Discussion on reducing emissions from deforestation in developing countries began at the United Nations Framework Convention on Climate Change (UNFCCC) Conference of the Parties in 2005, and the agenda for “reducing emissions from deforestation and forest degradation, and the role of conservation, sustainable management of forests and enhancement of forest carbon stocks in developing countries (REDD+)” was introduced under the UNFCCC. The REDD+ framework was developed with the expectation that it would significantly contribute to climate change mitigation at a relatively low cost and produce benefits for both developed and developing countries. Finance is a key element of REDD+ implementation, and many financial sources, approaches, and mechanisms have supported REDD+-related activities in various developing countries. However, the comprehensive challenges and lessons learned for REDD+ finance and its governance have not been fully explored. This paper reviews the relevant literature to understand the challenges for REDD+ finance and its governance in two areas—(1) REDD+ finance aligned with the UNFCCC and (2) REDD+-related finance outside the UNFCCC—which have developed differently and have different implications. This paper first identifies the six key elements of REDD+ finance and its governance across the two fields, and then reviews the related challenges and lessons learned with respect to public and private finance. The challenges for REDD+ finance and its governance aligned with the UNFCCC include enhancing the performance of REDD+ finance using mainly public finance, such as results-based finance and the jurisdictional approach. In contrast, the challenges regarding REDD+-related finance outside the UNFCCC include enhancing the engagement of the private sector in REDD+ finance, mainly targeting the project level, and the relationship between voluntary carbon markets and other investment and finance mechanisms. This paper also identifies the common challenges across REDD+ finance and its governance in the two fields. These challenges include the need to enhance linkages between REDD+ and other objectives, such as carbon neutrality/net-zero, deforestation-free supply chains, and nature-based solutions, as well as the need to develop learning systems for REDD+ finance. Although finance is a key element of REDD+ implementation, the characteristics of REDD+ finance and its governance, as well as the challenges and lessons learned to build effective REDD+ finance, have not been fully reviewed. Existing studies related to REDD+ finance have focused on particular funding sources or finance for specific programs and projects –21. TherThis review aimed to identify the challenges for REDD+ finance and its governance in two areas—(1) REDD+ finance aligned with the UNFCCC and (2) REDD+-related finance outside the UNFCCC—using the relevant literature. These challenges and experiences of REDD+ can be used for the current discussion of finance for nature-based solutions including REDD+, as presented in sections “REDD+-related finance outside the UNFCCC” and “Utilizing challenges and lessons learned to improve REDD+ finance and broader environmental finance”. In this paper, we use the term “REDD+ ” broadly, not just limited to REDD+ aligned with the UNFCCC but also including REDD+ outside the UNFCCC. This is because this term has been used broadly in practical and academic discussions. Furthermore, we define the governance of REDD+ finance as a set of processes, including interactions between institutions and actors in both the public and private sectors, aiming to promote REDD+ implementation through financing.REDD+ is one of a few items on the UNFCCC negotiation agenda that has been supported by both developed and developing countries . In theoThe Cancun Agreements clearly stated the need for providing adequate and predictable support for REDD+ in developing countries, including financial resources and technical and technological support, and requested the exploration of financing options for the full implementation of results-based activities of REDD+ (Decision 1/CP.16). Since then, results-based finance for REDD+ has been actively discussed. The UNFCCC COP18 in 2012 decided to undertake a work program on results-based finance in 2013 to ensure the full implementation of REDD+ activities and addressed options including (1) ways and means to transfer payments for results-based actions, (2) ways to incentivize non-carbon benefits, and (3) ways to improve the coordination of results-based finance . This woCurrently, REDD+ activities are financed through various sources , which are linked to different finance approaches and mechanisms  . Under tTo better understand the overall picture of REDD+ finance, this section summarizes the current status of REDD+ finance aligned with and outside the UNFCCC by highlighting public and private finance sources, which are the main financial sources in the respective areas.The REDD+ activities aligned with the UNFCCC are mainly supported by multilateral and bilateral public finance , 31. PubThe Global Environment Facility (GEF)—which serves as a financial mechanism for international environmental conventions, including the UNFCCC—has also supported REDD+ through its program on sustainable forest management (SFM) . The supIn addition to the GCF and GEF, which serve the UNFCCC, there are other types of multilateral funds and programs for REDD+, including those managed by international organizations, such as the World Bank’s Forest Carbon Partnership Facility (FCPF)—Readiness Fund (RF) and FCPF-Carbon Fund (CF), the World Bank’s Forest Investment Program (FIP), the World Bank’s BioCarbon Fund Initiative for Sustainable Forest Landscapes (ISFL), and the UN-REDD programme, which is a UN collaborative program on REDD+ led by the Food and Agriculture Organization of the United Nations, the United Nations Development Programme, and the United Nations Environment Programme. There are also multilateral funds and programs for specific countries and regions, such as the Amazon Fund (for the Brazilian Amazon), the Congo Basin Forest Fund , the Central African Forest Initiative , and REDD Early Movers . The FCPF-RF, FIP, UN-REDD programme, CBFF, and CAFI support mainly phase 1 and phase 2, while the FCPF-CF, BioCarbon Fund ISFL, Amazon Fund, and REDD Early Movers mainly support phase 2 and phase 3  REDD+ finance aligned with the UNFCCC and (2) REDD+-related finance outside the UNFCCC. Figure We collected the academic literature through the Web of Science  and selected the papers published in and after 2015, which is the year the Paris Agreement was adopted. Although REDD+ has been formally stated in the UNFCCC decision since 2007, the issues in the REDD+ finance debate have changed along with the discussion of the institutional design of REDD+ under the UNFCCC. Because the primary purpose of this paper is to identify the current challenges for REDD+ finance and its governance, we used recent papers since 2015. We selected the papers  using the keyword “REDD+ financ*.” From the selected 641 papers, we excluded 2 papers that were duplicated, 6 papers not written in English, and 1 paper that could not be accessed. We then divided the remaining 632 papers into five categories: (1) papers on REDD+ finance (198 papers), which we called “core literature”; (2) papers on REDD+ that did not directly discuss finance (130 papers); (3) papers that did not focus on REDD+, although they included financial matters that were somewhat relevant to REDD+ finance (62 papers); (4) papers that did not focus on REDD+ and did not discuss finance (182 papers); and (5) papers that were irrelevant to REDD+ finance and its governance (60 papers).In this review, we first identified the key elements of REDD+ finance and its governance aligned with the UNFCCC and outside the UNFCCC using the 198 papers on REDD+ finance as the core literature. Then, on the basis of the key elements of REDD+ finance and its governance, we reviewed the challenges and lessons learned, using both the core literature and supplementary literature. The supplementary literature involved other academic literature including papers categorized in (2) and (3), as well as the practical literature including reports of researchers, international organizations, and initiatives, mainly to supplement discussion that has limited literature such as that on private finance for REDD+.This section summarizes the key elements of REDD+ finance and its governance identified using the core literature on REDD+ finance published since 2015 Fig. . RegardiOne of the main issues related to REDD+ finance and its governance is fragmentation and complexity. The institutional fragmentation of REDD+ finance and international public finance mechanisms, which are the main sources of REDD+, are well covered in the literature , 46, 47.REDD+ activities aligned with the UNFCCC are mainly supported by multilateral and bilateral public finance . HoweverUNFCCC Decision 1/CP.21 identifies “the coordination of support from, inter alia, public and private, bilateral and multilateral sources, such as the Green Climate Fund, and alternative sources in accordance with relevant decisions by the Conference of the Parties.” Among the various multilateral and bilateral public finance sources, policymakers and researchers expect the GCF to play a central role in supporting REDD+ and in increasing transparency, coordination, and funds for REDD+, because there is no designated entity that can manage the funds , 30. AltWithin the UNFCCC, the SCF recommended to the COP that parties “ensure policy coherence, coherence of financing instruments and financial incentives and multisectoral coordination to address the drivers of deforestation and forest degradation, and promote sustainable management of forests” . The SCFKim et al.  reportedIn addition to the challenges related to the coordination of multilateral and bilateral REDD+ finance, other issues of fragmentation and complexity regarding REDD+ finance include multiple results-based finance approaches and different finance allocations to national and/or subnational programs or REDD+ projects , 53, as To address the multilevel institutional coordination of REDD+ involving multiple stakeholders, although the studies are limited, Gupta et al.  analyzedAs shown in section “REDD+ finance and its governance”, REDD+ uses a phased approach. In the full implementation phase, it provides an ex-post reward for the results of REDD+ actions, known as results-based payment/finance, to incentivize a REDD+ country (the recipient) to undertake REDD+ actions . The WarAs indicated in UNFCCC Decision 9/CP.19, the GCF has been expected to play a key role in collectively channeling adequate and predictable results-based finance in a fair and balanced manner. REDD+ results-based finance is provided for REDD+ actions that are fully measured, reported, and verified and have met all UNFCCC requirements . As descThe challenges and lessons learned for existing REDD+ results-based finance, such as the GCF and the Amazon Fund, have been extensively analyzed , 58, 59.Results-based finance has been at the core of the discussion on REDD+, in relation to financial uncertainty and the performance element in REDD+ . StudiesMuch of the literature regarding REDD+ finance has used case studies of recipient countries and touched on the relationship between financial issues and national and/or subnational frameworks, including institutions related to REDD+ in recipient countries. These national and/or subnational frameworks in recipient developing countries include issues on NDCs, benefit-sharing , safeguards, and REDD+ costs.The NDCs of many developing countries have recognized the important role of forests, showing mitigation measures in the forest sector, including REDD+, and further developing various green initiatives to achieve their mitigation goals , 66. HowTherefore, the development of national and subnational frameworks in recipient countries is important for REDD+. Gallo and Albrecht  indicateFurthermore, the existing literature has touched on the issues of benefit-sharing and safeguards in discussions of national and subnational frameworks for REDD+. One topic that is frequently discussed regarding national and subnational frameworks is the benefit-sharing mechanism of REDD+. Discussions of benefit-sharing reflect increased concerns over how to access REDD+ finance, how to assess REDD+ policy performance and results, how to generate co-benefits, and how to resolve issues related to equity and safeguards . UnclearIn realizing REDD+, there is a common understanding regarding the need to protect the rights of local communities through safeguards, as well as the recognition that they are key actors in implementing REDD+ and receiving its benefits , 72. TheAwung and Marchant  suggesteAnother issue related to benefit-sharing and safeguarding recipients is corruption . CorruptFurthermore, there are issues regarding costs. Concerns have repeatedly been raised about whether actors in REDD+ host countries will end up bearing the costs of REDD+ . CurrentAs described in section “REDD+ finance aligned with the UNFCCC”, many developing countries have incorporated REDD+ into their NDCs as their contribution to climate change; however, this is not the case for most developed countries , 84. ThiPrivate sector engagement in REDD+ finance is limited for various reasons, which have been identified in the academic literature , 85–87. To increase private finance inputs into REDD+, the importance of understanding the rationale, strategies, and behavior of private sector actors has been recognized . AlthougIn addition to the characteristics of private sector actors and their incentives for participating in REDD+, there are challenges associated with the nature of REDD+ as a natural climate solution, including the costs and complexity of the MRV of REDD+ activities. These challenges are attributed to the need to consider the risks of permanence (whether sequestered carbon will remain in the forest) and carbon leakage (whether deforestation will occur elsewhere because of the projects), as well as to precisely determine and monitor forest carbon sinks , 57. TheThe uncertainty of compliance carbon markets has also been a challenge for private-sector involvement in REDD+ finance. At the international level, integrating climate cooperation through carbon markets into Article 6 of the Paris Agreement and including REDD+ may enable more cost-effective emission reductions , 92. At Voluntary carbon markets have also enhanced private sector participation in REDD+ finance. The private sector’s enthusiasm for voluntary carbon markets and nature-based carbon credits could be targeted toward investments in REDD+ projects (to generate carbon credits because of their interests in offsets) and could be targeted toward corporate supply chain efforts designed to deliver deforestation-free commodities .2e with a peak price of $5.59/ton in 2020 [The number of voluntary projects marketing offsets to buyers motivated by corporate social responsibility or in expectation of future compliance obligations has continued to increase . The tot in 2020 . REDD+-r in 2020 .One challenge related to voluntary carbon markets is that their carbon price has been low , which cAnother issue is the relationship between projects and national-level carbon accounting because gaps between them may affect the leakage problem described in section “REDD+-related finance outside the UNFCCC” , 95. WesFurthermore, there are concerns that voluntary carbon markets could lead to company greenwashing  and undermining the goals of the Paris Agreement , 97. TheBecause of insufficient finance for REDD+, new investment and finance opportunities and models for REDD+ are being investigated . The expGolub et al.  discusseAlthough the literature on new finance opportunities for REDD+ is limited, they have been discussed in the context of nature-based solutions (NbS), which comprise a wide range of measures, including REDD+. NbS are “actions to protect, sustainably manage and restore natural or modified ecosystems that address societal challenges effectively and adaptively, simultaneously providing human well-being and biodiversity benefits” . The acaThere is also growing recognition from financial institutions and companies regarding the need to address not only the risks associated with climate change but also those associated with declining biodiversity, which include physical, transition, and reputational risks –110. An On the basis of the challenges and lessons learned for REDD+ finance and its governance from the literature review, in this section, we discuss ways to overcome these challenges.The fragmentation and complexity of REDD+ finance still occurs because it comprises different financing sources, mechanisms, and programs/projects, as well as different relationships between funders and recipients and the consideration of recipient domestic situations.The GCF and SCF can only partially address the fragmentation and complexity of REDD+ finance.Coordination of multilateral and bilateral financing REDD+ results-based finance approaches vary with different financing sources (non-market-and market-based finance) and targets .The challenges and lessons learned from REDD+ results-based finance, such as multilateral funds, the GCF, and the Amazon Fund, include the difficulty of the GCF in mobilizing additional finance for REDD+ due to its institutional constraints, the donors placing institutional burden on recipient countries’ ability to access finance, and a lack of targeted funding strategies to maximize the fund results.Studies on REDD+ performance, where results-based finance is the core of the discussion, have increased. The effectiveness of results-based finance schemes depends on the way results are defined and the conditions that enable social and political acceptance, including political–economic factors in recipient countries. In addition, it is important to have performance-based funding in combination with strong national ownership of the REDD+ process.Results-based finance The NDCs of many developing countries show mitigation measures in the forest sector. To tailor these measures to emissions reduction, clear policies and measures are required to address the drivers of deforestation and forest degradation, as well as transparent monitoring and evaluation frameworks. For this purpose, national and subnational approaches  could enhance changes to complex land-use systems so that they can achieve large-scale emissions reduction.Other challenges that are being studied regarding national and subnational frameworks include improving benefit-sharing mechanisms and safeguards, especially in terms of distribution to local communities. However, it is also important not to overlook the larger-scale drivers of deforestation. Furthermore, corruption among recipients and the sharing of REDD+ implementation costs also need to be addressed at the national and subnational levels.National and subnational frameworks Although it is important to examine ways to incentivize the private sector, various factors limit private-sector engagement in REDD+ finance. These factors include uncertainty over climate policy and markets, weak forest governance, and a lack of clear understanding of carbon rights.There is a growing need to understand the rationale, strategies, and behavior of private sector actors, which are linked to the opportunity costs associated with REDD+.Other challenges are associated with the nature of REDD+ as a natural climate solution, the costs and complexity of MRV for REDD+ activities because of the need to address the risks of permanence and carbon leakage, and the monitoring of carbon sinks.Incentives for private sector participation (section “REDD+-related finance outside the UNFCCC”)The uncertainty of compliance carbon markets has also been a challenge for the involvement of the private sector in REDD+ finance, although voluntary carbon markets have enhanced private sector participation.Forestry and land use is the leading category of volumes transacted in voluntary carbon markets, while the challenges of these markets include the low carbon price, the relationship between projects and national-level accounting , and company greenwashing.Private carbon finance and voluntary carbon markets (section “REDD+-related finance outside the UNFCCC”)Studies have explored new finance opportunities and models for REDD+, such as building new blended finance models  and developing enhanced bonds for mitigation in the forest sector .There is growing discussion on establishing new finance opportunities and business models for NbS, including REDD+, and on the needs for financial institutions and companies to address climate change and nature-related risks.New investment and finance opportunities (section “REDD+-related finance outside the UNFCCC”)The key findings of this review are summarized as follows.The literature review indicated that the two streams of discussion on REDD+ finance—those aligned with and those outside the UNFCCC—have developed differently and have different challenges. The discussion on REDD+ finance aligned with the UNFCCC has focused on enhancing the performance of REDD+ finance using mainly public finance, including results-based finance and the jurisdictional approach. In contrast, the discussion of REDD+-related finance outside the UNFCCC has focused on ways to enhance the engagement of the private sector in REDD+ finance, mainly targeting the project level. The discussion includes the relationship between voluntary carbon markets and other investment and finance mechanisms.Many existing studies have not comprehensively discussed the two streams of REDD+ finance and its governance, and the term REDD+ has been used differently in the literature. However, through this literature review, we identified common governance challenges in the two streams. One challenge is the need to consider REDD+ finance in terms of linkages with other targets and policies, such as net-zero/carbon neutrality, deforestation-free supply chains, and NbS , 113–115As described in section “REDD+-related finance outside the UNFCCC”, investment and finance have been explored in the context of NbS, including REDD+. Although the concept of NbS was not developed within the UNFCCC , the UNFAnother issue is the need to develop learning systems and techniques for REDD+ finance , 76, 118We reviewed the literature on the challenges and lessons learned for REDD+ finance and its governance in two areas: (1) REDD+ finance aligned with the UNFCCC and (2) REDD+-related finance outside the UNFCCC. We identified six key elements for REDD+ finance and its governance: (1) coordination of multilateral and bilateral financing, (2) results-based finance, (3) national and subnational frameworks, (4) incentives for private sector participation, (5) private carbon finance and voluntary carbon markets, and (6) new investment and finance opportunities. Based on these key elements, we reviewed the challenges and lessons learned for REDD+ finance and its governance aligned with and outside the UNFCCC.The discussion on REDD+ finance aligned with the UNFCCC has focused on enhancing the performance of REDD+ finance using mainly public finance and includes results-based finance and the jurisdictional approach. In contrast, the discussion of REDD+-related finance outside the UNFCCC has focused on ways to enhance the engagement of the private sector, mainly targeting the project level, and includes the relationship between voluntary carbon markets and other investment and finance mechanisms.Although there is a lack of comprehensive discussion of the above two streams, there are common governance challenges. One is the need to consider REDD+ finance in terms of linkages with other objectives and policies, such as net-zero/carbon neutrality, deforestation-free supply chains, and NbS. Another is the need to develop learning systems and techniques for REDD+ finance. These areas need to be explored to improve REDD+ finance as well as the broader environmental finance.


Drawing on perspectives from West and Southern Africa, this Comment critically examines the current state of neuroscience progress in Africa, describing the unique landscape and ongoing challenges as embedded within wider socio-political realities. Distinct research opportunities in the African context are explored to include genetic and bio-diversity, multilingual and multicultural populations, life-course development, clinical neuroscience and neuropsychology, with applications to machine learning models, in light of complex post-colonial legacies that often impede research progress. Key determinants needed to accelerate African neuroscience are then discussed, as well as cautionary underpinnings that together create an equitable neuroscience framework. In more recent decades, neuroscience - as an interdisciplinary field - has witnessed remarkable growth with the rise in the neuroimaging and computational sciences, driven by rapid technological advances. Such progress is yet to be achieved in arguably less research intensive and economically powered countries across the African continent. Despite the need to steer away from broad over-generalisations, many of the challenges and prospects outlined here may be echoed in what has been referred to as countries in the Global South, low-to-middle income countries or Majority World, and in some cases, to underrepresented populations across the globe.The rising discourse around equity, diversity and inclusion in science has propelled international focus on the current landscape of neuroscience in Africa. Neuroscience has its origins in Africa, with ancient Egypt boasting the first anatomical investigations of the brain2 of two decades of neuroscience research from the continent, there is a steady and encouraging rise in publications, dedicated neuroscience centres and funding prospects. This upward trajectory is most evident in specific regions and countries in North , West (Nigeria) and Southern Africa (South Africa), with notable publication increases in East  and central African countries. A growth in neuroscience outputs by smaller and less populated African countries and islands is particularly noteworthy. This rising trend however has been made against the backdrop of a post-colonial environment often characterised by political unrest, violence, poor basic infrastructure, and economic hardship. To conduct a critical analysis of the current state and future potential for growth, it is necessary to assume a historical lens and unpack the consequences of the wider socio-political climate.As skillfully mapped out by Maina and colleagues’ review3. However, such methods were used by the previous apartheid government to try and produce “scientific” evidence to justify highly racist legislative policies4, with local research funding often dependent on alignment with discriminatory government policy5. When findings were not aligned to the government agenda, as in the case with EEG data showing no cross-cultural difference in responses, researchers were heavily criticised and government research funding restricted7. As such, while there was rapid growth in pioneering neuroimaging technologies in the Global North, the highly politicised nature of research and research funding restricted local scientific progress8. Years later in 2007, after the political transition in South Africa, the Cape Universities Body (previously Brain) Imaging Centre (CUBIC) was established, housing the first dedicated research magnetic resonance imaging (MRI) scanner in Africa9.Using South Africa as an example, there is a strong research tradition of the neurosciences in behavioural and clinical disciplines spread across academic centres throughout the country. Cognitive science  and neuroimaging methods like electrophysiological (EEG) were utilised very early on as aligned with more international trends10 20 science, for example, excludes a conversation on race by omitting the bias in using majority white population groups21. Including important cross-cultural comparisons in social-cognitive neuroscience extends the use of the catchphrase ‘WEIRD’ to include biases in white and western populations. There is also a pressing need to increase research outputs with culturally diverse samples into training corpora for machine learning algorithms to counteract implicit biases and stereotyping with the recent surge in artificial intelligence systems and large language models22.However, the distinct research potential for the neurosciences in Africa is not only in health-related research. The rich cultural and linguistic diversity of the continent lends itself to the cognitive and social neurosciences. Highly multilingual populations in Africa for example, can offer a fresh perspective on the ongoing debate of the bilingual advantage23. This ultimately leads to slow(er) science. However, African neuroscientists and trainees are still evaluated using competitive international matrices for research progress . Continued infrastructural challenges, including a lack of dedicated research laboratories and neuroimaging facilities, also stunt innovation potential. Although it is encouraging to see a growth of dedicated centres for neuroscience research in recent years, having them condensed to one city or university, creates ‘academic monopolies’. Mirroring the economic organisation of many African countries, this saturation of neuroscience research in one academic setting often limits opportunities for students, employment and its application of research to the wider community.Despite this unique potential for neuroscience innovation, the wider socio-political climate in Africa  have a direct and indirect impact on research progress24 specifically and in broader neuroscience skills25. Nevertheless, the analysis of MRI data, as an example, is still mostly outsourced to collaborators in the Global North rather than targeting local capacity development. The shortage of validated and culturally appropriate cognitive and affective assessment tools remains a challenge. This challenge is then compounded by limited normative data for culturally and linguistically diverse populations coming from a range of educational and socio-economic backgrounds26. Publication bias already well documented for women and underrepresented groups are echoed for African neuroscientists27, with inaccessible costs for open-access publications for top-tier journals further limiting impact potential. These inequities even filter down to the use of experimental equipment, with caps for EEG research for example often not being suitable for diverse hair types28.In places where there is access to sophisticated research methods, there is still a skill dependency for analysis of data. For example, the use of MRI methods is increasing in cognitive and clinical neuroscience research. Pioneering efforts are being made to increase local capacity in MRI methods29.The scope for local research funding can be limited, which leads to inadequately powered studies that impends research impact. Many scientists often resort to using personal savings to support research, with few principal investigators having funds to support graduate students. PhD students are often self-funded, with limited opportunities for Postdoctoral Fellowships. Taken together, poor renumeration, work insecurity, limited training opportunities and funding are often push factors for rapid emigration of skilled African researchers30. International funding and partnerships with large organisations like the National Institute of Health in the USA and the UK’s Wellcome Trust have also been transformative for research groups.Surrounded by the research obstacles only briefly outlined here, African neuroscientists have been resourceful and inventive to produce impactful work. Key ingredients can be identified to catalyse growth potential. Despite challenges, the funding landscape for neuroscience research in Africa is growing. Local, African specific research investments in the last decade have propelled research progress on multiple fronts. For example, the Human Health and Heredity (H3Africa) and Data Science (DSI – Africa) initiatives have boosted African participation in the genomic revolution, built genomic research infrastructure and enhanced training of young African scientists as well as localising the analysis of big data on African soilAccess to more sophisticated research techniques also needs to run in parallel with local skill development. Strengthening research capacity through visiting placements, student exchanges, collaborative or shared graduate trainees, targeted training workshops, utilising virtual or hybrid methods, have all proven to be sustainable strategies to build critical skills and foster research independence. Targeted mentorship of graduate trainees and postdoctoral fellows also sharpens this impact. Similarly, building local, international and multidisciplinary collaborations is another critical factor to facilitate knowledge exchange between countries and disciplines. However, a cautionary note is needed here that international collaborations and initiatives for “capacity building” are not unidirectional and do not replicate historic power hierarchies of the knowledgeable and uninformed. Rather a shared and multidirectional knowledge exchange is needed. In a similar respect, collaborative research initiatives should encourage more African principal investigators, with equal ownership of data and credit for arising publications.31 or the African Stroke Organization (ASO)32, and international non-profit organisations such as TReND in Africa and the Neuroscience Alliance (NEURAL) that promote global engagement and healthy equity. In a similar respect, effective science communication initiatives have had encouraging results in building community trust and awareness, as well as in supporting science-informed policy change33.Societies and platforms for networking and building interdisciplinary spaces have been an effective strategy for growth and vision building. Established organisations like the Society of Neuroscience of Africa (SONA), the Southern African Neuroscience Society (SANS) and the International Brain Research Organisation (IBRO) have been widely effective. More recent initiatives are also gaining traction, like the African neuroscience ALLIANCE, clinical consortia such as the African Dementia Consortium (AfDC)who does science is important. Having greater representation in neuroscience research from Africa affords unique opportunities for new research trajectories to push forward our understanding of the brain. Purposeful and directed action is needed by multiple stakeholders to move towards this goal.What remains pivotal is that


The food system plays a crucial role in the relationship between environmental, population and individual health. While leading healthcare and environmental organizations call for urgent action to address climate–planetary–human health crises, it is often challenging for healthcare organizations to respond at a systems level to these concerns. Additionally, there is little consensus and limited research exploring how future health professionals should be trained in order to work at both the individual and systems level to address or prevent the negative health impacts related to the current food system. The intervention of a 6-week, hands-on cooking and nutrition course for graduate health professional students which examines these intersections and equips students with clinically applicable skills was examined using matched pre- and post-course surveys and thematic analysis of reflective assignments. Results indicate improved knowledge and confidence in areas including understanding the food system, guiding patients through dietary change, working interprofessionally, and applying basic nutrition concepts to clinical practice. The food system, including the interconnectedness of food and humans, communities and the environment, plays a crucial role in population and individual health ,2,3. WhiIn the United States (US), over 15,000 new food products are created annually . Recent In a systematic review conducted in 2020, among 43 studies reviewed, 37 found dietary UPF exposure was associated with at least one adverse health outcome. Among adults, these included overweight, obesity and cardio-metabolic risks; cancer, type-2 diabetes and cardiovascular diseases; irritable bowel syndrome, depression and frailty conditions; and all-cause mortality. Among children and adolescents, these included cardio-metabolic risks and asthma. No study reported an association between UPF and beneficial health outcomes . In contAdditionally, economic inequality is tied to disparities in food and land access, leading to disproportionate rates of chronic conditions among marginalized communities throughout the US. According to the Center on Budget and Policy Priorities (CBPP), a non-partisan research and policy institute, adults in households with very low food security are 53% more likely to be diagnosed with a chronic condition, such as hypertension, coronary heart disease, hepatitis or stroke, than adults in food-secure households . Recent Health sciences curricula increasingly include education linking the social determinants of health to clinical outcomes, but often fail to explore the upstream factors specific to the food system that have direct relationships to human health conditions; or the diverse experiences that play a role in shaping identities, preferences and behaviors related to food choices, food skills and food literacy.While specific nutrition competencies for health professional students have not been officially determined, Lepre et al. conducted a critical synthesis of publications proposing nutrition competencies for medical education internationally, and identified five common themes: (1) clinical practice; (2) health promotion and disease prevention; (3) communication; (4) working as a team; and (5) professional practice .We propose that clinically relevant experiential education including hands-on cooking and eating, self reflection and cross-disciplinary engagement is needed to translate awareness of system-level problems into actionable skills for future health professionals.In 2016, a chef/public health nutrition expert (JB) and an Internal Medicine/Pediatrics physician (KS) with expertise in integrative medicine developed and began teaching a food-systems-focused, hands-on culinary nutrition course . Initially piloted with medical students, then expanded to include any health sciences graduate students, the course offers experiential, interprofessional, clinically oriented culinary nutrition and food systems education. The 1-credit, 18 h graduate level course continues to be offered 1–2 times/semester through the Earl E. Bakken Center for Spirituality and Healing at the University of Minnesota, Twin Cities Campus. n = 65).Quantitative data from optional, identical pre-/post-course surveys were collected starting in 2018, with the description of students’ demographics and fields of study summarized in The course is taught over 6 weekly three-hour sessions, each with experiential, hands-on cooking, a didactic segment with interprofessional discussion opportunities and application to clinical care or public health spheres. The curriculum includes basic, clinically oriented nutrition concepts and their relationship to health in the context of the social, structural and commercial determinants of health and various facets of the food system. Culinary skills are integrated to enhance learning about nutrition concepts . See Students are invited to share their personal and cultural experiences with food, agriculture, cooking and community, as well as their experiences as graduate students in their respective health sciences fields, through an activity during the first class session called “The Food Story” . EngaginWeekly culinary experiences during class provide opportunities for students to practice foundational cooking skills, interact with relevant food ingredients, learn to cook with a range of whole foods and spices and sample delicious tastes from a diversity of flavor profiles. Additional culinary assignments outside of class complement the goal of improving food literacy around choosing, procuring, preparing and consuming nourishing food. Mindful eating practices are a recurring and foundational facet of the course’s experiential elements, allowing students to practice self-awareness, examine the relationships between food and mood and to explore resources which may be supportive to both self and patient care.Between weekly sessions, students are expected to complete assignments involving personal reflection, mindful eating experiences, review of relevant medical and nutrition literature and an online discussion forum about a personal cooking experience. The final project involves a patient case representing common clinical conditions in which students, assigned to interprofessional groups, are asked to design a meal recommendation as well as a patient education handout. The group creates a teaching video demonstrating their meal suggestion, explaining the relevance to the patient’s condition(s) and describing the cost per serving. The group also submits a brief academic paper, with supporting literature, for the rationale of their meal suggestion pertaining to the patient’s specific condition(s).Of note, the elements of this course have been consistent throughout the last 7 years, though the delivery shifted to virtual due to the COVID-19 pandemic, and has continued as such based on feedback from students, as well as the increased access the virtual platform allows. See ®  system, hosted at the University of Minnesota, independent of the course evaluation process. Survey data, managed in REDCap, were de-identified and instructors were not aware of which students completed surveys. Completion of the surveys was optional for students and did not impact their grade. The study was determined to be exempt from full Institutional Review Board review.Identical pre- and post-course surveys were administered through the REDCapSurvey questions were developed after a pilot course indicated priority content including personal wellbeing; habits and approach to food; knowledge and skills to help a patient adapt a recipe according to dietary patterns or preferences; knowledge in relation to clinical practice; and application to clinical practice. Survey questions referenced specific topics or concepts that were addressed in the course, as well as knowledge or skills highlighted in the course objectives. By using an identical pre- and post-course survey, matched responses from students follow the same timeline relative to the intervention (the 6-week course). An appropriate five point Likert scale was created for each section of the survey. The draft survey questions were reviewed by three experts in the fields of medicine, nursing and public health, and validated for content. The complete survey questionnaire, “Food Matters for Health Professionals Survey”, is presented in the t test. Statistical analyses were performed in SAS version 9.4 . P values of less than 0.05 were considered statistically significant.Participants’ demographics and characteristics were summarized using mean and standard deviation (SD) for continuous variables and frequency and percentage for categorical variables. Survey responses were summarized using mean and SD. Pre–post change was evaluated using a paired n = 69) were reviewed for frequency of codes derived through inductive coding.Qualitative data were collected from a post-course reflective assignment which asks students to respond to the following prompts: (1) Choose one or two specific lessons or themes that resonated personally with you in some way. Write a 1–2 paragraph description of how this has or will impact your life or your eating in the days ahead. (2) Write a 1–2 paragraph description of how you can use what you learned from Food Matters in your professional context. De-identified, collated reflective assignments from six course cohorts  students, so for the majority of students, the course is elective. Self-selection or a predetermined interest in the subject matter could also influence students’ enrollment in the class, as well as pre- and post-survey responses. The majority of students responding to the survey identified as female, with only a small portion indicating male gender. There was no control group, so there is no standard of comparison with which to measure knowledge or attitudes on the topic areas. Because of these factors, the results of this study may not necessarily be generalized to a larger or more diverse population of graduate health sciences students.Despite these limitations in the quantitative data, the qualitative data reflect the experience of all students enrolled in the cohorts examined and ultimately complement the survey results. Among the strengths of this study are the length of time over which the data have been collected, the diversity of health sciences fields represented and the alignment of the findings from qualitative and quantitative data.Given that the qualitative data show a high frequency of “food skills” and “translation of knowledge to patients/clients” themes, an area of future research could explore the impact of an experiential food systems and nutrition course as a required part of health sciences curricula.Health Sciences educators, major medical journals, Congress  and the larger public are calling for improved nutrition education for future physicians and health professionals .We suggest that sharing experiences around food with other people from diverse fields of study and/or backgrounds promotes the development of cultural humility—a key ingredient for compassionate, informed and well-rounded health professionals, as well as humans. The benefit of an interprofessional course combined with elements such as hands-on cooking, the Food Story activity and examination of various dietary patterns appears to make an impact on students’ self-reported confidence and knowledge of food preparation and nutrition information.These findings align with the growing body of literature supporting culinary and nutrition education for health professionals, yet includes the unique elements of food systems and interprofessional education. In order for nutrition education to be meaningful and memorable (and therefore effective), we believe our research indicates that such education needs to be experiential, clinically relevant, interprofessional and systems-oriented.


The global mental health crisis is a longstanding one that impacts a multitude of patient populations worldwide. Within this crisis, psychiatric medication adherence is yet another complex public health challenge that continues to persist and contribute towards the chronic nature of the increased incidence and prevalence of psychiatric morbidities, which in turn result in the sequalae of substantial costs to humanity, the healthcare system, lost productivity, functioning and disability among patients with mental disorders. Psychotropic medication adherence is a significant part of psychiatric care and treatment across severity levels of mental illness. This health behavior is also filled with complexities, given the abundance of social and behavioral determinants as well as intrinsic and extrinsic factors that surround this health behavior. Examining contexts for promoting this health behavior change is crucial in determining directions for addressing it more optimally. There have been several published studies on considerations and interventions to address this health behavior; however, to date, no studies have been published on assessing coverage and directions of content across social media platforms, which trend as a rising health communication medium in our digital era. The present study is the first of its kind to dive into exploring the nature of widely viewed content and deliverers of this content on a prominent social media platform, YouTube, as the basis to determine potential directions for future intervention that can extend to reaching more patients struggling with this high-risk health behavior across the world, given the global reach of social media. Nearly 970 million individuals are affected by psychiatric illness worldwide . PsychiaPsychotropic medication adherence is a complex health behavior affected by a range of social and behavioral determinants as well as intrinsic and extrinsic factors . There aSeveral published studies have explored different intrinsic and extrinsic factors affecting psychotropic medication adherence as targets for intervention in different in-person and telehealth contexts ,22,23,24Several clinical modalities have been utilized over time to assess for medication adherence across both medical and psychiatric illnesses. Cognitive behavioral therapy and motivational interviewing are among them . In the Our study was the first of its kind to critically examine the diversity of content on this health behavior across a prominent social media platform, but not to establish causality or assess the efficacy of interventions implemented on social media; rather, this study sought to uncover the existing stage of coverage related to a significant part of psychiatric care and treatment on a globally accessible social media platform. The goals of this study were the following: (1) present the sources and formats of the widely viewed videos on psychotropic medication adherence across YouTube; (2) critically assess the content across these widely viewed videos; (3) and provide recommendations for further research and practice endeavors in focusing on this health behavior as a target for intervention across social media platforms in our trending digital health landscape.The research design of the present study was cross-sectional in nature and involved collecting observational data at one conceptual point in time from the YouTube social media platform. From April to May 2023, browser history on computers of the two authors was cleared. Next, the researchers conducted a search on YouTube using permutations of specific key words and descriptors embodying psychiatric or psychotropic medication adherence or compliance. Piloting various key words  was instrumental in ultimately narrowing the range of phrase(s) that yielded the most relevant videos, highest view counts across videos, and greatest cumulative views for the top 30, 60, and 100 videos, respectively. After completing these pilot searches, the key words that formed the search strategy were “take psych medication”, which yielded the most widely viewed videos that were directly relevant to psychotropic medication adherence. Notably, psychotropic or psychiatric medication adherence (or compliance) yielded significantly fewer videos with low view counts. The results were subsequently filtered by view count, and the URLs for the 100 most widely viewed videos were safeguarded in a separate file. Overlapping URLs were deleted and replaced. In turn, only one URL for each video was kept for coding and analysis.The researchers then created a codebook based on a review of literature and guidelines from authoritative and expert sources such as the American Psychiatric Association, American Psychological Association, and the Diagnostic and Statistical Manual of Mental Disorders. Each researcher viewed and coded all videos between April and May in 2023. Intra- and inter-rater reliability of the coding was demonstrated for each researcher and between them, respectively. The following information was reviewed and coded for each video: (a) source of upload, (b) format, (c) number of views, (d) length (in minutes), (e) year of upload, and (f) content. IRB approval was not required for this study given that the videos are publicly available.All videos reviewed were in English. Any videos not narrated or presenting written content in English were excluded from analysis. Content across all videos pertained to psychotropic medication adherence. The researcher viewed the full video, which constituted the unit of analysis. There were no parameters for consideration of videos based on length of time.The instrument included the following basic information: coder, video identification number (which was assigned), date the video was uploaded, date the video was coded, length of video (in minutes), number of views, and title of the video. Next, there were three sections for source of upload, format and content in the instrument. Content included several content categories comprising many variables (discussed below), all of which were coded dichotomously  to indicate presence or absence across each video.The source of upload for each video was coded into one of the following four categories: organizational, consumer, governmental, and other sources. The categories for coding format included Documentary; Interview; Demonstration/Experiment; Talk by Professional; TV Talk Show/Discussion panel; Animation; Still images; News report with anchor; V-blog; Advertisement; Testimonial/Story; Multiple formats; and Other formats. The following 15 content categories were created in this codebook: (a) type of medication; (b) psychiatric diagnoses; (c) stressors; (d) health beliefs; (e) special considerations; (f) community resources; (g) support networks; (h) side effects of medication use; (i) stigma; (j) personal factors; (k) developmental/age groups; (l) additional interventions; (m) access to medications; (n) additional factors; (o) medication adherence assessment tools; and (p) open-ended comments on misinformation or disinformation depicted in the video. Conceptualization of the codebook involved developing these content categories to account for the comprehensive range of targets for intervention from addressing psychotropic medication adherence.The researchers demonstrated both inter- and intra-rater reliability of the data from coding content across all videos in the sample. To demonstrate intra-rater reliability, the researcher utilized a random number generator to randomly selected 10 videos and recoded them within 2 weeks of the original coding. This analysis included all of the dichotomously coded (Yes versus No) content variables in the instrument. Intra-rater reliability was found to be low/moderate/high (Kappa = 0.93). Inter-rater reliability was also demonstrated across coding completed by both researchers. Utilizing a random number generator, ten of the coded videos were selected for analysis across each variable. The researchers reviewed coding responses to clarify any discrepancies in the coding instrument. Inter-rater agreement was found to be low/moderate/high (Kappa = 0.94).n = 4,943,680 views). This process of analysis was conducted for all content categories in the codebook. All analysis was conducted using Excel and Statistical Package for the Social Sciences (SPSS).Composite statistical analyses entailed computing descriptive statistics for the different variables in this study. All observational data collected that delineated the features and characteristics of the videos were synthesized through computing frequencies and percentages of source, format, number of views, length, and content of each video. Across each content category, the number of videos that covered the content was first identified. Next, the total number of views from those videos covering the focused content area was determined. The proportion of total cumulative views was determined by dividing the number of views garnered by the particular videos covering each content area by the total cumulative views generated by all videos  were talks by professionals, these videos yielded fewer views (~2 million), representing almost 40% of the cumulative views. There were 30 videos that consisted of testimonials/stories, which generated nearly 1 million views, accounting for approximately 25% of the cumulative views. In addition, there were substantially fewer videos (n = 9) that consisted of animations, which also garnered about 1 million views and nearly 25% of the cumulative views. A total of 19 of the widely viewed videos were interviews that yielded ~800,000 views, accounting for almost 17% of the cumulative views. Lastly, documentaries, demonstrations/experiments, tv talk shows/discussion panels, news reports as well as multiple and other formats garnered ~1 million views, which represented less than 20% of the cumulative views. Still images and advertisements were not formats covered in the widely viewed videos.A total of 45 of the widely viewed videos were v-blogs, garnering almost 4 million views and nearly 80% of the cumulative views. Although more videos (n = 49) presented coverage on antidepressant medications, which garnered greater than 2 million views, accounting for nearly 55% of the cumulative views. Although 13 of the videos covered content on anti-anxiety medications, these videos ultimately generated more than 1 million views, comprising almost 35% of the cumulative views. In contrast, substantially more of the widely viewed videos included coverage of antipsychotic medications (n = 41), also comprising greater than 1 million views (about 30% of the cumulative views). There were 18 videos that included content on mood stabilizers, which yielded 1 million views and represented almost 25% of the cumulative views. Stimulants were accounted for in five of the widely viewed videos, generating about 300,000 views, which represented nearly 6% of the cumulative views.Anti-depressants, anti-anxiety, antipsychotic and mood stabilizer medications cumulatively received substantial coverage among the widely viewed videos. Nearly 50% of the videos (n = 13), these videos culminated in less than a million views . Eating disorders and personality disorders cumulatively garnered ~1 million views, representing about 20% of the total views. Borderline, other psychotic disorders, and schizoid collectively generated greater than 1 million views (25% of the cumulative views). Six of the widely viewed videos included content on PTSD, yielding about 300,00 views (about 6% of the cumulative views). Lastly, although substance use disorders were covered in marginally more of the widely viewed videos (n = 6), these videos garnered less than 200,000 views (nearly 3% of the cumulative views).Half of the widely viewed videos presented content on depression, generating more than 3 million views (approximately 70% of the cumulative views). The 37 widely viewed videos that covered anxiety culminated in greater than 1 million views, almost 30% of the cumulative views. Bipolar disorder was covered in 30 of the widely viewed videos, generating almost 2 million views (nearly 40% of the cumulative views). There were 29 videos that delineated content on schizophrenia, which ultimately yielded nearly 1 million views . Four of the widely viewed videos presented content on schizoaffective disorder, garnering almost a million views . Although there were more videos that included content on ADHD . There were 21 videos that covered weight gain, accounting for more than 1 million views (nearly 35% of the cumulative views). A total of 19 videos presented content on sexual side effects, yielding greater than 1 million views (nearly 30% of the cumulative views). In addition, among the 26 videos that delineated content on fatigue/lack of energy as a side effect, these videos garnered more than 1 million views, comprising nearly 35% of the total views. Insomnia and restlessness collectively generated greater than 3 million views (more than 60% of the cumulative views).There were 18 videos that included content on individual therapy, garnering more than 1 million views (nearly 25% of the cumulative views). Ten of the videos presented coverage of inpatient psychiatric hospitalizations, which yielded greater than 600,000 views and comprised almost 13% of the cumulative views. Seven of the videos delineated information on cognitive behavioral therapy, generating more than 300,000 views . Family therapy and informal support group were covered in fewer than 200,000 views, accounting for about 2% of the cumulative views. Group therapy, psychiatric rehabilitation programs, day hospital/partial hospitalization programs, and intensive outpatient programs were not covered in any of the widely viewed videos. Although there were only two videos that presented information on meditation, these videos culminated in almost 700,00 views, comprising 14% of the cumulative views. Content pertaining to seeking support from counselors/therapists, social workers, and psychologists generated ~500,000 views, comprising nearly 10% of the cumulative views. Peer recovery, nature-related resources, community groups, seeking support from primary and subspecialty care providers and psychiatric nurse garnered ~400,000 views, representing about 8% of the cumulative views.Eight of the widely viewed videos covered content on stigma related to employment, garnering ~1 million views (about 20% of the cumulative views). Although increasingly more of the widely viewed videos covered stigma pertaining to medication dependence, these videos similarly yielded nearly 1 million views, comprising approximately 20% of the cumulative views. There were seven videos that delineated content on stigma contributing to social isolation, generating greater than 800,000 views (approximately 17% of the cumulative views). Three of the widely viewed videos further identified stigma extending to peer network, culminating in greater than 600,000 views . Distrust in diagnosis and label for life were stigma-related considerations that garnered ~600,000 views, comprising nearly 7% of the total views. Surprisingly, none of the widely viewed videos covered content on stigma perpetuated by society.n = 10) delivered content on trauma/violence as stressors and triggers impacting psychotropic medication adherence, yielding more than 700 views and approximately 15% of the cumulative views. Two of the widely viewed videos delineated content on workplace-related stressors, accounting for more than 600 views (nearly 13% of the cumulative views). Although familial stressors were included in a marginally higher number of videos (n = 5), these videos culminated in greater than 500 views, accounting for almost 11% of the total views. Grief/loss and financial stressors/triggers both cumulatively generated ~200,000 views, comprising almost 4% of the cumulative views. Bullying, child care and life changes were not covered in any of the widely viewed videos. A total of 17 of the widely viewed videos delineated content on individual factors pertaining to quality of life and functioning, garnering about 500,000 views (about 11% of the cumulative views).Fourteen of the widely viewed videos presented content on medical conditions and illness as factors affecting psychotropic medication adherence, garnering greater than 2 million views (nearly 50% of the cumulative views). Academic stressors were covered in five of the widely viewed videos, generating almost 1 million views (about 20% of the cumulative views). More widely viewed videos . This reality certainly increases the risk of misinformation and disinformation in our digital era. Nevertheless, it is reassuring that several of the videos were published by independent healthcare providers who seek to be positive influencers on social media to demystify longstanding beliefs about psychiatric treatment.Notably, none of the prevalent measures to assess for medication adherence were referenced in any of the videos. This could be attributed to the fact that only a small number of videos presented content on research studies, and even among these studies, adherence was not assessed via subjective and objective measures. In many of these videos, the focus was primarily on either demystifying side effects and stigma of psychotropic medications or testimonials/stories shared by consumers or news coverage on the perils of side effects from these medications. It is possible that with more findings from published studies in this domain covered on social media, information will be more globally accessible as a learning tool for patients with psychiatric morbidities and their support networks.Coverage of a wide dispersion of side effects among the widely viewed videos reinforces the significance of accounting for the unique and diverse experiences of patients prescribed psychotropic medications. As these medications impact individuals differently, ensuring that the coverage of the totality of side effects is critical to assure relevance, support, and precision of information in navigating any of these side effects. There was a significant focus on side effects across the vast majority of the videos, which suggests that the constellation of them on social media could be a target for further intervention to address psychotropic medication adherence in the virtual space.Given the heavy coverage of side effects from psychotropic medication usage, it is crucial for the medical and public health community to take a more active role on social media in helping to present a more balanced representation of benefits and drawbacks with psychotropic medication usage. In addition, experts in psychiatry can further expand their visibility on social media to disseminate credible knowledge to the general lay population of viewers that these medications impact each patient differently based on a range of genetic, physiological, psychological and environmental factors. It follows that content creators can also engage with these experts and the government in disseminating credible, up-to-date information on psychotropic medication effects in a more engaging way to viewers, based on which kinds of formats across videos yielded the greatest number of views . Presenting this practical credible information will also provide more education to patients and their families, which could heighten their knowledge and awareness of these medications and could be an adjunct resource in combination with psychiatric care and treatment through the health system. Platform managers could also integrate this content onto their ten featured videos posted by health sources. Policymakers could also account for access to care and coverage considerations of psychiatric medications delineated across widely viewed content on social media to increase accessibility, affordability, quality and delivery of psychiatric care for both our national and global populations.In addition, considerations for specialized patient populations were not a central focus of the vast majority of the widely viewed videos. For example, only pregnancy and varying degrees of development were each covered in almost 20% of the videos; however, the total views for each of these unique considerations in navigating psychotropic medication management were still below 1 million. Furthermore, in this sample of the widely viewed videos, all of them were below 1 million views, which contrasts with different studies that have examined coverage of health-related considerations and conditions on YouTube with higher total view counts ,28,29. FA small number of widely viewed videos covered perceived concerns of taking psychotropic medications; however, the cumulative views for these videos was nearly 50%, which suggests that a selected number of videos yielded the highest views. This finding suggests that there are elements/features of these videos that attracted more views, potentially attributed to their appeal, valence, and relevance to the viewers. It is also possible that since several of these videos were posted by consumers or others who operated their own YouTube channels, there were likely elements about these videos that increased the relatability and acceptability of the content for these viewers. Furthermore, content shared on this selected number of videos among the widely viewed videos could be more in line with the preferences, wishes, goals, values, and needs of individuals prescribed psychotropic medications and their support networks.From a review of the literature, to date, there are no published studies on psychotropic medication adherence coverage on social media. Many published studies have explored several contextual factors surrounding the complexities of this issue ,31,32,33Notably, antidepressants received substantially more coverage among the widely viewed videos than anti-anxiety, antipsychotic, mood stabilizer and stimulant medications. As depression continues to be one of the leading psychiatric morbidities affecting the world, it is not entirely surprising that depression was covered in almost half of the widely viewed videos . HoweverThere were several strengths and limitations of the present study. Inter-rater and intra-rater reliability were both high, which further increased the precision of coding sources, format, and content among the widely viewed videos. A sample size of 100 videos was sufficient in presenting a prime opportunity to identify trends, patterns, and prevalence in content among the widely viewed videos. One limitation pertained to the study design, which was cross-sectional in nature. The sample of videos were extracted at one point in time. With the nature of social media continuing to evolve with increasingly more published content, drawing a sample of widely viewed videos at a later point in time will likely yield different results from this study, which further delimits replicability in the study design. Future work could also critically examine whether changes in content covered on psychotropic medication adherence align with trends in this domain on both national and global levels. Another limitation of this study was the fact that only videos in English were reviewed by the authors, which could preclude relevant content published in another language.With advances in science, technology and medicine alongside the increased prevalence of social media as a health communication medium, it is crucial to assure that content posted on social media for health-related considerations inclusive of different health behaviors is precise, up-to-date and engaging to draw in viewers as the basis to support them with navigating psychotropic medication management. Furthermore, in the meantime, until uninsured and underinsured patients have access to psychiatric care for prescribed medications, assuring that they are aware of options is ever more critical. Fortunately, social media as an educational tool has global reach, and in turn, these patients can uncover more information about the range of options as the basis to decide on the most cost-effective ones as well as the ones that align the most with their preferences, goals, values, needs and concerns. Notably, several videos covered perceived concerns linked to side effects, which could certainly be a target for future intervention across both traditional and non-traditional spaces in primary research.Digital heath trends across all generations form a prominent audience for the dissemination of digital health content in our contemporary times. Generation Z in particular has grown up during the advancing digital era and were likely one of the subgroups of the lay population greatly exposed to social media content during the pandemic. This generation was also closely affected by the sequalae of the pandemic with respect to the increased emergence and exacerbation of different public health crises during the pandemic, including our global mental health crisis. In addition, it is possible that larger pharmaceutical companies could be predatory, sharing content that is value-laden, skewed and misaligned from promoting optimal psychiatric care. It follows that increased visibility of experts in psychiatry and the behavioral and social sciences on social media could mitigate the uptake of misinformation surrounding psychiatric medication adherence.Successive content analyses could also yield more information over time on any changing trends in coverage of content on psychotropic medication adherence and subsequent engagement among viewers on social media. Future work could further examine topics covered and uncovered to ultimately determine resource allocation and outreach efforts in supporting any of these topics as further points of education and communication to the lay population. Coverage on social media of considerations surrounding psychiatric care yields promise in heightening parity in the consideration of psychiatric care as equivalent to medical care. It follows that integrating up-to-date, credible and accurate content could help achieve this parity. Deliverers of content are pivotal in this knowledge dissemination. Pairing them with content creators and platform managers could strengthen the production and precision of content along with the engagement and acceptability of content among viewers, thereby promoting a downstream effect that has the potential to reach individuals with mental illness and their networks worldwide.


Healthcare services can be re-traumatising for trauma survivors where they trigger memories of past distressing events and exert limits to a survivor’s sense of autonomy, choice, and control. The benefits of receiving trauma-informed healthcare are well established; however, factors that promote or impede the implementation of trauma-informed care are not yet well characterised and understood.The aim of this review was to systematically identify and synthesise evidence regarding factors that promote or reduce the implementation of TIC in healthcare settings.This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2.0 guidelines. Scopus, MEDLINE, Proquest, PsycINFO and grey literature were searched for original research or evaluations published between January 2000 and April 2021 reporting barriers and/or facilitating factors for the implementation of trauma-informed care in a healthcare setting. Two reviewers independently assessed the quality of each included study using the Mixed Methods Appraisal Tool (MMAT) Checklist.Twenty-seven studies were included, 22 of which were published in the USA. Implementation occurred in a range of health settings, predominantly mental health services. The barriers and facilitators of implementing trauma-informed care were categorised as follows: intervention characteristics , influences external to the organisation (e.g. interagency collaboration or the actions of other agencies) and influences within the organisation in which implementation occurred . Other factors related to the implementation processes  and finally the characteristics of individuals within the service or system such as a resistance to change.This review identifies key factors that should be targeted to promote trauma-informed care implementation. Continued research will be helpful for characterising what trauma-informed care looks like when it is delivered well, and providing validated frameworks to promote organisational uptake for the benefit of trauma survivors.The protocol for this review was registered on the PROSPERO database (CRD42021242891).The online version contains supplementary material available at 10.1186/s43058-023-00428-0. The impacts of psychological trauma have important implications for the provision and receipt of healthcare.This systematic review identifies key factors that should be targeted to promote trauma-informed care implementation, including interagency collaboration, staff and leadership buy-in, aligning implementation strategies with existing policies and procedures, allocation of adequate human and financial resources, flexibility in organisational policies and procedures, ongoing and tailored training, participatory co-design, and the collection and monitoring of data.Identifying factors that influence implementation success across trauma-informed care initiatives can help to inform the selection of implementation strategies and planning.Up to 70% of the population will experience exposure to one or more psychologically traumatic event in their lifetime . PsycholThe impacts of psychological trauma on interpersonal skills, perception, problem-solving, and other core abilities and experiences have important implications for the provision and receipt of healthcare. Healthcare services can present risk for re-traumatisation where they trigger memories of past distressing events and exert limits to a survivor’s sense of autonomy, choice, and control , 6. HypeRecognition of these impacts prompted the development of trauma-informed care in mental health and other settings where most service users have experienced psychological trauma –9. TraumOrganisational interventions aiming to promote the delivery of trauma-informed care have been implemented in healthcare settings in several contexts, including mental health services, inpatient emergency departments, hospital wards, and palliative care , 11. ForResearch has demonstrated that organisational interventions to promote delivery of trauma-informed healthcare can promote well-being among survivors, improve staff skills and collaboration, reduce the use of seclusion and restraint, and reduce the prevalence of the secondary effects of trauma including drug and alcohol use . HoweverAs such, the aim of this review was to systematically identify and synthesise evidence regarding factors that promote or reduce the effectiveness and/or implementation of TIC in healthcare settings.What facilitating factors improve the effectiveness and/or implementation of TIC in healthcare settings?What factors act as barriers that limit the effectiveness and/or implementation of TIC in healthcare settings?The research questions to be answered were:We conducted a systematic review following the guidance of the Cochrane Qualitative and Implementation Methods Group Guidance Series and report our findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2.0 (PRISMA 2.0) guidelines . A checkWe conducted a search of Scopus, MEDLINE, Proquest, and PsycINFO for English language studies published from January 2000 to April 2021. The search strategy is presented in Supplementary Table SWe included studies published since the year 2000 and in English, reporting original research or evaluation, and that reporting barriers and/or facilitating factors for the effectiveness or implementation of a TIC initiative in a healthcare setting. Studies published prior to 2000 were excluded because the TIC framework was not well-defined in research before this time . StudiesStudies included in this review described strategies to implement TIC. TIC has been criticised for lacking an agreed operational definition  and whatIncluded studies described implementation at the organisational level. In this case, ‘initiative’ is used to describe a discrete strategy or set of strategies aiming to implement the principles of TIC within the organisation. An organisational initiative was defined as any initiative listed in the Cochrane Effective Practice and Organisation of Care Review Group data collection taxonomy  Sects. 2Studies describing interventions targeted at individual clinicians  or individual service users  were excluded.‘Healthcare organisations’ included primary, secondary and tertiary healthcare settings . Mental health services, including drug and alcohol services, were included. Child welfare and out-of-home care services  were excluded unless they included a healthcare component.Finally, included studies were required to measure and report quantitative and/or qualitative data regarding factors that influenced initiative or implementation outcomes. Barriers were defined as any factor reported to impede implementation efforts, and facilitators were any factors reported to enable implementation.One reviewer (YH) screened all titles and removed irrelevant papers. Abstracts and full texts were screened for eligibility by two reviewers (YH and MC) using an eligibility checklist based on the criteria described above. Disagreements about inclusion were resolved via discussion between the reviewers, and a third reviewer (LC) was consulted where consensus could not be reached. Study authors were contacted where more information was required to confirm eligibility for inclusion in this review. Data extraction was conducted by one reviewer (YH) using a data extraction spreadsheet that was piloted with five studies before being finalised and being used with the remaining studies. The accuracy of data extraction was validated by a second reviewer. Extracted data included the study’s first author and year of publication, design, setting, population, number of sites, initiative elements (e.g. implementation strategies), outcome data type , evaluation method, implementation outcomes reported, barriers identified, and facilitating factors identified. Intervention outcomes were out of scope of this review so were not reported here.The Mixed Methods Appraisal Tool (MMAT) Checklist, shown in Supplementary Table SThe implementation strategies used in each study were synthesised into broad categories and mapped to the ERIC compilation of implementation strategies independently by two authors (YH and MC). These authors examined the features of each strategy and aligned these features with the most closely related category, and disagreements (which occurred for 8 out of 27 studies) were resolved on discussion with a third reviewer (LC).The core aim of this paper was the synthesise data about barriers and facilitating factors for implementation. As such, this process involved a more detailed, two-step process modelled on the method of a recent review of barriers and facilitating factors for person-centred care in long-term care settings . First, The initial search identified 3051 original results, of which 170 were retrieved in full text and screened against the review inclusion and exclusion criteria. Most exclusions were due to the implementation occurring in a non-health-related care setting. A total of 27 studies were included, reported across 28 publications  and Canada (n = 2). Implementation occurred in mental health settings (n = 15), maternal and women’s health settings (n = 2), paediatric health settings (n = 2), primary care clinics (n = 3), emergency departments (n = 1), or across whole systems within a geographical area including health, policy, child welfare, and other social services (n = 4). Implementation occurred within single health sites for eight studies, and the remainder reported implementation in multiple sites or across a whole service system. Nine of the studies explicitly described using existing implementation frameworks, theories and/or models to design and evaluate their implementation strategies, including the Exploration, Preparation, Implementation and Sustainment (EPIS) framework [Characteristics of the included studies are described in Table ramework , 24, theramework , 26, Cheramework , 28, CFIramework , 29, andramework , 31. Othramework , 33).TabStrategies used to implement the principles of TIC were similar across the included studies. Mapped to the ERIC compilation of implementation strategies , all butMost studies paired staff training and education with other implementation strategies to embed TIC throughout services. Several initiatives included activities to build buy-in and a shared rationale for implementing TIC within the organisation, including by developing position statements (e.g. ), aligniMost of the included studies examined barriers and facilitating factors for implementation of TIC using mixed-methods including staff interviews and/or focus groups, process data (e.g. uptake of screening tools and training attendance), and outcome data (e.g. rates of seclusion and restraint use). Eight studies reported across nine papers described author reflections on barriers and facilitating factors for implementation rather than reporting formal data , 45, 34.Barriers and facilitating factors for implementing TIC across the included studies are described in Table Characteristics of the intervention (TIC) were reported to influence implementation across seven studies, always related to the perceived relevance of TIC to the setting and their target population. Three studies reported that staff did not perceive that the principles of TIC were suitable for their organisation or that their service users were too diverse to make delivery of TIC possible , 27, 29.Seven studies reported barriers and facilitating factors associated with the outer setting . One study noted that other services implementing TIC set a precedent and created a sense of peer pressure for the organisation to also pursue implementation . A cultuFactors related to the inner setting (the organisation or system in which implementation occurred) were reported as barriers or facilitating factors for implementation across 25 of the 27 studies. In many cases, this referred to the culture of the organisation and climate for implementation. Common facilitating factors included high levels of engagement and commitment from organisational leadership , 54, 34,Other common barriers to implementation included competing priorities and staff time constraints , 43–48, Characteristics of individuals were reported as barriers and facilitating factors for implementation in nine studies. In all cases, this focussed on staff resistance to change as a barrier , 48, 50 All but one of the included studies noted barriers and facilitating factors related to the process of implementation. Most studies identified design and delivery elements of their staff training program as promoting or limiting implementation success. For example, delivery of training to a variety of staff at all levels of the organisation, a flexible format that could be tailored according to needs, practical training elements (e.g. role plays), onsite delivery, ongoing trainings and availability of resources, (as opposed to a once-off session), embedding training into new employee orientation, and making training compulsory were identified as facilitating factors across several studies , 50–53. Several studies noted that including service users in implementation efforts promoted implementation success. Relevant strategies included involving a service user as a co-facilitator of training programs, service user inclusion in senior leadership positions and/or implementation teams, seeking regular service user feedback, and designing initiatives in collaboration with service users , 51, 34.Finally, several studies reported that establishing mechanisms to collect and regularly review data about the uptake and outcomes of the initiative was a key facilitating factor for change , 42, 34.This systematic review sought to identify and synthesise evidence about barriers and facilitating factors for implementing TIC into healthcare settings. Given the very high community prevalence of psychological trauma exposure (up to 90% across the lifespan) , and theResults of this review demonstrate that factors related to the inner organisational setting and process of implementation are most often reported as influencers of TIC implementation success. Implementation was promoted where organisation leadership were highly engaged and committed to TIC and where sufficient resources were allocated to making change in practice. These facilitating factors are commonly reported as essential in efforts to implement innovation in healthcare –59, and change agents) was also an important facilitating factor across studies, consistent with evidence that regular, individualised follow-up is an integral component of success in quality improvement efforts [Training staff about psychological trauma is also an essential step in the delivery of TIC particularly in health settings where mental health is not the primary focus of treatment . The men efforts . This ma efforts .The process of implementing TIC is promoted where both staff and service users are engaged in both designing the implementation strategy and monitoring its ongoing progress. The value of engaging service users in the co-design of quality improvement initiatives is increasingly recognised and is mutually beneficial for both the service provider and the service user . In the Factors related to the characteristics of the intervention (TIC) and the individuals within the service generally focused on the sense of relevance of TIC for the service and service users, as well as staff openness to change. This is consistent with evidence that any intervention perceived by staff as not useful, not applicable to their clients, or not harmonious with their current practice is difficult to implement in practice . EffortsKey strengths of most of the identified studies included detailed information about the setting in which implementation occurred and examination of how these factors influenced implementation outcomes. The use of mixed-methods in 15 studies allowed an in-depth triangulation of data –54, 34. Strengths of this review include our broad search strategy that captured initiatives to implement TIC across countries and healthcare settings. Our synthesis generated common themes across diverse initiatives and mapped them to an existing framework to maximise interpretability. Limitations of this review include that we excluded any papers not published in English and this may limit the generalisability of the results. The lack of an operational definition of TIC and the breadth of interventions delivered at the system or organisation level in the included studies may also limit comparability and the conclusions that can be drawn from the results. However, core elements of the implementation strategies were common across studies  promoting comparability. Future reviews may be helpful for synthesising common implementation strategies used for TIC in more depth. Our coding and mapping to the CFIR framework may have been influenced by subjectivity, though our use of multiple coders and multiple rounds of coding reduces this risk. In addition, we did not assess the relative strength of each influencing factor. That is, factors that were reported less often across studies may nonetheless have a more powerful influence on implementation. The exclusion of an evaluation of relative strength of the influencing factors was primarily determined by few of the included studies providing such an analysis. Future studies that examine the strength of influence of each factor on implementation outcomes will be helpful for filling this research gap.There have been recent calls to implement TIC as a universal model of care across healthcare , aged caAdditional file 1. PRISMA Checklist; Search strategy; PRISMA diagram; Results of quality appraisal; Mixed-methods appraisal tool questions. The tile contains tables that provide additional information about the systematic review process. This includes the search strategy, PRISMA checklist and diagram, and tables pertaining to the quality appraisal undertaken.