This paper describes the development and feasibility of the Community Based Research Infrastructure to Better Science (CRIBS) training. The goal of this training program was to help new or existing community-academic teams to build strong partnerships and successfully develop together fundable research projects focused on breast cancer environmental causes and disparities. A comprehensive mixed-methods participatory approach was utilized to assess the training. Twenty-two community-academic teams applied for the training program; twelve teams were enrolled. All teams completed the training and subsequently submitted research applications for funding. All components of the training received high ratings and positive qualitative comments. Self-rated competency in all of the learning domains increased during the training. Four (33%) of teams were successful in their first attempt to garner research funding, and six (50%) were eventually successful. The evaluation of CRIBS found it to have successfully achieved all four goals of the training: (1) Twelve new CBPR (community-based participatory research) teams, (2) improved knowledge about CBPR and science, (3) twelve submitted grant proposals in the first year, and (4) six (50%) successfully funded research projects. Community-based participatory research (CBPR) pairs academically-trained scientific researchers with community members to partner in all steps of the research process . The benThe California Breast Cancer Research Program (CBCRP) of the University of California is the largest state-funded breast cancer research funder in the nation. In 2001 a comprehensive review of its and other agencies’ funded portfolios revealed a lack of investigator-initiated research focused on the role of the environment and breast cancer disparities, both areas of programmatic and community interest . To redrIn 2010, CBCRP partnered with Commonweal (a nonprofit community-based organization) and Plumbline Coaching and Consulting (a community-based training firm), henceforward the training team, to develop and pilot-test an intensive training program—Community-based Research Infrastructure to Better Science (CRIBS) to address the areas of difficulty identified in the previous studies. Commonweal is a nonprofit cancer retreat center and a convener of thought leaders for scientists and advocates to learn about and contribute to protecting human health and a healthy environment. Plumbline creates and conducts training programs in CBPR and public policy advocacy. The goal of the CRIBS training was to help new and existing community-academic teams build partnerships and develop fundable research projects focused on breast cancer environmental causes and disparities. Subsequent to completion of the training program, CBCRP anticipated the submission of a competitive CRC grant application from training program participants.The training team built a community-academic CBPR partnership, who met over twelve months to develop the outreach strategy and curriculum, select fellows, and conduct the training. Throughout the process, each party carried out specific tasks, and each party had equal decision-making authority. The training team took turns hosting meetings and, through collaboratively created agendas and meeting facilitation, recorded tasks each partner undertook to move the project forward. Team members presented their work at each meeting, allowing the training team to learn from each other and together develop the curriculum and individual sessions. Decisions were made by consensus. The project was reviewed and approved by the Institutional Review Board at the University of California, Berkeley.Candidates were recruited through eleven outreach workshops in areas across the state of California, at both community and academic venues. To choose workshop locations, the training team took a map of California and with shared knowledge of roads and mountains, determined eleven locations that the majority of Californians could reach. In total, 272 people attended these outreach workshops. In addition, the training team engaged in extensive electronic outreach to academically-trained researchers and a wide variety of breast cancer, environmental and women’s health organizations. Teams consisting of at least one academic partner and one community partner were eligible to apply. Applicants were self-identified pairs of one academic and one community partner who were in a new or existing partnership, interested in using CBPR to explore breast cancer disparities or environmental contributors to breast cancer. Teams were required to identify partners on their own and to apply as a team, but were not required to have experience working together. Some had met at the outreach meetings described above. Each team submitted a joint application that included their individual and joint community and research experience, and their initial research goals. Twenty-two community-academic teams from throughout the state of California submitted applications; applications were reviewed by all members of the training team using defined criteria and a standard review form, followed by a review meeting, during which the training team reached consensus on the acceptance of 12 teams, comprising 33 individuals (19 community partners and 14 academic partners). Of the 32 participants providing demographic data, ten (56%) of the community partners and seven (50%) of the academic partners were ethnic minorities. The mean age for both the community partners and the academic partners was 50.Academic partners who had not previously obtained an independent investigator grant  or equivalent) were considered for the training if they could demonstrate that a mentor would work with them to ensure they had the necessary support of a successful grant writer. Seven (58%) of the teams included academic partners who required and obtained a mentor.The training team first conducted an assessment of previously developed CBPR training materials, written information, and peer-reviewed literature. Twenty-five trainings, in addition to numerous other collaboration documents, were identified through web-based searches and a request for curricula sent to the Community Campus Partnerships for Health (CCPH) listserv. A copy of the annotated CBPR training curricula reviewed is available from the authors.Taking into consideration the design elements of the reviewed CBPR training programs, the CRIBS training team sought to fill a significant gap. Namely, the team developed a CBPR training program where community-academic teams could receive a significant amount of face-to-face, telephone, online, and webinar training and technical assistance. The training was designed so that teams would build skills and create a CBPR project described in a competitive grant proposal in the area of disparities in breast cancer and/or environmental causes of breast cancer.Further, given prior research findings that lack of scientific knowledge can limit community members’ ability to act as full partners, the training was structured to include education on scientific content around breast cancer, disparities, and the environment . The traIndividual motivation and personal goals to help the partners learn about each other and find purpose and goals for the partnership;Ability to work well with each other including understanding the differences and similarities of academic and community-based institutional pressures;Creating institutionalization and sustainability of CBPR within academic and community institutions;Dealing with conflict, while maintaining a strong relationship;Creating partnership agreements and team evaluation methods and timeline;Expanding the team to include additional team members;Establishing team agreements, including decision making and how to handle conflict;Dissemination to both community and academic audiences.Several theoretical and conceptual models for strengthening the characteristics of CBPR partnerships helped inform the curriculum ,10,11,12The training team determined that information and training related to the environment and disparities in breast cancer should be included in CRIBS for both the academic and community partners. This included neighborhood and social factors, such as racism and its associated stress, the physical and chemical exposures where people live, work, and play, as well as the lifetime exposure to chemicals and windows of susceptibility, and the ways these factors can be addressed to reduce incidence and mortality of breast cancer.In order for a research idea to move progressively from vision to detailed project stage, a number of factors must be addressed, including developing specific aims and detailed methodology. To ensure that both academic and community partners could fully participate in developing the research plan, training was included on scientific methods, how to conduct literature reviews, statistical concepts, scientific certainty, and understanding how to break up bigger research questions into more feasible research project questions.Writing research proposals that will go through a rigorous scientific peer-review is generally unfamiliar to most community groups. Understanding the key research grant proposal sections, how to prepare an equitable CBPR budget, and how the grant review process is conducted was shared to provide CBPR teams with mutual knowledge of their path forward.The structure of this training was based on best practices of the adult learning literature: Highly interactive, drawing on high personal motivation, and accounting for different learning styles. There were three primary formats of training provided: Face-to-face, online and telephone-based. (1) Face-to-Face (FTF): Five two-day FTF trainings were delivered in months 1–5 with sessions that corresponded to the four stated objectives of the program.The FTF sessions were each two days long and held in a consistent California location (CRIBS covering hotel and travel expenses). These allowed for ample time for training sessions and team work sessions, as well as team and cohort downtime to continue relationship building. Sessions conducted by academic and community trainers covered CBPR and partnership building, health disparities in and environmental causes of breast cancer, the research process and grant writing, as well as dissemination techniques.(2) Online Training (OLT): Ten OLT sessions.Ten OLT sessions and three webinars were delivered in months one through ten. Specifically, OLT sessions using a University-based online teaching platform and online webinars took place in between and after the FTF trainings. The online format encouraged active participation over the 12-month training period.(3) Telephone-based: Three technical assistance (TA) telephone calls of 50 min for each CRIBS team were delivered to support the team’s integration of knowledge of CBPR, health disparities, the environment, and the research process.Trainers provided written and verbal feedback on 8-page concept papers written by participants. An in-person “mock” grant review was held in which draft CRC proposals from each team were reviewed by former CRC reviewers with fellow teams present and observing.An outside evaluator developed a mixed-methods evaluation framework utilizing a participatory evaluation approach. Activities included an online demographics questionnaire; online pre-training and post-training self-rating of research and partnership competencies; online anonymous satisfaction and feedback evaluations after each FTF training and throughout the TA period; and a follow-up survey after submission of the final CRC grant proposal, but prior to the announcement of funding results. Response rates across online surveys were between 91% and 100%.The 80-item demographic questionnaire was comprehensive and included skip patterns to reduce participant burden. Participants responded to questions on areas such as ethnicity, age, gender, sexuality, income, and education. Several content areas included additional questions, such as nationality and immigration, neighborhood characteristics and resources, number and type of people in the household and contributing to income.n = 31 providing data at both time points) a Wilcoxon signed-rank test was used to analyze the data, examining the change in each participant’s competency from prior to the training to after the training. STATA 13  was used to conduct statistical analyses; significance was assessed at p < 0.05.Each assessment consisted of 62 questions examining current competence in six learning domains . Competency was self-reported on a scale from 1 (lowest) to 5 (highest). Mean values and standard deviations were computed for each of the learning domains in both pre-training and post-training competency. Due to the small sample size  to 5 (excellent) participants rated the quality of each session and associated faculty. Participants rated whether they had learned the primary objective of each session by using a scale of 1 (strongly disagree) to 5 (strongly agree). Several open-ended questions were included for participants to provide more detailed feedback. Unique identifiers were used to make sure that duplicate responses could be identified. Identifiers were a combination of participant’s birth month, birth year and first name of participant’s mother. Mean values and ranges of scores were computed for each of the quantitative questions in Microsoft Excel, and no statistical comparisons were made across ratings of sessions or presenters.A follow-up questionnaire was completed in 2013 between the spring submission of applications and summer notification of funding results. Participants answered questions on aspects of designing, preparing and submitting their Community Research Collaboration applications, and plans to submit additional applications. Response options ranged from 1 to 5 for quantitative questions, and question anchors depended on question content . Several open-ended questions allowed participants to provide feedback on how they might have improved their team process.Qualitative telephone interviews were conducted to collect additional satisfaction and feedback data. In this paper we have focused on reporting results from quantitative and qualitative data collected via online questionnaires and surveys. Presentation of the full set of telephone interview results is beyond the scope of this paper.The evaluation results are arranged into five areas: Demographics of CRIBS participants, the training’s feasibility, acceptability, and impact , and sustainability.The CRIBS cohort included 49% ethnic minority participants, the mean age of the group was 51 years, and a majority of the cohort was women. Forty percent of participants had earned a bachelor’s or master’s degree, and 37% had completed a PhD. More than half of the cohort was community partners. See Participation in this time-intensive training was high. Of the 33 participants providing data, 21 (64%) participants attended all ten FTF training days and the mock review. Of the twelve (36%) who missed any part of the 10 days or mock review, six (18%) missed no more than 2 days and one (3%) person missed five days, due to a family death. One (3%) person formally withdrew from the training program and one (3%) additional person discontinued their participation during the training program without formally withdrawing.OLT participation was more uneven. For ten OLT sessions , participants were asked to post at least once for each segment and respond to at least seven other posts at some point during the program, for a total expected post/response rate of 19. The average post/response rate was 21.4, median 20, but ranged from 8 to 49.Evaluation participation was strong. The online surveys were completed by a majority of participants, with 32 (97%) responding to the demographic questionnaire, 31 (94%) completing the pre-post questionnaires, between 27 (82%) to 31 (94%) completing five satisfaction and feedback surveys and 28 (85%) completing the follow-up survey.Participants rated all aspects of CRIBS highly see . In all The main findings from open-ended comments related to each of the training components revealed:Participants felt that the curriculum (presentations and activities) was exemplary;Teams benefited greatly from the partnership building activities;The environment supported co-learning among participants and between participants and trainers/speakers;Participants appreciated receiving detailed feedback from the Mock Review;The opportunity to observe the Mock Review benefited participants.Benefits of OLT included access to valuable resources, learning opportunities, and interaction with other participants;Challenges of OLT included time constraints and the difficulty some participants had engaging in the online environment because they did not feel stimulated, did not feel they had much to contribute, and/or were not comfortable communicating with others in an online forum;Webinars were positively received although technical problems with one webinar compromised its quality.Mentoring and feedback were very helpful to the teams;Some teams were frustrated and/or confused when they received conflicting feedback from the CRIBS trainers and mock reviewers;The TA, particularly the mock review debrief, helped validate feelings and concerns;The TA was helpful in answering team’s specific questions.Comparisons of pre-training and post-training self-rated competencies indicate that CRIBS participants improved their competency in all six learning domains . Out of When stratifying by type of partner (community or academic), the three greatest improvements for community partners were for CBPR (78.8% improvement), breast cancer science (64.5%) and partnership knowledge and skills (44.28%). Community Partners also showed significant improvements in scientific research (22.36%), funding (29.62%), and disseminating results (25.9%). For academic partners, due to the high self-rated competencies in the pre-training assessment, significant improvements were found in only two areas: Breast cancer science (25.14%) and disseminating results (9.7%).CRIBS participants overwhelmingly felt the training strengthened their knowledge and understanding of breast cancer science and CBPR, their grantsmanship skills, and their partnerships. Of particular note, among the 28 participants providing follow-up survey responses, both community and academic partners reported that their research plans included a strong focus on collaborative analysis. On a scale of 1 (Low) to 5 (High), both community participants and academic participants reported strong agreement that their research plan provides community partners with significant opportunities to participate in the planning and executing of data collection , the planning and/or executing analysis , and the plan involves the community partners in interpreting the research findings .When articulating their role in each stage of the preparation and submission process for their CRC application, community and academic participants indicated equity and power-sharing in their responses. Both community and academic participants noted that were very involved in defining the problem on which to focus , developing their research question(s) and specific aims , developing their collaborative agreements , developing their budget , developing their research plan (4.59 community and 5.00 academic), and submitting their application .Participants shared many positive comments about the training program, partnership building opportunities, and their ability to learn from each other. During the 12-month training period, ten (83%) teams stayed together and two (17%) teams reconfigured . The two teams that chose on their own not to continue working together were supported by the training team in identifying new partners who were brought into the training and provided access to previous session materials, videos and webcasts.Following the 12-month training period, the academic partner in one team secured a new position, and the team was able to engage in a real-world test of managing the impact of turnover, (an area of difficulty reported by CRC teams in the past). The team openly communicated about the change among themselves and with CRIBS staff and engaged in a collaborative process of identifying a potential new partner, discussing the collaborative fit and ultimately forming a team with a senior colleague of the original academic partner. The team has maintained their partnership for seven years and has been funded a total of four times by CBCRP.All twelve CRIBS teams submitted pilot applications to CBCRP that were competitively peer-reviewed together with applications from non-CRIBS applicants through their usual review process . The revOf the 12 applications from CRIBS fellows, four (33%) were successful in their first attempt to garner research funding and six (50%) were eventually successful. More specifically, four of the twelve applications submitted in 2013 were funded; one additional application was funded via resubmission in 2014; and in 2019, one more team was funded. In total, six out of 12 CRIBS teams (50%) were funded through CBCRP as of 2019. Further, four of the five (80%) of CRC pilot grant applications funded in 2013 by CBCRP were from the CRIBS cohort.While formal data on sustainability were not part of the evaluation plan for the program, the training team tracked the number of teams completing the various components of the training, as well as the number of teams submitting applications between 2013 and 2019. Ten teams stayed together with original partners throughout the training program and mock review and two teams reconfigured . Of the six teams that were funded between 2013 and 2019, three have sustained their partnerships for at least four years, with two of these staying together for at least seven years. Of the two seven-year partnerships, one secured CBCRP funding an additional three times between 2014 and 2019 and the second team an additional two times. Of the six teams that were not funded between 2013 and 2019, four sustained their partnership for at least two years and submitted applications to CBCRP in 2014 (three teams) and 2016 (one team). We have no knowledge of any teams receiving funding from other agencies.The training team developed a deep respect for each other through this work and has continued to work together, obtaining NIH funding for adapting this training into a short course.Community-based participatory research (CBPR) is by definition a collaborative process. While the theory and practice of CBPR can be and often is taught to individuals, this does not allow for experiential learning, one of the most powerful adult learning methods available ,17,18,19The CRIBS Training introduces some unique and important elements. Due to the previously-documented knowledge gap between academic and community researchers in science, and the impact this gap can have on power dynamics, we also included knowledge in science and scientific methods. This was possible because all teams were working in a single disease area. An equalizing factor is that both academic and community researchers learned new areas of science, since the topics covered two very disparate areas . Team members heard the same information about scientific methods and breast cancer science, both learning new science and methodology, and were able to discuss and find alignment in their understanding of their research. In addition, as Fording also found, guiding teams to openly discuss each partner’s needs and expectations, as well as factors leading to differential power and authority and ways to address these imbalances, improved power dynamics .Another unique aspect to the training was the use of a personality inventory (Myers-Briggs Type) as a tool to help teams relate to each other as equal team members, each with strengths and challenges . This seAn interesting finding was the differential pre-training self-assessment of competencies between academic and community researchers. While it is not surprising that academics rated themselves highly on scientific research and breast cancer science, it is striking that they also rated themselves more highly on CBPR, partnership, funding and dissemination as these are factors that are critical to success in community work, as well as academic research. We found no other trainings that measured pre and post-test competencies except one and those self-assessments were not reported separately for academic and community researchers . The traAnother indicator of a successful training program is the 33% funding rate for first time grant proposals, and 50% overall funding rate. Both are high funding rates compared to CBCRP and many other funders, including National Cancer Institute, which reported success rates of 11.3–14.0 per cent in 2013–2018 .It was designed to increase the number of CBPR teams conducting research on two understudied areas of breast cancer—environmental causes of breast cancer and disparities in breast cancer;It trained both new and existing CBPR teams to build a collaborative CBPR partnership;It offered participants a mock grant application review, providing an insider perspective on the decision-making process seldom experienced by research grant applicants;It coordinated the timing of the training so that CBPR teams were fed directly into a relevant funding cycle.To the best of our knowledge, CRIBS remains unique in several ways:Training is effective: Intensive training in CBPR can successfully build new and strengthen existing partnerships, as well as increase the chance that teams will be successful in receiving research funding.Team training has benefits: There are considerable benefits to training the academic partner and community partner together. Time together in a learning environment allowed teams to build agreements on how to work, develop a common language around the issues they want to address and test their compatibility in skills and working styles before beginning a multi-year working relationship.Teaching science and partnership skills deepened the experience: Combining training in both science and building a CBPR partnership allowed teams to gain a more holistic and grounded approach to the entire spectrum of responsibilities associated with conducting CBPR.Mock reviews added value: The mock review provided a realistic perspective on the strengths and weaknesses of the teams’ proposal, as well as insight into the wide range of interpretation reviewers may have to a proposal. We know of no other trainings that provide such an opportunity for grant applicants to experience such a realistic perspective on their work.Having a funding source matters: Connecting training to an opportunity to apply to a specific funding source strengthened the training. Specifically, it allowed experiential training sessions to be focused on results . Additionally, it gave teams a goal and a deadline to work through their process.Overall, CRIBS was a successful model for building capacity for community-academic partnerships to conduct CBPR. While there are opportunities for improvement, the overall approach holds promise as a model for supporting more teams to successfully build CBPR partnerships and develop scientifically rigorous research projects that are meaningful to communities. Some of the key lessons that can be applied to future trainings include the following:Shorter training: Many participants felt the training was valuable, but possibly too time intensive.More interaction: Teams expressed a preference for more unstructured time with their partners to develop research ideas and build their partnership.Tailor sessions to the participants’ needs: All sessions were required for both academic and community partners. Future trainings could split the partners for some sessions.Discuss the challenge of conflicting feedback more extensively: Even though this was raised, teams were still frustrated by conflicting feedback. More emphasis on the inevitability of conflicting feedback and how to work with it could be helpful.Improve the quality of webinars: Use a better platform to ensure that trainers and participants can interact smoothly.Proactively intervene when teams are challenged: As mentioned, two teams were reconfigured between the beginning of the training and submission of the grant proposals. CRIBS trainers should intervene at the earliest signs of trouble for teams, to assist their working through issues or restructuring.Some of the areas for improvement learned from the CRIBS training include: Developing and implementing CRIBS provided a significant opportunity to build capacity in California for CBPR teams to conduct research on the environmental and health disparities links to breast cancer. The high success rate of CRIBS teams competing for research funding indicates that the extensive effort of the training paid off. The CRIBS model has already served as a template for a condensed program by the same training team. As future trainings are offered, new adaptations will be made with the goal of building a more robust pool of academics and community members in California who are capable and experienced in CBPR.


Over 90% of adults in the United States have at least one social media account, and lesbian, gay, and bisexual (LGB) persons are more socially active on social media than heterosexuals. Rates of depression among LGB persons are between 1.5- and 2-fold higher than those among their heterosexual counterparts. Social media allows users to connect, interact, and express ideas, emotions, feelings, and thoughts. Thus, social media use might represent both a protective and a risk factor for depression among LGB persons. Studying the nature of the relationship between social media use and depression among LGB individuals is a necessary step to inform public health interventions for this population.The objective of this systematic review was to synthesize and critique the evidence on social media use and depression among LGB populations.We conducted a literature search for quantitative and qualitative studies published between January 2003 and June 2017 using 3 electronic databases. Articles were included if they were peer-reviewed, were in English, assessed social media use either quantitatively or qualitatively, measured depression, and focused on LGB populations. A minimum of two authors independently extracted data from each study using an a priori developed abstraction form. We assessed appropriate reporting of studies using the Strengthening the Reporting of Observational Studies in Epidemiology and the Consolidated Criteria for Reporting Qualitative Research for quantitative and qualitative studies, respectively.We included 11 articles in the review; 9 studies were quantitative and cross-sectional and 2 were qualitative. Appropriate reporting of results varied greatly. Across quantitative studies, we found heterogeneity in how social media use was defined and measured. Cyberbullying was the most studied social media experience and was associated with depression and suicidality. Qualitative studies found that while social media provides a space to disclose minority experiences and share ways to cope and get support, constant surveillance of one’s social media profile can become a stressor, potentially leading to depression. In most studies, sexual minority participants were identified inconsistently.This review supports the need for research on the role of social media use on depression outcomes among LBG persons. Using social media may be both a protective and a risk factor for depression among LGB individuals. Support gained via social media may buffer the impact of geographic isolation and loneliness. Negative experiences such as cyberbullying and other patterns of use may be associated with depression. Future research would benefit from more consistent definitions of both social media use and study populations. Moreover, use of larger samples and accounting for patterns of use and individuals’ experiences on social media may help better understand the factors that impact LGB mental health disparities. Despite growing acceptance and civil rights gains in recent years, lesbian, gay, and bisexual (LGB) individuals in the United States still face stigma and disparities regarding mental health conditions . LGB perSocial media includes a variety of websites and mobile apps that enable users to create content and participate in online social networking  . It is eSocial media use encompasses a series of measures that capture the experience of using social media. Although no clear consensus exists regarding which specific measures should be counted as social media use, common ones include time , frequency  , number In a broader context, previous research has also investigated the linguistic attributes of social media use that indicate self-disclosure and mental health information sharing and that predict receipt of social support and other therapeutic outcomes on social media ,24. MoreSome of the complexities associated with social media use among LGB persons have been studied in relation with parenting and gender transition ,35. The Meyer’s minority stress theory is the predominant framework for understanding the protective and risk factors for depression and other mental health disparities among LGB individuals . There aThe ubiquity of social media has led researchers to suggest its use to provide people with mental illness the opportunity to challenge stigma, provide and receive peer-to-peer support, and access either Web-based or mobile interventions . To do tThis systematic review has been reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement guidelines  47,48].,48.47,48We included quantitative and qualitative studies published in peer-reviewed journals, in the English language, during or after 2003 . We allowed manuscripts from conference proceedings only when full-research papers were required for submission and each submission went through a complete peer-review process. Included studies had to focus on social media use and depression among LGB minorities. We defined social media use as any usage measurement . Depression comprised major depressive disorder, bipolar depression, dysthymia, depressive symptoms, and psychological distress. LGB minorities were defined as lesbian, gay, bisexual, and men who have sex with men. Exclusion criteria included theses or dissertations, opinion pieces or reviews, and articles that studied use of short message service text messages . Research in which the sole focus was on gender minority populations  were excluded to avoid conflating results of sexual minorities, which may not be applicable to gender minorities. However, studies in which gender minorities were a subpopulation included in the study LGB sample were included.Literature searches were developed and executed by a health sciences librarian (CBW) in PubMed or MEDLINE (1946-Present), PsycINFO, Ovid (1806-present), and SocINDEX, EBSCOhost (1895-present). Controlled vocabulary from Medical Subject Headings (MeSH), the Thesaurus of Psychological Index Terms, and SocINDEX Subject Terms, along with keywords and descriptors were used for the concepts of lesbian, gay, bisexual, transgender, queer, and interse (LGBTQI), social media, and depression. For all three concepts, we included MeSH and text words in title and abstract. For social media, descriptors included sexual network or partner; seeking sex on internet, online, on the Web, or on websites; finding partners on the internet, online, on the Web, or on websites; and sexual behavior on the internet, online, on the Web, or on websites. For depression, descriptors also included all related depression terms. The Boolean operator “AND” combined the three search components. Searches were limited to journal articles only, with no language or publication year restrictions. The entire list of keywords, descriptors, and search strings used in each database is available as a supplement . Search Screening and data extraction were completed using DistillerSR . StructuExtraction forms included seven categories of information: (1) study logistics ; (2) study population characteristics ; (3) social media use ; (4) health outcomes measured ; (5) main results and limitations; (6) main tenet of the minority stress theory under study ; and (7) appropriateness of reporting. To ensure accuracy, we implemented a quality-control mechanism in which one reviewer completed a first data extraction and the second reviewer validated or disagreed with it. Again, disagreements were resolved in consensus meetings with each pair and the first author.We assessed the appropriate reporting of the included studies. For quantitative studies, we used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement Checklist v4.0 ,52. The We identified 1259 records through our database searching process. After excluding duplicates, we reviewed 1099 unduplicated citations .Of these, 1035 were excluded after title and abstract screening. Of the 64 full-text manuscripts that were assessed for eligibility, 53 were excluded for different reasons: 8 lacked a focus on sexual minorities, 15 did not specifically assess social media use, and 30 did not have depression as part of the outcomes under study. Eleven research articles were, thus, included in the final sample. Reference lists of included articles were examined for additional studies. However, no new study that met the inclusion criteria was identified using this method.Of the 11 included studies, 8 (72%) consisted of cross-sectional surveys -61, 2 1. The socThe studies that captured the age of participants ,59-62,64Overall, the reporting of sexual minority participants varied across studies; 46% (5/11) of studies combined gay and lesbian identity ,58,60,61Finally, the appropriate reporting of results was variable. Among 9 quantitative studies, STROBE scores  ranged fOperationalizing of social media use measurement varied across studies, and these findings are summarized in a condensed Similarly, assessment of depression varied across quantitative studies. Depression was operationalized as depressive symptoms in 44.4% (4/9) ,59-61,64Exposure to cyberbullying on social media among LGB individuals was frequent, and the majority of those who experienced it reported feelings of depression  condens. CompareAssociation between using social media and depression differed depending on which characteristic or pattern of use was under study. One study found that lesbian or gay participants had higher rates of sexting behavior than their heterosexual peers; however, psychological distress was not different across three levels of sexting . AnotherQualitative explorations about social media use and mental health among sexual minorities indicated both risks and benefits. Maintaining a Facebook profile was deemed part of everyday life among lesbian and bisexual females . HoweverFinally, while most of the reviewed studies assessed only one component of Meyer’s theory, other studies focused on more than one. Of the included studies, 81.8% (9/11) focused on social media experiences as a source of stressors, such as victimization or cyberbullying ,61,62,64In this systematic review, we found a low number of peer-reviewed published research examining social media use and depression among LGB persons. We found ample variation in measurement of social media use and operationalization of these measures. Variability across studies was also found in the definition of sexual minorities as well as conflating sexual and gender minorities in the same study population. The implications of these findings and suggestions for future research are discussed below.Despite our comprehensive inclusion criteria and systematic online search approach , there were few studies that examined the relationship between social media use and depression among LGB individuals; 9 studies were cross-sectional and only 2 examined qualitative data. Appropriate reporting of results was variable across the included studies. For quantitative studies, most of the variability was due to incomplete reporting of study results, such as demographics, clinical and social characteristics of participants and reasons for nonparticipation, incomplete report of estimates, and nonreporting of ad-hoc analyses . On the other hand, most of the variation across the 2 qualitative studies was due to inadequate reporting of sample size, nonparticipant characteristics, sample description, development of interview guides, or data saturation.We found variation in the included studies’ approach to whether assess social media use on a platform-specific approach or for social media as a whole. While social media sites share commonalities, in many aspects they are also very different. For example, certain social media sites are more popular among certain groups than others . MoreoveA key finding from this review, adding to other research on the same topic ,66, is tThere was considerable variation in how social media use was operationalized and measured among the included studies, which speaks to the complexity of using social media. In some studies, use was operationalized in terms of frequency, the number of platforms used, and for how long the individuals used them. In other studies, use was measured in terms of characteristics, such as experiences with cyberbullying and use of social media to find camaraderie online. These findings are consistent with those of other systematic reviews linking social media use to mental health outcomes within the general population ,66. For The results of this review echo a body of research that found an elevated prevalence of depression and psychological distress among LGB individuals compared with that among their heterosexual counterparts -75. Our This review found a strong focus within the literature on environmental and societal stressors that, via social media, may impact depression outcomes among LGB persons. Much less emphasis has been put on understanding the role of online social support and proximal stress processes  in the association between social media use and depression in this group. In addition, it is not clear to what extent experiences lived in the offline world translate to the social media world for LGB persons. For example, while social support is an important protective factor for depression, the findings regarding online social support in the general population have been mixed, with one study reporting lower levels of protection against adverse mental health outcomes and anothImportantly, we found methodological concerns across the included studies regarding the definition of sexual minority individuals, as well as the conflation of results from men and women in the sample, making it difficult to interpret as to which group the said results would apply. We found a lack of clearly defined LGB samples in this area of research. Of the 11 included studies, 2 did not report participants’ sexual orientation. Among studies that reported sexual orientation, several grouped gay men and lesbian women into one group. This reduction limits the ability to understand how using social media may be associated with psychological distress and depression in each group separately. Upon further analysis, studies that included both sexual orientation and gender identity often conflated these two groups, making it hard to determine the differences in experiences of depression based on sexual orientation or gender identity. The collapsing of groups complicated our ability to understand the nuanced differences experienced by individuals based on sexual orientation and gender identity . These fNone of the studies included in this review had participants older than 30 years of age. While young adults are the group with highest levels of social media use, around 70% of adults aged 30-64 years and over 35% of those aged 65 years and above have at least one social media account [Internal and social stressors related to minority status are at the core of the minority stress theory . Given tThere is a growing concern about the impact of social media use on mental health outcomes. LGB individuals are a well-suited population to study the nature of the relationship between social media use and depression due to the disproportionately high prevalence of both in this group. This systematic review supports the need for research that addresses the role of using social media in the pathway of depression and other mental health outcomes among sexual minority populations. Our findings suggest that social media use may be both a protective and risk factor for these outcomes among LGB individuals. Connections and support gained via social media may buffer the impact of geographic isolation, discrimination, and loneliness that some LGB persons experience in their daily lives. However, the pressure of maintaining a desirable social media presence, negative experiences on social media such as cyberbullying, and certain patterns of use may associate with increased depressive symptoms in this population. Our findings also indicate the need for future research in this field to recruit larger samples, have more consistent definitions of the study populations, better define the social media use construct, and incorporate the social media experience into the conceptualization of psychosocial factors that impact sexual minorities’ mental health disparities.


We found that phylogenetic signals for four functional traits were low but significant, indicating that phylogenetic diversity may be used as a crude surrogate measure of functional diversity. Temporal changes in alpha and beta components of the three diversity differed among forest strata and four study sites over time. This study also revealed that the temporal changes of phylogenetic and functional diversity for understory strata in a forest, which were consecutively damaged by typhoon, were more extreme and larger than those of understory strata in the other sites. Therefore, our study supports recent studies that plant community structures differ among forest strata and such differences of community structure among sites can be accelerated by disturbance. Although the role and relative importance of niche-based deterministic and neutral processes for the patterns of successional community structure differed among the study sites, we found niche-based deterministic processes are the dominant drivers in structuring plant community assembly regardless of forest age and disturbance in this study. From these results, our study suggests that contemporary forest ecosystems are composed of mosaics of plant communities that are formed by interactions among various processes.Species-based approaches to the analysis of changes in successional community assemblages are limited in the ability to reflect long-term evolutionary and functional trait responses of organisms to environment change. Recent advances in concepts and analyses of community phylogenetics and functional traits have improved the interpretation and understanding of community assembly processes. Here, we examined phylogenetic signals of four functional traits such as maximum height, leaf size, seed mass and wood density in woody plant species and temporal changes in species, phylogenetic, and functional diversity among forest strata  at four forest long term ecological research sites in South Korea. A census of woody plant species was implemented in a 1-ha permanent plot of each study site every 5 years. We analyzed community structure and compositional turnover using twenty-five 20 × 20 m Globally, environmental changes, such as climate change and human impact, are increasingly and simultaneously affecting ecosystem function and biodiversity at local and regional scales  quantified species, phylogenetic, and functional alpha and beta diversity for whole, overstory and understory strata at four long-term ecological research sites; (2) tested phylogenetic signals in four functional traits to evaluate the extent to which the phylogenetic relatedness between woody species reflects functional similarity ; (3) assessed degrees of dispersion in phylogenetic relatedness and functional traits compared with species diversity to understand the roles and relative importance of deterministic and neutral processes in succession; (4) clarified temporal changes in diversity metrics among forest strata and study sites; and finally (5) identified processes that may drive temporal patterns in diversity. Before analyses, we assumed that natural disturbance  acts as an environmental filter and ecological niches are phylogenetically conserved in this study. With these assumptions, we expected that; (1) species diversity has different pattern from phylogenetic and functional diversity and thus species diversity alone cannot reflect spatial and temporal changes in community structure; (2) old growth forest reaching late succession  and undisturbed forest  would have higher functional and phylogenetic overdispersion; (3) forests  damaged by typhoon would have phylogenetic and functional clustering; (4) a forest , which were consecutively disturbed by typhoon, would have more extreme and larger temporal changes in phylogenetic and functional diversity than the other forests; (5) different patterns of phylogenetic and functional diversity would be exhibited among forest strata in all the sites; and finally (6) if measured functional traits in this study are not conserved or have little on community assembly, functional, and phylogenetic diversities would not be highly correlated.Carpinus and Quercus spp.  sites in South Korea that represented temperature deciduous broadleaved (Gwangneung), temperate coniferous-deciduous mixed (Mt. Gyebang), warm temperate coniferous-deciduous mixed (Mt. Geum), and warm temperate evergreen broadleaved  forests in South Korea . The sit2. All standing woody stems ≥2 cm diameter at breast height (DBH) were identified to species, tagged, mapped, and measured for DBH and height following a standardized protocol  permanent plot. The permanent plot was divided and marked into 100 quadrats measuring 10 × 10 mcol Lim, . We conv3) and obtained for the recorded woody plant species from published literature and open databases  in each quadrat. Beta species diversity was calculated by two methods such as turnover between-quadrats in a same census  and between-censuses in a same quadrat  using Bray-Curtis dissimilarity index. Phylogenetic and functional alpha community structure in a quadrat of each census was calculated using abundance-weighted net relatedness index (NRI)  and the standardized effect size (S.E.S.) of Dpw  and an increase in recruitment rate of conifer species such as Chamaecyparis obtusa may have contributed to the reduction of leaf size, seed mass and wood density over time (Chun et al., In contrast to other study sites, the patterns of the three diversity metrics at whole strata were similar over time in Mt. Geum. The alpha and beta components of three diversity metrics decreased through time at whole strata , 3. ThesAt Mt. Halla, we found species and phylogenetic alpha diversity decreased between the first and second censuses and increased between the second and third censuses at whole and understory strata, whereas there was no change in phylogenetic alpha diversity at overstory vegetation and functional alpha diversity at all forest strata, and turnover of species composition was not changed while turnover of phylogenetic relatedness and functional traits decreased when we compared the last census with the first census. These results indicate phylogenetic relatedness may not correlate with functional trait diversity and there may have different assembly processes between phylogenetic and functional diversity (Swenson et al., Traditional theory of community dynamics proposes that abiotic processes dominate in early successional stages, whereas biotic processes become more important at the later stages (Muscarella et al., Quercus serrata and Styrax japonica, have well-developed root systems with large amounts of fine roots and a deep main root to facilitate rapid water uptake following rainfall events (Laiju et al., Contrary to our expectation, at Gwangneung, there was functional and phylogenetic convergence during forest succession possibly as a result of selection pressure from environmental conditions. Indeed, gaps formed by the death of large and old-growth trees create contrasting light environments of open and closed microhabitat and thus similar types of environments are repeatedly formed (Lim et al., Although phylogenetic and functional divergences were recorded at Mt. Gyebang as our expectation and Mt. Geum contrary to our hypothesis, drivers of ecological processes appeared to differ. The relative importance of competitive exclusion may become greater than environmental filtering at Mt. Gyebang due to the high elevation  that mayIn contrast, at Mt. Geum, the accelerated phylogenetic and functional divergence seemed to be induced by disturbance from frequent natural events. Damage caused by multiple typhoons at Mt. Geum probably removed phylogenetically and functionally similar species and triggered the development of highly dissimilar communities over phylogenetic and functional trait space. Competitive exclusion of functional groups also accelerates overdispersion (Mayfield and Levine, Quercus acuta, Carpinus laxiflora, and Distylium racemosum that belong to the Hamamelidae, and Camellia japonica, Cleyera japonica, and Eurya japonica that belong to the Theales, are phylogenetically close. These woody species inhabit both types of microhabitat (Chun et al., Contrary to our expectation, phylogenetic convergence and functional divergence were recorded at Mt. Halla, where soils were interspersed with rocky outcrops that constitute two types of microhabitat (Chun et al., Our study of phylogenetic and functional diversity of forest woody plant species emphasized the complex and unpredictable interactions between community assemblage and structuring processes (Mayfield and Levine, However, despite of these strength and advantages of our studies, the present study has also limitations. First, this study investigated plant community structure and dynamics with few simply measurable traits like previous studies (Swenson et al., A species-based approach to the analysis of changes in successional community assemblage is limited in the ability to reflect long-term evolutionary and functional trait responses of organisms to environment change (Swenson et al., J-HC and C-BL generated the key ideas and analyzed the data. J-HC designed and initiated the study, contributed to integration, visualization, and interpretation of the results, and contributed to the manuscript. C-BL co-designed and initiated the study, collated the plot data used in the analysis, contributed to the integration and interpretation of the data, and led the writing of the final manuscript. The authors have approved the final version to be published and agree to be accountable for all aspects of the work, ensuring questions related to its accuracy and integrity are appropriately investigated and resolved.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.


The distributions of migratory species in the ocean span local, national and international jurisdictions. Across these ecologically interconnected regions, migratory marine species interact with anthropogenic stressors throughout their lives. Migratory connectivity, the geographical linking of individuals and populations throughout their migratory cycles, influences how spatial and temporal dynamics of stressors affect migratory animals and scale up to influence population abundance, distribution and species persistence. Population declines of many migratory marine species have led to calls for connectivity knowledge, especially insights from animal tracking studies, to be more systematically and synthetically incorporated into decision-making. Inclusion of migratory connectivity in the design of conservation and management measures is critical to ensure they are appropriate for the level of risk associated with various degrees of connectivity. Three mechanisms exist to incorporate migratory connectivity into international marine policy which guides conservation implementation: site-selection criteria, network design criteria and policy recommendations. Here, we review the concept of migratory connectivity and its use in international policy, and describe the Migratory Connectivity in the Ocean system, a migratory connectivity evidence-base for the ocean. We propose that without such collaboration focused on migratory connectivity, efforts to effectively conserve these critical species across jurisdictions will have limited effect. Howeve2.Scientifically, migratory movement is commonly defined as collective, cyclical movement between separated or well-defined locations or habitats, and tends to be expressed at population or species levels . These lWhile scientific definitions usually include some measure of separation, they are commonly not restricted by the need to cross geopolitical boundaries as is often the case with established policy definitions. For example, the Convention on Migratory Species  defines migratory species as ‘the entire population or any geographically separate part of the population of any species or lower taxon of wild animals, a significant proportion of whose members cyclically and predictably cross one or more national jurisdictional boundaries'. This definition shares two commonalities with scientific definitions by referring to collective and cyclical movements, however, it specifically requires the crossing of national boundaries. There are strong policy rationales for this requirement in the Convention's text. Primary principles of the CMS are that States are the protectors of the migratory species that live within or pass through their jurisdictions, and international cooperation of States is essential for the conservation of migratory species.Danaus plexippus). The CMS Conference of the Parties propose and approve appendix listings, and many species, clearly migratory by scientific definitions, are not included . To underpin an evidence-base on migratory connectivity, we developed a list of migratory megavertebrate species from multiple sources including Lascelles et al. ).(c)inter alia, ‘well-connected systems of protected areas'. The CMS has gone further in describing connectivity and migratory connectivity by adopting resolutions on ecological networks  and the importance of including migratory connectivity in conservation decisions (UNEP/CMS/Resolution 12.26). Resolution 12.7 recommends making connectivity between important areas explicit.4. Encourages Parties and other Range States, when identifying areas of importance to migratory terrestrial, avian and aquatic species, to take into account and make explicit by description, schematic maps or conceptual models the relationship between those areas and other areas which may be ecologically linked to them, in physical terms, for example as connecting corridors, or in other ecological terms, for example as breeding areas related to non-breeding areas, stopover sites, feeding and resting places (CMS 2017).Beyond site-selection and network criteria, intergovernmental organizations have also addressed the question of connectivity through decisions, resolutions and targets. For example, Aichi Biodiversity Target 11 calls for 10% of coastal and marine areas to be conserved through, in-situ’ efforts to conserve biodiversity  targeted joint analyses of animal movements and other factors using these databases in an integrated way across the marine and terrestrial realms so as to improve understanding of the biological basis of migratory species connectivity’ (UNEP/CMS/Resolution 12.26). Below, we consider in more depth what databases and information are currently available.5.(a)Products with spatial information on species distribution are currently available . The Global Register of Migratory Species (GROMS) summarized the state of knowledge on the distribution of migratory species globally ,63. GROM(b)The most readily accessible information for directly informing area-based management  rest in data repositories, e.g. the United States' Animal Telemetry Network, Australia's Integrated Marine Observing System Animal Tracking Database, BirdLife International's Seabird Tracking Database, OBIS-SEAMAP, the Ocean Tracking Network, Movebank or the satellite tracking and analysis tool of seaturtle.org . However, for most decision-making purposes, a substantial amount of work is required to make practical use of tracking data. Considerations including deployment location, sample size, location error and representativeness of life-history stages, sexes, populations and species need to be assessed and treated appropriately prior to use which requires analytical expertise and time . The nee(c)Taxa-specific and/or regional efforts to summarize information pertaining to migratory connectivity have been published (e.g. ), but ha6.www.mico.eco). The MiCO consortium designed the system to be a bridge between individuals/organizations generating data or products that describe migratory connectivity and policy fora or management organizations engaged in marine resource management, conservation, spatial planning and environmental assessment processes  provides additional value to both data/product contributors, and policy-makers and managers; (ii) complements the strengths of existing data repositories and research programmes globally; (iii) integrates information across data types, primary scientific literature, traditional knowledge and expert opinion; (iv) facilitates the delivery of those products to management organizations and policy processes in a transparent manner with explicit acknowledgement of contributors; and, (v) is easily accessible, freely available and updated on time-scales relevant to policy and management requirements. To ensure that the system provides value to both contributors and users, advisory panels were developed including: (i) strategic  and technical (frequent input on methods and implementation) advisory panels populated with leading researchers from academia, government agencies and data repositories and (ii) a policy advisory panel including staff from CMS (and its family of instruments), CBD, UNESCO, OBIS, IUCN, the Sargasso Sea Commission and NGOs.MiCO integrates information across data types by aggregating and synthesizing available information about migratory connectivity through a comprehensive literature review, aggregating existing data and synthetic products from contributors, and creating new synthetic products to serve policy processes. Six types of data can be used to derive products to help describe migratory connectivity: electronic tracking data, capture–mark–recapture, observations including visual surveys, data on stable isotope ratios, population genetics and passive acoustic monitoring. Each of the methodologies has unique characteristics, provides information at different spatial and temporal scales, and may be better suited for species with different traits. To serve as an evidence-base for available scientific information on the migratory connectivity of marine species, the systematic literature review reduces biases by: (i) the transparent development of a list of migratory megavertebrate species to be included ; (ii) vetting this list with species experts (many of the co-authors of this paper); (iii) creating and testing taxa-specific search strings for sensitivity in results returned; (iv) conducting the searches over a short period to avoid biases in literature availability; and (v) ensuring an exhaustive search by conducting searches on two separate large, multi-disciplinary indexing and citation databases (Web of Science and SCOPUS), as well as a separate manual searches on an un-indexed and highly relevant journal . While our search was systematic and exhaustive for English-language literature, broadening the evidence-base to include non-English sources is a future goal. The initial focus of MiCO analyses has been the development of products from this literature review and from electronic tracking data, provided either directly by data holders or through literature review, with the intent to add additional data types in the future to underpin network diagrams illustrating directionality and strength of connectivity among use areas.www.mico.eco/system) was developed to provide a basis for contributors and policy-makers to offer feedback on methods and usability. The system was launched in April 2019 at the second UN Intergovernmental Conference on a new international treaty for the conservation and sustainable use of marine biological diversity of ABNJ. The prototype includes a set of 38 standardized area-use models describing general and core-use areas for a given population/species by activity  for 357 animals from seven species across 55 EEZs. To provide this knowledge in as transparent a manner as possible, metadata describing datasets, animals, activity and (if known) population, sex, age class and data density are graphically presented by month and year for each area or population/species. System users can view summaries of area use by species, by a country's EEZ or relative to ABNJ, and review summaries of data contributed per provider, with associated references created from the data. An interactive mapper allows detailed geographical exploration, examination and overlays of animal use areas filtered by any combination of available metadata. Species range maps, when available, are layered under use areas to describe the degree of coverage of MiCO products.To facilitate delivery of migratory connectivity knowledge to policy and management arenas, a prototype system , the CMS in their development of resolution 12.26, and considerations of area-based management tools, environmental impact assessments and capacity building and technology transfer in the negotiations for a new treaty for marine biodiversity in ABNJ. A key component of the system is its ability to track how contributor data have been used in these arenas, providing individual researchers the ability to assess and report their impact on management and policy fora. This provides incentive for researchers to contribute data to policy processes and measure their impact by doing so, while at the same time, the system protects raw data that may not yet be available for public sharing by disseminating only synthesized products.Support for the system's development and for outreach to intergovernmental organizations has come from a national government , and frMiCO seeks to build on its strong foundation and invites engagement from additional stakeholders to inform its continued development and enhancement to best serve both users and contributors. Strong forward momentum in global ocean governance will soon result in major policy changes for the ocean with many management implications for migratory marine species. By integrating and scaling up the information gained through the tens of thousands of scientific papers about migratory species into knowledge that is relevant and usable in this new era of ocean policy, we hope to make a step-change in evidence-based policy to conserve migratory marine species.


Thirty-one state and territorial public health agencies participated in a learning collaborative to improve diagnosis and management of hypertension in clinical and community settings. These health agencies implemented public health and clinical interventions in medical settings and health organizations using a logic model and rapid quality improvement process focused on a framework of 4 systems-change levers: 1) data-driven action, 2) clinical practice standardization, 3) clinical–community linkages, and 4) financing and policy. We provide examples of how public health agencies applied the systems-change framework in all 4 areas to assess and modify population-based interventions to improve control of hypertension. This learning collaborative approach illustrates the importance of public health in the prevention and control of chronic disease by supporting interventions that address community and clinical linkages to address medical risk factors associated with cardiovascular disease. Integrating public health, clinical care, and community approaches can improve the clinical, social, and economic burdens of cardiovascular disease.A learning collaborative to support state and territorial health agencies, health care systems, and community partners was developed to implement evidence-based practices for hypertension diagnosis and control across communities. A systems-change framework and rapid quality improvement process helped increase coordination between health agencies and health care systems.This learning collaborative shows that health agencies in various jurisdictions can improve communication between community health organizations and public health and leverage technical and financial resources to support programs for patients to self-manage their blood pressure.Cardiovascular disease (CVD) is the most common cause of death in the United States and a source of suffering and disability. Reductions in deaths from CVD are largely due to decreased use of tobacco products, improvements in blood pressure and cholesterol control, and advances in medical treatment ,2. HowevIn 2017, the American College of Cardiology and the American Heart Association released new blood pressure guidelines that suggest lowering the optimal blood pressure target from below 140/90 mm Hg to below 130/80 mm Hg; however, among people with high blood pressure in the United States, only half were in compliance with the previous guidelines, and fewer will meet the new ones –7.In 2013, the Centers for Disease Control and Prevention (CDC), Division for Heart Disease and Stroke Prevention, began a cooperative agreement with the Association of State and Territorial Health Officials (ASTHO), a national nonprofit organization representing public health agencies in the United States, the US territories, and the District of Columbia. ASTHO and CDC developed a learning collaborative, defined as a group of public health leaders and partners who have a common interest in a subject area that collaborates to achieve sustainable change and improvement. The ASTHO/CDC Heart Disease and Stroke Prevention Learning Collaborative was designed to support state and territorial health agencies, health care systems, and community partners in efforts to improve hypertension diagnosis and control in and across communities by supporting the implementation of evidence-based practices .ASTHO and CDC developed a logic model for the learning collaborative that served as a blueprint for health improvement measures and approaches . The logJurisdictions, including state, territorial, and tribal-serving organizations, partnered with local public health agencies, community health centers, and private clinics to implement programs that prevent, detect, and reduce hypertension rates. States, tribal-serving organizations, and territories developed an aim statement to summarize their project’s intervention approach, objectives, and program, which provided a source of continuity of reporting and data sharing, as officials and partners regularly communicated and reported on project progress to CDC, ASTHO, and other jurisdictions in their cohort. Jurisdictions used the logic model as a guide to help categorize their intervention approaches into the 4 main components of the ASTHO framework. The learning collaborative also used a rapid quality improvement process focused on the “plan,” “do,” “study,” and “act”  model tWe reviewed our experience using a 4-component framework to address systems change and the rapid quality improvement process to help states change systems, provide an overview of activities from 3 state health departments who implemented the framework, and summarize the implications for public health practice of using this approach.After an ASTHO-led Request for Proposal, states, tribal-serving organizations, and territories (jurisdictions) submitted proposals and were funded to develop a quality improvement process to improve hypertension diagnosis and control (Phase 1) . UltimatWe applied the strategies used to implement the ASTHO/CDC framework in 3 states, each with a unique set of characteristics: New York, Oklahoma, and Arkansas . New YorNew York. New York used data-driven action to support Federally Qualified Heath Center use of electronic health records to identify and track patients with hypertension, resulting in an improvement in hypertension control rates of 18.7% across centers in just 2 years. Their use of a regional health information exchange provided real-time county-level rates of hypertension, hypertension control, and undiagnosed hypertension and is now a model for other state and territorial programs.Arkansas. Arkansas developed and tested well-defined hypertension care management plans in 4 counties, on the basis of a community team-based care approach that ultimately became the model for a standardized protocol that is now used statewide. They used a web-based pharmacy platform to help community pharmacists identify patients with uncontrolled blood pressure and calculate and monitor patient medication adherence . It will provide further insight into differences in governmental public health structures that may better integrate diagnosis and control of hypertension at the community level and improve outcomes.


Patients with multiple myeloma (MM) are often treated with chemotherapy, radiation, and, if indicated, autologous stem cell transplant. In addition to side effects of the treatment, patients with MM often have bone pain, pathological fractures, spinal cord compressions, fatigue, and muscle weakness, which negatively impact functional performance and quality of life. Currently, there are no related guidelines for safe and effective physiotherapy (PT) management. Accordingly, the aim of the present study is to develop guidelines for effective physiotherapy management of patients with MM by systematically reviewing and evaluating the available evidence followed by a consensus process to specifically describe the research questions as detailed below.Physiotherapy management guidelines for patients with multiple myeloma will be developed based on the results of a systematic search of the following databases: US National Library of Medicine Database (PubMed), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Elton B. Stephens Co. (EBSCO), Web of Science, Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Review, and Physiotherapy Evidence Database (PEDro). All articles will be screened for inclusion and exclusion criteria. Relevant potential articles will be identified and systematically reviewed for final phase of inclusion. Two independent reviewers will systematically review and analyze the quality of identified articles using standardized assessment tools. Scientific conclusions will be drawn and recommendations will be made based on a critical appraisal process. The guideline development will also be based on the team’s judgment about the overall quality of the studies and a consensus process.Draft guidelines will be developed in the form of action statements based on the strength of evidence and grades of recommendations. The draft guidelines will be reviewed internally by two independent reviewers using AGREE II and externally by a methodological expert from Evidence-Based Care – Cancer Care Ontario and will be sent to the Canadian Physiotherapy Association (CPA) for feedback from physiotherapists.CRD42017064056PROSPERO The online version of this article (10.1186/s13643-018-0785-7) contains supplementary material, which is available to authorized users. Multiple myeloma (MM) is a malignancy of plasma cells that normally reside in bone marrow, producing immunoglobulins (antibodies). In MM, the uncontrolled growth of these cells result in increased osteoclastic activity with the destruction of bone matrix leading to hypercalcemia and an increased risk of fracture . AccordiPatients with MM are generally treated with chemotherapy, radiation and potentially autologous stem cell transplant, and/or radiation. High-dose chemotherapy is a systemic therapy that uses high doses of cytotoxic drugs to destroy myeloma cells. In addition to destroying myeloma cells, the cytotoxic drugs also destroy hematopoietic stem cells leading to neutropenia and thrombocytopenia . This puRadiation therapy is often prescribed for management of bone pain and osteolytic lesions, preventing paralysis in patients with spinal cord compression. Radiation therapies induce apoptosis and reduce the tumor size . This rePatients considered as candidates for high-dose chemotherapy and autologous transplantation are admitted to hospital for a 2- to 3-week period. During the in-patient stay, number of factors may significantly affect the physical performance and functional status of hospitalized patients with MM including, prolonged periods of bed rest with muscle inactivity, older age, effects of cancer treatments including fatigue. Careful attention to pain management, safe mobilization by providing exercises that are safe and preventing functional decline (deconditioning), improving strength and physical performance are significant in improving quality of life and also help in preventing complications.Physiotherapy (PT) is a part of cancer rehabilitation and is often recommended for patients with MM; however, there are no specific guidelines for safe and effective PT management. Evidence-based guidelines also known as clinical guidelines are systematically developed statements that guide health care practitioners and patients in making decisions on the selection of appropriate health care services/treatments –14. GuidThe aim of the present study is to develop guidelines for effective physiotherapy management of patients with MM by systematically reviewing and evaluating the available evidence followed by an expert review process to specifically describe the research questions as detailed below.The following steps recommended by the American Physical Therapy Association (APTA)  will be The APTA recommends draft guideline review by content experts and stakeholders  published by Centre for Reviews and Dissemination, University of York, in order to reduce duplication of effort and publication bias , 20. ThiThe studies that are of interest for this current investigation are those that focus on physical therapy intervention in patients with MM who had been actively receiving cancer treatment and in follow-up care. However, a preliminary literature search suggested that few randomized controlled trials addressing this topic were available. Therefore, the guideline development team has decided to include systematic reviews, meta-analyses, interventional and observational studies, and case series, which collectively might be informative and helpful in developing the guidelines. In addition, a gray literature search will be conducted to ensure that any potential informative articles are not missed. Only articles published in the English language from the earliest to Aug 2017 will be included.Articles with human participants diagnosed with MM of any age, regardless of gender, tumor stage, and type of cancer treatment will be included.Articles examining the effects of exposure or the effects of physical therapy interventions including physical activity, exercise, and other modalities will be included. Articles with comparison groups with standard interventions or no intervention will be included.Articles reporting on the following primary outcomes of interest will be included: (1) pain, (2) safety, (3) laboratory values, (4) length of stay, (5) range of motion, (6) muscle strength, (7) balance, (8) gait, (9) endurance, (10) fatigue, (11) physical performance, (12) functional performance, and (13) aerobic capacity. The secondary outcomes of interest are (1) quality of life and (2) anxiety/depression.A detailed literature search will be conducted on the US National Library of Medicine Database (PubMed), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCO, Web of science, Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Review, and Physiotherapy Evidence Database (PEDro). All relevant literature from the abovementioned databases will be retrieved for each research question. Table Steps recommended by Pai et al.  will be Two independent reviewers will extract the data from all the articles that are included in the final selection phase using a standardized data extraction form. The standardized data extraction form will be customized from the data extraction and assessment template proposed by “The Cochrane Public Health Group” . Data exEach article will be critically appraised using standardized critical appraisal tools including the PEDro scale, the Methodological Index for Non-Randomized Studies (MINORS), the Critical Appraisal Skills Programme (CASP) checklists , the MeaScientific conclusions will be drawn and recommendations will be made based on the critical appraisals, the guideline development team’s  judgment about the overall quality of the studies and consensus from the expert group.The levels of evidence for each article will be determined based on the recommendations of Kaplan and colleagues  and critThe Grading of Recommendations, Assessment, Development and Evaluation (GRADE) will be used to determine the strength of evidence . See Tabmust will be used if the evidence supports a strong recommendation (grade A) and harm might occur if the action is not followed. The term should will be used if the evidence supports a strong (grade A) or moderate (grade B) recommendation. The terms may or could will be used if the evidence is weak (grade C).The following terms will be used in describing levels of obligation as recommended by the APTA Who, When (under what specific conditions), Must, Should, or May (the level of obligation), Do what (precise action), and to Whom. Action statements will be supplemented by action statement profiles listing aggregate decisions made by the guideline development team and consensus process. The action statement profiles will include the following headings: aggregate evidence quality, level of confidence in evidence, benefits, risks, harm, costs, benefit-harm assessment, value judgments, intentional vagueness, role of patient preferences, exceptions, policy level, and differences of opinion [Recommendations will be made in the form of action statements. Brief, precise, quality-driven action-oriented statements will be created using a BRIDGE-Wiz software as recommended by the APTA. The action statements will be described in terms of  opinion , 34.Five physiotherapists across Canada experienced with the care of patients with MM will independently review the contents of the guidelines and provide feedback. Aggregate level of evidence will be assigned after the group reaches consensus on the evidence supporting each key action statement. The guidelines will be revised till 80% consensus is achieved on each of the statements and profiles. Action statements that do not reach 80% consensus after three rounds of consensus process will be removed from the guideline document.Three independent reviewers will evaluate the guideline using AGREE II. It is a reliable and valid instrument used to assess the quality of clinical practice guidelines. AGREE II consists of 23 items clustered under 6 domains  developed to assess the quality of the guidelines. Each item in the questionnaire is evaluated on a 7-point scale where score 1 refers to strong disagreement and score 7 refers to strong agreement.The guideline will undergo two external reviews. The guideline will be sent to CPA for feedback from physiotherapists. The guideline will also be reviewed by a methodological expert from Evidence-Based Care - Cancer Care Ontario. The draft guideline will be posted on the Health Sciences North (HSN) website for public comment.This study will employ validated methodologies such as PICO guidelines, systematic reviews, and consensus process. This study will also use standardized quality assessment tools for specific research designs. The literature search and data extraction processes will be done by independent reviewers thereby enhancing the validity of the study. Additionally, the review panel will consist of experts in patients with MM. Moreover, the formulated guidelines will also be evaluated using the AGREE II instrument, which adds to the validity of this study.The following study limitations are noted. We acknowledge that this study might have significant result publication bias, meaning that this study might review articles showing significant results (effects) on earlier described research question, which tells nothing about possible ineffective interventions, as non-significant results are less likely to be published; however, this is beyond the control of any researcher. This study may be subjected to selection bias by not including relevant articles published in languages other than English. Reporting bias will be minimized by having two independent reviews and by having a third independent reviewer intervene when there are disagreements at each stage of data identification, data extraction, and critical appraisal.The outcomes of the study are expected to benefit practitioners because it will provide clear evidence-based guidelines regarding best practices to administer physiotherapy treatment to patients with MM. The recommendations made from this study will be based on rigorous and validated methods that will assist in minimizing potential harms and improve the quality of care. The patients will benefit from receiving the best possible treatment that is tailored to their unique set of health concerns. Rather than using a “one-size fits all” approach to PT treatment, the study will focus specifically on patients that have MM and will seek to determine what specific PT treatment options are best suited for this population. The benefits could be measured qualitatively by requesting input from practitioners regarding the guidelines (clarity and ease of implementation). The benefits to the patients could be assessed in a follow-up study comparing standard PT care compared to the MM-tailored PT intervention program. The findings of this study will also provide a comprehensive platform for future research directions by identifying gaps in the literature.Additional file 1:PRISMA-P checklist. (DOCX 26 kb)