cases as confirmed, probable, or discarded ; all but two were adults aged ≥18 years. No patients were hospitalized or had complications. Among the 50 cases for which laboratory testing was conducted, 32 (64%) tested positive by any test, including 29 (66%) of 44 tested by rRT-PCR, and seven (15%) of 47 tested for IgM. Twenty-five (48%) patients had evidence of prior immunity , and immune status of 27 (52%) patients was unknown. Twenty-two patients reported having attended several common neighborhood bars and restaurants during either their incubation or infectious period. Initial control measures implemented during August–November, 2015, included home isolation of infectious patients, notifications to health care providers in the Rockaways, provision of vaccine to two local clinics for administration at no cost, and distribution of informational posters and flyers throughout the neighborhood, specifically targeting the common bars and restaurants attended by patients.Because DOHMH continued to receive mumps reports from the Rockaways during October despite usual control measures, DOHMH conducted a Facebook advertisement campaign targeted to Facebook users aged 20–59 years in the Rockaways zip codes, as determined by accounts’ home addresses, Internet Protocol addresses used to access the Internet, or locations of mobile devices. The advertisement provided information about mumps and the outbreak and instructed persons with symptoms to stay home, and was shown to 86,118 unique persons during its run . It was clicked on 4,085 times and received 954 likes, 297 comments, and 843 shares, which was more shares than any other DOHMH post at that time. The $3,200 cost was less than that for traditional print media, and the advertisement could be placed quickly and removed once the outbreak had concluded. DOHMH responded to commenter questions in real time, necessitating the availability of DOHMH personnel to respond quickly. Social media provided a timely and inexpensive means for successfully and rapidly communicating with a large population in the target demographic and facilitating public engagement with DOHMH about the mumps outbreak, and therefore, might be useful for disseminating messages to a targeted population during future outbreaks.


Higher prevalence of suicide notes could signify more conservatism in accounting and greater proneness to undercounting of suicide by method. We tested two hypotheses: (1) an evidentiary suicide note is more likely to accompany suicides by drug-intoxication and by other poisoning, as less violent and less forensically overt methods, than suicides by firearm and hanging/suffocation; and (2) performance of a forensic autopsy attenuates any observed association between overtness of method and the reported presence of a note.This multilevel , multivariable analysis employed a generalized linear mixed model (GLMM). Representing the 17 states participating in the United States National Violent Death Reporting System throughout 2011–2013, the study population comprised registered suicides, aged 15 years and older. Decedents totaled 32,151. The outcome measure was relative odds of an authenticated suicide note.An authenticated suicide note was documented in 31% of the suicide cases. Inspection of the full multivariable model showed a suicide note was more likely to manifest among drug intoxication  and other poisoning suicides  than firearm suicides, the referent. Respective excesses were larger when there was no autopsy or autopsy status was unknown  and  relative to the comparisons with a forensic autopsy . Hanging/suffocation suicides did not differ from the firearm referent given an autopsy.Suicide requires substantial affirmative evidence to establish manner of death, and affirmation of drug intoxication suicides appears to demand an especially high burden of proof. Findings and their implications argue for more stringent investigative standards, better training, and more resources to support comprehensive and accurate case ascertainment, as the foundation for developing evidence-based suicide prevention initiatives. Emerging as the leading cause of injury mortality in the United States (US) by 2009 , suicideAvailability of a suicide note or an equivalent—whether written, typed, digital, or audio —can servTwo earlier American studies found an excess of note-leaving among suicides by poisoning relative to other methods ,28, wherIn this multilevel, multivariable study of NVDRS data for 2011–2013, we posited that a higher proportion of suicide notes in manner of death determinations involving fatal drug introxication, as compared to those involving a firearm or hanging, reflected their use as key evidence in the differential process of establishing suicide as the manner of death. This could signify stricter  evidentiary standards when making these determinations, leading in turn to a greater potential for undercounting suicides.We addressed two questions in our examination of the differential determination of suicide, with a view to informing and improving surveillance, etiologic understanding, and prevention of suicide and related injury mortality. Was an evidentiary note more common among suicide cases involving drug intoxication and other poisoning, less self-evident causes and manner of death, as compared to the violent methods of firearm and hanging, where apparent motivation is more overt? Did the performance of a forensic autopsy serve to mediate the association between the reporting of a note and the overtness of the suicide method? Although a forensic autopsy is not a personal window into decedent intent , togetheSalient to our study, forensic autopsy and toxicological testing rates vary greatly across states ,39. SincThe source for our individual-level variables was the Restricted Access Database from the NVDRS, which is administered by the Centers for Disease Control, and Prevention (CDC). This state, territory, and incident-based surveillance system employs public health informatics for making data linkages, primarily among death certificates, law enforcement records, and medical examiner and coroner records. Also variably incorporating such optional supplements as laboratory reports and hospital records, the NVDRS provides de-identified information about suicide and other violent deaths, including their geographic location, circumstances, and personal sociodemographics, in addition to investigation specifics –44. DisaOur study population comprised registered suicides , whose method and state and county of death were specified, and was further confined to decedents aged 15 years and older, since fewer than 1% of known suicides were younger. The number of decedents in our multivariable analyses totaled 32,151. As further background, our first table provides comparative data on suicide methods for the 17 NVDRS states and the US. These comparisons were based on separate counts for the selected demographic variables, not study population and corresponding national population counts. Similarity between the states and the nation would fortify the generalizability of the results. The data source was CDC WISQARS™ (Web-based Injury Statistics Query and Reporting System) [The outcome variable in this study was suicide note (yes versus no or unknown). Our predictor distinguished suicide methods as follows: drug intoxication, other poisoning, jumping and drowning , hanging/suffocation, firearm (referent), and all other methods specified in the NVDRS suicide cases. Additional individual-level covariates were prior suicide attempt; primary mental diagnosis; current mental health treatment; blood alcohol concentration; number of other specified drug positives; physical health problem; number of intimate partner or legal or job or financial or school problems; crisis in past two weeks; emergency medical services at scene; region of death; age; sex; race/ethnicity; marital status; education; and military veteran status. The mediator was autopsy status (yes versus no or unknown).Linked to the individual-level data in this study, our county-level death investigation system covariates were mode of selection of the chief medical examiner or coroner for a given system (elected versus appointed) and accreditation status and type . Selection mode was identified through a CDC website , and accWe used a generalized linear mixed model (GLMM) to test the following two hypotheses: (1) an evidentiary suicide note is more likely to accompany suicides by drug-intoxication and by other poisoning than suicides by firearm and hanging/suffocation; and (2) performance of a forensic autopsy attenuates the observed association between overtness of method and the reported presence of a note. In testing the first hypothesis, we progressively applied four models, beginning with a univariable analysis, confined to suicide method, followed by multivariable analyses that cumulatively incorporated medicolegal system and investigation characteristics, mental health antecedents and precipitating circumstances, and decedent and areal demographics. Providing for a fifth multivariable model, we then tested our second hypothesis. The GLMM is a two-level model that is logistic at the individual level and linear at the county level. We also included a state-level random effect to incorporate the data structure of counties nested in a state and individuals nested in a county. The statistical software was SAS (Copyright(c) 2002–2010, SAS Institute Inc., Cary, NC).Bivariable frequency data on suicide notes for the study population are presented in Partially affirming the principal hypothesis, the univariable analysis showed drug intoxication suicides and suicides by other poisoning were respectively 71% and 122% more likely than their referent, firearm suicides, to be associated with a note . NeitherThe stratified analysis supported our second hypothesis as performance of a forensic autopsy attenuated the association between suicide method and suicide note outcome . PercentOur findings caution users against uncritically taking suicide and other official data at face value. Under-ascertainment means suicide undercounting. Indicative of differential undercounting by method, increased odds of a suicide note manifested both for cases of suicides by drug intoxication and by other poisoning relative to their referent, firearm cases, as consonant with the first hypothesis concerning the relative violence and forensic overtness of methods. Hanging suicides did not deviate from the referent, nor did the combined category of jumping and drowning suicides. The observed note excess for both drug-intoxication and other poisoning suicides persisted through application of each of the multivariable models, including the full multilevel, multivariable model that incorporated autopsy status.The study implication of growing suicide misclassification and suicide undercounting among drug intoxication deaths assumes added importance as an impediment to prevention in the face of the burgeoning opioid mortality epidemic  and seveAs hypothesized, performance of a forensic autopsy attenuated the observed associations between overtness of suicide method and odds of an evidentiary suicide note. Although an autopsy can help investigators identify the mechanism or cause of an injury death, it does not invariably enlighten decedent intentionality . Indeed,National Association of Medical Examiners (NAME) Forensic Autopsy Performance Standards require an autopsy when “the death is by apparent intoxication by alcohol, drugs, or poison, unless a significant interval has passed, and the medical findings and absence of trauma are well documented” [The US umented” . NAME doumented” .By comparison with the US, Finnish medicolegal authorities conducted forensic autopsies in 99% of suicides, 98% of homicides, 98% of unintentional poisoning deaths, and 97% of undetermined deaths in the period 2000–2003 . ResearcMore generally implicating an artifactual component in suicide rates and rate variation, an ecological or correlational study of 35 Eurasian countries reported spatial and temporal associations between the respective magnitudes of the combined clinical and forensic autopsy rate and the suicide rate . SpatialOur research, examining registered or known suicides, complements another multilevel , multivariable study which used NVDRS data from the same observation period to predict differential odds that suicides pooled with deaths of undetermined intent, included as possible suicides, would be classified by medical examiners and coroners as suicide if there was documentation of a suicide note and mental health antecedents . One hypBased on medicolegal and police investigations, which often involve family and friends of the decedent, NVDRS data are vulnerable to reporter bias, especially among persons who are ashamed or embarrassed by what transpired. This deficiency also may reflect a lack of willingness of investigators to collect data about decedent background and circumstances when suicide is readily apparent as the manner of death, or when as an elected local official, coroners are reluctant to probe potentially sensitive personal issues. Our study and the complementary NVDRS investigation jointly reveal a need for qualitative as well as quantitative research on whether family and friends of the decedents variably destroy or otherwise conceal suicide notes, and withhold other potential corroborative evidence from authorities. The field now would benefit from mixed methods investigations that integrate psychological autopsies, focus groups, surveys, sociocultural autopsies, content analysis, and thematic analysis to examine values and attitudes towards suicide that may continue to influence its reporting. Although high quality data regarding suicides are essential for planning, implementing, and evaluating suicide prevention programs, few resources have been devoted to improving fundamental data quality. Without such rigor, it will be difficult to accept the validity of future efforts to reduce suicide rates.The enriched Restricted Access Database of the NVDRS provides the only population-based data in the US appropriate for evaluating our research questions about the relationship between suicide methods, a forensic autopsy, and an evidentiary suicide note. Besides reporter bias, a limitation of this study was restriction of the geographic domain to the 17 states that contributed data to the NVDRS throughout the observation period, 2011–2013. Nevertheless, high demographic concordance between these states and the nation . MoreoveSuicide requires substantial affirmative evidence to establish manner of death, and affirmation of drug intoxication suicides appears to demand an especially high burden of proof. Findings and their implications argue for more stringent investigative standards, better training, and more resources to support accurate and comprehensive case ascertainment, as the foundation for developing evidence-based suicide prevention initiatives.


Adverse pregnancy outcomes are more common among Aboriginal and Torres Strait Islander populations than non-Indigenous populations in Australia. Later in life, most of the difference in life expectancy between Aboriginal and Torres Strait Islander women and non-Indigenous women is due to non-communicable diseases (NCDs). Most Aboriginal and Torres Strait Islander women attend health services regularly during pregnancy. Providing high-quality care within these appointments has an important role to play in improving the current and future health of women and babies.This study engaged stakeholders in a theory-informed process to use aggregated continuous quality improvement (CQI) data to identify 1) priority evidence-practice gaps in Aboriginal and Torres Strait Islander maternal health care, 2) barriers and enablers to high-quality care, and 3) strategies to address identified priorities.Three phases of reporting and feedback were implemented using de-identified CQI data from 91 health services between 2007 and 2014 . Stakeholders (n = 172) from a range of professions and organisations participated.Stakeholders identified four priority areas relating to NCDs: smoking, alcohol, psychosocial wellbeing and nutrition. Barriers or enablers to high-quality care included workforce support, professional development, teamwork, woman-centred care, decision support, equipment and community engagement. Strategies to address the priorities included upskilling staff to provide best practice care in priority areas, advocating for availability of healthy food, housing and local referral options, partnering with communities on health promotion projects, systems to facilitate continuity of care and clear referral pathways.This novel use of large-scale aggregate CQI data facilitated stakeholder input on priority evidence-practice gaps in maternal health care in Australia. Evidence-practice gaps relating to NCD risk factors and social determinants of health were prioritised, and stakeholders suggested both healthcare-focussed initiatives and approaches involving the community and the wider health sector. The findings can inform health service planning, advocacy, inter-agency strategies, and future research. Approximately 4% of all women giving birth in Australia are Aboriginal and/or Torres Strait Islander 12,817 in 2014) –7. This  in 2014 While many Aboriginal and Torres Strait Islander women have healthy pregnancies and babies, considerable disparities in perinatal outcomes, such as low birth weight and preterm birth, persist compared to the general population in Australia . These oNCD risk factor prevalence in Aboriginal and Torres Strait Islander populations is associated with socio-economic disadvantage and the intergenerational effects of colonisation –7. SociaOne strategy used to drive evidence-based care is Continuous Quality Improvement (CQI), a management approach that aims to constantly increase the efficiency and effectiveness of organizational systems and processes , 19. MatData collected by individual PHC centres as part of their CQI activities can be aggregated and used to identify trends across health services and over time , includiWe hypothesise that one way to generate research evidence that is better matched to the needs of health services, policy makers and affected populations , and morThe “Engaging Stakeholders in Identifying Priority Evidence-Practice Gaps and Strategies for Improvement in PHC” (ESP) Project was designed to combine evidence on how to achieve large-scale change with knowledge co-creation . This waThe ESP Project drew on aggregated CQI data collected as part of the Audit and Best Practice for Chronic Disease (ABCD) National Research Partnership–a collaboration that brought together PHC services, policy, support organisations and research institutions to guide and support collaborative CQI research to improve the quality of Aboriginal and Torres Strait Islander PHC across Australia. The ABCD Partnership linked more than 170 PHC centres in different parts of Australia in collaborative CQI research. The protocol and outcomes have been reported in detail previously , 28 and Each phase of the ESP Project used the same recruitment methods, aiming to engage stakeholders in different roles across the health care system. Stakeholders were identified by drawing on the extensive networks of the ABCD National Research Partnership, the Centre for Research Excellence in Integrated Quality Improvement and the ESP Project research team. These networks included health practitioners , managers and policy makers at various levels of the health system, researchers, and staff of peak bodies and support organisations that represent the interests of community-controlled health services and Aboriginal and Torres Strait Islander communities. Stakeholders were recruited by email invitation to individuals and organisations with known interest in Aboriginal and Torres Strait Islander maternal health care , professional society newsletters , and websites . A snowballing distribution technique was used, whereby all stakeholders initially contacted were requested to forward the ESP reports and links to the online questionnaires through their networks to increase ESP Project reach. To enable engagement of those less likely to provide individual responses, we encouraged responses from facilitated group discussions.Ethical approval for the ABCD National Research Partnership was obtained from research ethics committees in each relevant Australian jurisdiction . All parIn all phases the online questionnaires could be completed by individuals or on behalf of a group of people. A group facilitation guide was provided to assist with group discussion. The first section of each questionnaire covered information about the stakeholder including their profession, organisation and jurisdiction. The specific data collection tools and methods for each phase are described in the following paragraphs.In Phase One stakeholders were asked to identify priority evidence-practice gaps for maternal health care (Phase One outcome) using cross-sectional, national CQI data. The data comprised the most recent maternal health audit completed by health centres during the period 2012–2014 .Prior to stakeholder recruitment, the research team used this data to develop a preliminary set of priorities based on the following criteria:Aspects of maternal health care that were generally recorded at low levels.Aspects of care where there was wide variation between health centres in recorded delivery of care.Aspects of care that were being delivered at high levels by most health centres, but that were being delivered at much lower levels by some health centres.Organisational systems that were relatively less developed.The data and preliminary priorities were then circulated as a report and a plain language summary with a link to an online questionnaire . The queIn Phase Two stakeholders were asked to identify barriers and enablers and strategies for best practice maternal health care (Phase Two outcomes). In this phase, stakeholders were provided with longitudinal, national CQI data for the evidence-practice gaps prioritised in Phase One (from 2007 to 2014: 4402 audited records and 242 systems assessments from 91 PHC centres), and a brief on the evidence from previous quality improvement research, including research in Aboriginal and Torres Strait Islander PHC. A plain language summary of the full report, jurisdiction-specific data supplements and a link to the Phase Two questionnaire  were alsThe questionnaire asked stakeholders to consider the longitudinal data, the evidence brief and their experience in PHC, and then to rate the quality of staff and health centre or system attributes relevant to supporting best practice in maternal health care, particularly relating to the priority evidence-practice gaps. A five-point Likert scale was used: strongly disagree that the attribute is in place, partly disagree, partly agree, strongly agree, I don’t know. The list of attributes that could be potential enablers (if in place) or barriers (if not in place) to improvement was drawn from international and national research –41 and hThe questionnaire then asked stakeholders to suggest “strategies and actions that could be used to address barriers and enablers for each priority evidence-practice gap” using free-text comment boxes.A final draft report was prepared and sent to stakeholders, summarising the CQI data for the prioritised evidence-practice gaps, the barriers and enablers stakeholders agreed were important for addressing the priority evidence-practice gaps, and the strategies that stakeholders suggested. An online questionnaire was also provided, asking for any additional comments or suggestions on the presented barriers, enablers and strategies for maternal health care (Phase Three outcome) . This prQuestionnaire responses were analysed after each phase so that the data could inform the next phase. Individual and group responses were analysed together. In Phase One the aspects of maternal health care that received importance ratings of 8–10 by more than 90% of stakeholders were considered the prioritised evidence-practice gaps. In Phase Two if two-thirds of stakeholders strongly or partly agreed that an attribute was in place it was considered a current enabler. If two-thirds of stakeholders strongly or partly disagreed that an attribute was in place it was considered a current barrier. For the suggested strategies (free text) one of the ESP Project team (MGH) collated and summarised the strategies and actions. A second ESP Project researcher (JB) then checked the summary against the raw questionnaire data to ensure accuracy. In Phase Three any new barriers, enablers or strategies suggested by stakeholders were incorporated into the final report by one ESP Project team member (MGH) and checked by a second (JB).One final piece of synthesis was conducted once all phases had been completed. The ESP project had guided stakeholders through a process, starting with prioritising evidence-practice gaps, then identifying barriers and enablers, and finally suggesting strategies. At each stage stakeholders were encouraged to consider the findings and their responses from the previous step so that the stages built on each other. Therefore, we hypothesised that the suggested strategies could be mapped back to both the barriers/enablers and to the evidence-practice gaps and attempted to organise the findings to map these relationships. The synthesis drew on the multidisciplinary expertise of the ESP Project team: quality improvement, Aboriginal and Torres Strait Islander health, obstetrics and gynaecology, primary health care, public health, management, knowledge translation and implementation. One of the ESP Project team members (MGH) conducted the initial mapping by hypothesising links between the suggested strategies and specific barriers/enablers and evidence-practice gaps. The ESP Project team reviewed and refined the mapping to generate the final version. This mapping allowed us to assess whether stakeholders had indeed kept the barriers and enablers in mind when discussing strategies to address the evidence-practice gaps.Fifty-one discrete responses, representing over one hundred stakeholders, were received across the three online questionnaires . The represented organisations included community-controlled (n = 19), government (n = 12) and general practice health services (n = 3), research organisations (n = 13), government health departments (n = 13), and health service support organisations (n = 9). Participants included nurses and midwives (n = 30), doctors (n = 18), Aboriginal and/or Torres Strait Islander Health Practitioners or Workers (n = 10), managers and board members (n = 10), CQI facilitators (n = 3), researchers (n = 10) and others (n = 8). Five individual respondents identified as Aboriginal and/or Torres Strait Islander, and all groups had some Aboriginal and/or Torres Strait Islander members. Numbers may not tally with the total number of responses, as respondents were able to select multiple answers.Approximately 112 people  participated in Phase One.The aggregated CQI data showed that many key aspects of maternal health care were provided at high levels by most health centres. Examples included laboratory investigations related to maternal immunity and infection, follow-up for abnormal glucose tests and anaemia, measurement of blood pressure, fundal height and foetal heart rate, and discussion of breastfeeding and contraception at the postnatal visit. Stakeholders identified eight evidence-practice gaps as priorities for improvement Figs  and 2. TApproximately 60 stakeholders  participated in Phase Two. The attributes of health centres, the health system and staff that the majority of stakeholders agreed or disagreed were in place are presented in Enablers of best practice maternal health care, particularly regarding the priority evidence-practice gaps, were systems that support adequate health centre equipment, staff training and development, teamwork, decision support resources and systems for health centre staffing and workforce support for some staff types . SystemsStakeholders used the free-text sections to provide context for their ratings of health centre, system and staff attributes, and to suggest strategies to address barriers and enablers for each prioritised evidence-practice gap. The suggested strategies are summarised in Some strategies addressed health centre and staff attributes such as training, continuity of care, and processes to support consistent care. Other strategies built on the existing strong staff attributes but require partnerships across the broader health system such as enhancing referral processes, advocating for local services and working with communities on health promotion and education projects. An overarching theme across all strategies was the importance of working with communities and in a culturally appropriate manner.Five responses were received regarding review of the draft final report , providing feedback from nine people in a variety of roles. An additional strategy suggested at this stage was to take a long-term funding approach to midwifery-led maternal health care and Aboriginal and Torres Strait Islander women’s health care to enable successful temporary services or programs to continue. A second suggested strategy was to strengthen systems to recruit, retain and support doctors and nurses, especially Aboriginal or Torres Strait Islander doctors and nurses, with language skills and cultural knowledge. All respondents indicated that the ESP process had improved their understanding of how to use aggregated CQI data to inform decision-making.As hypothesised, the strategies  included those that support the Aboriginal and/or Torres Strait Islander workforce, woman-centred care, and community engagement. Strategies to address the evidence-practice gaps related to training, referral processes, continuity of care, processes to support consistent and comprehensive care, advocacy for availability of local services and working with communities on health promotion and education projects.Aboriginal and Torres Strait Islander women are populations at increased risk of NCDs and many young women will enter pregnancy with existing NCDs or NCD risk factors. Six of the eight prioritised evidence-practice gaps directly related to NCD risk factors and social determinants of health. Therefore, we conclude that stakeholders in this research recognised these elevated risks and the important role of maternal health care in reducing NCD risk for both mothers and babies. Addressing social determinants of health requires both improving health care at individual health centres and broader approaches. Therefore, it’s not surprising that some strategies addressed attributes of individuals and health centres or the health system. However, such strategies require partnerships with communities, external services and policy makers. This fits with the hypothesis that evidence-practice gaps across many health centres are due to failures of the wider health system  and requAs shown in There is a growing emphasis on the importance of meaningful stakeholder involvement in setting research priorities and co-creation of implementation research projects, both generally and specifically in PHC –48. The Dissemination of research evidence and timely implementation in policy and clinical practice is a key challenge for researchers, policy makers, health services and health professionals –26. Our The findings can also be a starting point for strategies to be developed collaboratively across different levels of the health system. For many of the prioritised gaps a key strategy was to improve the availability of local, appropriate services and resources to support health services to take a life-course and woman-centred approach to maternal health care. The findings relating to current service performance data and stakeholder-identified barriers and enablers address a challenge to evidence uptake frequently reported by policy makers: inadequate access to timely, relevant and high-quality research evidence .The ESP Project process created an important opportunity for stakeholders to contribute their perspectives to research. Capturing these perspectives enables researchers to focus on areas important to people involved in health service delivery. The process and findings may facilitate researchers and stakeholders working together to develop research programs with real world application.As barriers exist across multiple levels of the health system, we included questions on broader health centre and system attributes in the Phase Two questionnaire. These additional questions have not been validated like the questions relating to individual attributes. Another limitation is that recruitment relied on stakeholders passing on the invitation through their networks, so it is not possible to accurately measure reach or response rates. Caution is needed when interpreting the findings from the Phase Two questionnaire as relatively fewer responses were received, which limits generalisability.One of the main strengths of this research is that it used the largest and most comprehensive longitudinal dataset relating to Aboriginal and Torres Strait Islander maternal health care provision. However, it is important to note that the dataset captured recorded delivery and may underestimate actual service delivery due to under-documentation. Another strength is that a range of stakeholders was recruited and so the findings reflect knowledge of front-line health workers and others working within the health system.This novel study used large-scale aggregated CQI data and a theory-informed dissemination strategy to engage stakeholders involved in Aboriginal and Torres Strait Islander maternal health care in Australia. Stakeholders identified priority evidence-practice gaps in maternal health care relating to NCD risk factors and social determinants of health, some barriers and enablers associated with these gaps, and strategies for achieving improvement. These findings can be used in health service planning, advocacy efforts, development of inter-agency strategies, and to inform the maternal health care research agenda.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(PDF)Click here for additional data file.S1 TablePHC: primary health care, CQI: continuous quality improvement, n: number.(DOCX)Click here for additional data file.