High rates of cannabis and illicit drug use are experienced by young people during the final stages of neurodevelopment (aged 15-24 years), a period characterized by high neuroplasticity. Frequent drug use during this time may interfere with neurophysiological and neuropsychological development pathways, potentially leading to ongoing unfavorable neuroadaptations. The dose-response relationship between illicit drug use, exposure, and individual neurodevelopmental variation is unknown but salient with global shifts in the legal landscape and increasingly liberal attitudes and perceptions of the harm caused by cannabis and illicit drugs.This systematic review aims to synthesize longitudinal studies that investigate the effects of illicit drug use on structural, functional, and cognitive brain domains in individuals under the neural age of adulthood (25 years). This protocol outlines prospective methods that will facilitate an exhaustive review of the literature exploring pre- and post-drug use brain abnormalities arising during neurodevelopment.Five electronic databases  will be systematically searched between 1990 and 2019. The search terms will be a combination of MeSH , with keywords adapted to each database. Study reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and if relevant, study quality will be assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. Eligible studies are those that sampled youth exposed to cannabis or illicit drugs and employed neurophysiological or neuropsychological assessment techniques. Studies will be excluded if participants had been clinically diagnosed with any psychiatric, neurological, or pharmacological condition.This is an ongoing review. As of February 2020, papers are in full-text screening, with results predicted to be complete by July 2020.Integrating data collected on the three brain domains will enable an assessment of the links between structural, functional, and cognitive brain health across individuals and may support the early detection and prevention of neurodevelopmental harm.PROSPERO CRD42020151442; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=151442PRR1-10.2196/18349 Illicit drug use and associated harms are highest among young people aged 15-24 years . It comeAdolescence and emerging adulthood represent a period of protracted neurobiological development marked by structural and functional remodeling, contributing to improved cognitive performance ,10. StruThe neurotoxic impact of illicit drugs on the developing brain has been studied extensively; however, a clear relationship between exposure (drug class[es] and patterns of use) and neurological sequelae is yet to be established. Sustained use of most drugs, such as cannabis inhalants, opiates, psychostimulants, and ecstasy, tends to be associated with executive dysfunction such as declines in working memory, verbal fluency, learning, and attention -18 and sThe age of drug use onset and corresponding stage of brain development may mediate neurophysiological and neuropsychological vulnerability to harm ,33. ManySeveral narrative reviews have synthesized the evidence of the long-term impact of illicit drug use on the developing brain ,43; howeInvestigate pre-existing neurodevelopmental risk factors associated with increased cannabis and illicit drug use and related harm for young people (<25 years).Assess the residual, dose-dependent effects of cannabis and illicit drugs on the function, structure, and cognitive profile of the developing brain (<25 years).Determine to what extent cannabis and illicit drug use during neurodevelopment (<25 years) predict sustained structural, functional, and cognitive brain changes.This systematic review has been registered with the International Prospective Register of Systematic Reviews  and was written per the Preferred Reporting Items for Systematic Review (PRISMA) guidelines  as proviStudies that target young people aged 10-25 years who have any lifetime exposure to cannabis or another illicit drug will be included. We will exclude studies in which the average age of participants is older than 25years.The proposed systematic review will include published studies that focus on young people aged 10-25 years who have used cannabis or an illicit drug; report on empirical, longitudinal data, where the same measurement has been employed over multiple time points; and where the measurements include test batteries assessing structural, functional or neuropsychological brain domains. Studies will include a sample with exposure to cannabis, illicit drugs, or both, where exposure involves at least single time use. Studies must compare participants who meet the criteria for cannabis or illicit drug exposure with a comparison group with less exposure. Eligible studies published after January 1990 in the English language will be included.Participants who have been clinically diagnosed with psychiatric or neurological conditions will be excluded from the review to prevent confounding results. As this review focuses on brain changes over time, we will exclude cross-sectional studies.Aided by a research librarian, five electronic databases will be systematically searched: Medline (Ovid), Embase (Elsevier), PsycINFO (OvidSP), ProQuest Central, and Web of Science, using Medical Subject Headings (MeSH). Search terms will be developed individually for each database, and specific terms for each search group are defined in the additional search strategy file ;Study characteristics ;Sample characteristics ;Drug exposure characteristics ;Data characteristics ;The statistical approach used to investigate change over time; andKey results.Where necessary, the corresponding author of the included studies will be contacted via email to obtain any relevant data not presented in the published paper. In the case of study attrition bias, authors will be contacted to request additional data to be incorporated into the review.The primary outcomes of interest will be the residual and long-term differences in neurobiological  and neuropsychological (cognitive) brain domains between the active and control group. The neuroanatomical development trajectories of particular interest include global and local gray matter measures ; integrity of white matter microstructure and fiber connectivity  ; and recWe anticipate a high degree of heterogeneity among study design and participant characteristics, and will, therefore, conduct a narrative synthesis on all available data. If it is appropriate to combine studies, meta-analysis will be conducted using Review Manager software (Cochrane). Synthesis of the included study data will be structured according to technique type, and differences between the control and exposed groups will be compared. Pre-existing cognitive, structural, and functional features will be accounted for through standardization. If possible, a subanalysis of gender-based differences will be conducted.Reviewers will independently assess the risk of bias by adapting Cochrane Collaboration’s tool for assessing the risk of bias in trials . The tooThe overall quality of the body of evidence will be determined using the Grades of Recommendation, Assessment, Development, and Evaluation approach . Study qThis paper describes an ongoing review. As of February 2020, papers are in full-text screening, with results predicted to be complete by July 2020.Accumulating research assessing the impact of illicit drug use on the developing brain underscores the need for a systematic review to assist clinicians, educators, and public health advisors in evidence-based practice. The significant consequences of illicit drug use, such as an increase in the likelihood of developing a drug use disorder or a persisting mental deficit, may be preventable ,60. The


Actions to transform food systems are key to addressing biodiversity loss. Current food production and consumption trends are inconsistent with the Convention on Biological Diversity’s 2050 vision of living in harmony with nature. Here, we examine how, and under what conditions, the post-2020 biodiversity framework can support transformative change in food systems. Our analysis of actions proposed in four science-policy fora reveals that subsidy reform, valuation, food waste reduction, sustainability standards, life cycle assessments, sustainable diets, mainstreaming biodiversity, and strengthening governance can support more sustainable food production and consumption. By considering barriers and opportunities of implementing these actions in Peru and the United Kingdom, we derive potential targets and indicators for the post-2020 biodiversity framework. For targets to support transformation, genuine political commitment, accountability and compliance, and wider enabling conditions and actions by diverse agents are needed to shift food systems onto a sustainable path. Food is an essential contribution from nature to people, ultimately underpinned by biodiversity  recognized that to achieve its 2050 vision of “living in harmony with nature,” it was necessary to address food production and consumption, as major underlying causes of biodiversity loss. Shifting toward sustainable production and consumption is a cornerstone for mainstreaming, as stipulated within CBD Aichi Target 4 , CBD members will decide on the post-2020 global biodiversity framework. Recognizing the need to go beyond incremental change, the IPBES global assessment identified several “leverage points” for initiating transformations through multilevel governance interventions (“levers”), to influence values and behavior and address the direct and indirect drivers of biodiversity loss  is one important issue for marine biodiversity, though marine ecosystems are also degraded by stressors such as coastal eutrophication (partly caused by agriculture), deoxygenation, ocean warming, and ocean acidification. To feed the world, it is necessary to think about how to optimally use terrestrial, aquatic and marine food systems. Although these food systems are frequently discussed separately, there is a need to consider how these food systems interact in relation to sustainability and how they link with the needs of producers and consumers  What are the key actions proposed, related to production and consumption of food, in science-policy fora intended to inform the post-2020 biodiversity framework? (ii) To what extent are these key actions addressed in the Aichi Targets, the SDGs, the CBD Zero Draft, and Update? (iii) What barriers and opportunities exist in implementing the key actions, at the global level, and in relation to two country case studies: Peru and the United Kingdom? (iv) What potential targets and indicators could support a post-2020 biodiversity framework that effectively addresses sustainable food production and consumption? and (v) What are the enabling conditions needed to support the achievement of these targets?Our investigations  are based on systematic analyses of outputs from four science-policy fora intended to inform the post-2020 global biodiversity framework: the “IPBES visioning workshop,” New Zealand 2017; two fora organized by the International Union of Biological Sciences (IUBS): “4th Science Forum,” CBD/COP14 Egypt 2018 and the 100th General Assembly, Norway 2019; and the “9th Trondheim Conference on Biodiversity,” Norway 2019 (details in table S1). These fora were selected because they brought together diverse groups of policy-makers, private sector actors, and researchers from multiple disciplines. The groups examined a range of topics in environmental and social sciences, therefore representing diverse perspectives of food systems from beyond the biodiversity sector. We extracted direct text relating to actions  specifically related to sustainable food production and consumption from output documents (full list in table S2). From relevant documents, we derive a “short list” of eight key actions that particularly mitigate the main direct causes of biodiversity loss—loss of habitat due to agricultural activities and unsustainable use of fisheries.We undertook document analysis to examine the extent to which the eight key actions were addressed by the following policy frameworks: the Aichi Targets .Box 1Peru is one of the world’s megadiverse countries, still retaining vast natural ecosystems  with low human intervention. Of its 1,280,000-km2 land area , Aichi Target 3, and the CBD Zero Draft [D. 12 (c) 12] and its update [E. 12 (c) 17]. The removal, phase-out, or reform of harmful incentives are part of the Aichi Targets and SDG 6 but are insufficiently addressed in associated indicators, thus highlighting ambiguity in the concrete actions needed and a lack of accountability for action. Politically, incentives are often difficult to reform because of strong opposition from recipients and tight linkages with regional and international trade. Shifts in subsidies may have negative economic impacts on low income and poorly resourced producers if they are insufficiently thought out  leaving the EU, there may be shifts in political and trade barriers, as well as uncertainties for U.K. food production following its withdrawal from the EU Common Agricultural Policy (CAP). While the CAP was created to ensure food security and economic viability for rural farming communities following World War Two, the subsidizing of food production has substantially affected natural habitats, while driving over-production of various commodities  13], indicating some alignment on policy language. However, details on how these should be integrated, beyond strategic environmental assessments and environmental impact assessments, are lacking. Governmental policies and market transactions typically do not reflect the full value of nature’s contributions to people , which would strengthen its implementation. This is likely to require changes in objectives and behavior of businesses and consumers, as well as new progressive laws and regulations. The CBD could therefore include a target that aligns with the SDG target 12.3, which states that “by 2030, halve per capita global food waste at the retail and consumer levels and reduce food losses along production and supply chains, including post-harvest losses”  . Standards should include recognition and autonomous rights of indigenous people and local communities. Because of the risks of standards creating exclusions and large-scale bias, they should also incorporate agrobiodiversity and multifunctionality. Producing and consuming countries can also provide more support for the uptake of standards, with producing countries requiring minimum sustainability standard for export and consuming countries requiring sustainability certification for import of high-biodiversity risk commodities. Governments’ public procurement plans should also incorporate sustainability requirements. Research into the effectiveness of integrated landscape approaches in supporting biodiversity and sustainable development goals, and the role of sustainability certification in these, is an important frontier for research. Potential indicators could include the number of companies using SMART biodiversity indicators and the percentage of ISEAL Alliance  members (sustainability standards) with stronger biodiversity requirements, including “No Net Loss” as a minimum and management and monitoring of High Conservation Value areas. Biodiversity Impact Indicators for Commodity Production could also support in strengthening the impacts of standards.Life Cycle Assessment is the most widely used method to assess environmental impacts of agricultural products over their full life cycles  fleet found that significant environmental impacts stem from other parts of the industry, in particular, construction of the fleet (∼11%) and its maintenance (∼23%) . This would help consumers to better understand the impacts of products on biodiversity, while mainstreaming biodiversity concerns of food consumers. Associated indicators could include the ecological footprint across the life cycle of product and the availability of information about life cycle impacts for a particular product. An important challenge for the implementation of Life Cycle Assessment is to address transparency of agricultural products and fisheries in opaque supply chains. There are also important questions related to responsibility for data collection and who monitors, evaluates, and audits, as this could pose burdens for data collection needs and management. Given the problems associated with current methodologies, the development of standardized protocols by 2025 would be beneficial, with data aggregated and monitored at municipal/national levels. As current methodologies misrepresent less intensive or smaller-scale agroecological systems, the development of Life Cycle Assessment reporting should include multiple stakeholders, e.g., small-scale farmers and informal markets, to address the challenge of exclusion of certain actors and development pathways.While the SDGs clearly seek to address issues of nutrition, “sustainable diets” are not mentioned. The Aichi Targets 6 and 7 mentioned the goals of sustainable agriculture and fishing but did not explicitly mention diets. The CBD Draft Zero documents state that “People everywhere take measurable steps towards sustainable consumption and lifestyles, taking into account individual and national cultural and socioeconomic conditions, achieving by 2030 just and sustainable consumption levels.” This emphasizes the importance of food security and inequality in distribution and access  in reducing their high environmental footprints  to direct human consumption , as well as labeling and awareness campaigns, could support changes in diets  have taken the lead to review and report on member state progress  . The devFrom a practical perspective, greater support will be needed for gathering the necessary indicator data. Here, there are opportunities for synergies. For instance, Peru has set up a forest monitoring system for the UNFCCC, and both agriculture and environment ministries are using one system. In 2019, the Ministry of Environment of Peru developed a map on ecosystem degradation for the United Nations Convention to Combat Desertification, which can also be used to monitor habitat changes.While multistakeholder collaboration and negotiations are frequently considered normative aspects of sustainability governance, it is important, and in many instances challenging, to ensure that negotiations and participatory practices between actors are meaningful. To that end, all actions need to be linked to broader, long-term processes of empowerment  of the world’s gross domestic product (GDP) is highly or moderately dependent on nature , as immediate implementation is required that will demand practical steps to be taken related to the availability of data and resources, and institutional arrangements. Only the highest level of ambition in setting and implementing the goals will support the CBD’s 2050 target of living in harmony with nature (


Preliminary metrics of success are interdisciplinary collaborations and grant funding. We describe recent examples of how interdisciplinary collaboration, academic-community partnership, and pilot funding contributed to the development and funding of innovative interdisciplinary research, including the New York site of the HEALing Communities initiative. The processes are now being used to support interdisciplinary approaches for other translational public health issues.Effectively addressing public health crises requires dynamic and nimble interdisciplinary collaborations across the translational spectrum, from bench to clinic to community. The Clinical and Translational Science Award (CTSA) Program hubs are uniquely suited to facilitate interdisciplinary collaborations across universities and academic medical centers. This paper describes the activities at the Columbia University CTSA Program hub to address a current public health crisis, the opioid epidemic. Columbia’s CTSA Program hub led a three-phase approach, based on the Conceptual Model of Transdisciplinary Scientific Collaboration as described by Stokols  The opioid crisis in the USA shows no signs of abating. In 2015, over 33,000 people died from opioid overdoses. By 2016, this had risen to over 42,000 [However, due in part to the specialized training and focus of academic specialties, many researchers need assistance or support to build interdisciplinary collaborations . The NatThe Clinical and Translational Science Award (CTSA) Program is uniquely suited to foster interdisciplinary collaborations within and across universities and academic medical centers. CTSA Program hubs, supported by the NIH National Center for Advancing Translational Science (NCATS), are currently located at 58 academic medical centers across the USA, as of fiscal year 2018. CTSA Program hubs are designed with the hub-and-spoke model, with a central “hub” at each institution that facilitates interactions with “spokes” – departments, divisions, and schools across the university and medical center as well as regional partners including other hospitals, health clinics, and nonprofit organizations. These hubs provide resources that promote collaboration, including providing data and informatics core support and community engagement resources to help investigators identify partners and participants for clinical trials, and supporting researchers  that can facilitate collaborations. Additionally, CTSA Program hubs aim to help build connections with entities outside of the university/medical center, including with community-based nonprofit organizations and the pharmaceutical and informatics industry. The CTSA model of “Develop, Demonstrate and Disseminate” is well suited to help foster high-quality research, evaluate and demonstrate efficacy, and disseminate findings, beyond peer-reviewed publications, into materials usably by stakeholders such as community-based organizations and industry representatives.This article describes how one CTSA Program hub, located at Columbia University’s Irving Institute for Clinical and Translational Research (Irving Institute), is responding to this public health crisis by organizing experts from numerous disciplines, both inside and outside of the university, to promote interdisciplinary dialogue, explore ways of designing research to address this crisis, and provide opportunities for collaboration across multiple entities.et al. [The Irving Institute’s opioid response is based on the conceptual model of transdisciplinary scientific collaboration, described by Stokols et al. , which iThe first step in this process is identifying individuals who are key leaders across the broad range of disciplines with expertise in addressing the crisis. The initial planning phase began in the fall of 2017 with a local environmental scan, identifying relevant experts across the medical center and the university, for example, in the schools of Medicine, Dentistry, Nursing, Public Health, Arts and Sciences, Business and Engineering as well as in the hospital and community. This led to the convening of informal meetings, with participants identified via a snowball method – participants recruited other participants who were identified as having expertise in needed areas. The brainstorming phase culminated in a seminar attended by almost 100 participants on December 21, 2017, to identify how the Irving Institute could best support collaborative research to address the opioid crisis. Speakers at the seminar included representatives from across the university, including Psychiatry, Anesthesiology, Biomedical Engineering, and Medicine, as well as New York Presbyterian Hospital and the New York State Psychiatric Institute, and the upper Manhattan community covered topics, including the mechanisms of pain, epidemiology of addiction, and informatics needed to coordinate data sharing across multiple systems.Following the plenary sessions, participants were invited to join one of the four breakout sessions: (1) improving prescribing and pain management, (2) improving addiction treatment, (3) engaging community partners and resources, and (4) facilitating bench to bedside discoveries and translation. Each breakout session generated recommendations for their respective focus areas to address the opioid crisis as well as potential additional participants in the process.The four breakout sessions evolved into ongoing work groups, with 11–17 members each, incorporating expertise in each of the four content areas. The work groups continue to meet on a regular basis, to develop new collaborations and stimulate research within and across work groups and beyond Columbia, as well as engaging colleagues at other CTSA hubs.Following the identification of key leaders, the next phase consisted of systematic efforts aimed at identifying and engaging all investigators who are interested in, or working in, an area relevant to the opioid crisis. Activities have included a campus- and community-wide interdisciplinary symposium, campus-wide email request, and ongoing monitoring of funded grants and published papers. The CTSA Program hub began planning an interdisciplinary symposium to discuss issues related to prevention and treatment of the opioid crisis, from January to June 2018. The symposium, held on June 22, 2018, on the campus of the Columbia University Irving Medical Center in New York City, included 192 registered attendees. Attendees represented a wide spectrum of departments and divisions from across Columbia University/New York Presbyterian Hospital, including (but not limited to) the schools of medicine, dental medicine, psychiatry, business, social work, and public health. In addition, attendees included representatives from federal, state and local government agencies, local community-based organizations, industry firms, and other local universities/academic medical centers.The symposium included a plenary session in which speakers from the NIH describing funding priorities, including Michael Kurilla, Director of the Division of Clinical Innovation at the NIH NCATS and Carlos Blanco, Director of the Division of Epidemiology, Services and Prevention Research at the National Institute for Drug Abuse. Speakers also included experts in epidemiology and addiction treatment discussing the current state of research in the field, and New York City Commissioner of Health who discussed the City’s current activities. Following the plenary session, two breakout sessions were held – one focusing on pharmaceutical industry activities and one focusing on activities of local community-based organizations. The day also included a luncheon in which networking was facilitated through interdisciplinary-themed luncheon tables.Following the symposium, we further aimed to identify as many investigators as possible with opioid-related research interests. Investigators have been identified through campus-wide email blast, as well as from visitors to our dedicated website. We also routinely conduct searches for additional NIH-funded investigators (though NIH Reporter) and opioid-related publications (through PubMed and Google Scholar) generated by Columbia-affiliated faculty.Following the symposium, participants were invited to join one of the four specialized working groups . Each group identified between three and eight new members. The working groups continue to meet and collaborate on research and grant ideas.Additionally, a Steering Committee was developed, comprising leaders from each of the four work groups and leaders in each of the specialized practice areas. The Steering Committee meets bimonthly and serves as an overall brain trust for the effort. Members continue to meet to discuss newly funded grants and upcoming grant applications and identify the need for collaborators. For example, an investigator might discuss the need for an economist on an upcoming grant application and solicit suggestions for economists who have worked in these areas.The Columbia CTSA continues to promote communication by maintaining a database of interested investigators, establishing regular communications with and across work groups, convening steering committee meetings, and providing website updates on the initiative. The database (which currently has nearly 200 members) is used to distribute information on funding opportunities and new developments through an email listserv. It is also used for collaborator identification. For example, if an investigator contacts the CTSA program hub and asks for assistance in identifying collaborators working in the dental school, they can be put in touch with dental faculty who are included in the database. The CTSA program hub keeps track of opioid-related federal grants awarded and peer-reviewed publications from Columbia University and the affiliated New York State Psychiatric Institute; these listings can also be used to identify faculty working in these areas. We also connect investigators with other CTSA resources, including the Trial Innovation Network which provides resources for investigators developing clinical trials.https://www.irvinginstitute.columbia.edu/about-us/key-initiatives/opioid-crisis-response), with an email address to contact the team. The website provides search links which enable real-time searches of all federal and nonfederal funding opportunities with a keyword of opioid. Additionally, the CTSA Opioid response team collaborates with other external initiatives, including the National Academy of Medicine’s Collaborative on Encountering the US Opioid Epidemic. Table Information on Columbia CTSA program hub activities is maintained on a public website  were awarded a series of CTSA pilot grants to advance understanding of how to implement opioid education and naloxone training on college campuses. As part of Phase I of the pilot, investigators collaborated with a multidisciplinary research group across the university, to establish a platform for implementing evidence-based practices and programs that address the opioid epidemic. A second CTSA pilot was funded to further support this work on a larger scale, which will examine the acceptability, feasibility, and implementation of opioid awareness education and naloxone training on Columbia undergraduate campus, with the goal of facilitating national dissemination ,13.The CTSA connected Columbia investigators to CTSA-affiliated investigators in other institutions, and an innovative U01 application was submitted to NCATS, which has been funded.At a CTSA meeting, an investigator noted a lack of resources to develop cost-effectiveness analyses and was connected to an economist. The collaboration has led to a grant proposal which incorporates cost-effectiveness analysis into the intervention effectiveness study.Following an email blast, a surgeon was added to the Advisory Board of a recently funded grant, providing needed expertise to facilitate the research.The success of this CTSA interdisciplinary intervention can be measured, on a preliminary basis, by (1) the success in supporting new interdisciplinary collaborations, 2) later, on securing additional grant funding for research, (3) with time, on the impact of CTSA activities on grant funding and publication, and (4) ultimately, on new research output (e.g. new discoveries in pain and addiction science or new pain therapies), implementations, and intervention that impact the opioid crisis. Table  later, oEfforts to facilitate interdisciplinary research provided critical support to facilitate the development of the New York State HEALing Communities project, a multistate project funded by the National Institute of Drug Abuse that aims to reduce opioid-related deaths by over 40% in the next 3 years . The NewThe key investigators were introduced to each other through CTSA opioid crisis brainstorm activities. Drs. Nabila El-Bassel and Edward Nunes, PIs on the New York State proposal, were first introduced and brought together by their participation in the Opioid Crisis Initiative Community Work Group at the brainstorming seminar convened in December 2017. Their discussions in that work group seeded their planning for Columbia’s successful HEALing Communities Study grant application. Their planning efforts were also supported through Irving Institute seed funding directed specifically to address the opioid crisis (below). Moreover, Dr. Frances Levin was introduced to Dr. El-Bassel through CTSA-supported activities, and now the national Substance Abuse and Mental Health Services Administration (SAMHSA) initiatives led by Dr. Levin are components of the awarded HEALing Communities project to support the training initiatives.The Irving Institute/CTSA helped foster the critically important relationships with semirural/rural upstate counties that are the focus of the HEALing Communities application via a pilot award to Dr. El-Bassel’s group and by supporting Dr. Nunes group’s initiative with Orange County Medical Center. These relationships led to additional grant applications currently under review, in addition to the HEALing Communities project. Moreover, the Irving Institute/CTSA provided introductions and facilitated the research collaborations between Columbia/New York State Psychiatric Institute, Yale University, Medical University of South Carolina and their CTSA hubs as well as other institutions nationally for these innovative applications.Dr. El-Bassel was a recipient of our Irving Institute inaugural Opioid Strategic Planning pilot award in 2018 for the project entitled, “Mid-Hudson Opioid 2CARE Pilot.” This pilot provided funds to develop and test innovative methods, technologies, and approaches to engage and care for individuals with Opioid Use Disorders in urban and rural communities. This award provided critical proof-of-principle and preliminary data that facilitate a successful HEALing Communities application. The Irving Institute/CTSA also nominated Dr. Timothy Hunt of Columbia School for Social Work, co-investigator on Columbia’s HEALing Communities program, to participate in the NCATS/CTSA Rural Engagement “unmeeting”, University of Florida, Gainesville. The ideas generated and collaborations established at that national brainstorming event, highlighting the disparities that exist and the resources available in cooperative extensions in these communities, will certainly serve our community engagement in New York State and collaborations with other HEALing Communities centers and the national CTSA hub network.Community engagement and implementation are key to the success of the Columbia HEALing Communities program, and so the work of Columbia’s Opioid Crisis Initiative Community Work Group and the Irving Institute/CTSA Implementation Science Program established in 2018 are providing critical support to the regional and national HEALing Communities program. Columbia’s CTSA and Irving Institute leadership are working directly with Drs. Nabila El-Bassel and Edward Nunes, PIs of Columbia’s HEALing Communities award, to strategize how the Irving Institute/CTSA extensive resources, including its Opioid Crisis Response Initiative, as well as other New York CTSA Program hubs, and the national CTSA Program network, can effectively support community engagements and care model implementation for the regional and national HEALing Communities program.Thus, the CTSA emphasis on interdisciplinary collaboration across the medical center, and locally and nationally, as well as the development of relationships with state and local government partners and community leaders, has contributed to the emergence of this dynamic opportunity to participate in this national effort to rapidly reduce opioid-related deaths through the development and implementation of evidence-based practices to communities experiencing high rates of opioid deaths.Columbia’s CTSA Program hub has acted quickly to bring together a large team-science-based, collaborative interdisciplinary initiative, from different divisions across the university, other local academic medical centers and universities, state and local policymakers, and community-based organizations. While investigators at Columbia have an extensive prior track record of innovative substance use research, including opioid research, the activities described in this paper serve as examples of how silos can be bridged to build on existing strengths and facilitate broader interdisciplinary research. These CTSA-initiated activities were designed to enable investigators to mobilize when the NIH HEAL initiative launched. While it is still too soon to identify the public health impacts of this funded research, monitoring outcomes is a component of such research. For example, HEALing Communities cite a goal of reducing opioid-related deaths by 40% in the next 3 years. Columbia CTSA-affiliated investigators, notably Arthur Robin Williams, are examining how best to effectively assess outcomes . After nGoing forward, the CTSA will continue to support team science interventions, through regular large and small group meetings, investigator matchmaking locally and nationally, the provision of core resources and seed funding to help interdisciplinary projects secure grant funding, and the assessment of outcomes to examine the public health impact of opioid-related research.This effort showcases how a CTSA hub can work to help disparate organizations  and disciplines work together to address a significant public health crisis. As new public health crises are identified, the processes developed here  are being used to support interdisciplinary approaches for other research challenges and public health crises. For example, the Columbia CTSA hub has created an Implementation Science Initiative and an Exposomics Initiative, which is applying a similar process – identifying and engaging key experts and leaders to brainstorm effective strategies for campus-wide outreach and ongoing support of collaborations, interdisciplinary teams, and proposal development.Through their interdisciplinary nature, CTSA hubs are uniquely positioned to help academic medical centers work across disciplines to address public health needs. The model used here is now being used by other CTSA initiatives and can be adopted by the over 50 CTSA hubs nationwide. CTSA leaders should meet regularly and stimulate NIH and NCATS responses, to address new public health crises that may require interdisciplinary interventions, and can begin the process laid out here to stimulate research collaborations.


The spatial distribution of humans on the earth is critical knowledge that informs many disciplines and is available in a spatially explicit manner through gridded population techniques. While many approaches exist to produce specialized gridded population maps, little has been done to explore how remotely sensed, built-area datasets might be used to dasymetrically constrain these estimates. This study presents the effectiveness of three different high-resolution built area datasets for producing gridded population estimates through the dasymetric disaggregation of census counts in Haiti, Malawi, Madagascar, Nepal, Rwanda, and Thailand. Modeling techniques include a binary dasymetric redistribution, a random forest with a dasymetric component, and a hybrid of the previous two. The relative merits of these approaches and the data are discussed with regards to studying human populations and related spatially explicit phenomena. Results showed that the accuracy of random forest and hybrid models was comparable in five of six countries. As of 2017, the global human population is estimated to be near 7.6 billion, demonstrating a global population growth of roughly 200 million since 2015 –5, disasHowever, gridded population techniques vary greatly in their methods, ancillary inputs, complexity, and resolution of interest . GeneralThis paper presents the results of three different modeling approaches using three different high-resolution built-area datasets. Population was disaggregated using a representative selection of low- to middle-income countries, chosen for their high number of recent census administrative units, availability of ancillary inputs, and frequent exclusion from methods applied in higher income countries. The nine different gridded population datasets are available for six different countries for a total of 54 datasets at three arc second resolutions (~100 m at the equator).This dataset provides a set of 54 different high-resolution, gridded population raters produced for the purposes of methodological and built area data product comparison. Gridded products represent population as people per pixel (ppp) at ~100 m resolution for recent census years in select countries. This includes Madagascar, Rwanda, and Malawi from Africa, Nepal, and Thailand from Southeast Asia, and Haiti from the Caribbean. The gridded population datasets depict population distribution under the constraints of 3 different approaches explored in https://gadm.org/index.html) that is specific to the region and not comparable to units of the same level in different countries , Global Human Settlement Layer (GHSL), and the Facebook Connectivity Lab’s High-Resolution Settlement Layer (HRSL) .The first, World Settlement Footprint (WSF), represents a global coverage of earth’s land surface from the German Space Agency (DLR) Earth Observation Center based on Landsat 8 and Sentinel 1 optical and radar imagery for 2014–2015. The initial dataset was retrieved through personal communication with Thomas Esch and Mattia Marconcini and represents an initial version prior to public release ,27. SecoA wide range of ancillary data are used as explanatory variables of the random regression forest used in Models 2 and 3, as outlined in The following section outlines the open-access archive of comparable, high-resolution datasets of gridded population distribution for the countries of Haiti (HTI), Madagascar (MDG), Malawi (MWI), Rwanda (RWA), Nepal (NPL), and Thailand (THA). These countries represent criteria of comparable human distribution, heterogeneous land-cover types, and diverse continental representation. The approach utilized here is adapted from published WorldPop random forest methodology that has been altered to suit this study needs . For an The covariate selection and data preparation step has three primary phases of preparation, including built data processing, covariate standardization, and hydrofeature mask creation.First, we process the three built areas mentioned in Next, we cluster covariates into three groups depending on their subsequent transformations . For exaThe last component is generating a hydrofeatures mask based on the European Space Agency’s land use classification product  and procWe use three different models and the four built area configurations across six different countries to produce 54 models . The firThe second model Model 2,  creates Last, the third model Model 3,  uses theTo assess the accuracy of each model, population based on a two-thirds aggregate of available administrative units at the finest level was resampled in Python 2.7.8 by dissolving boundaries with the longest shared border, sorted randomly without spatial consideration. These final mapping products are then compared to the finest level of census data available for a given country by summing gridded population estimates within each administrative unit . The staAccuracy assessment of each map featured a suite of error metrics, including the RMSE and MAE for both population counts and density. Results show a consistent decrease in error relative to model complexity, with a few exceptions . Those eThe random forest model that produces the population density-weighting layer for the RF and Hybrid approaches has a variance explained for each country noted in The datasets presented in this paper facilitate comparisons and considerations of different approaches to the production of gridded population data. When producing such data, it is worth assessing the underlying built data and associated population densities to assess whether a binary dasymetric or hybrid approach may be more appropriate than statistical or smart interpolation models. The datasets presented here are endogenous and should not be used to explore relationships and correlations between the ancillary datasets and the resulting population distribution . Please Click here for additional data file.


Background: There is need for the childhood obesity treatment literature to identify effective recruitment and engagement strategies for rural communities that are more likely to lack supportive infrastructure for healthy lifestyles and clinical research relative to their urban counterparts. This community case study examines recruitment and engagement strategies from a comparative effectiveness research (CER) trial of two family-based childhood obesity (FBCO) treatment interventions conducted in a medically underserved, rural region. Guided by a Community Based Participatory Research (CBPR) and systems-based approach, the primary aim was to analyze interviews from academic partners, community partners, and parent study participants for recruitment and engagement assets, challenges, and lessons learned.Methods: Over the 3-year lifespan of the study, researchers conducted 288 interviews with Community Advisory Board members (n = 14), Parent Advisory Team members (n = 7), and study participants (n = 100). Using an inductive-deductive approach, interviews were broadly coded for recruitment and engagement assets, challenges, and recommendations; analyzed for descriptive sub-coding; and organized into stakeholder/organization and participant level themes. Codes were analyzed aggregately across time and examined for differences among stakeholders and parent study participants.Results: Adherence to CBPR principles and development of strong community partnerships facilitated recruitment and engagement; however, variability in recruitment and engagement success impacted partner confidence, threatened outcome validity, and required additional resources. Specifically, assets and challenges emerged around eight key needs. Three were at the stakeholder/organization level: (1) readiness of stakeholders to conduct CBPR research, (2) development of sustainable referral protocols, and (3) development of participant engagement systems. The remaining five were at the participant level: (1) comfort and trust with research, (2) awareness and understanding of the study, (3) intervention accessibility, (4) intervention acceptability, and (5) target population readiness. Future recommendations included conducting readiness assessments and awareness campaigns, piloting and evaluating recruitment and engagement strategies, identifying participant barriers to engagement and finding a priori solutions, and fostering stakeholder leadership to develop sustainable protocols.Conclusion: Collective findings from multiple perspectives demonstrate the need for multi-leveled approaches focusing on infrastructure supports and strategies to improve stakeholder and participant awareness of, and capacity for, recruiting and engaging medically underserved, rural families in a FBCO CER trial. Recruitment and engagement challenges are well-documented in childhood obesity treatment studies –8. Poor The current study attempts to expand this literature by examining recruitment and engagement  strategies from a comparative effectiveness research (CER) trial and family-based childhood obesity (FBCO) treatment intervention targeting a high need, medically underserved, rural region. Using a case study approach, researchers analyzed qualitative interview data across the 3-year study from three stakeholder groups that included academic partners, community partners, and parent study participants. The primary aims were to explore the assets and challenges to the various recruitment and engagement strategies attempted during the lifespan of the study and to highlight insights into effective practices and recommendations to help build sustainable systems to engage rural families in FBCO interventions.The study takes place in the Dan River Region (DRR), located in south central Virginia. It includes a small city, Danville, surrounded by large rural areas and small towns. The DRR is a federally designated, medically underserved area with challenging social determinants for poor health outcomes such as high poverty, unemployment, and minority concentrations , 18. OutiChoose, an evidence-based FBCO (2013–2015) (iChoose parent participants. Continued collaboration with the CAB and PAT resulted in a Patient Centered Outcomes Research Institute (PCORI) contract (2017–2020) to conduct a randomized CER comparing two different FBCOs in the DRR: iChoose (high intensity) and Family Connections (low intensity). The rationale and study protocol are published elsewhere (The current study evolved from a preliminary Community-Based Participatory Research (CBPR) study in the DRR that adapted and piloted 13–2015) –28. As plsewhere .iChoose was adapted from an evidence-based FBCO, Bright Bodies , engaged with families and program facilitators during classes, and provided support via phone and texts to participants. PAT membership fluctuated from five to seven members, with all receiving a monthly stipend of $100–$200 depending upon activities and responsibilities.Interested families were screened for eligibility criteria . The majority of the 139 enrolled children (70%) and 128 enrolled parents (75%) were obese. Over half the children were black (45%) or other minorities (8%), lived in single parent homes (55%), and were enrolled in Medicaid (62%). About one-third of parents (average age of 39) had a household income of < $20,000 (29%), were unemployed (32%), had a high school diploma or less (30%), and a less than adequate health literacy score (29%).During the study, a total of 288 interviews were conducted with five academic CAB partners, nine community CAB partners, seven PAT partners, and 100 parent study participants .CAB and PAT partners participated in three annual interviews conducted and recorded by an independent evaluator using a semi-structured interview script. The script was developed from a capacity framework guided by CBPR principles , 26, 35.Parent study participants from each cohort participated in face-to-face interviews at 3-, 6-, and 12-month follow-up assessments. Trained researchers probed about recruitment and randomization processes and intervention adherence, usefulness, and satisfaction. Children were also interviewed at these assessment points; however, the focus of these interviews was more upon individual and family behavior changes and general satisfaction with the program (iChoose only) than with recruitment and engagement facilitators and obstacles. Their data added little value to the purpose of this paper and therefore is not included. Incentives of $25 for 3-month and $50 for the 6-and 12-month follow-ups were offered to study participants. Interviews lasted 10–20 min. Researchers summarized responses on paper and recorded verbatim responses when possible.Analysis of the qualitative data were conducted in two phases . In the Phase two analysis was completed by the Principal Investigator and Study Coordinator. Together they used a deductive approach to thematically categorize codes into eight higher level study needs that present at the stakeholder/organization and the individual levels , 37. DatAt the stakeholder/organization level, three thematic needs emerged: (1) improve readiness of stakeholders to conduct CBPR research, (2) develop sustainable participant referral protocols, and (3) develop feasible and sustainable participant engagement protocols. As illustrated in Despite strong initial assets to meet stakeholder/organization level needs, the study under-performed with regard to milestones and expectations for recruitment and engagement. Suggestions to address these challenges included a number of already enacted strategies see , such asAt the participant level, five thematic needs for target population improvements emerged: (1) level of comfort and trust with research, (2) accessibility to the intervention, (3) awareness and understanding of the study, (4) acceptance of the intervention, and (5) readiness to engage in an obesity treatment study. As seen in the assets outlined in Similar to the stakeholder/organization level needs, challenges outweighed assets and many of the recruitment and engagement milestones were not met. Regardless, existing strategies such as using community members from trusted local organizations and the targeted population to recruit and implement the study see  were seeWith regard to stakeholder/organization level needs, academic CAB, community CAB, and PAT partners' perceptions of assets and challenges aligned similarly. However, there were notable difference in perceptions between these study stakeholders and the parent study participants for these needs. While parent study participants had opportunity to discuss issues surrounding their participation, they were much less likely than the community stakeholders to identify system level assets or barriers and largely kept their comments at the participant level. As noted later in the discussion, this disparity may also be a result of methodological differences in the intention and structure of the interview scripts in which study participants were not specifically prompted to reflect at the system level.At the participant level, academic CAB partners were more likely than community CAB partners, PAT partners, and parent study participants to acknowledge target population's distrust of research. However, community CAB partners identified pathways to increase comfort through provision of interventions that clearly address key community burdens. All interviewee groups stressed challenges to accessibility and assets to intervention acceptability; however, CAB members mentioned challenges to acceptability less frequently than did PAT partners and parent study participants. Intervention acceptability, according to parent study participants, was particularly impacted by the level of satisfaction with randomization and intervention components. Finally, relative to enrolled parent study participants, CAB and PAT partners were less likely to perceive assets and more likely to perceive challenges to participant readiness to engage in a childhood obesity study.Findings across the lifespan of our study demonstrated a pattern of recruitment and engagement challenges. These struggles were not fully anticipated by the CAB and PAT due to the application of evidence-based strategies that were previously successful with this target population  and addiWhen considering the recommendations supported by our qualitative case study, it is clear that full system-changes are necessary to improve recruitment and engagement in similar childhood obesity studies being conducted in comparable health disparate regions. Potential changes to community and organizational structures that provide opportunities and access to these studies in a way that ensures broad exposure across the intended audience are likely to be the most impactful. While we note that participant readiness is both an asset (from parent study participant perspectives) and a challenge (from CAB participant perspectives), it is critical to avoid the assumption that the challenge of low recruitment is based on an unmotivated intended audience. As such, our recommendations include a strong focus on ensuring target population awareness and access to research, including trust building opportunities. Likewise, we focus on system changes that could influence norms related to how initial recruitment and sustained engagement can be supported at the research and community-system level.Lesson 1. Nurture CBPR principles that encourage co-learning and foster capacity building to conduct research. The cornerstone of this study was partner readiness to conduct CBPR. Interviewees credited the CBPR approach in developing recruitment and engagement strategies reflective of community partner knowledge of the population and achieving higher milestone success than what might have been possible without this approach. The importance of community stakeholder engagement in research is supported in the CBPR literature  continuous individual assessment and support for attendance, (2) proximal sites, (3) incentives, and (4) flexible time options ( options , 44, 47. options , 51, 52.Lesson 8. Actively engage community partners in promoting readiness of the intended audience to engage in a childhood obesity treatment study. CAB and PAT partners suggested that researchers should go beyond strategizing recruitment and engagement protocols and work to promote participant readiness. Childhood obesity awareness campaigns have successfully targeted physicians (ysicians  and famiysicians  for engaOur case study retrospectively evaluated stakeholder and participant interviews for recruitment and engagement indicators that were not explicitly intended by the interview protocols. Consequently, direct questions about recruitment and engagement were not consistently asked in the same manner over time or across interviewee groups. Furthermore, parent study participant data was only gathered from retained participants at follow-up assessments and does not include perspectives on recruitment and engagement from families that completely disengaged. Therefore, quantified analysis of the qualitative data should be interpreted cautiously when examining differences among key stakeholder responses. This approach to the data was meant to provide insight into the importance of multiple perspectives in painting a holistic picture of assets, challenges, and opportunities surrounding recruitment and engagement within the study. Due to the above mentioned methodological constraints, frequency of themes cannot suggest relative importance of one asset, challenge, or recommendation over another. However, a frequently mentioned theme may indicate something that is obvious to one or more of these interviewee groups and therefore provides insight into priorities and how they might fit together.When examining the frequencies reported by the four interviewee groups, it is clear that a single perspective approach would have resulted in less complete and meaningful feedback on recruitment and engagement strategies within the study. For instance, enrolled parent study participants emphasized their readiness to participate in a childhood obesity treatment study and their positive perceptions of the interventions' acceptability. However, CAB and PAT members who experienced the recruitment and engagement efforts understood barriers for the larger target population. Likewise, while academic CAB members appeared to conclude that mistrust and discomfort with research hindered recruitment, community CAB members saw this as more of a mismatch between research and its ability to address community needs. Yet, parent study participants indicated research mistrust was largely due to randomization procedures. Furthermore, community partners and parent study participants were more inclined to understand intervention accessibility barriers than academic partners not living in the region.In addition to providing a more holistic picture as to the assets, challenges, and opportunities related to recruitment and engagement, frequency patterns also suggested small nuances in the priorities of the interviewee groups. For instance, academic partners wished to improve the health of the targeted population. Additionally they wished to develop systems to continue research efforts with established partners. Thus, while community CAB and PAT partners were aware of the challenges related to building partner capacity at the organizational/systems level, these challenges may have been perceived more keenly by academic partners. Similarly, parent study participants' focus on assets and challenges related to the accessibility and acceptability of the interventions may suggest that they prioritized finding resources to meet their immediate family needs. Overall, the consistent approach of examining the data for prevalence of themes across stakeholders provided rich content information directly relevant to the strengths and pitfalls of our study. These findings may be relevant to other practitioners and researchers who work with populations that face numerous barriers to participation in research.Recruitment and engagement are perhaps the highest hurdles to overcome for FBCO and other interventions examining health behavior change, particularly for those engaging underserved, rural populations , 16. OurThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board for Health Sciences Research University of Virginia. The patients/participants provided their written informed consent to participate in this study.JZ and PE designed the overall study and methodology with substantial input from D-JB and JH. The focus of the manuscript was conceived by D-JB and JZ with support from PE, MY, and JH. Data analysis for this study was completed by D-JB, MY, and BP under the supervision of D-JB. As community partners in this project, JW, DM, and KE provided feedback on content interpretation. D-JB and JZ drafted the paper with section contributions from MY and editing from MY, PE, and JH. All authors provided feedback on the manuscript draft and approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Globally, the number of older people requiring appropriate and safe management of medicines is growing. This review aimed to identify the roles and responsibilities of pharmacists supporting older people living in a community setting with their palliative care needs and to synthesise key themes emerging from the data, as well as any gaps in knowledge. The literature search included Medline (Ovid), Scopus, and Cinahl (Ebsco) databases. An English language limit was applied. The search included all international articles and any date of publication. Data were synthesised utilizing a systematic text condensation technique and presented according to Theme, Domain, and Meaning Units. Fourteen studies met the inclusion criteria. Selected papers predominantly focused on care provided by the pharmacists supporting people receiving residential aged care services. Clinical review, supply of medicines, and clinical governance were identified as key pharmacist roles. Pharmacists’ communication skills, personal behavioural approach, and positive attitude emerged as supportive characteristics for effective person-centered care. Minimal, or no information, were available related to pharmacists located in general medical practices and in Aboriginal health services sector, respectively. The multifaceted role of pharmacists presents an opportunity to provide comprehensive health care for older populations at the end of their life. It outlines some of the non-dispensing roles that community pharmacists have with care teams such as advising on medicine management, medicine safety, and the rational use of medicines in a cost-effective manner [As the population ages, the number of older Australians with palliative care needs is increasing . Multimoe manner .Home Care (HC) services—where the person receives care in their home dwelling; orResidential Aged Care (RAC) services—where the individual is provided care within a Residential Aged Care Home (RACH).While changes in an older person’s condition can contribute to multiple hospital admissions, the last 12 months of an older person’s life is spent predominantly in the community ,11. TheyIn Australia, a multidisciplinary approach to care is dependent on a range of Non-Government Organisations (NGO) working together, including general medical practices, aged care providers, Aboriginal health services, and dispensing pharmacy services. NGOs predominantly deliver care that is subsidised using National funding levers, including the Medicare Benefits Schedule (MBS), 6th Community Pharmacy Agreement (6CPA), Pharmaceutical Benefits Scheme (PBS), and Home Care Packages Program (HCPP). Within this complex, multi-faceted Australian healthcare system, rational use of medication management services for older people is provided by the primary healthcare services and aged care organisations collaboratively via referrals between pharmacists and general medical practitioners .Although structures exist to facilitate pharmacist involvement in care, we are unaware of any extensive research discussing the full spectrum of their roles and responsibilities, specifically relating to the care of older people receiving HC or RAC toward the end of their life . This raThis rapid review applied a streamlined systematic review method ,15. ScieThe full search strategies for each database are detailed in online only Criteria for inclusion weref developed—these are summarised in Two reviewers (SH and PT) independently assessed titles and abstracts against the priori inclusion criteria outlined in The full-text articles identified from the title and abstract screening were independently assessed by two reviewers (AC and PT), using the inclusion criteria before selecting for final data extraction and synthesis. Reference lists of the included studies were not examined to identify additional articles. A range of published literature were included, such as papers of experimental and quasi-experimental primary studies, review papers, program evaluation reports, expert commentaries, and surveys.Studies were excluded if they lacked discussion of the role of the pharmacist, had no specific focus on older people, or were describing care in an acute hospital care setting (including discharge planning).A data extraction tool was developed using Microsoft Excel and tested with three randomly selected articles. Two researchers (PT and AC) extracted the following data: (1) study characteristics, (2) summary description, and (3) Data Elements. Study characteristics pertained to author, study year, study design, study setting, country, and level of evidence. The assessment of “level of evidence” employed an adaptation of the Johns Hopkins Model of Evidence-Based Practice . The levSynthesis of data was conducted in sequential steps utilizing a systematic text condensation technique .Two researchers (AC and PT) independently read each of the full text papers to establish a preliminary list of Themes. The researchers then reviewed each of the included papers, line by line, to identify Data Elements. A Data Element was defined as a text fragment that described a certain idea . Common Data Elements were combined into a single Meaning Unit . Domains emerged out of the Data Elements through linking similar Meaning Units into groups . Domains were then mapped into relevant Themes.Assignment of Data Elements into Meaning Units and Domains were performed independently by two researchers and the results were combined with consensus. An overview analysis of the coded Data Elements by individual researchers (AC and PT) determined that a high degree of inter- and intra-group thematic homogeneity existed, suggesting that the data could be combined with minimal bias.Further characteristics of included papers are provided in Among the included papers, the levels of evidence varied . Seven p(1)Type of care delivery;(2)Work context of the pharmacist; and(3)Supportive professional and personal characteristics as soft skills.In total, 196 Data Elements were identified from the 14 selected papers see . These wThe selected articles examined various pharmacist-led services for older people with palliative care needs. These included clinical review, supply of medicines, and contribution to clinical governance.Clinical reviewThe bulk of the 14 papers discussed the pharmacist’s involvement in direct person-centred care involving a one-on-one clinical review. While this often involved the older person, some papers discussed inclusion of their carer ,27,29. TA number of key barriers to providing pharmacist-led clinical reviews were identified including: inadequate remuneration ; involveSupply of medicinesResponsibilities relating to supply of medicines featured in a few of the included papers, with references to people in receipt of HC and RAC services. This Theme comprised activities related to ordering and stocking of medicines ; dispensClinical governancePharmacist roles also involved indirect care through broader engagement at the organisational level ,31,32,33Ten of the papers described pharmacists working in a range of work settings, including Community Pharmacy, Residential Aged Care Homes (RACH), and General Medical Practice ,31,32,33Community PharmacyReal time liaison with GPs as part of case conferencing ;Clarification of information relating to the prescription, including changes to the packing of dose administration aids ; andAnticipating which subcutaneous medicines to stock that are useful in managing symptoms expected in the last days of life .Aside from their dispensing role, pharmacists working in community pharmacy also provide direct medication management support for those receiving HC services through informal connections with local GPs. Barriers to care are related to community pharmacies being geographically isolated from prescribers. Selected papers illustrated activities that maintain the pharmacist’s connection with the local healthcare teams, including:These connections were led by the person’s acute needs and were often driven at an individual clinician level.Residential Aged Care HomesMany papers described the pharmacist’s clinical role or function of supply of medicines to the organization within a context of a formal arrangement or contract between the organisation providing RAC services and the individual pharmacist or pharmacy. As such, the role of the pharmacist within a multidisciplinary team was largely process driven, providing consistent care across the organisation, impacting on all people living in the organization. The clinical role of the pharmacist in this setting—such as the “medication review”—is performed in consultation with onsite nurses and GPs. In one paper, this role extended to communication and handover of medicines information at critical transitions of care such as admission to the RACH .General Medical PracticeOne study described how pharmacists working in a general medical practice setting improved timeliness and quality in how medication reviews were conducted . EmployiFour ,27,28,32Soft skills in supporting person-centered careAdvocating with prescribers  to change medicines or doses and/or deprescribe medicines that maybe are unnecessary ; andFollowing-up with people after a home visit to monitor how changes to medicines are going and answer any medication-related questions .Pharmacists advocate for and follow up on behalf of the people they provide services for (as well as their carers), ensuring better clinical outcomes. Examples of these skills include:Soft skills in working with clinician prescribersWriting medication review recommendations as a “medication management plan” to make it more acceptable and relevant for GPs to provide feedback ;Supporting and maintaining trusting relationships with a multidisciplinary team of practitioners ;Demonstrating a positive and helpful attitude to medication prescribers and other clinicians ;Communicating with medication prescribers in a clear and honest manner ; andFollowing-up with medication prescribers if no response to medication reviews outcome reports are received .Key skills of the community pharmacist workforce that enable building effective working relationships with a range of clinicians included creative communication and people skills. Examples of these skills are: This rapid review has identified several matters relating to the roles and responsibilities of the pharmacist workforce supporting older people living in a community setting with palliative care needs. Despite diversity in the health care systems across the USA, Canada, UK, and Australia from where the studies were generated, similar themes across the literature were observed.Reviewed papers predominantly focused on care provided by the pharmacist for people receiving RAC services; only a few examined the role of pharmacists with older people receiving HC services. This may be explained by the complex health and social care needs of people receiving RAC services. Services established for delivery of RAC are also likely to have more formal systems and processes in place as a result of contractual arrangements, making this aspect of care easier to review and assess. In contrast, HC service provision is less visible due to informal processes and relationships between individuals.The findings observed in this rapid review suggest that a pharmacist’s role (in developed countries) continues to evolve beyond their traditional medication dispensing responsibilities, with pharmacists stepping away from the dispensary and gaining larger significance in RAC services and General Medical Practices. A focus on the clinical role of pharmacists when working with older people in the community—including guidance on deprescribing, monitoring of medicines use, and detecting adverse drug events—is particularly important considering the growing prevalence of age-related multimorbidity resulting in polypharmacy and the increasing number of older populations receiving RAC and HC services.In Australia, existing government-funded programs support pharmacists conducting clinical reviews, including: MedsChecks, home medicines reviews (HMRs), and residential medication management reviews (RMMRs) . Such prThis review also identified organizational wide benefits of involving pharmacists from involvement on MACs to the conducting of audits or guideline reviews. While articles discussing this broader role for pharmacists were limited to organisations providing RAC services, NGOs such as those providing HC services could learn from the RAC experience, particularly in light of the Royal Commission into Aged Care . The RoyThe pharmacist’s role within the multidisciplinary team—supporting the care of older people—has been established: contributing to the improvement in health outcomes by working with others to provide medication management in older people who take multiple medications within a context of complex health care needs ,43,44. RHealth care services provided to older Australians are delivered by multiple providers across primary, secondary, and tertiary health care services. These services are often fragmented, with poor information sharing at points of transition. In addition, polypharmacy is inherent in the older population, making them more vulnerable to several risks, including adverse drug reactions and drug interactions. As such, pharmacists have a significant opportunity to contribute to and ensure appropriate and timely provision of medication and ensure that medication advice is available for all older Australians . There aThis rapid review was a resource constraint and time bound analysis. We applied a search strategy involving only three databases, focusing on indexed English language literature. Due to the streamlined search approach, relevant papers indexed in other databases and non-English literature would have been missed. The search approach adopted in this rapid review, however, is in line with existing rapid reviews that reported to have searched a minimum of two databases to retrieve literature and synthesise data .The rapid review only located papers of level III and level V evidence. There were no papers graded at Level I, suggesting that scientifically strong papers in this area may be lacking. The lack of papers classified into the Level I category may also have been due to our specific research question and search strategies. The review question applied in this study sought a snapshot of the evidence exploring pharmacist’s role in supporting the older population with palliative care needs. Therefore, intervention studies assessing the effectiveness of the roles of community pharmacists within the context of multidisciplinary palliative care may have been missed due to our streamlined research question and search strategies.Further, this review resulted into relevant papers being sourced predominantly from developed countries, including the USA, Canada, UK, and Australia. As such, the health care settings in developing and less developed countries may not reflect the same health system structure and practices. In other countries, the community pharmacist role may not be as well established and they may not have the same roles and responsibilities identified in this review. Hence, the results generated from this review may not be generalisable in developing and less developed health care settings.The roles and responsibilities of community pharmacists continue to evolve. The multifaceted role of pharmacists presents an opportunity to provide comprehensive medicines management for the older population at the end of their life. There is scope within the current health care system to increase organisational support for pharmacists working with older populations in aged care organisations delivering RAC or HC services. This is likely to facilitate better management of medication and improved care on discharge from the acute sector for older people with palliative care needs. Further studies should aim to build the level of evidence relating to the effectiveness of pharmacist roles in supporting people living with palliative care needs in the community.


Mental ill-health is a leading cause of disease burden worldwide. While women suffer from greater levels of mental health disorders, it remains unclear whether this gender gap differs systematically across regions and/or countries, or across the different dimensions of mental health. We analysed 2018 data from 566,829 adolescents across 73 countries for 4 mental health outcomes: psychological distress, life satisfaction, eudaemonia, and hedonia. We examine average gender differences and distributions for each of these outcomes as well as country-level associations between each outcome and purported determinants at the country level: wealth (GDP per capita), inequality (Gini index), and societal indicators of gender inequality . We report four main results: 1) The gender gap in mental health in adolescence is largely ubiquitous cross-culturally, with girls having worse average mental health; 2) There is considerable cross-national heterogeneity in the size of the gender gap, with the direction reversed in a minority of countries; 3) Higher GDP per capita is associated with worse average mental health and a larger gender gap across all mental health outcomes; and 4) more gender equal countries have larger gender gaps across all mental health outcomes. Taken together, our findings suggest that while the gender gap appears largely ubiquitous, its size differs considerably by region, country, and dimension of mental health. Findings point to the hitherto unrealised complex nature of gender disparities in mental health and possible incongruence between expectations and reality in high gender equal countries. •Girls have worse average mental health than boys across 4 measures of mental health.•There is large heterogeneity in the size of the mental health gender gap across countries.•The gap is most pronounced for psychological distress and life satisfaction.•More gender equal countries have larger gender gaps in mental health. Mental ill-health is a leading cause of disease burden globally , and in Adolescence is a formative time of changing identity  and is cDespite evidence documenting a gender difference in adolescent mental health, it remains poorly understood. First, existing evidence is largely from a small number of high-income Western countries  and cautCross-national comparisons can also identify factors at the country-level which are associated with mental health. Particularly, economic factors and gender equality may play a role. Poverty is considered an established risk factor for worse mental health . HoweverExisting research on the association between gender equality and mental health largely yields inconsistent findings with studies demonstrating no association , strongeUsing a large cross-national dataset from 73 countries and economies and spanning a range of income groups, we aimed to 1) describe the gender gap across different measures of mental health  in terms of both average and distributional differences, and 2) investigate the correlations of macro-level economic and gender equality indicators with wellbeing in boys and girls to better understand the gender mental health gap in adolescents. Consistent with previous literature we hypothesise that girls will have worse average mental health than boys across all outcomes. However, given the inconsistency of relationships between mental health and country level indicators we ask two further research questions: 1) what is the relationship between the economic indicators - GDP and income inequality - and mental health in each gender and the gender gap? 2) What is the relationship between gender equality and mental health in each gender and the gender gap?We used data from the 2018 Programme for International Student Assessment (PISA) . PISA ishttps://www.who.int/choice/demography/euro_region/en/). The countries sampled cover a number of regions: North and South America; Europe; Eastern Mediterranean; South East Asia; and the Western Pacific Region. Unfortunately, PISA does not collect data on mental health from any African countries apart from Morocco, so we were unable to include this region in our analysis. Morocco is grouped under Eastern Mediterranean according to WHO regional groupings.In total 73 countries and participating economies were included, containing 566,829 students (49.8% girls and 50.2% boys), representing around 28 million students. Countries excluded were Singapore; Norway; New Zealand; and Israel as they did not collect the mental health measures. Subsamples that were not nationally representative were dropped, such as China. In order to investigate regional patterns, countries were grouped by region according to the World Health Organisation’s groupings  per capita and income inequality (Gini) were taken from the World Bank dataset. GDP per capita is the total economic output of a country divided by its population and is an estimate of prosperity. The Gini index is a measure of how unequal the income distribution is and ranges from 0, representing perfect equality, to 100 representing perfect inequality.http://hdr.undp.org/sites/default/files/hdr2019_technical_notes.pdf). In contrast, the GGGI aims to separate gender equality from the country’s level of development by rewarding or penalizing countries based on the size of the gender gap in a particular resource regardless of the overall level of said resource  and the newly created Gender Social Norms Index (GSNI) derived from the World Values Survey, both produced by the UNDP; and the Global Gender Gap Index (GGGI), produced by the World Economic Forum. Whilst all three use the same themes of education, health, political and economic participation they use different indicators to make these up  and plotted the relationships between the average score for each gender by country against the 5 country-level indicators: GDP per capita, Gini, GII, GSNI, GGGI. We use multi-level linear regression in order to estimate the between country variation in different mental health outcomes and to formally statistically investigate the associations between each of our four mental health outcomes, gender and country-level factors – GDP per capita, Gini and GGGI. We use a single indicator of gender equality to avoid multicollinearity with other equality measures . Random As additional and sensitivity analyses, we plot quadratic country-level associations to test for non-linear associations. Secondly, to check that models are robust to the inclusion of different measures of gender equality we ran the models using the GSNI instead of the GGGI. Thirdly, we investigated if ecological findings were robust to adjustment for individual level controls - socioeconomic background, age and immigration status. Socioeconomic status was controlled for using the PISA derived economic social and cultural status (ESCS) index that is a composite measure of parental education, highest parental occupation and home possessions. Fourthly, to test if findings are robust to the removal of country outliers, we calculate cook’s distance of countries for single-level models, with countries as data points and GGGI, GDP per capita, and Gini as independent variables, and the outcome variable as the average gender gap in each mental health outcome. The 3 countries with the highest cook’s distance are removed from the final models as a robustness check.On average, girls have worse mental health across all indicators . Life sa2 > 95% for all outcomes, p <0.001 , hedonia  and eudaemonia  and higher psychological distress  for both boys and girls  model C.Higher income inequality was associated with slightly lower life satisfaction for boys and slightly higher life satisfaction for girls and thus a slightly smaller gender gap in more unequal countries : a2. HigMore gender equality was associated with a larger gender gap across all mental health outcomes ; Table 2Firstly, results were similar when analyses are controlled for age, socioeconomic status, and immigration status at the individual level (S5-8). Secondly, the interactions between gender and gender equality are robust to the use of the GSNI instead of the GGGI . ThirdlyAcross four mental health outcomes - life satisfaction, psychological distress, hedonia, and eudaemonia - we find that girls typically had worse mental health than boys. Whilst there is considerable cross-cultural variation in the size of this average difference, it appears largely ubiquitous in this global sample - particularly for life satisfaction and psychological distress. Perhaps counterintuitively, richer European countries including the Scandinavian nations, such as Sweden and Finland, have some of the largest gender gaps in mental health. By contrast, countries with worse society gender equality scores – such as Jordan, Saudi Arabia, and Lebanon - have some of the smallest gender gaps and the direction of the gap is sometimes reversed . The outcomes vary in their distributions and where in the distribution the gender gap appears, indicating that mean differences are driven by different parts of the mental health distribution for the different outcomes. This highlights the importance of considering the underlying distributions of any mean differences observed. An identical mean difference may be driven by different parts of the population distribution, and this may have public health consequences. For example, we found that girls were less likely than boys to report the highest life satisfaction score, rather than having particularly higher counts in the lower part of the life satisfaction distribution. Previous research typically only focuses on mean differences – future research to understand cross-national differences in mental health may benefit from such analyses.Higher GDP per capita was associated with a larger gender gap, albeit the magnitude of effect was small. This contrasts with other findings where a positive relationship between GDP and adolescent wellbeing has been found , and thiMore gender equal countries had larger gender gaps across all outcomes examined, consistent with previous literature in adults . While tOur results present a complex picture for the relationship between gender equality and the adolescent gender mental health gap. While the feminist movement is itself old, extensive judicial and social change towards gender equality is a fairly recent development, with the UN Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) only being instituted in 1981.Graham and Pettinato  coined tIn more gender equal countries girls and women are now faced with a double burden of balancing both increased economic and political participation as well as the traditional female responsibilities and norms. While in more gender equal countries women have entered traditionally male dominated areas of employment, men have not entered female dominated areas of employment to the same extent, nor do they do equal amounts of domestic work . In counAdolescence and puberty marks a particular period of changing identity  includinFuture research should examine some of the theories we have highlighted above to better understand the individual level mechanisms. For example, to examine whether girls who attempt to satisfy multiple gender norms, such as being - femininely attractive, high achieving, and ‘one of the boys’ - have worse mental health. Additionally, examination of other country-level indicators may yield further results to help explain country-level differences in the gender gap, such as, availability and access to mental health support , levels Firstly, our study relies exclusively on cross-sectional cross-country correlations; thus, we cannot make any strong conclusions regarding the causal pathways involved. However, cross-country comparisons are necessary to elucidate risk factors that operate at the population level , such asOur findings demonstrate that overall girls have worse mental health than boys, but the direction and size of the gender gap and distribution varies across a range of mental health outcomes and a large sample of countries. Wealthier and more gender-equal countries, contrary to expectation, have larger mental health gender gaps. For life satisfaction and psychological distress, this was driven by negative associations in females but positive associations in males. Findings point to the complex nature of gender disparities in mental health and possible incongruence between expectations and reality in more gender equal countries.All individual level data used in the research article is secondary data and publicly available. The mental health data is collected by the OECD's Programme for International Student Assessment (PISA). All data is anonymised by PISA. Due to the secondary nature of the data ethical clearance was not required to be sought from University College London.The authors declare no competing interests or have any financial declarations to make.Olympia L K Campbell: Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, VisualizationPraveetha Patalay: Conceptualization, Writing - Review & Editing, Formal analysis, SupervisionDavid Bann: Conceptualization, Writing - Review & Editing, SupervisionThere are no financial relationships between any of the authors and other organisations that may bias or influence the conclusions of this work.The authors have no affiliations or involvement with any organisations or individuals that may bias or influence the conclusions of this work. Olympia L K Campbell thanks the ESRC-BBSRC Soc-B Centre for Doctoral Training and the ERC (Grant: EvoBias 834597) for funding her PhD.