The COVID-19 pandemic suggests that there are opportunities to improve preparedness for infectious disease outbreaks. While much attention has been given to understanding national-level preparedness, relatively little attention has been given to understanding preparedness at the local-level. We, therefore, aim to describe (1) how local governments in urban environments were engaged in epidemic preparedness efforts before the COVID-19 pandemic and (2) how they were coordinating with authorities at higher levels of governance before COVID-19. We developed a survey and distributed it to 50 cities around the world involved in the Partnership for Healthy Cities. The survey included several question formats including free-response, matrices, and multiple-choice questions. RACI matrices, a project management tool that helps explain coordination structures, were used to understand the level of government responsible, accountable, consulted, and informed regarding select preparedness activities. We used descriptive statistics to summarize local-level engagement in preparedness. Local authorities from 33 cities completed the survey. Prior to the COVID-19 pandemic, 20 of the cities had completed infectious disease risk assessments, 10 completed all-hazards risk assessments, 11 completed simulation exercises, 10 completed after-action reviews, 19 developed preparedness and response plans, three reported involvement in their country’s Joint External Evaluation of the International Health Regulations, and eight cities reported involvement in the development of their countries’ National Action Plan for Health Security. RACI matrices revealed various models of epidemic preparedness, with responsibility often shared across levels, and national governments accountable for the most activities, compared to other governance levels. In conclusion, national governments maintain the largest role in epidemic and pandemic preparedness but the role of subnational and local governments is not negligible. Local-level actors engage in a variety of preparedness activities and future efforts should strive to better include these actors in preparedness as a means of bolstering local, national, and global health security. Ensuring that urban settings are prepared for public health emergencies, such as infectious disease outbreaks, is critically important. This is because, in addition to potentially being where outbreaks originate, characteristics of urban environments can promote the spread of disease, both within the city and globally –3. In toWhile local authorities and public health departments in cities can play key roles in promoting preparedness and preventing the spread of infectious diseases, they are not the only entities involved in preparedness efforts. Much attention has been given to national-level public health preparedness and health security efforts, such as the International Health Regulations Monitoring and Evaluation Framework . This FrBefore the COVID-19 pandemic, many countries reported high levels of preparedness through these assessments. Other assessments, such as the Global Health Security Index and the Epidemic Preparedness Index, also suggested that many countries were well prepared for an epidemic or pandemic, especially those in Europe and North America , 8. StilIn addition to overlooking local-level contexts in preparedness assessments, the roles of local authorities  in these aforementioned efforts and the coordination between different levels of government remain poorly understood. This gap is notable given the widely recognized role that local authorities play in implementing policy decisions and producing the outcomes associated with governance processes, including the protection of public health . In muchThe actual or potential actions that may be taken by local governments are often influenced by policy, guidance, and financing from higher levels of governance , 19. In These considerations lead to questions about not only how local governments and authorities were engaging in epidemic preparedness before the COVID-19 pandemic, but also the roles they played and how these efforts were coordinated with higher levels of government. The objectives of this descriptive research, then, are to understand the ways in which local-level authorities in urban environments were engaging in preparedness efforts before the COVID-19 pandemic, as well as how they were coordinating with authorities at higher levels of governance to complete key tasks and preparedness activities.The research described in this article used a survey study design to ask local public health authorities in cities around the world about their city’s engagement in pandemic preparedness efforts prior to the COVID-19 pandemic and how select preparedness activities were coordinated with higher levels of government. The data were collected from June–August 2021.This research effort involved public health authorities from cities that were a part of the Partnership for Healthy Cities. The Partnership for Healthy Cities is a city network of 70 cities that have committed to preventing noncommunicable diseases and injuries through proven, evidence-based interventions and approaches. In March of 2020, recognizing the urgency of the COVID-19 response, the network temporarily expanded its scope to include support for pandemic response. The population involved in this study included 50 cities in the Partnership for Healthy Cities that were purposively selected based on their involvement in a voluntary mini-grant program that focused on bolstering the local response to the COVID-19 pandemic.We developed a survey questionnaire based on existing pandemic preparedness frameworks and guidance , 23. TheIncluded in the survey questionnaire were RACI  matrices . RACI maFor the purposes of this study, we used standard definitions associated with RACI models and defined responsible as implementing the work required to complete an activity; defined accountable as overseeing the correct and thorough completion of an activity; defined consulted as engaging in two-way communication to provide information necessary for the completion of an activity; and defined informed as being updated on progress toward or on the results from a given activity  . AdditioOnce finalized, we translated the questionnaire and accompanying instructions into French and Spanish in an effort to ensure that the materials were accessible and comprehensible to potential survey participants. We submitted all study materials to the Georgetown University Institutional Review Board for ethical review. The Institutional Review Board granted an exemption to the study (STUDY00003948) in June 2021 after determining that the research posed no more than minimal risk to those who would be participating. Formal consent was, thus, not required. However, we still provided an informed consent form to all study participants that emphasized the voluntary nature of the research, that their participation was not incentivized, and that they could withdraw from the study at any time without consequence. Consent was then informally provided through participation.Following ethical review, we uploaded the survey to Qualtrics  and distributed it with instructions to local-level authorities in June 2021, before closing the survey in August 2021. We collected the data from survey responses and compiled them in a spreadsheet created with Microsoft Excel . Prior to beginning data analysis, we reviewed data for consistency and validity. We used Microsoft Excel and STATA v.17BE  to perform basic descriptive statistical analyses to summarize local-level engagement in preparedness efforts and how they coordinated with higher levels of government to complete preparedness activities.Local-level health authorities from 33 cities–Abidjan (Côte d’Ivoire), Accra (Ghana), Addis Ababa (Ethiopia), Amman (Jordan), Athens (Greece), Bandung (Indonesia), Bangkok (Thailand), Barcelona (Spain), Bengaluru (India), Buenos Aires (Argentina), Cali (Colombia), Chicago (United States), Colombo (Sri Lanka), Fortaleza (Brazil), Guadalajara (Mexico), Harare (Zimbabwe), Kampala (Uganda), Kigali (Rwanda), Kumasi (Ghana), León (Mexico), Lima (Peru), London (United Kingdom), Lusaka (Zambia), Melbourne , Medellín (Colombia), Montevideo (Uruguay), Ouagadougou (Burkina Faso), Quezon City (Philippines), Rio de Janeiro (Brazil), Santiago (Chile), Santo Domingo (Dominican Republic), Vancouver (Canada), and Yangon (Myanmar)–completed surveys. Eight (24.2%) of these cities are located in countries that are classified as high income countries, 12 (36.4%) are located in countries that are classified as upper-middle income countries, nine (27.3%) are located in countries that are classified as lower-middle income countries, and four (12.1%) are located in countries that are classified as low income countries . SeventeThe preparedness experiences of cities varied across the world, reflecting the heterogeneity in the geographic, epidemiologic, political, and development contexts in which the cities exist. No city reported that they had completed or participated in all seven of the preparedness efforts. The greatest number of preparedness efforts reported was five of the seven, which was reported by Chicago, Colombo, and Melbourne.Twenty of the cities (60.6%) reported that they had completed an infectious disease risk assessment prior to the COVID-19 pandemic, 10 (30.3%) reported the completion of an all-hazards risk assessment prior to the COVID-19 pandemic, 11 (33.3%) reported the completion of a simulation or table-top exercise, and 10 (30.3%) reported the completion of an after-action review prior to the COVID-19 pandemic . NineteeThree cities–Abidjan, Accra, Kumasi–reported that they had been involved in their country’s JEE, while eight cities–Abidjan, Accra, Addis Ababa, Amman, Bandung, Colombo, Kigali, and Kumasi–reported that they were included in the development of their countries’ respective NAPHS. Survey response data are available in a .Responses to the RACI matrices revealed a heterogeneous landscape of authorities, responsibilities, and communication networks. Some cities, such as Abidjan, Bangkok, and Montevideo reported that the national government maintained primary authority and was accountable for virtually all pandemic preparedness activities in the city; other cities, such as Bengaluru, Buenos Aires, and Vancouver reported that subnational governments were primarily accountable for pandemic preparedness activities; and other cities, such as Bandung, Chicago, and Kampala, reported that the local government was primarily accountable for pandemic preparedness activities. However, most often, the accountability and responsibility for pandemic preparedness activities were shared across the various levels of government. All reported RACI matrices are available in a .The activities national authorities were most often responsible for include developing pandemic preparedness and response policy (n = 32), financing routine public health activities (n = 28), and identifying and mapping resources required for the response to public health emergencies (n = 25) ; the actRelative to the other levels of government, national authorities were most often reported to be accountable for seven of the 11 pandemic preparedness activities, national and subnational authorities for one of the activities, subnational and local authorities for one of the activities, and local-level authorities for two of the activities . Yangon Survey responses indicated a relatively high degree of consultation for pandemic preparedness activities. National authorities were most often engaged in consultation for operationalizing pandemic preparedness and response policy (n = 20), developing pandemic preparedness and response policy (n = 14), and developing mechanisms for coordination between levels of government (n = 14) ; subnatiSurvey responses indicated a relatively low degree of one-way communication for preparedness activities. National authorities were most often informed regarding conducting routine infectious disease surveillance activities (n = 6), conducting the initial investigation of infectious disease outbreaks (n = 5), and conducting simulation or table-top exercises to test capacities (n = 4) ; subnatiThis study examined the ways in which local-level authorities were engaging in epidemic and pandemic preparedness efforts before the COVID-19 pandemic, as well as how they coordinated with higher levels of government for select preparedness activities. Answering these questions and better understanding the roles of local authorities in health security will be important as the world reflects on the experiences of COVID-19 and looks to prepare for future public health emergencies.The results of this work highlight that, according to local governments and public health authorities, before the COVID-19 pandemic, epidemic and pandemic preparedness in cities was largely left to higher levels of government. Of the activities included in our survey, national governments were both responsible for implementing and accountable for overseeing a majority of the activities, when compared to subnational and local governments. Still, the role of local governments was not insignificant, as they were the level of government most often accountable for overseeing and responsible for operationalizing pandemic preparedness and response policy, and for overseeing routine infectious disease surveillance activities and conducting the initial investigation of outbreaks. They were also frequently consulted by higher levels of government as they developed mechanisms for coordination between levels of government, developed and maintained pandemic preparedness and response plans, and identified and mapped resources required for the response to public health emergencies.These results corroborate the widely held view that local governments are often at the frontline of epidemic preparedness efforts–especially as they relate to infectious disease surveillance activities . They alStill, others have argued that the future success of global health interventions, may depend on the ability of local governments, especially those in cities, to promote health . To thisTo this end, should the COVID-19 pandemic prove impetus enough to reexamine how the world approaches measuring public health preparedness, one practical and impactful opportunity that exists for better including local governments in preparedness efforts would be to formally or informally incorporate them into existing preparedness assessment activities and tools. Alternatively, local governments could take it upon themselves to conduct preparedness assessments by using resources specifically designed for them , or by cAlso of importance is that local governments, while frequently responsible or accountable for many of the preparedness activities, are not as frequently consulted or informed. This suggests that there are opportunities to improve governance, planning processes, financing, collaborative networks, and communication–all of which are essential elements of public health emergency preparedness . PreviouThis study and its results suffer from several limitations. First, and most significantly, the results relied on the completion of a survey by one individual. While we attempted to distribute the survey to the local authority who would be most knowledgeable about epidemic and pandemic preparedness in the city, we cannot guarantee that the data captured by responses are completely valid or factual. One person’s knowledge regarding all of the preparedness efforts, activities, and arrangements in their city may be limited. For instance, a majority of survey participants had served in their current professional role for one to four years and may not have been aware of preparedness efforts in their city before this time or known the intricacies of coordination arrangements for all preparedness activities included in the survey. Future research may wish to more deeply examine preparedness efforts in specific cities or to validate the results of this study by reviewing the legislation, regulations, and other legal frameworks that provide the foundation for public health preparedness and coordination between levels of government.Additionally, the specific results from each city are unlikely to hold great amounts of external validity. The governance contexts in which participating cities exist vary widely, and it would be inappropriate to generalize results across contexts without examining the specific authorities of local-level authorities. It must also be noted that many of the cities included in this survey are the national capitals of their respective countries. This consideration is important to the interpretation of these results because capital cities often have unique governance models that impact the relative autonomy, roles, and responsibilities of the local government. Together, these considerations mean that the specific powers of local governments can differ significantly between cities in different countries, as well as within the same country. It is for this reason that our study provides descriptive statistics to summarize broad trends in urban health security in cities around the world, instead of attempting to overstate our results and risk inappropriately generalizing across contexts. Future research may also wish to explore the contextual aspects that determine the roles and responsibilities of local governments in pandemic preparedness and how these vary both domestically and internationally.In conclusion, the results of this research suggest that, according to local-level authorities, their involvement in epidemic and public health preparedness before the COVID-19 pandemic was relatively limited. While many had completed risk assessments and developed some form of response plan, fewer had been involved in capacity assessments or tested the functionality of existing capacities through simulation exercises or after-action reviews. Further, while national governments seemingly represent the level of government that is primarily responsible and accountable for preparedness, local governments still maintained much responsibility and a large role in operationalizing policy and implementing activities. Opportunities for improving public health preparedness in the future may include improving coordination between levels of government, involving local-level authorities in capacity assessments, and examining the functionality of capacities at the local-level.S1 Text(PDF)Click here for additional data file.S1 Data(PDF)Click here for additional data file.S2 Data(PDF)Click here for additional data file.


During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation. The COVID-19 pandemic catalyzed the rapid development, implementation, and scaling of telehealth, which we define for this commentary as the synchronous delivery of health care services by phone or video . Prior thow telehealth should be equitably implemented, adapted, and sustained to reach entire target populations  and diverse institutions . It also highlights an urgent need to address unintended consequences of widespread telehealth and apply strategies to ameliorate inequity where possible. We present a broad perspective on equitable implementation of telehealth and provide discussion and recommendations through the literature, an illustrative example, and our own practical experiences. The specific purposes of this commentary are to (1) describe the importance of and nuances in equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation processes. Recognizing the complexities in equitable implementation of telehealth, we provide a perspective on how implementation can either exacerbate or proactively address inequity. Other authors have described inequalities in patients who have access to, use, and adhere to interventions and intervention inequalities if technology-based interventions are not equally effective for all .-28.25-28EPIS encompasses a 4-phase implementation cycle  and describes implementation processes, inner and outer contextual factors, and bridging factors that facilitate the interplay between inner and outer factors through each of these phases . For exaThe DHEF adds an equity focus to the internal and external factors in EPIS . The DHEwhy. An understanding of who in the population is not reached and why they may have been excluded can lead to diverse community and health system engagement and offer contextual adaptations to the telehealth clinical practice and implementation strategy.The integration of EPIS and the DHEF informs equitable implementation in telehealth by considering who can or cannot (1) access telehealth, (2) receive telehealth, and (3) deliver telehealth and EPIS contains “bridging factors,” which consider and account for the interconnectedness and bidirectional nature of movement within and across internal and external factors that shape telehealth access, receipt, and delivery ,28,30. Icommunity partnerships are the backbone of successful implementation research and can create the bidirectional flow of information necessary to align telehealth goals across care systems, individuals, and national or state policies. Second, communicating mental models nurtures the sharing of an interrelated set of beliefs that shapes a person’s expectations for the future and how they understand the ways the world works [digital infrastructure bridges an organization’s human and technical resources to provide telehealth with a focus on advocacy at federal or state levels to incentivize payers to reimburse telehealth and invest in digital infrastructure. In future, if rapid deployment suggests bridging factors as key considerations for the equitable implementation of telehealth. In ld works ,35. Whenld works ,35. FinaWe offer a case scenario that illustrates the implementation phase of EPIS and considerations for equitable telehealth as outlined by DHEF. We first illustrate the health system as a social determinant of health and socioeconomic and cultural contexts defined by DHEF that drive the multilevel context in which the delivery of web-based physical therapy evolved over the pandemic. During the initial weeks of the COVID-19 pandemic in the United States, in-person services provided by outpatient physical therapists were immediately discontinued. Outpatient physical therapists across a multitude of health care systems and clinic networks transitioned from almost 100% in-person visits to almost 100% web-based visits in a matter of weeks ,37. ThisAs the pandemic has progressed, so has the phased reopening of outpatient physical therapy services for in-person care. However, the value of telehealth—for example, the potential for expanded access and decreased transportation burden—has created momentum to continue the provision of physical therapy care via web-based modalities ,45. An oestablishing community partnerships is needed to engage patients, families, providers, and communities to better identify (needs assessment) who receives physical therapy (or not) when telehealth is offered and why. Methods to build community partnerships in implementation research offer opportunities for reflexivity and iteration, which informs strategies to ensure whether telehealth is delivered in a manner that is fair and just. For example, Miller et al [The context described above impacts groups at multiple levels and creates opportunities to enhance equity in the delivery of web-based physical therapy. As such, to consider further adaptations to and appropriate sustainment of web-based physical therapy care, we describe the bridging factors necessary to promote equitable implementation. First, er et al  showed tcommunicating shared mental models within and across systems and sectors allows groups of people delivering, receiving, or being impacted by physical therapy telehealth to be on the same page regarding equitable implementation. Telehealth delivery of physical therapy will likely persist post pandemic and adjusting how patients, providers, and systems perceive this new reality is essential to promoting equitable implementation. Discordant mental models may unintentionally hinder access to any modality of care such as in the case example where system or clinic policies drive the (1) proportion of telehealth versus in-person appointments available and (2) type of appointment necessary for entry into the care pathway. For example, individuals without stable internet access in a secure, private setting may be unable to engage in physical therapy if telehealth is initially required for entry into that service. Additionally, some patients may feel more comfortable receiving in-person care in a physical therapy clinic during which they can discuss sensitive topics influencing their recovery and feel less vulnerable undressing or exposing certain areas of their body for examination. Alternatively, some patients may feel more comfortable discussing sensitive topics in their own homes, thus creating an inviting atmosphere for greater sharing and conversation between patient and provider.Second, Convening a diverse group of community members can help build a shared mental model by asking questions such as the following: what proportion of telehealth visits per provider reaches the most patients? What is considered a successful telehealth episode of care? What criteria indicate other modalities of care be considered? Mapping clinic workflow is also essential for identifying gaps where patients may be unable or do not receive the necessary physical therapy services in a timely manner. Practice facilitation may be one strategy to allow physical therapists in a health care system to internalize approaches to ensure the right patient has access to the right modality of care at the right time ,49. Pracdigital infrastructure at multiple levels is necessary to ensure any patient who would benefit from physical therapy services has the option to participate in telehealth, if clinically appropriate and it aligns with patient preferences. To understand the baseline level of infrastructure, research is needed to measure (1) individual-level factors such as technology skills and proficiency, equipment availability, acceptability, and preferences for care and (2) community-level metrics such as neighborhood availability of Wi-Fi or broadband and transportation to in-person appointments. This information and ongoing evaluation inform policies and oversight of policy implementation. Building a digital infrastructure is interconnected with establishing community partnerships and communicating shared mental models as the infrastructure involves cross-sector collaborations for resources, governance, and continual monitoring. An opportunity exists to co-design or adapt aspects of digital infrastructure to better meet the needs of all patients who would benefit from physical therapy care, clinicians providing physical therapy, and health systems offering physical therapy services. To be truly successful, a digital infrastructure must develop a plan for transparency and sharing of data, engage the community throughout the infrastructure planning and implementation, and manage data privacy and security [Third, building security . A stronDeployment of telehealth will likely persist in the post pandemic era, given patient preferences for such care, emerging advances in technologies, paradigm shifts in health care professional training, and the potential to serve populations with limited potential for high-quality in-person care  ,51. Reevcommunity partnerships  is the intentional and meaningful involvement of impacted community members to understand key issues and problem solving [shared mental models between those impacted by telehealth adoption can determine the level of telehealth they are willing to accept and what changes—such as adaptations to implementation—they may consider for enhanced equity [First, establishing  solving ,52. Feed solving ,54. We ad equity ,35. Adapd equity -57 into d equity ,59.digital infrastructure has the potential to mitigate long-standing issues with the inverse relationship between the need for health care and use or access [Finally, as we approach postpandemic implementation of telehealth, building a r access  across dr access ,60,61. Fall persons. The tension between ongoing innovation in telehealth that is occurring in the context of the evolving pandemic creates opportunities for innovation and unanticipated challenges to equitable implementation. Equity frameworks help connect internal and external contexts that create disparities and to consider the implementation strategies that may address them. Bridging factors such as community partnerships, shared mental models, and digital infrastructure can guide implementation, adaptations, and sustainability in the setting of a rapidly changing landscape for telehealth.Enhancing equitable implementation of telehealth is timely and critical to advancing the health and well-being of


By the end of 2020, more than 500,000 migrants from Central America, Haiti, Africa, and Asia sought asylum along the US-Mexico border despite COVID-19-related travel restrictions and public health measures. A scoping review was conducted to understand the role of COVID-19-related policies on irregular migration flows through Central America and Mexico and to examine the experiences of asylum seekers traversing this region. Peer-reviewed literature, policy briefs, and commentaries were screened for inclusion, resulting in 33 documents selected for this review. This review identified three dominant themes: border closures due to multiple national migration policies, delays in asylum procedures, and increased risks to migrant wellbeing. This article argues that border closures were a punitive policy measure to deter irregular migration during the COVID-19 pandemic. Implications for future research and policy include prioritizing the health needs of asylum seekers and advocating the appropriateness and effectiveness of immigration and public health policy. In September 2021, images of US border patrol agents on horseback forcefully preventing Haitian migrants from crossing the US-Mexico border circulated national and international media outlets Kosman, , with apCentral America, Mexico, and the US continue to receive an influx of irregular migrants fleeing violence, humanitarian disasters, and economic instability MDP, . IrregulExamining these migration patterns in more detail, this article investigates the impact of COVID-19-related policies and restrictions on irregular migration in Central America and Mexico. The following section details the background of the scoping review, specifically the context of irregular migration within Central America and Mexico and the policies that governed mobility prior to COVID-19. The next section explains the methodological approach to conducting this scoping review and is followed by the results. The findings provide in-depth insight into existing peer-reviewed literature and policy briefs on COVID-19, and migration policies implemented at the onset of the pandemic. The discussion argues that the themes presented in the results are increasingly relevant to current public health and migrant policy debates, as emerging and unprecedented migration flows impact all corners of the world. The paper concludes with drawing attention to migrant experiences traversing this region and the gradual, yet stark contrast in the increased implementation of restrictive migration policies that do not sufficiently account for their wellbeing.Guatemala, El Salvador, and Honduras, commonly referred to as the Northern Triangle, experienced a dramatic increase in violence, crime, and narco-trafficking in recent years, leading to the forced migration of almost 2 million individuals to North America Orozco, . Over thThe agriculture sector in Central America has also been affected by climate change, like destructive coffee rust, a fungus in coffee plants that negatively impacts vulnerable economies and precipitates food insecurity throughout Central America  How have COVID-19-related policies and restrictions in Central America, Mexico and the US impacted irregular migration flows to the US-Mexico border; 2) What are the experiences of irregular migrants stranded in Central America and Mexico as a result of these interregional COVID-19 policies and restrictions?Irregular migrants traversing Central America are extremely vulnerable to experiencing discrimination, violence, extortion, human smuggling, and other crimes because of their precarious migration status and living conditions  Manual for Evidence synthesis 2021 and checked for appropriateness with the PRISMA for Scoping Reviews Checklist.n = 157), Web of Science (n = 209), and ScienceDirect (n = 77). All digital sources were imported and assessed for inclusion with the use of Rayyan by two study authors. Articles were included if they included information on irregular migration during the COVID-19 pandemic and within the geographical restrictions of Central America, Mexico, and the US-Mexican border , wrong study context (n = 12) , wrong population or participants (n = 10) . Eleven eligible articles were identified by screening the reference lists of included studies. In total, 33 sources were included in this scoping review; 28 were qualitative studies, one quantitative, and four mixed methods (Table n = 26) focused on irregular migrants, of which three sources specifically examined the experiences of irregular migrant families and children. The remaining sources (n = 7) had a broader scope and focused on general migration policies without specifically focusing on irregular migrants (n = 5) or did not specify the location (n = 2). Around half of the sources (n = 16) did not explicitly mention a policy name or restrictive measure, broadly referring to policy decisions as “border closures.” The remaining sources provided the policy names, such as Title 42 in the US, Migrant Protection Protocols (MPP) MPP in Mexico, and the US-Guatemala Asylum Cooperative Agreement. COVID-19-related policies or restrictions were mentioned in almost all sources (n = 30), and fewer studies reported migration flows (n = 23) and migrant experiences (n = 22). Overall, 14 studies reported information on all three categories.A total of 442 non-duplicate articles were reviewed to determine eligibility Fig. . After sThree thematic findings were identified in this review: 1) border closures to halt migration flows in Central America and Mexico, 2) delays in asylum procedures and subsequent consequences, and 3) migrant wellbeing in detention centers. Together, these themes illuminate how COVID-19-related policies impacted irregular migration flows and its affect on migrants with limited mobility.Several articles detailed swift border closures to halt irregular migration into Mexico and eventually deter migration into the US. In the summer of 2019, before the COVID-19 pandemic, Mexico dispatched 10,000 troops of their National Guard to the southern border to police migrant entry. For comparison, there were 15,000 troops at the US-Mexican border, showing a clear resemblance to the guarded northern border with the US Selee, . Funded In March 2020, 10 months after the signing of the US-Mexico Joint Declaration, the COVID-19 pandemic became the basis for restricting non-essential travel into the US Soto, . The traMany Latin American countries enacted travel and movement restrictions for citizens and international travelers in response to the COVID-19 pandemic IOM, . In the The Guatemalan government also enacted public health-related travel restrictions and deployed their military to block all land entry for non-citizens, which subsequently increased the number of informal crossings by circumventing immigration protocols and officials Kauffer, . MoreoveStarting in April 2019, Mexico implemented a restrictive migration policy to prevent the transit of migrants through the country Astles, . AlthougThe implementation of the MPP alongside court closures due to the COVID-19 pandemic left thousands of migrants stranded in Northern Mexico  present in these two countries  were prioritized. Mexico strengthened migration control at the Mexico-Guatemala border and accepted more non-Mexican asylum seekers deported by the US, as outlined in the protocols; however, humanitarian protections were not increased and the US did not expedite processing asylum cases. Rather, opposite outcomes were identified during the pandemic, highlighting how the MPP obligations have been selectively prioritized to deter migration and satisfy the US’s migration policy interests. The fulfillment of the remaining obligations could not be identified within the scope of this review; however, it is important to note that the damage done to the asylum process by the Trump administration in the US has not been restored by the Biden administration Kocher, . DespiteFollowing in the trend of increasingly restrictive migration policies within Central America, Mexico and the US, the delays in processing asylum cases prior to the pandemic  also increased during the border closures in 2020, resulting in further delays and suspension of asylum cases. Rather than migrants being placed under MPP, an initial response during the pre-pandemic period, the US accelerated deportations and expulsions from the US-Mexico border and many asylum seekers were stranded in transit destinations where they were exposed to violence, kidnapping, robbery, and sexual abuse  enhance methodological approaches, data collection and analysis of disaggregated data to better capture the demographics of asylum seekers and intentions to continue transiting; 2) improving humanitarian protection measures and creatively utilizing existing legal frameworks for individuals in need; and 3) addressing migration-related risks within countries of origin to allow for planned and legal migration, allowing relocation to occur in a safe manner Martin, . Though This review also highlighted how these policies also exacerbated health inequities for irregular migrants, revealing that migration policies have not considered nor taken responsibility for the health needs of irregular migrants. Policies implemented to manage irregular migration flows should consider the health implications of existing infrastructures and implement health and safety measures that address current public health concerns and migrant wellbeing. This review reveals that the protracted displacement experienced by irregular migrants throughout Central America and Mexico may increase their risk of developing mental health issues. Refugees and asylum seekers experience post-traumatic stress disorder (PTSD), anxiety, and depression over time, and many continue to experience mental health issues for years to come (Henkelmann et al., Future research should consider the diversity of migrants groups and how these vary during transit and at their final destination. Future research should also examine the relationships between discrimination and subjective wellbeing along migratory routes in Central America. By capturing experiences along common routes, policymakers, practitioners, and humanitarian organizations can address and mitigate the risks of irregular migration, including precarity and instances of violence.Multilateral refugee agreements in Central America, Mexico, and the US have prioritized national interests and have overlooked the public health concerns of the asylum seekers at their borders. The restrictive migration policies implemented before and during the COVID-19 pandemic along with the increased militarization of several Central American borders reveal how asylum seekers have not been sufficiently considered in the creation and implementation of public health-related policies. The conditions in which asylum seekers are fleeing are public health issues, whereby exposure to violence and humanitarian disasters in countries of origin remain a priority area of concern, which has only been exacerbated by the COVID-19 pandemic. This review emphasizes the importance of distinguishing immigration policy from public health policy and the need to prioritize appropriate and effective implementation of these policies. The interplay between public health priorities and forced displacement require a coordinated response that take into account social, public health and migration policies. By doing so, a multilateral public health and refugee resettlement agreement has the potential to improve the conditions within countries of origin and the capacity to adequately provide resources for asylum seekers in countries of destination. The health inequities exacerbated by these policies will not be easily resolved with changes to immigration policies alone, however, but will require a multifaceted approach to ameliorating health for such a vulnerable population. Future multilateral agreements should clearly outline social and environmental indicators as a benchmark for successful implementation, and create risks assessments and strategies to anticipate unprecedented shifts in migration flows. By examining how national political interests and popular political discourses shape multilateral refugee agreements amidst public health crises, we gain a better understanding of the context surrounding interregional and extra-continental migration flows and its impact on overall migrant wellbeing.


Risk of suicidal ideation and suicidal behaviors greatly increases during adolescence, and rates have risen dramatically over the past two decades. However, few risk factors or biomarkers predictive of suicidal ideation or attempted suicide have been identified in adolescents. Neuroimaging correlates hold potential for early identification of adolescents at increased risk of suicidality and risk stratification for those at high risk of suicide attempt.  In this systematic review, we evaluated neural regions and networks associated with suicidal ideation and suicide attempt in adolescents derived from magnetic resonance imaging (MRI) studies. A total of 28 articles were included in this review.  After descriptively synthesizing the literature, we propose the Emotional paiN and social Disconnect (END) model of adolescent suicidality and present two key neural circuits: (1) the emotional/mental pain circuit and (2) the social disconnect/distortion circuit. In the END model, the emotional pain circuit—consisting of the cerebellum, amygdala, and hippocampus—shows similar aberrations in adolescents with suicidal ideation as in those with a history of a suicide attempt . The social disconnect circuit is unique to adolescent suicide attempters and includes the lateral orbitofrontal cortex (OFC), the temporal gyri, and the connections between them.  Our proposed END brain model of suicidal behavior in youth, if confirmed by future prospective studies, can have implications for clinical goals of early detection, risk stratification, and intervention development. Treatments that target emotional pain and social disconnect may be ideal interventions for reducing suicidality in adolescents. Alarmingly, rates of death by suicide have risen dramatically over the past two decades. The Centers for Disease Control and Prevention (CDC) reported a 30% increase in suicides in the United States from 2000 to 2016, with rates increasing among all age groups. Adolescents and young adults are at particularly high risk, concomitant with increased social media use, anxiety disorders, major depression, and self-inflicted injuries  OR “DTI” [Title/Abstract] OR “magnetic resonance” [Title/Abstract]) AND  AND (“adolescent” [Title/Abstract] OR “youth” [Title/Abstract])).An additional updated search was conducted in May 2023, after the data synthesis had been performed and the brain model of suicidal behavior in youth had been built. The findings of this additional search are discussed in Discussion.narrative synthesis was chosen instead of a meta-analysis, as meta-analysis is not recommended for diverse study types [A high heterogeneity was expected among the studies with respect to the study population, type, and duration of training; studied brain regions; and, importantly, the specific MRI methodology. Therefore, a descriptive, dy types . The endThe initial search resulted in 49 entries . Eleven Of the 28 included articles, all investigated neuroimaging correlates of suicidality in clinical populations. Twelve of the articles investigated subjects with unipolar depression and healthy controls; nine articles studied clinically mixed populations containing subjects with bipolar disorder, unipolar depression, and other psychiatric diagnoses , temporal gyrus, and connections between the latter two . DetailsFour of the reviewed studies identified abnormalities of the cerebellum in subjects with a history of suicide attempt. Adolescents with bipolar disorder and a history of suicide attempt showed reduced gray matter volume of the bilateral cerebellum and reduced white matter fractional anisotropy (FA) in the right cerebellum compared to those without a history of suicide attempt . In a faTwo of the reviewed studies identified abnormalities of the hippocampus in subjects with a history of suicide attempt. Among adolescents with bipolar disorder, Johnston et al. reported reduced right hippocampal gray matter volume in those with a history of suicide attempt compared to those without . Among aThree of the reviewed studies identified functional abnormalities of the amygdala in adolescents with a history of suicide attempt, each of which examined clinical populations using task-based fMRI. In a study comparing subjects with MDD with prior suicide attempts, subjects with MDD and suicidal ideation symptoms but no prior suicide attempts, and healthy controls during a facial emotion processing task, Alarcón et al. found that those with prior suicide attempts had greater connectivity between the amygdala and the dlPFC, dmPFC, precuneus, and ACC than low-suicidality depressed subjects, as well greater connectivity between the left amygdala and the rostral anterior cingulate cortex (rACC) than all other groups . In a stThree of the reviewed studies identified abnormalities of the lateral OFC in subjects with a history of suicide attempt. In a study of subjects with MDD, those with a history of suicide attempt demonstrated reductions in the right and left lateral OFC thickness and pars orbitalis thickness relative to the non-suicide-attempting subjects . AdditioMiddle temporal gyrus: two of the reviewed studies identified abnormalities of the middle temporal gyrus (MTG) in subjects with MDD and a history of suicide attempt, specifically increased activity in the right MTG in response to angry faces in a facial emotion processing task [Superior temporal gyrus: three of the reviewed studies identified abnormalities of the superior temporal gyrus (STG) in subjects with MDD and a history of suicide attempt, including reduced temporal pole volume [ing task  and incring task . Superioe volume , reducede volume , and ince volume .Two of the reviewed studies identified abnormalities of the uncinate fasciculus in the heterogeneous group with a history of suicide attempt, including reduced fractional anisotropy in the left frontotemporal white matter, including the uncinate fasciculus , and red(i)Cerebellum findingsSuicidal ideation was associated with decreased cerebellum activity (2 studies) and inconsistent changes in resting-state functional connectivity with other regions (2 studies)Suicide attempt was associated with reduced cerebellum gray matter volume (1) and increased connectivity between the cerebellum and the left lingual gyrus (1)(ii)Hippocampus findingsSuicidal ideation was associated with reduced hippocampus activity (2)Suicide attempt was associated with reduced hippocampus volume (1)(iii)Amygdala findingsSuicidal ideation was associated with reduced activity in the amygdala (1) and greater connectivity between the amygdala and dlPFC (1) and the amygdala and rACC (1)Suicide attempt was associated with greater connectivity between the amygdala and dlPFC (1) and the amygdala and rACC (1) and reduced amygdala connectivity to the ventral PFC (1)(iv)Lateral OFC findingsSuicide attempt was associated with decreased lateral OFC thickness (5) and decreased OFC volume (1)(v)Temporal gyrus findingsSuicide attempt was associated with decreased temporal pole volume (1), decreased right superior temporal gyrus volume (1), increased temporal gyrus activity (3), and reduced fractional anisotropy in temporal regions (3)(vi)Connections between lateral OFC and temporal gyrusSuicide attempt was associated with reduced fractional anisotropy in the uncinate fasciculus (3)The following list summarizes which cross-diagnostic neural aberrations listed above were observed in suicide attempters (compared to nonattempting ideators) and in nonattempting ideators (compared to nonideators), how many studies reported such aberrations, and what type of MRI was utilized. The most common transdiagnostic abnormalities in suicide-attempting adolescent patients compared to nonattempting or healthy controls were found in cerebellum, hippocampus, amygdala, lateral orbitofrontal cortex (OFC), temporal gyrus, and connections between the latter two, whereas abnormalities in the cerebellum, hippocampus, and amygdala were also present in nonattempting ideators (probably to a lesser degree); lateral OFC and temporal circuitry abnormalities appear to be unique to adolescent suicide attempters.We suggest that abnormalities in the cerebellum, hippocampus, and amygdala may be present in nonattempting ideators to a lesser degree compared to attempters based on the following consideration. If a brain region appears in both columns of Our systematic review highlighted several brain regions/connections that may be associated with adolescent suicide attempts across psychiatric diagnoses. We suggest that these findings can be subdivided into two circuits that roughly correspond to traits 1 and 4 in the Mann and Rizk stress-diathesis model of suicidal behavior described in the introduction : (1) “emtolerance may be an even better indicator for suicidal behavior [Emotional pain, also referred to as mental pain, psychological pain, or subjective distress, is thought to be a key component in understanding suicidal thoughts and behaviors . Higher behavior .The relationship between emotional pain and suicidality provides an important insight because it suggests that suicidal thoughts are utilized as a way to cope with such pain. When one experiences distress, and subsequently emotional pain, suicide may be considered as a way to escape this feeling. In the early 1990s, Shneidman et al. proposed a theory of suicide in which emotional pain, for this reason, was a necessary phenomenon in the etiological development of suicidal thoughts . This idexperience of emotional pain, the amygdala and hippocampus appear to play a modulatory role. Whereas the studies reviewed here link them with adolescent suicidal ideation and attempts , 23expers , all th of pain . The intTo conclude, the hippocampus-amygdala-cerebellar network's aberrations may be associated with the emotional pain experienced by adolescents with suicidal thoughts and behaviors. The observation of such aberrations both in attempters and ideators  suggests that these aberrations and the associated emotional pain may be a necessary, but not sufficient condition, for attempting suicide by the adolescent.Social distortion/disconnect, “thwarted belongingness” , and coThe most comprehensive description of how social variables may be impacting suicidality is given by Thomas Joiner's interpersonal theory of suicide (IPTS) , 52. TheWhile IPTS found preliminary empirical support in adolescents , it has According to Mann and Rizk's model, the social distortion trait is associated with a brain region also found in our review, the lateral OFC, and its hyperactivity to negative facial expressions and hypoactivity to positive facial expressions . In our To conclude, the frontotemporal network aberrations may be associated with the social disconnect experienced by adolescents with increased suicidality. The observation of this network aberrations appears to be unique to adolescents with a history of a suicide attempt, compared to nonattempting ideators.We synthesize the findings described above into the Emotional paiN and social Disconnect (END) brain model of suicidal behavior in youth . In thisAs mentioned in Methods, we conducted an additional updated search in May 2023, after the data synthesis had been performed and the brain model of suicidal behavior in youth had been built. The search resulted in 8 papers that met the inclusion criteria –65. To pWhile the END model has been derived from adolescent literature, it may, in principle, also apply to adults. At the same time, there may be some unique aspects that characterize the adolescent brain, which we would like to discuss here. Notably, the adult literature reports impairments in vPFC and dPFC and decreased top-down inhibition of behavior that is associated with suicidal behavior . The litThe convergent findings from the reviewed literature and our proposed END brain model of suicidal behavior in youth, if confirmed by future prospective studies, can have implications for eventual clinical goals of early detection, risk stratification, and intervention development. Our model suggests that future research should consider therapies such as interpersonal psychotherapy for depressed adolescents (IPT-A) for reducing suicidality or new interventions that would address the social disconnect , 67. An within the diagnostic category and (2) on the brain circuitry aberration across all diagnoses when synthesizing the findings. Finally, our proposed END brain model of suicidal behavior in youth is simplified in that it focuses only on the most general mechanisms supported by the largest number of findings, leaving out several other implicated brain regions and circuits . It is worth noting that 25% of all included papers derived their results from resting-state functional connectivity. While our END model, to a large extent, focuses on discrete brain regions, future work may benefit from network science approaches to neuroimaging of suicidality . To addrcircuits . While tIn this systematic review, we descriptively synthesized results from 28 studies on the neural underpinnings of suicidal behavior in adolescents that used various MRI methods. The brain regions that were the most common transdiagnostic findings in suicide-attempting patients compared to nonattempting or healthy controls were cerebellum, hippocampus, amygdala, lateral orbitofrontal cortex (OFC), temporal gyrus, and connections between the latter two. We proposed the Emotional paiN and social Disconnect (END) model of adolescent suicidality, according to which suicidal behavior is driven by two key neural circuits: (1) emotional/mental pain circuit and 2) social disconnect/distortion circuit. In the END model, the emotional pain circuit, consisting of the cerebellum, amygdala, and hippocampus, shows similar aberrations in adolescents with suicidal ideation as in those with a history of a suicide attempt . The social disconnect circuit is unique to adolescent suicide attempters and includes the lateral OFC, the temporal gyri, and the connections between them. Using the END model, we discussed potential clinical treatments and suggested that future research should consider therapies such as IPT-A for reducing suicidality or new interventions that would address the social disconnect.


Objectives: Across many Asian countries, family caregivers provide a wide range of patient care activities while staying in the patient’s room. This unique care arrangement has been reported as a factor contributing to the spread of outbreaks including Middle East respiratory syndrome and coronavirus disease 2019 (COVID-19) in many Asian countries. We sought to understand the context in which direct patient care activities are provided by family caregivers and/or private caregivers in hospitals across Bangladesh, Indonesia, and South Korea from the infection prevention and control (IPC) perspective. Methods: We used a multimethod design with both quantitative and qualitative approaches. In total, 432 patients were surveyed from 5 tertiary-care hospitals across 3 selected countries, and 64 participants from 2 groups were interviewed: group A comprised patients, family caregivers and private caregivers and group B comprised healthcare workers. Survey data were analyzed descriptively, and the interview data were analyzed using thematic analysis. Results: The study findings highlight the different landscapes of care provision in the selected countries. Both the interviews and surveys highlighted 2 aspects of family caregiving. (1) Family caregivers inhabit in the patient zone for long periods, resulting in overcrowding, and (2) they provide a wide ranges of physically associated care activities, including those associated with the risk of healthcare-associated infections (HAIs). Despite the high number of family caregivers and their in-depth involvement in direct patient care, education and support provided to family caregivers around IPC/HAI were insufficient and varied. Also, challenges related to maintaining adequate hygiene in the environment for minimum IPC were reported. Conclusions: This study has elucidated the current landscape of family involvement in inpatient care provision and acknowledges their contribution to high risks of HAI, as well as their current lack of IPC knowledge and practice. These findings reveal that future updates in IPC strategy should acknowledge this arrangement with family caregivers and should address this role with IPC measures.


Since the turn of the century, innovations in science and technology have been in full swing across the globe. A new wave of scientific inventions and industrial transformations are constantly reshaping the economic structure of the world. At the forefront of this trend is the digitalization of industries. When combined with a new form of productivity such as artificial intelligence (AI), this wave of scientific and technological revolution is driving digital transformations and adoptions of smart devices throughout society.To seize the strategic opportunity of the global digital economy, and to demonstrate its leadership, starting from 2022, Pazhou Lab (Huangpu) has been hosting an International Algorithm Case Competition in the Guangdong-Hong Kong-Macau Greater Bay Area (Huangpu) (GBA). This is an effort intended to help the GBA to build a Big Data and AI ecosystem with a nationwide prestige and influence. Based in GBA and aimed at the entire country, the competition invites algorithmic solutions, gathers cutting-edge technology, and attracts top talents worldwide.Themed as ‘Seeking cases in the Bay, creating algorithms together’, the first competition proposed the ‘knockout’ system and the ‘rating’ system. With 10 high-value topics, the competition attracted participating teams from top universities at home and abroad, establishing a top-level AI competition located in the GBA and achieved national and international exposure. Five of the 10 topics, targeting algorithms in basic research of national strategic needs, focused on key issues in AI and related fields in the post–deep-learning era (i.e. (i) Chinese historical document analysis and recognition, (ii) robust adversarial attack and defense algorithms for deep learning, (iii) tuning algorithms for pre-trained language models, (iv) algorithms for sample selection and label correction and (v) algorithms for singular value decomposition and inverse). Targeting core technologies in mainstream industrial developments, the other five topics concentrated on important sectors such as smart city and smart manufacturing (i.e. (i) character recognition for street-view shop signs, (ii) detection technology for surface defect in industrial products, (iii) algorithms for 3D object detection with roadside cameras, (iv) object recognition of remote sensing imagery and (v) the panoptic scene graph generation challenge), aiming to develop optimal AI algorithms and achieve breakthrough innovations. It's worth mentioning that the competition topic ‘tuning algorithms for pre-trained language’ is a forward-thinking research effort for the AI-driven natural language processing tools, such as ChatGPT, showcasing its visionary and cutting-edge features.Centering around the topic ‘AI Algorithms and Cases: To Energize Digital Economy’, this special topic includes a news report to briefly introduce the competition and 10 perspective articles to introduce the 10 champion algorithmic solutions, respectively. The news report was written by the competition committee, covering the competition overview, competition structure and achievements  focus onThe competition provides potential breakthroughs in fundamental research in the field of AI and gathers optimal algorithms for solving practical problems. We sincerely hope this special topic will inspire readers from related fields and encourage more participation and attempts in exploring the wonderful world of AI to energize the digital economy.


National mental health surveys play a critical role in determining the prevalence of mental disorders in a population and informing service planning. However, current surveys have important limitations, including the exclusion of key vulnerable groups and increasing rates of non-response. This review aims to synthesise information on excluded and undersampled groups in national mental health surveys. We conducted a targeted review of nationally representative adult mental health surveys performed between 2005 and 2019 in high-income OECD countries. Sixteen surveys met our inclusion criteria. The response rate for included surveys ranged between 36.3% and 80.0%. The most frequently excluded groups included people who were homeless, people in hospitals or health facilities and people in correctional facilities. Males and young people were the most commonly underrepresented groups among respondents. Attempts to collect data from non-responders and excluded populations were limited, but suggest that mental health status differs among some of these cohorts. The exclusion of key vulnerable groups and high rates of non-response have important implications for interpreting and using the results of national mental health surveys. Targeted supplementary surveys of excluded or hard-to-reach populations, more inclusive sampling methodologies, and strategies aimed at improving response rates should be considered to strengthen the accuracy and usefulness of survey findings. Nationally representative mental health surveys play a critical role in providing quality data to help understand and track the mental health of a population. Most contemporary mental health surveys collect data on more than disorder prevalence alone to gain better insight into the impacts of mental disorders and the types of interventions or services required. For example, surveys conducted as part of the World Health Organization (WHO)’s World Mental Health Survey (WMH) Initiative also collect data on disease burden, relevant risk factors, comorbidities, service use and unmet treatment needs..On a broad scale, global estimates of the burden of mental and other disorders rely on population-based prevalence surveys as a key input. At a national level, these surveys help to shape the public narrative around mental health within a country and play a fundamental role in influencing mental health policy, planning and funding . In factWhile such mental health surveys provide critical insight into the mental health status and needs of a population, it is important to recognise their limitations. These include the ongoing exclusion of key vulnerable groups through sampling methodologies and growing rates of non-response. To date, there has been no review synthesising information on the impacts of non-response or excluded populations in large mental health surveys. Understanding these systematically excluded subpopulations is critical to identifying potential underreporting of population mental health needs and to ensure equity of access and tailored service planning for the highest needs groups.This review aims to (1) identify which groups are commonly excluded from large mental health surveys in high-income OECD (Organisation for Economic Co-operation and Development) countries, (2) identify survey response rates and describe the characteristics of non-responders, and (3) describe any efforts to examine, supplement or adjust for the impacts of non-response and missing or underrepresented populations.We conducted a targeted literature review of national mental health surveys to extract detail on survey sampling methods by drawing on previous systematic reviews of prevalence data.The Global Burden of Disease Study 2019 (GBD 2019) Data Input Sources Tool  was usedEnded between January 2005 and December 2019, inclusive; included a nationally representative sample of adults; surveyed multiple classes of mental disorders ; andwas completed as either a stand-alone mental health survey or conducted as part of a general health survey.Sources were excluded from further review if the survey they described:was limited to only one gender;focused on adults in a narrow age cohort only ;was a follow-up of a previously surveyed cohort and therefore not a random sample from the general population;had specific aims other than determining prevalence of mental disorders that otherwise restricted the eligibility criteria;focused exclusively on one class of mental disorder, e.g. depressive disorders only;restricted the sample to one region within a country;sampled populations across multiple countries as part of the same survey.From this list, sources were included for further consideration if they described a population-based mental health survey that:A list of relevant surveys was then compiled from the included GBD sources. Where multiple iterations of a survey were conducted for different years, only the most recent version included in GBD was selected.scite [A Google search was then conducted from May to September 2021 using the name (or the title of the GBD source where no name was given) and year of each survey as search terms to collect academic and grey literature sources associated with each survey, such as methodology reports and results studies. The first 50 search results were scanned for publications that described the survey in their methodology or findings. Where websites or webpages devoted to listing or archiving a survey’s publications were identified in the search results, these were thoroughly checked. Forward and backward snowballing  was condscite , while bA full-text review of all relevant publications was conducted to identify the primary source of data for the survey methodology. Where multiple publications described the methodology in comparable detail, the earliest published or available resource was selected. Supplementary sources were also included where they provided additional information on: (1) the survey design; (2) survey response rate; (3) excluded populations; (4) characteristics associated with response as judged by the authors of relevant sources; (5) survey adjustments for excluded or underrepresented populations; (6) supplementary or parallel mental health surveys of non-responders or excluded populations; or (7) additional analyses on the association between survey response and disorder prevalence. Where supplementary surveys or additional analyses were explicitly identified in the primary publication, an additional search was conducted using the same Google search and snowballing method to identify relevant publications.Supplementary non-response surveys were included for data extraction if they collected data on mental health, including symptom measures or diagnosis history. Since resource limitations may restrict the number of additional surveys conducted over time, supplementary surveys of excluded populations conducted for both past and current iterations of the primary survey (up to a maximum of two) were included for data extraction so long as they collected information on mental health, including a diagnostic interview, symptom measures or diagnosis history. Non-response and supplementary surveys focused solely on substance use disorders, mental health treatment or self-harm, suicide attempts and suicidal ideation were not included.Survey information extracted from relevant sources included country, survey year, survey design, sample size, psychiatric disorders of interest, psychological assessment instruments and response rate. Information extracted on psychiatric disorders excluded indicators of self-harm; suicidal thoughts; suicide attempts; smoking; use of tobacco products; nicotine use, dependence or withdrawal; alcohol or drug use where this was not characterised as harmful, problematic or a substance use disorder; and other general health and well-being measures . Next, data were extracted to describe populations that were identified as underrepresented or less likely to respond, as well as groups that were excluded from participating in the survey because of the sampling methodology or eligibility criteria.Finally, information was extracted from the relevant literature on additional efforts undertaken to survey non-responders or excluded groups, or to investigate the impacts of response rate on prevalence estimates. This included data on the general design and methodology of the supplementary survey or analysis as well as the year, sample size, psychological assessment measures used, response rate and key findings.Where relevant data were missing from existing literature or questions remained regarding the sampling methodology, exclusion criteria or supplementary surveys, up to three contributing authors of included sources were contacted for more information.Following a preliminary review of the data, categories for frequently excluded groups were established through an iterative process, beginning with the categories identified in the source literature and grouping these based on similar characteristics and reasons for exclusion. This process facilitated comparisons between surveys. The data extraction and synthesis were conducted and reviewed by EW, IP and CP.Twenty-two sources from the GBD Data Input Sources Tool described surveys that met our criteria. After accounting for sources that used the same survey, 16 individual surveys –29 conduHomeless people with no fixed address (14 of 16 surveys).People in hospitals and health facilities (14 of 16 surveys.)People residing in correctional facilities (14 of 16 surveys).People in residential care facilities (12 of 16 surveys).Military personnel on base or abroad (12 of 16 surveys).Non-local language speakers (11 of 16 surveys).People residing in temporary housing (11 of 16 surveys).Short-term overseas visitors (11 of 16 surveys).People living on islands, in remote areas or in specific territories (9 of 16 surveys).People living in other non-private dwellings  (8 of 16 surveys).People living in educational institutions (7 of 16 surveys).Non-residents (7 of 16 surveys).People with a cognitive impairment (7 of 16 surveys).Details about inclusion and exclusion criteria were identified for all included surveys; however, the amount of information provided was highly variable. Based on available published data, we identified 13 populations or groups that were commonly excluded from national mental health surveys Table . These pInformation was missing and could not be obtained on the inclusion or exclusion of some of these groups for ten of the surveys, two of which only had data available on the eligibility of one population .Supplementary survey populations: ethnic minorities , homelesThe APMS 2014 in England.Supplementary survey populations: military personnel –57 and pThe 2014 NSDUH in the USA.Attempts to capture excluded populations through supplementary surveys were identified for four of the primary surveys included in our analysis Table :The 2007Supplementary survey findings from Australia showed that while the overall rate of moderate psychological distress in rural and remote areas was similar to that reported for the general household survey , distresThe supplementary survey of people in correctional facilities in England and Wales showed that significant neurotic symptoms and functional psychosis were far more common among prisoners than members of the general population . While cThe supplementary survey of homeless people conducted in Great Britain showed that the prevalence rates of common mental disorders, psychotic disorders, and alcohol and non-cannabinoid drug dependence were significantly higher in this group than the general population , 62. In Lastly, the supplementary survey of residents of institutions catering to people with mental illness in Great Britain showed a high proportion of people with severe disorders including schizophrenia, delusional disorder, schizoaffective disorder and affective psychoses, particularly in hospital settings . NeurotiThe 2007 National Survey of Mental Health and Wellbeing (NSMHWB) in Australia and the Netherlands Mental Health Survey and Incidence Study (NEMESIS-2) attempted to contact non-responders for information on their mental health Table . In bothThe NSMHWB Non-response Follow-up Survey (NRFUS) found that psychological distress, as measured by the Kessler Psychological Distress Scale (K10), was higher among non-responders than in the responding NSMHWB sample . HoweverAnother survey in Japan, the WMHJ2, analysed the association between response rate and mental disorder prevalence in different regions and conducted additional sampling of an area with a low response rate . The finOur review of national mental health surveys found that people not living in private dwellings in the community, especially those who are homeless, in health or correctional facilities, were commonly excluded from sampling, while males and young people were commonly underrepresented among survey respondents. Supplementary surveys of excluded populations and non-responders, where available, indicated higher prevalence of mental health problems in many of these groups. The common exclusion of key vulnerable groups and relatively high rates of non-response in these surveys have important implications for how results are used and interpreted.The findings of this review show that most national mental health surveys recently conducted in high-income countries employ a similar approach and therefore have similar limitations concerning excluded populations and non-responders. This is not entirely surprising as six of the surveys included for review were either part of the WMH Survey Initiative or rooted in a previous WMH survey conducted in that country , 22–26. Four surveys included for review explicitly attempted to quantify the proportion of the population that would be excluded according to their methodology, with estimates ranging between 1% and 3.5% , 27, 29.For example, data from 12 high-income OECD countries in 2019 showed that the proportion of people 80 years of age or older receiving care in long-term  facilities  ranged between 10-19% . TherefoData from the supplementary surveys indicated that many of the other groups commonly excluded from population-based mental health surveys are also especially vulnerable to psychological distress and mental illness, including prisoner populations , 58, 59,The lack of clear criteria around the inclusion or exclusion of people with cognitive impairment was another important finding of this review. Research has shown that individuals with a cognitive impairment or intellectual disability have a higher prevalence of mental disorders than those without, and have more complex service needs as a result of their comorbid conditions , 76. As Survey results may be skewed if non-responders have a different mental health profile. Recent research shows that the response rates for health surveys in high-income countries have generally declined over time –79 and tSimilar to previous findings, supplementary analyses of non-response did not show a consistent relationship between survey response and mental health status. The first NEMESIS survey conducted in 1996 found that non-responders who agreed to complete the 12-item General Health Questionnaire (GHQ-12) had slightly better average mental health scores when compared to those who participated in the full diagnostic interview . On the Strategies adopted for the purposes of improving response rates included financial incentives, i.e. money or vouchers (Response Rate (RR): 57.3-65.1%) , 20, 25,The underrepresentation of males and young people in our findings has also been reported in other health and health-related surveys –100. OnePlanners and policymakers should be aware of the limitations of the mental health surveys that they use to understand mental health service needs and resource requirements. Ideally, efforts to sample non-responders and previously excluded populations would be included in all national mental health survey designs, or in complementary studies that use a standardised methodology to allow direct comparisons. However, given the significant additional resources required, sampling these populations may not always be feasible. In such instances, end users of survey results could consider other available data on the level of need within excluded populations to adjust estimates where appropriate. Adjustments of this kind were recently made to the prevalence estimates informing the mental health service demand and resource requirement modelling for adequate care in Australia’s NMHSPF . The exclusion of these populations, and the few attempts to follow-up survey non-responders, may limit the generalisability of survey findings and result in underestimates of need for care. Collectively, our findings suggest the need for more inclusive sampling methods, or targeted population surveys, to strengthen the accuracy of prevalence estimates drawn from these surveys to inform policy and service planning decisions. If there are resource restrictions that limit the feasibility of these options, consideration should be given to whether prevalence estimates may be adjusted to account for any exclusions. Additionally, clear reporting on who is included and/or excluded in survey sampling procedures may ensure greater accuracy in the interpretation of survey findings.


In addition, communication studies in reproduction related domains in sexual and reproductive health and rights were included. Data extracted included study design, study population, and details of the communication intervention. Communication strategies were analysed and categorized based on existing conceptualizations of communication goals and interpersonal communication processes. A total of 138 articles were included. These reported on 128 strategies to improve interpersonal communication and were conducted in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). Strategies addressed three communication goals: facilitating exchange of information (n = 97), creating a good interpersonal relationship (n = 57), and/or enabling the inclusion of women and partners in the decision making (n = 41). Two main approaches to strengthen interpersonal communication were identified: training health workers (n = 74) and using tools (n = 63). Narrative analysis of these interventions led to an update of an existing communication framework. The categorization of different forms of interpersonal communication strategy can inform the design, implementation and evaluation of communication improvement strategies. While most interventions focused on information provision, incorporating other communication goals  could further improve the experience of care for women, their partners and the families of newborns.Effective interpersonal communication is essential to provide respectful and quality maternal and newborn care (MNC). This scoping review mapped, categorized, and analysed strategies implemented to improve interpersonal communication within MNC up to 42 days after birth. Twelve bibliographic databases were searched for quantitative and qualitative studies that evaluated interventions to improve interpersonal communication between health workers and women, their partners or newborns’ families. Eligible studies were published in English between January 1 Improving the quality of maternal and neonatal health services would accelerate reductions in maternal and neonatal deaths in low- and middle-income countries (LMICs) . QualityEffective interpersonal communication is a cornerstone of medical practice , 6. EffeInterpersonal communication between health workers and patients can affect health care outcomes, including patients’ satisfaction, knowledge and understanding, adherence to treatment, quality of life and psychological and physical health , 10, 11.Various aspects of interpersonal communication processes between health workers and patients have been described. The communication framework of Feldman-Stewart and Brundage is particularly useful to illustrate ‘how’ interpersonal communication works , 15, andDespite the increased recognition of the importance of interpersonal communication for MNC there is no clear overview of the different strategies that can be adopted to reduce mistreatment and improve respectful care . TherefoThis review was drafted and conducted in accordance with the PRISMA guidelines  and the The domain of our review consisted of studies that implemented a strategy to improve interpersonal communication between health workers, women, and their partners in care across the continuum of MNC. We also anticipated that experiences to improve interpersonal communication from related domains in sexual and reproductive health and rights (SRHR) would facilitate cross-learning from MNC, and therefore extended the domain to include the reproduction-related SRHR subdomains of safe abortion, family planning and (in)fertility.The study population included women and their partners as well as newborns and their parents/caregivers/families throughout the continuum of MNC and reproduction-related SRHR subdomains. This included antenatal, intrapartum and postnatal care up to 42 days. In this paper, we used ‘women and partners’ to describe the population. Health workers included different cadres as specified in the WHO recommendations to optimize health workers’ roles within MNC : lay heaStudies were eligible for inclusion if they were primary, peer-reviewed articles reporting on interpersonal communication quality improvement strategies between health workers and women and partners in MNC and reproductive-related SRHR subdomains. All studies that included health workers who were engaged with in-service training  were eligible. Studies conducted in any setting within MNC and reproductive-related SRHR subdomains were eligible. Studies that included a paediatric population were only eligible if >50% of participants were newborns (up to 42 days old) or newborns’ parents. Studies published from January 2000 to July 2020 were included to reflect contemporary practices.interpersonal communication within the delivery of the health service. We excluded reviews, but primary studies from relevant systematic reviews were checked for eligibility. We included only English articles, because of language limitations within the team. In total, six studies were excluded in full text screening because of language restrictions.We excluded studies that focused on mass communication, group communication, one-way communication, interprofessional communication and communication between mothers and babies. Furthermore, we excluded studies that reported on packages of strategies where communication was not a primary aim, because in these complex intervention studies communication was usually a small part of the intervention, and so difficult to disentangle from other activities. Furthermore, studies that implemented a new communication-based treatment programme  to treat a specific disease or problem were excluded because these constituted a new form of health service delivery, except when the intervention specifically focused on improving the We searched the following information sources: PubMed/Medline, EMBASE, CINAHL, SCOPUS, PsychINFO, Anthropology PLUS, SocioINdex, Cochrane Central Register of Controlled Trials (CENTRAL), Latin American and Caribbean Health Sciences Literature (LILACS), African Journals Online (AJOL), and Global Health Library.Search terms consisted of MeSH and combined text related to ‘communication’, ‘health workers’, ‘MNC or related SRHR domains’, ‘women and families’ and ‘intervention’. The search was developed with support from a librarian. For the complete search strategy see https://rayyan.qcri.org/welcome) was used to screen articles. Any disagreement that arose was discussed by the persons who screened the articles until consensus was reached, or a fifth review team member was consulted (JLB or BCdK) to resolve the issue through further discussion.First, titles and/or abstracts of studies identified through the search strategy were independently screened to assess whether studies met the inclusion criteria by two of the four reviewers . Next, full texts were screened in the same way. In case a full text article was missing or inaccessible, authors were contacted once through email or ResearchGate and were given the option to respond within a month to provide us with the full text. Rayyan QCRI . The data extracted included study characteristics and information for evidence synthesis: first author, year of publication, country, study setting, aims and objectives, study design, study population characteristics, description of intervention and communication goals of the intervention, and the types of outcomes measured. Extracted data were double checked by one of the team members (KMOL).We initially planned to perform a systematic review including a meta-analysis on interpersonal communication strategies’ effectiveness. However, the number and heterogeneity of designs and interventions among the retrieved articles led us to convert the study to a scoping review with narrative synthesis that focussed on providing an overview and categorization of the various strategies taken to improve interpersonal communication . In thisWe identified a total of 19956 articles through our search  addressed at least one of the communication goals . Fifty-Example 1. Bakker et al. 2003. Manual, intervention card and training on a counselling protocol on smoking cessation in pregnancy, consisting of 7 steps.Example 2. Maurer et al. 2019. Regular communication through messages/emails with information and tools to support discussions with health workers.Example 1. Shao et al. 2018. Simulation based training for NICU nurses to improve their empathic communication skills.Example 2. Bashour et al. 2013. Training for effective communication skills with a focus on the interaction between health workers and patients.Example 1. Muthusamy et al 2012. Written information to receive before counselling including tips about questions to ask.Example 2. Chinkam et al. 2016. Scripted counselling package about birth choices and trial of labour after caesarean using shared decision-making principles.The goal ‘facilitating the exchange of information’ was present in most strategies (n = 98/128) –137. ExaIn total, 58 studies aimed to improve the goal ‘creating a good interpersonal relationship’ (n = 58/128) , 138–164The goal ‘inclusion of women and partners in the decision making’ was addressed by 41 strategies (n = 41/128) , 160–169Two main types of strategy were used to improve interpersonal communication: training of health workers (n = 81) and tools to facilitate interpersonal communication (n = 67), with a few employing other distinct approaches (n = 7). Box Training of health workers to improve their communication.Example 1: Toivonen et al. 2020. An education intervention to increase the quality of family-centred care in different NICU’s.Example 2: Posner et al. 2011. Workshop for residents in obstetrics and gynaecology on disclosing an adverse event.An (electronic) aid that can be used by health workers or women and partners to improve communicationExample 1: Langston et al. 2010. WHO decision support tool to structure the family planning counselling session.Example 2: Kakkilaya et al. 2011. Visual aid with visual/graphical information for parents when delivery at the threshold of viability is imminent.The majority of studies n = 81/128) trained health workers to improve interpersonal communication skills as a single strategy, or as one of their strategies  trained , 172. TrSixty-seven studies n = 67/128) used tools to improve interpersonal communication between health workers and women and partners: decision aids, visual aids, prompts and scripts, and guidelines based on specific theory-based approaches to communication /128 used, 174.Decision aids n = 23/67) , 174 wer , 174 weSeven studies used other strategies to facilitate interpersonal communication, including facilitation, women and partner or family empowerment, and multidisciplinary consultations , 150. Thinteraction between health workers, women and partners to emphasize its bidirectional nature. This bidirectional nature was already acknowledged in the original papers for the framework by using a double arrow. By explicitly mentioning it in our updated framework we aimed to create awareness that focussing on women and their partners  might be an important alternative strategy to improve interpersonal communication. Third, we included the three communication goals  to further explain the nature of communication processes or interaction. Including the different goals of communication may remind health workers that these three goals will need different and specific attention in case they need to be improved. Inclusion of these goals in a communication framework will facilitate making deliberate choices when designing interventions to improve interpersonal communication. Fourth, we divided the ‘environment’ into different health system levels  to emphasize that multiple types of context influence interpersonal communication [Based on our findings, the reflections embedded in related articles, and the reflections of the review team, we adapted the communication framework developed by Feldman-Stewart and Brundage  to illusnication . Again, This review identified 128 different interventions to improve interpersonal communication between health workers and women and partners in MNC. We found studies across different thematic areas to facilitate cross-learning for MNC. The majority were in high-income countries. They addressed three main goals of communication: facilitating the exchange of information, creating a good interpersonal relationship, and enabling the inclusion of women and partners in the decision making. The majority of studies focused on facilitation of exchange of information, and only a few incorporated all three goals. Strategies to improve interpersonal communication primarily consisted of health worker training and providing communication tools to facilitate interpersonal communication. We observed substantial heterogeneity in intervention design, implementation and outcome evaluation and measurements. This reduced the opportunities for an evaluation of effectiveness across different interventions within this scoping review.how interpersonal communication works within the MNC context by updating the previously developed framework. As such, in the absence of a clear definition of what ‘effective communication’ is, our classification and adapted model can contribute to developing such a clearer definition.Interpersonal communication within health care settings is a broad and diversely defined concept. Our comprehensive approach, in which we incorporated studies about interpersonal communication within pregnancy-related reproductive health domains, facilitated learning from related domains. This helped us to build on insights from other more specific reviews of interpersonal communication improvement strategies for care during antenatal care , and labAlthough arguably the principles of patient-centred care date back to the ancient Greeks , the conCommunication is a cornerstone of healthcare . Most stEffective interpersonal communication is a core principle of respectful MNC, and all three goals of communication support this . The recThe importance of an enabling environment, however, needs to be recognized. The health care setting at all levels  impacts the ability of individual health workers to effectively communicate . Enablinhow to design to make these interventions more context specific, and what the underlying mechanisms of action are.This review highlights the importance of interpersonal communication between health workers and women and partners. There are other aspects of communication within MNC that can be possible anchors of quality improvement as well. These include interprofessional communication between health workers, which can be improved by simulation training  or ‘timeOur broad domain and systematic search enabled us to capture a large number of intervention studies and thereby to incorporate a broader perspective of effective interpersonal communication in different domains of SRH and MNH. Due to the large number of included studies, we may not have done full justice to complexities and nuances because we were only able to summarize limited information from each intervention. Language limitations may have resulted in the exclusion of relevant studies or reduced the diversity of study settings (six non-English articles were excluded). Exclusion of grey literature prevented review of potentially relevant reports from  organizations and other projects.always be adapted to local settings irrespective of their high- or low-income status. Because of the broad domain and inclusion of many studies from diverse settings, we believe our classification could serve well as a basis for designing strategies, measurement tools and implementation studies that can be further shaped and tailored to local settings.Although our search deliberately included databases that indexed journals from LMICs, the vast majority of studies were conducted in high-income settings. More research and better documentation of strategies to improve interpersonal communication in LMICs is therefore necessary, given both the need to develop culturally-tailored strategies in general and the greater health system constraints in these settings , 219. Cowhat has been done, its effectiveness and an understanding of how the strategies worked, and whether they are sustainable over time. Existing tools [Finally, our review also points towards the need to develop guidance for the reporting of communication interventions’ implementation and evaluation. We observed often a lack of detail on the exact design of a communication intervention and heterogeneity in reported outcomes, which reduces the opportunities for others to learn and adapt these strategies elsewhere. Such reporting guidance would ideally reflect the value of mixed methods designs to ensure evaluation studies report both ng tools , 221 canThis scoping review provides a classification of strategies to improve interpersonal communication between health workers and women and partners. This classification can be used as the foundation to inform the design and further tailoring of strategies to improve interpersonal communication, measurement tools and evaluation studies at local settings. While most communication strategies focus on the facilitation of information exchange, incorporation of the other goals of communication  are essential to ensure optimal improvement of patient-centred communication in MNC. A learning agenda on how to do this especially in low-resource settings could provide concrete and actionable guidance for settings where the burden of maternal and newborn mortality is highest, and quality of care improvements are urgent.S1 Checklist(DOC)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(XLSX)Click here for additional data file.