The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world’s population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them.Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow.This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great. About five years ago, the World Heart Federation (WHF) launched a Roadmap initiative to reduce death and disability from non-communicable diseases (NCDs), focusing on the increasing global burden of cardiovascular disease. This rise in cardiovascular disease disproportionately affects people in low- and middle-income countries (LMICs). The aim of this WHF initiative is to reduce death and disability through effective interventions targeting prevention, early detection, and treatment. One of the main problems in achieving the desired outcomes is that the health system resources required to make an impact are most challenging for LMICs, which vary enormously between and within countries in availability of cardiovascular health resources, so it is difficult to generalize. Even in high-income countries (HICs), areas of health inequalities, socioeconomic deprivation, and often poverty are present in many areas and in minorities including first nation peoples , migrants and different ethnic or racial groups, and may co-exist with greater cardiovascular burdens including atrial fibrillation (AF) and its complications.The WHF Roadmap for AF was published in December 2017 [Much has happened in the three years since publication, including technological advances that will change our ability to detect AF early before it becomes symptomatic, and to better predict those who have silent AF or are likely to soon develop it. There have also been technological advances in reducing AF symptoms through more effective ablation of the arrhythmia, and in prevention of cardio-embolism, but the relevance of these technological advances for LMICs is uncertain. The widespread adoption of mobile technology, particularly smartphones, has also facilitated new approaches to healthcare delivery, which could impact general community awareness of the condition and increase patient knowledge, in turn facilitating adherence to effective lifestyle and pharmacological approaches. Finally, an important outcome of the WHF Emerging Leaders Programme was preparation of a successful submission to the World Health Organization to add the non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) to the Essential Medicines List . These dTo accomplish this, an international panel of AF experts was assembled to summarize the areas of the original Roadmap requiring updating – what is new and important for the ideal AF patient-care pathway – and to place this information in perspective. Additionally, an online consultation of national society and foundation representatives was carried out, with respondents from 23 countries. The majority stated that the previously identified roadblocks and the suggested solutions were still relevant in their countries, but it was uncertain how much progress had been made. This update will serve as a vehicle to restate the roadblocks and strategies to overcome them and to examine whether the advances reviewed might provide novel ways to more effectively prevent, detect, treat, and reduce complications associated with AF.AF remains the most clinically significant arrhythmia seen in clinical practice 345. Prev343456789911141513171820211924252627AF burden is lowest in sub-Saharan Africa , possibl32130343536Additionally, AF occurs at a relatively younger age in some LMICs 414243, t414244454648Prevention of AF is of paramount importance given its rising incidence, associated disease burden, and cost. As a condition closely associated with ageing and co-morbidity, AF also demonstrates distinct race and sex trends not yet fully understood . There i525356Successful primordial and primary prevention requires a sustained long-term effort. Effective AF prevention will require primordial prevention of modifiable predisposing risks such as diabetes and rheumatic heart disease. Lifestyle modifications including weight loss to reduce obesity 5960, no 59565761626365For optimal benefit, individuals should actively participate in shared decision making and a team-based approach to deliver care, which promotes self-management and provides adequate support 6869. The68The following sections focus on a series of new opportunities to overcome roadblocks in the detection and management of AF. An updated overview of roadblocks and possible solutions based on the 2017 WHF Roadmap, WHF members’ feedback, and a review of the literature by the expert writing group is shown in Table AF is often paroxysmal 727374 an72737576747880Multiple investigators 8384 have8384868588Proprietary technologies already allow direct recording and interpretation of an ECG tracing from a smartwatch . For exaA number of stand-alone handheld or chest-applied ECG devices, or small inexpensive devices attached to a smartphone, are available and commonly used as event recorders providing an ECG rhythm strip for AF diagnosis when symptoms are suggestive or to estimate AF burden in known AF. These devices can also be used to screen for AF by either health professionals or personnel with minimal training in LMICs 95 or by 96Although adoption of smart watch technology in LMICs is very low, surveys conducted in 11 LMICs in four global regions found that 53% of adults have access to a smartphone capable of accessing the internet and running apps . Data frA potential alternative or addition to using wearables/apps and devices utilizes modern computing technology to examine existing clinical specimens, samples, or data (including ECG data) to identify patients at high risk of actionable AF, or even cardiovascular disease . Such teA recent study showed that an AI-ECG algorithm trained using over 500,000 normal sinus rhythm ECGs from over 180,000 patients, had favorable performance characteristics for the identification of concomitant paroxysmal AF  . While s104clinicaltrials.gov NCT04208971). Furthermore, the lack of ‘explainability’ of current convolutional neural networks leaves many clinicians reluctant to accept the predictions that emerge from a ‘black box’. While the potential implications of AI-ECG in AF screening and treatment is only beginning to emerge, it is clear that significant questions remain.Before such approaches can be implemented, considerable work is needed to externally validate these algorithms in diverse populations  and to tWearable ECG monitors are noninvasive, easy to use, and readily available compared to other medical devices  but may Developments in technology certainly show promise for increasing detection and diagnosis of AF that may lead to stroke and other complications, which could be prevented by interventions such as OAC therapy. PPG on smartphones seems the most scalable option, but the diagnosis still requires an ECG for confirmation – that is, another test – which poses challenges. Smartphone ECG devices can provide an AF diagnosis without another test and have been used successfully for screening in many countries, including LMICs 25281132114  remains a significant problem 43. The c27167Even within HICs, pockets of social deprivation and poverty can produce disparities in OAC usage that may require a different approach. High AF risk at a younger age and low OAC utilization are seen in first nation peoples and minorities 171172.171i to vii are equally applicable to risk-factor management and rate and rhythm control.Many of the strategies described in To improve OAC use in LMICs calls for a team approach. Delivery of anticoagulation services can be expanded to a large geographical area through a hub-and-spoke model Figure , applicaLMICs face a number of challenges in providing cost-effective antithrombotic therapy in AF patients. Monitoring quality of anticoagulation for VKA to achieve the minimum TTR threshold is required for optimal results . Robust Medication adherence to durable anticoagulation therapy is essential for reducing AF-related stroke and thrombotic events, health-care related cost, and rate of hospitalizations . Althoug174175176177178179180177180182183184187189Health literacy refers to the appropriate skills and knowledge needed to understand, and the confidence to access, evaluate, utilise, and navigate health care . It has Two multinational surveys showed that more than half of the patients with AF had low levels of knowledge about the increased risk of stroke related to AF or did not even know the name of their condition 193. A reIdentification of deficiencies of patients’ knowledge plays a substantial role in designing and conducting evaluation of effective patient education platforms 196. The Educational intervention programs to improve patient knowledge, particularly about therapy, could significantly impact therapeutic adherence, persistence, and therefore efficacy . An easy200201203204www.NOACforAF.eu. Patient-led organisations such as the Arrhythmia Alliance and the AF Association also provide valuable information, awareness, education, and support but are not active in many LMICs. Establishing such networks would be valuable.Most physicians (80–95%) deliver patient information themselves, 30% recommend information brochures, and around 25% refer patients to other clinics specialized in OAC management for further education . Only 9–Technology effectively supports patient self-management and can facilitate medication adherence. Connected devices provide information about wider health and well-being issues related to AF, quite apart from ability to monitor for AF as previously discussed. It is essential that diagnostic technology is supported by a clear treatment pathway to ensure anxiety is not heightened by an abnormal result . ParadoxIn the context of shared decision, nursing and allied professionals have an important role to play in supporting patients through detection, management, and treatment of AF. Successful community AF screening programs (such as the Arrhythmia Alliance Know Your Pulse campaign) have been led across the globe by patient organisations, pharmacists, and nurses, with high levels of participant satisfaction. Management of AF requires a patient-centered approach to support medication adherence and effective lifestyle risk reduction. Guidelines now recommend an ‘integrated-care’ approach, involving primary care physician, exercise specialists, dietitians, pharmacists, specialist nurses, psychologists, podiatrists, sleep physicians, as well as electrophysiologists, and cardiologists 210, whicAccess to a range of specialists including professional patient organisations can support people with AF to self-manage. Management of AF requires a collaborative approach with the patient and family at the centre of all decisions . In AF, While stroke prevention has been the primary focus of therapy for AF, heart failure is the most common cause of death among individuals with atrial fibrillation, and one of the leading causes of hospitalization 214215. T214In addition to stroke, patients with AF are at increased risk of silent cerebral thromboembolic lesions 221, and The global impact of AF is evident from current epidemiological data and projections. Aside from the impact of AF on quality of life, the deleterious effects of AF on stroke and heart failure on healthcare costs including hospital admissions will only increase the economic burden of the condition. As a result of the COVID-19 pandemic, there has been an understandable concentration of the health care sector on this infectious disease. This has had an adverse and hopefully transient impact on non-committable diseases such as AF.The focus of this Roadmap update was to identify what has changed in the recognition and management of AF, particularly the emerging role of mobile technology and mHealth, and to consider the advances described in recent publications, many summarized in the 2020 ESC guideline on AF . Most ofAdvocacy: Dissemination of knowledge on the importance of AF as one of the leading issues of cardiovascular disease must be improved. Too many decision makers in the health care sector do not know the threats of AF precisely and intensely enough. The campaign to change this should be led by the continental cardiac societies , national heart societies and foundations, patient organisations such as the Arrythmia Alliance and AF Association, and civil organisations, supported and united by the World Heart Federation.Implementation: There are still gaps in implementation of guidelines for management of AF, particularly in LMICs. Although patient education is important, improving healthcare provider awareness and education updates is crucial. Periodic educational courses and 24/7 hub backup helpline are examples of effective methods to increase adherence to guideline-based therapeutic approaches.Access: Aside from knowledge dissemination and implementation, global access to cost-effective health care resources must be achieved. Priorities are precise diagnosis and access to pharmacologic treatment, preferentially to modern oral anticoagulation using NOACs [ng NOACs , and alsLiteracy: Improving health literacy among patients and using shared decision-making tools by improving adherence to and long-term persistence with therapy will reduce AF-related complications and health-care related costs. Therefore, promotion of tailored, context-specific strategies to increase medication adherence and persistence should be considered as one of the priorities for all health-care units.Integrated Care: In the context of shared decision-making, use of an ‘integrated-care’ approach for AF management to further improve the structured management of patients, promote patient values, and finally improve patient outcomes should be prioritized in all countries, irrespective of income status.Digital Transformation of Care: Use of mHealth technologies to educate patients, provide patient support in areas with less health care facilities, increase adherence to lifestyle and pharmacological therapeutic approaches, and facilitate AF screening should be considered as one of the priorities in the next years. At the same time, finding practical solutions for the previously mentioned potential barriers for using these technologies, mainly for AF screening using wearables/apps, should be kept in focus. Moreover, digital technologies will enable the systemic implementation of quality indicators for several domains in the AF management pathway.Prevention and Screening: Much more attention should be paid to AF preventive strategies including development of new strategies. Both physicians and patients need to be better informed about the important role of risk factors and lifestyle in AF development and recurrence after a successful ablation or other rhythm control strategy. Identification of unrecognized AF using technological advances is another important priority for prevention of complications, especially stroke.Overcoming Barriers: Local stakeholders at the national level should hold roundtables to improve understanding of local barriers and develop practical solutions to identified local barriers, thus contextualizing and adapting the AF roadmaps. Publishing the result of such interventions is encouraged to increase understanding of remaining problems and to generate solutions from other experts.


Clinical preventive services play an important role in preventing deaths, and Healthy People 2020 has set national goals for using clinical preventive services to improve population health , Guam, and Puerto Rico; these include colon, cervical, and breast cancer screening; HIV testing; and pneumococcal and influenza vaccination. The other four services were included in the optional modules, which are asked by some states; these include diabetes screening , HPV vaccination (asked by eight states), shingles vaccination (asked by four states), and tetanus vaccination (asked by four states).In the 2018 BRFSS, the median survey response rate was 49.9% with a sample size of 437,436 adults aged ≥18 years. Participants were considered uninsured if they didn’t have any health care coverage at the time of the interview. Federal poverty level (FPL) was calculated by using the number of adults, the number of children, and the midpoint income value of the categorical household income level  .The highest adjusted use was observed in the insured-higher income-urban group for six of the 10 services . Insurance status was the factor most strongly associated with use of clinical preventive services, followed by income level and rurality, respectively. Uninsured persons used seven of the 10 clinical preventive services less frequently than those with insurance, regardless of income level and rurality. Among those with insurance, use of six of the 10 services was higher among persons with higher incomes, regardless of whether they lived in rural or urban counties  . Third, FPL was estimated based on the categorical income value provided by BRFSS rather than a precise estimate of household income. Fourth, whether BRFSS participants received services from in-network providers could not be determined, nor could whether survey participants were enrolled in insurance plans subject to ACA requirements to provide clinical preventive services without cost-sharing be determined (The findings in this report are subject to at least six limitations. First, the analysis was based on self-reported use data, which could be subject to recall and social desirability bias. Second, use of some services as measured by BRFSS was not entirely aligned with the recommendations; BRFSS questions, recommendations, and important distinctions are provided (Supplementary Table 2, As the health care policy landscape continues to shift, understanding factors associated with use of recommended clinical preventive services could help decision makers better identify policy levers to increase use of clinical preventive services. The ongoing monitoring of trends could improve understanding of how modifiable factors affect use of clinical preventive services, especially during the pandemic, because a decrease in use of routine vaccinations was observed. Although insurance status, income level, rurality, and state of residence appear to be associated with use, examining other barriers could also help better identify strategies to achieve public health goals.Ongoing federal and state health reform efforts, particularly the Patient Protection and Affordable Care Act, have affected use of clinical preventive services in the United States.Analysis of 2018 Behavioral Risk Factor Surveillance System data indicated use increased for selected recommended clinical preventive services; however, use of nine of the 10 services examined was lower among the uninsured, those with lower income, and those living in rural communities. Among those factors examined, insurance status had the strongest association with use of clinical preventive services, followed by income level and rurality.Understanding factors influencing use of clinical preventive services can potentially help decision makers better identify policies to increase their use including strategies to increase insurance coverage.


Since 2012, the World Health Organization has recommended household contact investigation as an evidence-based intervention to find and treat individuals with active tuberculosis (TB), the most common infectious cause of death worldwide after COVID-19. Unfortunately, uptake of this recommendation has been suboptimal in low- and middle-income countries, where the majority of affected individuals reside, and little is known about how to effectively deliver this service. Therefore, we undertook a systematic process to design a novel, theory-informed implementation strategy to promote uptake of contact investigation in Uganda, using the COM-B (Capability-Opportunity-Motivation-Behavior) model and the Behavior Change Wheel (BCW) framework. We systematically engaged national, clinic-, and community-based stakeholders and collectively re-examined the results of our own formative, parallel mixed-methods studies. We identified three core behaviors within contact investigation that we wished to change, and multiple antecedents  of those behaviors. The BCW framework helped identify multiple intervention functions targeted to these antecedents, as well as several policies that could potentially enhance the effectiveness of those interventions. Finally, we identified multiple behavior change techniques and policies that we incorporated into a multi-component implementation strategy, which we compared to usual care in a household cluster-randomized trial. We introduced some components in both arms, including those designed to facilitate initial uptake of contact investigation, with improvement relative to historical controls. Other components that we introduced to facilitate completion of TB evaluation—home-based TB-HIV evaluation and follow-up text messaging—returned negative results due to implementation failures. In summary, the Behavior Change Wheel framework provided a feasible and transparent approach to designing a theory-informed implementation strategy. Future studies should explore the use of experimental methods such as micro-randomized trials to identify the most active components of implementation strategies, as well as more creative and entrepreneurial methods such as human-centered design to better adapt the forms and fit of implementation strategies to end users. More than 10 million patients develop active tuberculosis annually, but over three million are never diagnosed because they cannot or do not access diagnostic evaluation and treatment services . The arcImplementation strategies are specific techniques used to promote adoption, uptake, implementation, and sustainability of innovations and evidence-based practices previously known or believed to improve individual or public health outcomes , 12. A vTherefore, beginning in 2014, we undertook a series of formative and implementation studies in Uganda, a low-income country preparing to roll-out household TB contact investigation as a routine service. We first characterized factors that might prevent or enable uptake and completion of contact investigation  and thenThe World Health Organization has designated Uganda one of 30 high HIV-TB burden countries , with anThe overall objective of this project was to adapt household TB contact investigation to the local context and design a theory-informed implementation strategy  to overcThe British Medical Research Council (MRC) defines complex interventions as ones that (1) include multiple, interacting components; (2) address multiple behavioral targets among those delivering and/or those receiving the intervention; (3) target multiple groups or organizational levels; (4) address multiple outcomes that may vary between groups and cluster at different levels of an organization; and (5) allow adaptation of the intervention to local circumstances . Complexpsychological capability  and physical capability ; physical opportunity  and social opportunity ; and automatic motivation  and reflective motivation   , 37. A s; goals) . The pro; goals) . For exa; goals) . Our thiintervention functions  through which the target behaviors that need to change can be modified and the policies that could support the intervention functions at the organizational and/or societal level; and (3) identify intervention content and implementation options by selecting specific behavior change techniques, policies, and modes of delivery  lay health workers screening household contacts for TB, including referring contacts screening positive for possible active TB disease based on symptoms or predisposing factors to attend clinics for testing and evaluation; and (3) contacts screening positive attending clinics to complete TB evaluation and treatment by health care workers  including the Uganda National TB Programme Manager (FRM) attended an international workshop to review newly issued WHO guidelines on TB contact investigation ; a lack of time and space in clinics for LHWs and index patients to meet for counseling and high travel costs to and from households for LHWs and contacts ; a perceived need for permission from the head of household for index patients to consent to a home visit and for contacts to attend clinic visits ; anticipated TB-related stigma reported by household contacts, lay health workers, and health care workers and a lack of trust between clinic-based health care workers and household members (automatic motivation), including both index patients and contacts. The most important enabling factors noted by both clinic health workers and household contacts were the personalized and supportive services provided by LHWs.Third, we carried out and analyzed focus group discussions with health care workers, focus group discussions with lay health workers (LHWs), and interviews and one focus group with household contacts. We used the COM-B model to categorize emergent themes to identify antecedents of the specified behaviors that we could target for change . A full Fourth, we carried out a quantitative evaluation of the three required behaviors of household TB contact investigation in routine practice, in order to localize bottlenecks in the delivery process, as previously described . We founAt the conclusion of Step 1, we summarized the perspectives and experiences of stakeholders and discussed them with implementing partners. Together, we agreed that all three component behaviors could be targets for improvement during implementation, because they shared common behavioral determinants ; because implementation components targeting these determinants could all be delivered by lay health workers; and because the close linkage between key screening and evaluation processes within the contact investigation cascade increases the possibility of positive spillover effects on other related behaviors.e.g., lack of knowledge of TB and benefits of screening), and persuasion and modeling targeting social opportunity , reflective motivation , and automatic motivation . We also identified environmental restructuring  and enablement  as intervention functions addressing the physical opportunity  and other automatic motivation  barriers.In August 2015, the implementation research team met to discuss and select the functional components of the implementation strategy using the Behavior Change Wheel framework . To targe.g., lack of skills in screening for TB), environmental restructuring through re-timing of visits to weekends to address physical opportunity , and persuasion to address automatic motivation .To target the determinants of the second behavior, lay health workers screening household contacts for TB, we identified education, training, persuasion, environmental restructuring, enablement, and incentivization as possible intervention functions. Specifically, we found the most promising of these were education and training to address physical capability , environmental restructuring by initiating the TB testing process at home in order to address physical opportunity , enablement to address social opportunity , and education and persuasion to address reflective motivation .To target the determinants of the third behavior, eligible contacts completing TB evaluation clinic, we identified the same set of intervention functions—education, training, persuasion, environmental restructuring, enablement, and incentivization. The most promising of these implementation components included education to address psychological capability  ensuring that health information provided to index patients has been approved and validated by a credible source, the national TB program; (3) describing anticipated regret and possible social and environmental consequences in the form of blame by family members for not referring household contacts for evaluation; (4) providing information about the social & environmental consequences of not agreeing to a home visit, including putting household contacts at risk; and (5) eliciting comparative imaginings of future outcomes of doing and not doing the behavior. We also considered several other behavior change techniques but did not adopt them routinely because clinic-level stakeholders found them infeasible or inappropriate: (6) inviting a former index TB patient to share the difficult decision to agree to household contact investigation as a demonstration of the behavior; (7) restructuring the social environment by phoning the head of household to obtain permission for a household visit rather than asking an index patient who is not head of household to consent; and (8) restructuring the physical environment by screening the index patient by phone to allow greater privacy and convenience.Having identified possible intervention functions, we proceeded to select specific behavior change techniques from the Behavior Change Techniques Taxonomy , design instruction on performing the behavior through lectures about how to carry out TB screening; (2) encouraging behavioral practice/rehearsal through role plays with one another; (3) framing/reframing the first priority of the home visit as supporting the index patient during treatment rather than as performing symptom screening; (5) providing electronic prompts/cues to lay health workers using decision support on electronic tablets to guide whom to refer to clinic for further evaluation; (6) adding objects to the environment by providing lay health workers with N95 respirators to reduce the risk and fear of contracting TB; and (7) providing material incentives for the behavior in the form of a modest financial allowance to lay health workers for transportation to the community and for meals. We also considered one other behavior change technique but did not select it routinely because it was not deemed feasible or acceptable to programmatic officials: (8) restructuring the physical environment by screening unavailable contacts by phone.To change the second target behavior of lay health workers to enable them to screen more contacts for active TB, we identified multiple possible behavior change techniques, including (1) providing information about health consequences, (2) credible source, (3) anticipated regret, (4) information about social & environmental consequences, and (5) comparative imaginings of future outcomes were selected with very similar content and modes of delivery as used for the first target behavior of encouraging index patients to agree to contact investigation. There were also several other possible behavior change techniques that we identified, including (6) restructuring the physical environment by collecting sputum and performing HIV counseling and testing at home, a more convenient and accessible location for testing than the clinic and by asking follow-up screening questions by SMS; (7) restructuring the social environment, by initiating TB and HIV testing at home, a less threatening social environment than the clinic; (8) providing instruction on how to perform a behavior, specifically sputum expectoration for TB examination; (9) encouraging action planning, by asking contacts to schedule a time to complete TB evaluation in clinic, (10) seeking a commitment in the form of a promise to complete TB evaluation in clinic; (11) recommending emotional social support by encouraging contacts to travel to clinic together; (12) providing feedback on the outcome of the target behavior by delivering results and follow-up instructions via SMS; and (13) offering a non-specific reward by enabling contacts to bypass the clinic waiting area when they present for TB evaluation. We also identified (14) providing an incentive for the outcome in the form of a small electronic cash transfer upon returning to the clinic, but did not include it, as it was not deemed feasible or acceptable by programmatic stakeholders. All selected behavior change techniques were integrated into contact investigation training materials, procedures, and operating protocols, for easy reference during the trial.To change the third target behavior, getting household contacts to complete TB evaluation, we also identified multiple potential behavior change techniques. Several of these, including (1) Finally, we also identified three policy changes that could leverage the impact of the selected intervention functions as part of an integrated implementation strategy. The first was a service delivery innovation, shifting responsibility for contact investigation from already over-burdened clinic heath care workers to lay health workers. The design team identified a large body of evidence supporting the feasibility, acceptability, and effectiveness of lay health workers in delivering community interventions for TB treatment and other disorders, when provided adequate training, supplies, and modest compensation . In addie.g., weekend visits, language related to framing of invitations) to the preferences of participants. Lay health workers also completed training on implementation components targeting health-workers, and were similarly instructed to apply all of the environmental restructuring, incentivization, and enablement techniques in all households. The implementation effectiveness of these strategies was therefore evaluated in comparison to historical controls. These trainings were jointly delivered by National TB Program implementing partners and research staff, who also provided longitudinal supportive supervision and regular data audits; these were the only two implementation components not derived from BCW and they were implemented because high quality data was required to ensure the integrity of the evaluation. In the pre-post implementation evaluation, uptake of contact investigation  among index patients improved markedly from 31 to 79% after introduction of the implementation strategy, while uptake among contacts  improved from 89 to 99%, relative to the pilot period  and household HIV testing (4 weeks), training on electronic-tablet based data entry and decision-support by a regional information technology consultant (5 days), and completed a 9-month pre-trial pilot period delivering standard TB contact investigation. Prior to the launch of the trial, they completed a 5-day refresher training covering the specific behavior change techniques and intervention functions that emerged from the BCW design process. Specifically, lay health workers completed didactic and practice sessions with the components targeting uptake, including all of the client-centered education, persuasion, and enablement techniques laid out in t period .i.e., the third key behavior), including home-initiated HIV-TB testing and follow-up text messaging, in a household cluster-randomized, controlled implementation trial involving 471 eligible index TB patients and 919 household contacts (p = 0.57), and these proportions were similar to the proportion of 20% observed in the pilot study carried out prior to the implementation period. The negative trial results were primarily attributable to low fidelity delivery of the core implementation components. First, home sputum collection was successful in only 39% of eligible contacts; the reasons for failure included lay health workers not carrying enough sputum collection cups to the home visit, lay health workers being afraid of contracting TB while collecting or transporting sputum; and clients not understanding how to produce sputum and anticipating stigma if neighbors saw or overheard them in the act of expectorating  approach offer methods for organizational change . Second,The original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding author.All studies involving human participants were reviewed and approved by the Uganda National Council for Science and Technology, the Makerere University School of Medicine Research Ethics Committee, the Committee on Human Research at the University of California San Francisco, and the Yale University Human Investigation Committee. Participants and/or their legal guardians/next of kin provided written informed consent and/or assent for contact investigation study activities. In addition, health workers provided either written or verbal consent for participation in qualitative studies.Material preparation, data collection, and analysis were performed by JLD, IA, AJG, MA-H, JG, EO, DB, and PT. The first draft of the manuscript was written by JLD. All authors commented on previous versions of the manuscript, read and approved the final manuscript, and contributed to the study conception and design.This work was funded by NIH R01AI104824 (JLD), Nina Ireland Program in Lung Health, University of California, San Francisco (JLD), and NIH D43TW009607 (JLD).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The COVID-19 pandemic has increased the demand for youth mental health services in Canada as disruptions to clinical care continue to persist due to the risk of transmission and exposure to the virus. Digital mental health interventions, including web-based resources and mobile apps, have provided opportunities to support youth mental health remotely across Canada. There is a need to better understand how these digital interventions are being selected, recommended, and used in various regions across Canada.A national jurisdictional scan was completed to (1) determine what web-based programs, apps, and websites are promoted and licensed in Canada for youth mental health; (2) identify criteria and decision-making processes that Canadian jurisdictions use to select web-based programs, apps, and websites for youth mental health; and (3) identify upcoming trends, innovations, and digital mental health possibilities that are emerging in the youth sector.The aims of the jurisdictional scan were addressed through a review of related academic and grey literature; stakeholder interviews, including individuals involved in various areas of the youth mental health sector; and a social media review of pertinent Twitter content.A total of 66 web-based resources and apps were identified for use by youth in Canada. 16 stakeholder interviews were completed and included discussions with researchers, clinicians, youth organizations, and others involved in digital interventions for youth mental health. These discussions identified a limited use of frameworks used to guide decision-making processes when selecting digital interventions. Many clinicians agreed on a similar set of eligibility requirements for youth mental health apps and digital resources, such as the evidence base and cultural relevance of the intervention. Stakeholders also identified upcoming trends and innovations in the youth digital mental health space, including artificial intelligence, digital phenotyping, and personalized therapy. Over 4 weeks, 2184 tweets were reviewed to identify and compare global and national trends and innovations involving digital mental health and youth. Key trends included the promotion of regional chat services as well as the effects of the COVID-19 pandemic on youth mental health and access to care.As organizations begin to plan for the delivery of mental health care following the pandemic, there are concerns about the sustainability of these digital mental health interventions as well as a need for services to be more informed by the experiences and preferences of youth. Canadian jurisdictions have significantly altered their delivery of mental health care for youth over the past year, given the rising need for mental health services related to the COVID-19 pandemic . In consTo identify digital mental health resources, criteria, and decision-making processes used to select resources, and upcoming trends and innovations, the following aims were established:Determine what web-based programs, apps, and websites are promoted and/or licensed by Canadian jurisdictions  for youth mental health.Identify criteria and decision-making processes that Canadian jurisdictions use to select web-based programs, apps, and websites for youth mental health.Identify upcoming trends, innovations, and digital mental health possibilities that are emerging in the youth sector.A review of current academic and grey literature was completed, including searches of databases , reports, working papers, and presentations from Canadian digital health organizations. Titles and abstracts were reviewed to determine if information about youth mental health and digital interventions was included. Sources that met this inclusion criterion were then subjected to rapid content analysis and were organized based on identified themes. App stores, including the Google Play Store and Apple App Store, were also reviewed to identify digital mental health apps currently available to youth in Canada.sources such as websites and mobile apps. Trending and emerging innovations were also discussed, and all participants were able to provide additional information relevant to the topic. One research member took notes during each interview, and this information was later used for thematic analysis to identify key themes.A series of key stakeholder interviews were conducted with representatives across Canada. Single interviews were conducted by two members of the research team via videoconferencing or telephone and followed a semistructured design based on a set of six questions. Participants were asked to discuss the criteria their organization uses to select resources for youth or decision-making processes/appraisals that are used to evaluate digital reData mining techniques and content analysis were used to retrieve and analyze information collected from the Twitter application programming interface over 4 weeks using a Twitter Archiving Google Sheet (TAGS). As Twitter is a platform commonly used by researchers, clinicians, youth organizations, health care leaders, and others involved in youth mental health care, Twitter data provided a snapshot of in-the-moment insights into trending topics and innovations related to digital mental health interventions for youth during the COVID-19 pandemic. These trends were identified to understand the similarities or disparities between the experiences of national and international stakeholders.Further information about the methodology used for this research is available upon request from the corresponding author.A total of 66 digital interventions were identified as promoted or licensed by Canadian jurisdictions and organized based on their delivery methods, including web-based resources or mobile apps. Information was recorded for each resource based on the American Psychiatric Associations App Evaluation Model . A complThe review of related literature identified current trends in the youth digital mental health space. A common theme that was highlighted throughout the review of the literature was the limited availability of evidence-based apps. Numerous reviews revealed that formal evaluation methods were often not used to support the use of mobile apps for youth mental health, raising concerns about the efficacy of digital interventions used in clinical settings -8. ReseaResearch studies also reviewed the use of evaluation methods for digital mental health interventions for youth and provided various metrics used to quantify effectiveness and improvements to mental health -11. A syCo-design was identified as a powerful tool in the development of digital mental health interventions for children and youth. Researchers indicated that there is a need for co-design with youth, including “creative collaboration, varying stages of involvement, collaboration activities, user-engagement techniques, prototype development, and consideration for diversity within youth populations” .Most of the articles focused on the development and use of mobile apps targeting child and youth experiences with anxiety and depression -16. TherGamification was also identified as a prominent topic in the results of the review. Some considerations were discussed that can address the needs of specific youth groups who may benefit from the use of personalized game-based interventions -21. SomeA total of 16 stakeholders, including clinicians, researchers, youth organizations, online therapists, business analysts, and others involved in the youth mental health space, took part in the interviews. Organizations included representation from numerous regions within Canada, including Ontario, British Columbia, Alberta, and Nova Scotia, as well as the US state of Massachusetts. Stakeholders discussed the digital mental health interventions they currently use, that their organization endorses, or that they are involved in for research purposes.Additionally, the stakeholders discussed the need for improved guidance when selecting and appraising digital mental health interventions for youth. Overall, most respondents relied on individual selection criteria to inform their decision-making processes as opposed to standardized frameworks. The discussions with stakeholders also identified new trends and innovations these individuals and organizations have seen in the youth digital mental health space. A total of 2184 tweets containing content or hashtags relating to digital interventions for youth mental health were included. Of these tweets, themes included promotion of regional chat services, such as text and telephone lines available 24 hours per day, 7 days per week for youth mental health support. Effects of isolation due to COVID-19 on youth mental health were highlighted, primarily concerning families who have experienced suicide and self-harm in youth . A greatAlthough digital mental health interventions can provide great benefit during the COVID-19 pandemic, there is concern among some clinicians and researchers about the sustainability of these interventions once in-person care resumes across Canada. As digital mental health interventions are developed for youth, there needs to be increased awareness of how these interventions are being selected and the opportunities to better integrate these interventions with clinical care. One consideration includes improved transparency and quality considerations in how digital mental health interventions are selected, as shown in Current literature, key stakeholder interviews, and mining of a social networking platform all point to the need for a greater understanding of digital intervention use for youth mental health during and beyond the COVID-19 pandemic. The use of digital interventions such as web-based resources and apps can be driven using suitable frameworks and selection criteria. Upcoming trends and innovations indicate an opportunity to improve and expand the use of digital interventions for youth in Canada.


More than 61% of all human pathogens are zoonotic, representing 75% of all emerging pathogens during the past decade. Albeit significant technological leaps in diagnostics development and disease surveillance, zoonotic emerging infectious diseases are evermore a matter of concern, particularly in modern days where global warming keeps providing ideal climatic conditions to the introduction of exotic infectious agents or disease vectors in new territories. Worryingly, the 2019 novel coronavirus epidemic acts as an extreme reminder of the role animal reservoirs play in public health, accounting for over 4,200,000 deaths worldwide until today. In this Special Issue, we approach a myriad of zoonotic infectious diseases and their complex mechanisms. This Special Issue is composed of three reviews on zoonotic diseases of African Lions, hemogregarine classification, and hepatitis E virus in Brazil, followed by one letter and one opinion piece that broadens the spectrum of disease emergence to mechanistic aspects of emerging non-communicable diseases. The Special Issue is completed by six research papers covering a wide array of emerging and re-emerging diseases of poultry, bovine, poultry and tortoises, of various nature such as parasitic, bacterial, and viral. This is a brief but assertive collection that showcases the need to address health at the animal–human–environment interface, in a One Health perspective. The notion of crossing the species barrier in infectious diseases derives from the relationship between infectious agents, such as viruses and bacteria, and their host species, which is restricted by genetic adaptations that develop through co-evolution . SpillovThis Special Issue of Animals: “Emerging and Re-Emerging Diseases—Novel Challenges in Today’s World”, presents a total of 11 manuscripts focusing on an important group of aspects related to diseases that are found to significantly imbalance ecosystems where humans/animals, pathogens, and the environment interact.Panthera leo) that are bred in captivity on commercial farms across South Africa and often have close contact with farm staff, tourists, and other industry workers, hence posing a potential risk of disease interchange between lions and humans [It first starts with three interesting reviews, the first on zoonotic diseases of African Lions, (d humans . The sysd humans  is focusd humans . The revThese reviews are followed by one letter and one opinion piece that broadens the spectrum of disease emergence to mechanistic aspects of emerging non-communicable diseases by developing the topic of trefoil factor family member 2 (TFF2), discussing, particularly, the role of high-fat diet-induced TFF2 in counteracting immune-mediated damage  and as aCygnus cygnus) from rescue/rehabilitation centers in Honshu, Japan, reporting that swans most likely died from obstructive phlebitis associated with Allobilharzia visceralis [Salmonella Minnesota, with the genomic characterization of clonal lineages associated with poultry production in Brazil, demonstrating the dissemination of two distinct S. Minnesota lineages with high resistance to antibiotics and important virulence genetic clusters in Brazilian poultry farms [Hyalomma aegyptium ticks from tortoises of a black market in Doha, Qatar. This study includes the detection of Hemolivia mauritanica, Ehrlichia spp., and Candidatus Midichloria Mitochondrii and highlights the dangers of the international trade of tortoises carrying ticks infected with pathogens of veterinary and medical importance [The Special Issue is completed by six research papers covering a wide array of emerging and re-emerging diseases of poultry, bovine, poultry and tortoises, of various nature such as parasitic, bacterial, and viral. The first is a descriptive pathological study of avian schistosomes infection in Whooper Swans (sceralis . Additiory farms . A studyry farms . This Isry farms . This arry farms . Lastly,portance .This is a brief but assertive collection that showcases the need to address health at the animal–human–environment interface, in a One Health approach. The global perspective highlighted by the content of this Special Issue reinforces the need of joint and wide efforts by stakeholders.


Viruses and for expert researchers in the related scientific areas. The sustainable methodologies tackled by basic researchers could hopefully pave the way for highly valid preventions and/or treatments for infectious diseases caused by various human RNA viruses. Numerous species of RNA viruses pathogenic for humans are present worldwide. They are highly divergent in biological and molecular properties, and are therefore classified into distinct viral families. Of particular note, these parasitic entities can diversify significantly in their own groups to resist natural and artificial environmental changes that happen to be hostile to their existence. These adaptation events in pathogenic RNA viruses that currently represent major medical issues, sometimes deadly and highly transmittable infectious diseases, should be settled as promptly as possible. Through extensive experimental studies, we virologists have found and are presently learning how ingeniously RNA viruses of various species generate their genetic variant progenies for survival. In order to fully understand their pathogenic potentials and to effectively fight against them, some kinds of demonstrative model studies are prerequisite for successful establishment of anti-RNA virus strategies, such as vaccines and antiviral drug development. In this Special Issue named “Cell, Organoid and Animal Models to Study Pathogenic Human RNA Viruses”, we focus on these model studies to provide useful relevant information on the topic for devoted readers of Retroviridae), measles virus (Paramyxoviridae), and Zika virus (Flaviviridae). Review articles: Rotavirus (Reoviridae), influenza virus (Orthomyxoviridae), norovirus , astrovirus (Astroviridae), coronavirus SARS-CoV-2 (Coronaviridae), and human immunodeficiency virus (HIV) (Retroviridae). The authors have clearly described or summarized the details of the experimental systems used for the studies and the results obtained by the studies.Original research and review articles are included in this Special Issue. Target viruses for studies are as follows. Original research articles: Simian immunodeficiency virus (SIV) (Family Finally, we editors greatly appreciate all contributors to this Special Issue for their excellent works. We are happy with the final version of the issue and are very proud of the contributed articles.


Populations affected by humanitarian emergencies are vulnerable to substance  use disorders, yet treatment and prevention services are scarce. Delivering substance use disorder treatment services in humanitarian settings is hampered by limited guidance around the preparation, implementation, and evaluation of substance use disorder treatment programs. This study aims to identify and prioritize key gaps and opportunities for addressing substance use disorder in humanitarian settings.UNODC convened a consultation meeting (n = 110) in coordination with UNHCR and WHO and administered an online survey (n = 34) to, thirteen program administrators and policymakers, eleven service providers, nine researchers, and one person with lived experience to explore best practices and challenges to addressing substance use disorder in diverse populations and contexts. Participants presented best practices for addressing substance use disorder, identified and ranked challenges and opportunities for improving the delivery of substance use disorder treatment interventions, and provided recommendations for guidelines that would facilitate the delivery of substance use disorder treatment services in humanitarian emergencies.Participants agreed on key principles for delivering substance use disorder treatment in humanitarian settings that centered on community engagement and building trust, integrated service delivery models, reducing stigma, considering culture and context in service delivery, and an ethical ‘do no harm’ approach. Specific gaps in knowledge that precluded the delivery of appropriate substance use disorder treatment include limited knowledge of the burden and patterns of substance use in humanitarian settings, the effectiveness of substance use disorder treatment services in humanitarian settings, and strategies for adapting and implementing interventions for a given population and humanitarian context. Participants emphasized the need to strengthen awareness and commitment related to the burden of substance use disorder treatment interventions among communities, practitioners, and policymakers in humanitarian settings.Results from this consultation process highlight existing gaps in knowledge related to the epidemiology and treatment of substance use disorders in humanitarian emergencies. Epidemiological, intervention, and implementation research as well as operational guidance are needed to fill these gaps and improve access to substance use treatment services in humanitarian settings.The online version contains supplementary material available at 10.1186/s13031-021-00407-z. Global displacement reached unprecedented levels in 2021 with over 80 million people forced to flee their homes due to humanitarian emergencies , have shPopulations affected by humanitarian emergencies may experience an elevated vulnerability to alcohol and other drug use disorders, hereafter referred to as ‘substance use disorders’. While there is an absence of prospective longitudinal studies examining changes in risk and incidence of substance use disorder among populations affected by humanitarian emergencies, qualitative and quantitative cross-sectional or retrospective studies suggest that exposure to humanitarian emergencies is associated with substance use disorder and related harms. For example, a systematic review of opiate use in the context of armed conflict found that five out of six studies suggested that opiate use and related harms, including hospital admissions and drug-related deaths, increased after periods of armed conflict . ElevateWhile the mental health and substance use disorder-related needs of those in humanitarian settings are high, resources are scarce and the existing health infrastructure is often too overwhelmed to provide sufficient care to all those who need it , 18. AddAlthough interventions and guidelines have been developed to address substance disorders in humanitarian settings –27, therCalls to expand the knowledge base for substance use disorder interventions, reflect humanitarian programming capacities and practitioners’ need for additional guidance to inform planning and implementation for these programs –31. The In September 2020, UNODC in coordination with the United Nations High Commissioner for Refugees (UNHCR) and the World Health Organization (WHO), convened a three-day expert consultation meeting. Participants were invited by stakeholders to participate based on their role as a policymaker, practitioner, advocate, researcher, or person with lived experience working on issues related to substance use interventions in humanitarian settings. United Nations Member States were invited to nominate a representative to attend the meeting and other experts were identified through referral and the networks of UNODC and other meeting organizers. We also invited authors of relevant publications that were identified through literature review. No additional eligibility criteria were set for participation. The meeting included presentations on best practices, experiences, and research from 55 participants. Plenary discussion and small breakout groups were used to identify key populations, gaps in knowledge, principles, and resources needed to improve the treatment of substance use disorder in humanitarian emergencies. One member of our team took detailed notes on each presentation and discussion, which were also recorded. We collected all presentation materials from participants for the analysis.In February 2021, all expert consultation meeting attendees who were not directly involved in the development of the technical handbook (n = 92) were invited to participate in a 20-min online survey  and review of codes by another author (MCG). For questions that involved ranking response options, we calculated the median rank across all interviews to estimate the relative priority of responses.Consultation meeting attendees included 110 participants from 32 countries in Europe (n = 61), Latin America and the Caribbean (n = 4), the Middle East and North Africa (n = 7), North America (n = 10), South Asia (n = 7), South East Asia and the Pacific (n = 7), and sub-Saharan Africa (n = 14). Fifty (45.5%) of participants were female. Professional roles included policymaker or UN/government advisor (48.6%), practitioner (28.6%), researcher (20.0%), or advocate (2.9%) working on issues related to substance use interventions in humanitarian settings. Some participants possess multiple professional roles; however, those reported reflect the role that most closely relates to their primary title and affiliation.Through the content analysis of meeting notes and presentation materials we identified a set of guiding principles for addressing substance use and substance use disorders in humanitarian settings, which included building trust; community engagement, including people with lived experience, families, and caregivers; reducing stigma; ensuring that programs are inter-sectoral, integrated, inclusive, and inter-layered; promoting dignity and empathy; ensuring an ethical ‘do no harm’ approach; and considering culture and context in the design and implementation of substance use disorder treatment programs in humanitarian emergencies.Thirty-four experts completed an online survey, of whom 11 (32%) were health or low-threshold service providers, 11 (32%) were program planners or administrators, 2 (6%) were policymakers, 1 (3%) was a person with lived experience, and 9 (26%) were researchers/academicians. Of the respondents, 16 (47%) work in humanitarian settings, 4 (12%) work in non-humanitarian settings, and 14 (41%) were not specified.The online survey participants identified seven key gaps in knowledge regarding the epidemiology and treatment of substance use disorders in humanitarian settings: (1) Substance-use disorder related needs, prevalence of substance use and substance use disorder, and burden of substance use disorder in humanitarian settings ; (2) Substance use disorder treatment options and their relative effectiveness and feasibility in humanitarian settings ; (3) The role of context in substance use disorder and implementation of treatment and care services ; (4) Capacity needed to provide substance use disorder assessment, treatment, and advocacy ; (5) Stigma ; (6) Substance use disorder comorbidities ; and (7) Availability and utilization of substance use services . Survey participants reported challenges navigating existing operational guidelines to select appropriate interventions, adapting clinical guidelines and implementation approaches in diverse contexts, and generating relevant policy frameworks to inform systems- and policy-level strategies to promote the provision of substance use disorder treatment services for people in need in humanitarian emergencies.After describing gaps in knowledge and skills needed to deliver substance use disorder treatments, survey participants were prompted to ascertain the most critical challenges experienced when delivering substance use disorder treatment services in humanitarian settings. At the policy level, both lack of political prioritization and other legal and political constraints were noted as barriers to implementing substance use disorder treatment. The lack of political will, which can be defined as the lack of “committed support among key decision makers for a particular policy solution to a particular problem,”  was attrChallenges related to capacity and knowledge presented obstacles to service delivery. 29% of survey participants mentioned that the lack of skills and resources dedicated to substance use and substance use disorders make it challenging to design and implement treatment interventions. Often, substance use interventions are not addressed due to competing demands on humanitarian agencies and individual provider time. One respondent stated that “support staff like psychiatric nurses and social workers are very difficult to find and there are no training programs to support current models of treatment.” The limited training and capacity were attributed to outdated research and service delivery guidelines. Even in the presence of up-to-date guidance and information, cultural and language barriers present challenges to delivering substance use services in humanitarian emergencies. A consistent theme in the consultation meeting and the online survey related to the uncertainty about how to adapt evidence-based substance use interventions in situations when existing guidance did not fit the needs of a specific population or the resources available in a given humanitarian context.A central challenge that influenced all other determinants of substance use disorder treatment delivery in humanitarian settings was stigma. People living with a substance use disorder often face social and structural stigma, especially in certain cultural contexts, which can influence how services are implemented and prioritized, help-seeking and utilization of services, and community support. Individuals with substance use disorder displaced by humanitarian emergencies were described as experiencing double-stigma due to substance use disorder and due to being displaced. Gender was described as a factor that modified stigma toward substance use, usually with women experiencing greater stigma relative to men.Online survey participants ranked substance use assessment and intervention activities according to which they thought were most essential Table . The mosSurvey participants indicated that additional guidance is needed to plan for, implement, and evaluate substance use disorder treatment programs in humanitarian settings. In the planning phase, survey respondents reported that knowledge about the epidemiology of substance use disorder in the community is critical to preparing relevant programs , human resource capacity, stigma, and limited advocacy for services were central barriers to service delivery . In contRecommended adaptations to existing substance use disorder assessment tools and treatment guidelines related more to improving the fit and cultural relevance of the intervention as opposed to adapting implementation processes to operate within available resources, capacities, and type of emergency setting. We anticipated that potentially life-saving interventions, such as overdose management, acute withdrawal management and other interventions to reduce the negative health and social consequences of substance use would be prioritized during acute emergencies while other potentially longer-term psychosocial and pharmacological drug use disorder treatment interventions would be increasingly prioritized in protracted or stabilized settings. Instead, participants considered increasing access to services, raising awareness, and psychoeducation as the most highly prioritized activities in both acute and protracted emergencies. This finding is consistent with many of the minimum health services required to minimize harms related to alcohol and other substance use in emergencies .Several recommendations emerged for strengthening community-based strategies for addressing substance use disorder in humanitarian settings. First, building community awareness and psychoeducation about substance use disorder was described as essential for improving help-seeking and treatment utilization, which is consistent with prior research among conflict-affected and displaced populations , 36, 37.Implementation priorities, such as the need to increase access to services and health systems strengthening, reflects the preference among refugee participants for coordinated and integrated care models. Intersectionality and the role of social and structural determinants of health in substance use disorder in humanitarian settings emerged as an important gap in existing knowledge that is consistent with prior qualitative research with populations affected by humanitarian emergencies , 42. OveThrough this expert consultation process we identified some key gaps in knowledge, challenges, and priorities for addressing substance use disorders in humanitarian settings. These findings build on existing research documenting current gaps in research and practice within the context of a high and growing burden of substance use disorders globally –45, and A strength of this approach was that the consultation process enabled the investigators to draw from the experience of stakeholders with diverse professional roles  in humanitarian response and/or substance use epidemiology, treatment, and policy. Representation of people with lived experience was limited, which was due, in part, to our recruitment strategy. This research would be strengthened by inclusion of individuals with a history of substance use disorder in a humanitarian setting. We did not collect detailed demographic or other information from participants. However, UNODC operates based on UN rules and regulations and always seeks to have a balance in gender and regional representation in its activities to the extent possible. Few participants possessed expertise in both humanitarian assistance and substance use programming, further highlighting the need to build capacity in this area. Furthermore, recruitment relied on expert nominations from various stakeholders and we did not collect information about individuals who were not selected or declined participation. Our small sample size in the online survey also limits generalizability of these findings or examining differences across world regions, professional role, or other factors. Additionally, the survey was designed by study investigators primarily to inform the development of a technical handbook and, while the survey questions were informed by the key findings of the expert meeting, they were not drawn from standardized or validated measurement tools, which precludes our ability to directly compare our findings to previous research.Findings from this study suggest future directions for both research and practice. Critical gaps in knowledge related to the burden and patterns of substance use disorder, the effectiveness of treatment interventions, and the processes for implementing services to address substance use disorders in humanitarian settings are pervasive. Epidemiological, intervention, and implementation research are needed to fill these gaps in knowledge. For practitioners, guidance is needed to translate existing and forthcoming evidence into practice including processes for adaptation, implementation, and evaluation of substance use disorder treatment interventions. Further models are needed to integrate substance use services within mental healthcare and positioned within existing health systems to reduce fragmentation and promote sustainability. In all these future efforts, participation of communities, caregivers, and people with lived experience is needed to reduce the health and social burden caused by substance use disorders and improve the relevance and acceptability of substance use assessments and interventions.Additional file 1. Online survey questions and detailed results.


IPF: Societies) is an interrelated set of strategies that can help ProSs change leaders  and organizations identify and address mental models hindering DEI reform. The IPF: Societies uses four “I's”—Identity awareness and Intercultural mindfulness  upon which inclusive relationships and Influential DEI actions are scaffolded. We discuss how the IPF: Societies complements existing DEI tools . We explain how the IPF: Societies can be applied to existing ProS policy and practice associated with common ProS functions . The next steps are to pilot the IPF: Societies with a cohort of STEM ProSs. Ultimately, the IPF: Societies has potential to promote more efficient, effective, and lasting DEI organizational transformation and contribute to inclusive STEM disciplinary excellence.Science, technology, engineering, and mathematics (STEM) professional societies (ProSs) are uniquely positioned to foster national-level diversity, equity, and inclusion (DEI) reform. ProSs serve broad memberships, define disciplinary norms and culture, and inform accrediting bodies and thus provide critical levers for systems change. STEM ProSs could be instrumental in achieving the DEI system reform necessary to optimize engagement of all STEM talent, leveraging disciplinary excellence resulting from diverse teams. Inclusive STEM system reform requires that underlying “mental models” be examined. The Inclusive Professional Framework for Societies ( Addressing complex global challenges, such as climate change and health disparities, requires optimal engagement of people trained in science, technology, engineering, and mathematics (STEM). Because diverse teams embody enhanced capacity for problem solving, innovation, and resilience, they advance disciplinary excellence in a way that homogenous groups cannot e.g., . ConsequUnfortunately, STEM cultures often discourage diversity by reproducing exclusionary norms and values . CurrentWhile STEM systems reform is clearly needed to attract, retain, and support a thriving diverse STEM talent pool, there is widespread expectation that minoritized and marginalized people will, and should be, the ones tasked with changing a system by which they are oppressed and largely excluded . Majoritpolicies, practices, resource flows), semi-explicit , and implicit . Mental models hold the other conditions in place. Unless we learn to work at the mental models level, other structural changes “...will, at best, be temporary or incomplete” , STEM ProSs are uniquely positioned as critical levers for STEM systems change e.g., . Peters Inclusive Professional Framework for Disciplinary and Professional Societies (IPF: Societies) as an approach to help elucidate and adjust mental models that underlie STEM ProS functions . The IPF: Faculty was developed by the Aspire Alliance's National Change Initiative, which is part of the National Science Foundation's Inclusion across the Nation of Communities of Learners of Underrepresented Discoverers in Engineering and Science (NSF INCLUDES). The IPF: Societies was developed with input from leaders from the NSF ADVANCE-funded IPF: Societies graphic was created, along with example functions  differ is in the contexts and roles of those applying the framework. The IPF: Faculty was developed to promote inclusive skill development for faculty across their roles within academic institutions  , in the various functions that the society performs for its members and discipline, as discussed in greater detail below (see IPF: Societies with example ProS functions).Given the parallel role that mental models play in university and ProS systems, we propose that it is valuable to adapt the dership) . For theIPF: Societies has dual target audience foci: 1) DEI change leaders  and 2) the ProSs as a system . Key individuals within the organizational system are ProS DEI change leaders, known as “boundary spanners,” who are people within an organization who work to connect ideas, resources, and stakeholders  and external-focus  DEI awareness and organizational capacity are enhanced, better positioning ProSs to enact DEI systems change.The eholders . These ieholders ; 2) traneholders ; 3) diffeholders ; 4) gaineholders ; and 5) eholders . Boundareholders . We propM system . SimilarIPF: Societies' processes, showing how the equity mindset is developed and expands into relationships and actions that guide ProS core functioning, catalyzing STEM DEI systems change. We propose that the IPF: Societies can be usefully applied at both individual and organizational levels. Below we describe specific aspects of the IPF: Societies as well as its application.Identity awareness is an awareness of aspects of one's own social and cultural identities and how those identities are situated within larger intersecting systems of power. Intercultural mindfulness is the “ability to understand cultural differences in ways that enable one to interact effectively with others from different racial, ethnic, or social identity groups in both domestic and international contexts” . CollectEquity mindedness underpins building inclusive relationships. At both personal and organizational levels, willingness, capacity, and the communication skills to effectively engage those whose lived experiences may not match one's own is vital for examining mental models and advancing inclusive ProS DEI reform. At the boundary spanner level, inclusive relationships mean reflecting on whose voices are, and are not, centered and carry decision-making power when discussing important ProS policies, processes, and activities. From the STEM ProS perspective, building inclusive relationships could be reflected in collaborations with a range of organizations with intention to build mutual capacity. Inclusive relationships at the society level help shift social narratives and can inform sense making around information collected about the ProS, two examples of how mental models have critical impact on organizational systems .IPF: Societies-informed boundary spanners will engage in the influential actions associated with establishing new mental models and create accountability for nurturing the new diverse, equitable, and inclusive ProS look, feel, and actions.Influential actions are how boundary spanners and ProSs drive STEM system change. We propose that informed and diversely networked people serving as DEI boundary spanners will be motivated and held accountable for positive DEI change. Boundary spanners' actions can be focused on core ProS functions. Peters and others (2021) identified 11 functions of STEM ProSs for action focus. For explanatory purposes, we focus on a subset of five ProS functions identified by IPF: Societies complements the use of other DEI organizational tools and increases both individual and organizational capacity to more efficiently and effectively identify and engage with DEI actions resulting from use of these tools. For example, we offer the Women in Engineering ProActive Network's (WEPAN's) Four Frames for Promoting Gender Equity Within Organizations ; examine and recommend DEI changes to organizational structures, policies, and practices (Frame 2); call attention to ways in which ProS leaders and the organization are not “walking the DEI walk” (Frame 3); and identify and remedy incongruences between ProS existing practices and goals outlined in the ProS strategic plan (Frame 4). Similarly, from an organizational perspective, WEPAN's frames could be used to evaluate the equity of professional development programs and educational pathways (Frame 1); examine and revise organizational structures, policies, and practices to support greater DEI integration across all society functions (Frame 2); ensure that all leaders are, and continue to be, trained and coached on how to enact DEI-focused changes (Frame 3); and create opportunities to re-vision ProS culture and reflect that updated vision in the ProS mission and strategic plans (Frame 4).The izations . OriginaIPF: Societies complements the Equity Environmental Scanning Tool (EEST)  of IPF: Societies lens to the policies and practices associated with each of these functions will help uncover and offer an opportunity to change previously implicit ProS mental models. We use questions to illustrate application of the IPF: Societies. In each core ProS function (column 1), existing policies or practices are presented that might appear reasonable to some (column 2), but when the IPF: Societies lens is applied (column 3), systemic and structural inequities affecting how the ProS engages with staff and members become more visible. We offer example ideas of equitable practices that could emerge from application of the IPF: Societies (column 4). This table shows how the ProS may not be making programming decisions with an understanding of structural issues , therefore missing out on the opportunity to address them and counter obstacles to DEI through inclusive relationships and influential actions.As with WEPAN's four frames, the l (EEST) . The EESIPF: Societies is brought into the ProS DEI change cycle will likely be dictated by the culture of the ProS and/or ProS leaders. Examples for how the IPF: Societies can be used and inform engagement is depicted in When and where the IPF: Societies provide a framework for reflecting and acting on ProS culture at individual  and organizational levels. The IPF: Societies offers a way to guide change of mental models. ProS DEI boundary spanners employing the IPF: Societies can leverage their positionality and ability to straddle groups to affect cultural change across STEM ProSs, in combination with the efforts of other boundary spanners and in the disciplines in which they engage.In sum, Identity awareness and Intercultural mindfulness create an equity mindset that supports inclusive relationships and influential actions. The four “I's” core to the IPF: Societies offers a framework to begin difficult discussions and offers a structured approach for working toward change. Of course, to be effective, the IPF: Societies requires sustained mobilization of its pieces, vis-à-vis making DEI concerns part of the fabric of ProSs.Of critical importance when working with mental models in ProSs is the expectation that there may be resistance to DEI initiatives, especially among members with majoritized identities who may be invested, even subconsciously, in maintaining existing power structures . BecauseIPF: Societies could be ProS actions in service of a more diverse, inclusive, and equitable STEM culture writ large. Resultant increased individual capacity to engage in the articulation and reframing of legacy mental models in turn guides organizational transformation and culture reform through broader systems change. As organizations engage in systemic change, greater ProS and STEM culture DEI changes can be made. Eventually, DEI change becomes less about individual efforts for specific DEI actions and more about broad, structurally patterned ProS organizational transformation and, ultimately, STEM culture reform.Potential outcomes of wide-scale implementation of the


Pennisetum glaucum R. Br.) is an important staple and nutritious food crop in the semiarid and arid ecologies of South Asia (SA) and Sub-Saharan Africa (SSA). In view of climate change, depleting water resources, and widespread malnutrition, there is a need to accelerate the rate of genetic gains in pearl millet productivity. This review discusses past strategies and future approaches to accelerate genetic gains to meet future demand. Pearl millet breeding in India has historically evolved very comprehensively from open-pollinated varieties development to hybrid breeding. Availability of stable cytoplasmic male sterility system with adequate restorers and strategic use of genetic resources from India and SSA laid the strong foundation of hybrid breeding. Genetic and cytoplasmic diversification of hybrid parental lines, periodic replacement of hybrids, and breeding disease-resistant and stress-tolerant cultivars have been areas of very high priority. As a result, an annual yield increase of 4% has been realized in the last three decades. There is considerable scope to further accelerate the efforts on hybrid breeding for drought-prone areas in SA and SSA. Heterotic grouping of hybrid parental lines is essential to sustain long-term genetic gains. Time is now ripe for mainstreaming of the nutritional traits improvement in pearl millet breeding programs. New opportunities are emerging to improve the efficiency and precision of breeding. Development and application of high-throughput genomic tools, speed breeding, and precision phenotyping protocols need to be intensified to exploit a huge wealth of native genetic variation available in pearl millet to accelerate the genetic gains.Pearl millet ( Pennisetum glaucum R. Br.) is an important crop in the semiarid and arid ecologies of South Asia (SA) and sub-Saharan Africa (SSA) that are characteristically challenged by low and erratic rainfall and high mean temperature and simultaneously have soils with low organic carbon and poor water-holding capacity  in 1958 Burton,  at TiftoRecurring DM epidemics in pearl millet hybrids in India prompted to intensify efforts on genetic diversification of hybrid parental lines, especially after the 1980s. This involved both cytoplasmic and nuclear diversification of parental lines. In addition to A1 CMS source Burton, , A2, A3 A range of germplasm material from India and Africa with diverse phenotypic characteristics, such as tillering, panicle size, earliness, grain size, grain color, and so on, was strategically exploited to diversify the genetic base of both seed and restorer parents  to extremely challenging drought-prone environments . This led to the prioritization of research to improve necessary phenotypic traits, climate adaption, disease resistance, and nutritional traits taking full cognizance of production constraints and differential requirements of various regions.A single pearl millet cultivar cannot be expected to perform well under all the environmental conditions, and a cultivar planted outside its adaptation zone would suffer yield reduction due to significant genotype × environment interactions. Therefore, breeding and evaluation require a subdivision of the testing environments into relatively more homogeneous groups of locations, called megaenvironments, where specific genotypes can be targeted for individual megaenvironment.1, A, and B zones) considering the geographical location, rainfall pattern, local adaptation, and other environmental conditions , and seed size and have been strategically manipulated. Genetic variation for these traits is widely available with high heritability , is the most important consideration. High yield, however, is achieved in combination with other agronomic and farmers' preferred traits. The foremost requirement in the restorer lines is to produce highly fertile hybrids and to produce profuse pollen that remains viable at air temperatures as high as 42–44°C. It is desirable to breed pollinators that are taller than A lines, usually in the range of 150–180-cm height.The A lines have been bred for complete and stable male sterility and B lines for profuse pollen production ability across the seasons and sites. In the breeding of A lines, high grain yield potential, both as lines There has been a clear distinction between the public and private sector hybrid breeding programs regarding trait-based breeding. For instance, private sector breeding programs have largely focused on relatively better-endowed environments (A and B zones), giving greater emphasis to breeding dual-purpose hybrids. As a result, private sector hybrids are generally taller, later in maturity, with longer panicles and less number of effective tillers/plant  as these traits are reported to contribute toward higher productivity in better-endowed environments. In contrast, most of the public sector hybrids are generally shorter in height and early in maturity, with smaller panicles and a higher number of effective tillers/plant. The private sector has also placed greater emphasis on breeding high grain yield and large-seeded hybrids.The strategy of trait diversification led to the development of a diverse array of high-yielding hybrids with adequate adaptation to different agroecologies. This was evidenced from a recent investigation where 122 commercial hybrids showed the existence of significant variation for flowering time (42–58 days), tillering (1.1–4.4 panicles/plant), individual grain size (7.6–17.3 mg), plant height (185–268 cm), and panicle length (20–33 cm), which highlighted the successful efforts of the national program of pearl millet improvement toward genetic diversification of hybrids  and field conditions in heat stress–prone target ecology  as it does not incur an additional cost.Disease management through HPR involves a sound knowledge of biology and epidemiology of diseases, availability of pure culture of the pathogens, effective inoculation techniques, greenhouse and field screening facilities, appropriate disease rating scales, and availability of resistance sources.Sclerospora graminicola (Sacc.) J. Schröt is the most important disease causing heavy economic losses in India and Africa. Greenhouse and field screening of a large number of germplasm accessions and breeding lines has led to the identification of several resistance sources  is generally considered as a disease of less importance in the grain crop; however, it is of great importance in fodder crop where it reduces both the quantity and quality of the produce. The field screening in the late rainy season under high disease pressure and greenhouse screening led to the identification of stable resistance sources  and smut (Moesziomyces penicillariae Bref. Vanky) are important floral diseases, and grain yield losses are proportional to their severity. Both pathogens are soil-borne and infect the host at flowering through stigma. Pollination before pathogen infection prevents infection , stem borers  and white grubs (Holotrichia consanguinea) in India, earhead worms (Helicoverpa armigera), gray weevil (Myllocerus species), and leaf roller  . Thus, high general combiners are likely to occur in lines with high grain yield per se than in any other yield group. Pearl millet breeding programs in India have been advancing progenies based on performance per se of lines during trait-based pedigree breeding, although now there is a shift toward combining ability-based selection approach. Considering the seed production economy and the high probability of producing high-yielding hybrids from high GCA lines, it is prudent that seed parents should possess both high yield per se and GCA.Combining ability studies conducted in pearl millet have shown that either there was no negative correlation or there was a positive correlation between their There is not much information available about the extent of specific combining ability (SCA) and GCA variances in the existing B- and R-gene pools of pearl millet. A recent study has shown high SCA:GCA ratio (about 2 times), indicating the predominance of SCA variance over GCA variance in pearl millet hybrid parents, which was different than many of the established maize hybrid breeding programs of the United States and Europe, where low SCA:GCA ratio was observed  including wild species provides a great resource to look for new sources of economic traits, disease resistance, abiotic stress tolerance, and better nutritional quality. A small fraction of germplasm has been utilized so far primarily due to the huge number of germplasm accessions and the presence of undesired traits in the unadapted genetic background. These twin problems have been largely circumvented. Development of core and minicore collections  under severe drought conditions, given the reports that genetically heterogeneous OPVs might exploit population buffering mechanism  would make biofortified hybrid development a regular activity to enhance genetic gains for the micronutrient traits in the long term.This is very encouraging that no negative association has been reported between grain yield and micronutrients in pearl millet, suggesting the feasibility of combining high yield with a greater concentration of micronutrients. Efficacy studies have indicated bioavailability of 7% of Fe and 25% of Zn in pearl millet. Biofortified pearl millet may provide up to 80% of Fe and 100% of Zn daily requirements and would have a greater impact on human health.Although pearl millet is mainly cultivated on sandy and sandy-loam soils that are inherently low in their nitrogen (N) and phosphorous (P) contents, its adaptation to low nutrients is seldom addressed assuming that this issue can be easily addressed through the external use of fertilizers. Limited studies conducted on this aspect . With such new facilities in place, we are now moving toward the new era of speed breeding in pearl millet where genetic gains are poised to take a further leap.Genetic gains of any breeding program significantly depend upon the number of crop breeding cycles a program can undertake in a year. This varies in different breeding programs as per their local weather conditions. For instance, only one crop of pearl millet can be taken in north India, while two crops per year can be grown in western, central, and peninsular India. Under this current scenario, breeding a new crop cultivar takes about a decade or more, with 6 or 7 years spent in seasonal generational advancements to arrive at elite materials that go for testing and release. Now, new environmentally controlled facilities, known as “RapidGen,” have been developed, which will shorten the 6–7-year window significantly. When used with the full suite of breeding acceleration techniques, RapidGen can make it possible to take four crop cycles in a year  is the ICRISAT-Private Sector Pearl Millet Seed Companies Consortium, established in 2000 and which has an engagement of ~30 seed companies. This consortium has proved to be a very effective vehicle to quickly deliver research outputs of ICRISAT's breeding program (Gowda et al., Pearl millet is becoming an indispensable food crop that provides calories, nutrition, and livelihood security to the poor and marginal people living in the fragile ecosystem of arid and semiarid regions of SA and SSA. Pearl millet is a crop of choice because of its critical role in enhancing the resilience to climate change. The past breeding priorities and strategies have been able to deliver significant productivity growth realized in pearl millet. Greater use of hybrid technology, employing modern tools, wider interinstitutional, and intersectoral partnerships, and improved crop management practices would play a greater role to accomplish much higher genetic gains for yield and nutritional traits for growing populations in SA and SSA. The success would depend upon a deeper understanding of new germplasm, genome, and trait-specific genes for novel traits through an amalgamation of conventional and modern tools and rapid generation techniques in national and international pearl millet breeding programs.OY conceived the idea of writing this review and prepared the draft of the manuscript. SG, MG, RS, RV, RKS, AR, and RM contributed and strengthened different sections included in the review. All authors read and approved the manuscript.RM was employed by company SeedWorks International Pvt Ltd, Hyderabad, India. The remaining 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.