The overarching objective was to examine the effectiveness of intervention strategies to promote fruit and vegetable consumption. To do this, systematic review evidence regarding the effects of intervention strategies was synthesized; organized, where appropriate, by the setting in which the strategies were implemented. Additionally, we sought to describe gaps in the review of evidence; that is, where evidence regarding the effectiveness of recommended policy actions had not been systematically synthesised.We undertook a systematic search of electronic databases and the grey literature to identify systematic reviews describing the effects of any intervention strategy targeting fruit and/or vegetable intake in children or adults of any age.The effects of 32 intervention strategies were synthesised from the 19 included reviews. The strategies were mapped across all three broad domains of the NOURISHING framework , but covered just 14 of the framework’s 65 sub-policy areas. There was evidence supporting the effectiveness of 19 of the 32 intervention strategies. The findings of the umbrella review suggest that intervention strategies implemented within schools, childcare services, homes, workplaces and primary care can be effective, as can eHealth strategies, mass media campaigns, household food production strategies and fiscal interventions.A range of effective strategy options are available for policy makers and practitioners interested in improving fruit and/or vegetable intake. However, the effects of many strategies – particularly those targeting agricultural production practices, the supply chain and the broader food system – have not been reported in systematic reviews. Primary studies assessing the effects of these strategies, and the inclusion of such studies in systematic reviews, are needed to better inform national and international efforts to improve public health nutrition.The review protocol was deposited in a publicly available Open Science framework prior to execution of the search strategy. https://osf.io/unj7x/.The online version contains supplementary material available at 10.1186/s12966-020-01046-y. Low fruit and vegetable consumption are a modifiable risk factor that is contributing to the rising international burden of non-communicable diseases , 2. In 2The World Health Organization (WHO) recommends a combined consumption of at least 400 g (g) of fruits and vegetables per day . HoweverImproving population intakes of fruits and vegetables represents a considerable challenge. The determinants of intake are complex, and nest within a dynamic food system where there is interaction of factors such as food production, supply and affordability, access, food environments and individual behaviours . SeveralTo date, government action to improve fruit and vegetable consumption has been variable. The Global Nutrition Policy Review found that just 63% of 167 countries with national nutrition polices included goals, targets or indicators focused on improving fruit and vegetable intake; also, initiatives to promote fruit and vegetable consumption varied considerably by WHO region . HoweverTo maximise the potential impact of investment in initiatives to improve fruit and vegetable intake, it is recommended that evidence be used to influence decision-making in health policy and practice. Rigorous systematic reviews aim to identify, capture and consider all relevant evidence , 19. As Given the importance of fruit and vegetable intake to human health, and the breadth of strategies suggested to improve intake, we conducted an umbrella review to inform a background paper for the 2020 Food and Agriculture Organization of the UN (FAO)/WHO International Workshop on Vegetables and Fruits for Food and Quality of Life. The workshop seeks to support public sector organisations to develop national policies, strategies, regulatory frameworks and other intervention strategies, to improve population fruit and vegetable intake. The overarching objective is to examine the effectiveness of intervention strategies to promote fruit and vegetable consumption. To do this, we synthesized systematic review evidence regarding the effects of intervention strategies, organized (where appropriate) by the setting in which they were implemented. We also sought to describe gaps in the review of evidence . In both synthesis of evidence and identification of gaps, we used the recommended policy areas identified in the WCRF NOURISHING framework.The review was guided by recommendations for the conduct of umbrella reviews from the Joanna Briggs Institute  and the We included systematic reviews that assessed the effectiveness of intervention strategies on a measure of fruit and vegetable intake. We included one systematic review per intervention strategy identified. Consistent with recommendations in the Cochrane Handbook, where multiple reviews report the effects of the same intervention strategy, we selected the most recent high-quality review for inclusion. This approach meant that the number of systematic reviews included could not exceed the number of strategies reported in this umbrella review. However, in some instances, a single review was included that reported on the effects of multiple intervention strategies.We included systematic reviews with or without meta-analysis that described the effectiveness of any intervention strategies on a measure of fruit and/or vegetable intake in children or adults. Initially, we included only reviews of controlled trials; however, following initial citation screening, we modified the criteria to include reviews of any prospective evaluation design . The aim of this modification was to provide greater opportunity for the inclusion of reviews reporting the effects of macro-level intervention strategies  that may not be amenable to group allocation. All citations were rescreened using this modified criterion to ensure consistency with the screening method.We excluded reviews comprising solely qualitative research, because they do not provide quantitative estimates of the effects of intervention strategies. Reviews published before 2011 were also excluded (as per Joanna Briggs Institute guidance), because those published in the past 10 years represent the contemporary evidence base and will capture primary research conducted over the previous 30 or so years .Also excluded were reviews of intervention strategies on population groups selected on the basis of pre-existing comorbidities ; reviews focused on strategies that targeted the treatment or management of eating disorders (e.g. anorexia nervosa or bulimia) or other diseases; reviews of intervention strategies undertaken in laboratories or other simulated contexts (e.g. laboratory-based experiments of infant feeding practices); reviews in which intervention strategies were defined only by the population group targeted and not characterised by setting, delivery modality or content; and reviews examining intervention mechanisms (e.g. theory-based mechanisms of effect), or in which the effects of intervention components were synthesised at the level of individual behaviour change techniques.The primary outcome for the umbrella review was fruit and/or vegetable intake (referred to here as ‘fruit and vegetable intake’ unless otherwise specified), assessed via self-report, observational, biochemical or other measures, or via objective measures of fruit and vegetable purchases (as an accepted proxy). Specifically, fruit and vegetable intake is measured in, for example, grams, portions or serves, assessed using measures such as food diaries, dietary recalls, food frequency questionnaires, observation or other approaches (e.g. measures of plate waste or photographs). Before undertaking the search, we also included objective measures of purchases of fruits and vegetables (e.g. those supplied by food outlets or supermarkets) as a proxy for dietary intake. Such outcomes are more likely to be used in evaluations of intervention strategies at policy or food system level, and represent a reliable surrogate measure of intake. To be included, systematic reviews must have synthesised the effects of strategy types on any measure of fruit and vegetable intake across the included reviews, in narrative or quantitative form . We excluded reviews that included primary studies that reported on fruit and vegetable outcomes as part of other dietary measures , but did not explicitly synthesis across primary studies. We also excluded measures of behavioural intention, preference or liking for fruits or vegetables.A search of peer reviewed and grey literature was undertaken on 11 June 2020 in the following bibliographic databases: MEDLINE, Embase, CINAHL, The Cochrane Library, Scopus and Academic Search Ultimate. We combined terms for ‘intervention strategy’, ‘systematic reviews’ and ‘fruits and vegetables’, and limited the search to the dates 2011 to 11 June 2020. Search strategies developed in MEDLINE were adapted for other databases by an information specialist see . We alsoA single reviewer (LW) initially screened all citations, and excluded all clearly ineligible citations based on title. The remaining titles and abstracts were screened in duplicate  for eligibility. The full texts of all potentially relevant reviews were obtained and assessed against the inclusion criteria in duplicate . Manuscripts published in non-English languages were translated using ‘Google Translate’ and, if manuscripts were eligible for inclusion, a native language reviewer was sought to assist with screening and extraction. Disagreement regarding the eligibility of a review was resolved by discussion and consensus, or by consultation with an additional reviewer (LW).Data were extracted independently and in duplicate by review authors . The data extracted included the following information recommended by the Joanna Briggs Institute for the conduct of umbrella reviews:  citationWhere a review reported separate syntheses of the effects of different intervention strategies, we extracted information describing the effects of each synthesis. If two or more reviews reported the effects of the same intervention strategies, we included only the findings of the most recent high-quality review. To do this, we assessed all reviews with a search date within two years of the most recent review, and selected the review with the highest quality rating. This meant that, for each intervention strategy, we included and reported only the findings of syntheses in the most contemporary and rigorous reviews available, and thus reduced the risk of any potential bias from overlapping reviews and primary studies.Where reviews examined the effects of the same intervention strategy but in mutually exclusive population groups – for example, children and adults – we reported the effects in both groups. However, where reviews were undertaken on a population group and a subset of a population group – for example, children and girls only – we included only the more inclusive sample .We assessed the methodological quality of included reviews independently and in duplicate , using the critical appraisal tool developed by the Joanna Briggs Institute , 37. DisWe used basic frequencies to describe the search results; described excluded and included reviews in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance ; and narp-values and measures of heterogeneity in any included meta-analysis. Where the included reviews had narratively synthesised intervention strategies, we extracted and reported statements within the review that best summarised their overall effects. Summary statements were agreed on by two authors . Where reviews used both a formal measure of risk of bias or assessment of the quality of primary studies (e.g. Cochrane Risk of Bias tool), [To describe the effectiveness of the intervention strategies we reported, where available, the point estimates of effect, measures of variability, s tool),  and an es tool),  we repors tool), .We used the WCRF NOURISHING framework  to descrA total of 3588 records were identified through database searching, with an additional 115 identified through targeted Google Scholar searches. After deduplication, and full text assessment, 46 reviews reporting the effects of 32 intervention strategies were identified. Following an assessment of review search date and quality , 19 systematic reviews reporting the effects of 32 intervention strategies were ultimately included , [Additional file n = 12), , 53–57. n = 12), , 52, 58.The effects of 32 intervention strategies were synthesised from the 19 included reviews. There was evidence supporting the effectiveness of 19 of the 32 intervention strategies  or reduce (for price increases or taxes) fruit and vegetable intake, the long-term effects of other strategies that could be implemented within retail environments (e.g. choice architecture strategies) were mixed. Similarly, there was some evidence to support the introduction of mobile produce markets as a strategy to improve intake of fruits and vegetables among market users, but the introduction of new supermarkets (which offer both fresh and packaged foods) may reduce intake. The rest of this section outlines the effects of intervention strategies reported in the included reviews, grouped by setting where appropriate., which assessed the effects of cooking lessons, four of six primary studies were undertaken in the school setting (the other two occurred in the home) [n = 2 primary studies) [n = 6 primary studies).Six included systematic reviews reported the effects of seven school-based intervention strategies. In one of these reviewshe home) . Five ofhe home) ; implemehe home) ; providihe home) ; providihe home) ; and apphe home) . With thstudies) . Reviewsstudies)  and schostudies)  – suggesp = 0.002; n = 8 primary studies), but not for parent nutrition education intervention strategies delivered through childcare, or for multi-component childcare intervention strategies.One review, reporting the effects of three childcare-based intervention strategies, was included. The review of randomised trials reported a significant pooled effect on child fruit and vegetable intake for child-feeding interventions delivered by childcare staff ; however, parent nutrition education strategies were not effective [One review, reporting the effects of two parent or family home-based intervention strategies, was included. A review of randomised trials found intervention strategies targeting child-feeding practices of parents (i.e. repeated food exposure) were effective in the short term (< 12 months) on fruit and vegetable intake   reportedn = 26 primary studies). Heterogeneity of the primary studies precluded meta-analysis, but the review concluded that nutrition intervention strategies based in primary care generally resulted in small increases in fruit and vegetable intake.One included review  examinedn = 4 primary studies).One review examined community-based after-school programs . It founp < 0.001; I2 not reported; n = 19 primary studies). Subgroup analyses reported significant effects for computer-based, SMS and Internet-based intervention strategies, but not for those delivered via CD-ROM, mobile apps or video games.One review reported the effects of various eHealth intervention strategies . An overA narrative synthesis of five primary studies of mass media intervention strategies targeting nutrition behaviours suggested the potential effectiveness of these as stand-alone approaches in improving the consumption of fruits and vegetables in adults and young people .n = 7 primary studies) [n = 3 primary studies) [Two narrative reviews that examined the effects of choice architecture strategies reported mixed findings. One review did not disaggregate the effects of specific strategies, but found that evidence of the long-term effects of choice architecture intervention strategies  was unclear overall (studies) . The othstudies) .n = 4 primary studies), [Two reviews reported the effects of the introduction of three types of new food retail outlets. These reviews, which were restricted to primary studies undertaken in the US, , 53 suggtudies),  and new tudies), .n = 5 primary studies). It concluded that household gardens, with or without an animal production component, improved intake of fruits and vegetables rich in vitamin A rich.One review  of randon = 9 primary studies). The other review [n = 24 primary studies). Price increases on other food types, such as sweets, were found to have a marginal positive impact on consumption of fruits and vegetables [Two reviews reported the effects of two fiscal intervention strategies: price reductions and price increases. One review  pooled dr review  found thgetables .Table All the intervention strategies synthesised by the included reviews that mapped to the ‘food environment’ domain were reportedly effective in improving fruit and vegetable intake, including those within the policy areas of ‘Nutrition label standards and regulations’ and ‘Offering healthy food and set standards in public institutions and other settings’, such as schemes to increase the availability of fruits and vegetables in schools. There was also direct evidence from systematic reviews regarding the impact of interventions in the policy area of ‘Use of economic tools to address food affordability and purchase incentives’. This evidence supported sub-policy areas such as the use of food taxes  on foodsIn contrast to intervention strategies mapped to the food environment domain, the strategies mapped to the food system and behaviour change communication domain did not always have a beneficial effect. Within the ‘food system domain’, evidence from systematic reviews could be mapped directly to just one sub-policy area – ‘Community food production’ – for which reviews found that home gardens in LMIC improved fruit and vegetable consumption, whereas evidence of the benefits of introducing fresh-produce markets was less certain .Within the ‘Behaviour change communication domain’, direct evidence of a beneficial effect was identified within the policy areas of ‘Informing people about food and nutrition through public awareness’   and ‘nutThis umbrella review sought to consolidate the global evidence base from systematic reviews regarding the effectiveness of intervention strategies to improve fruit and vegetable intake. It identified several strategies with evidence of a beneficial impact, mapped to the WCRF NOURISHING framework, including those undertaken in community settings , eHealth and mass media, household food production strategies, and fruit and vegetable subsidies. The findings indicate that policy-makers and practitioners have a range of effective options to improve population level intake of fruits and vegetables. Nonetheless, the evidence on the effects of intervention strategies represented only a fraction of the options suggested by comprehensive nutrition frameworks; thus, many recommended nutrition actions have not been the subject of systematic synthesis to determine their specific impact on fruit and vegetable intake.Intervention strategies for which systematic reviews reported an effect were predominately focused on the food environment and behaviour change communication domains of the WCRF NOURISHING framework, and most of these reviews reported the effects of setting-based interventions (particularly schools). Encouragingly, school-based fruit and vegetable intervention strategies are frequently undertaken by governments, and this umbrella review provides further evidence to support investment in such initiatives. However, the included reviews did not assess the impacts of most of the framework sub-category areas, and none of them reported the effects of intervention strategies within the broad categories of ‘Restrictions on food advertising and commercial promotion’ or ‘Improving the quality of the whole food supply’. Strategies such as nutrition labelling and food reformulation can improve energy or macronutrient intake, , 60 and Pricing strategies have been suggested as a powerful determinant of dietary behaviour. Their use to improve public health nutrition has been recommended by the UN General Assembly at a High-Level Meeting on Non-Communicable Diseases . Indeed,Access to fruits and vegetables is a critical determinant of intake . This umInterestingly, the umbrella review found mixed effects reported from efforts to improve the physical availability of fruits and vegetables through new food retail outlets, such as supermarket grocery stores, mobile produce markets and farmers markets. Farmers and mobile produce markets were suggested to be beneficial in improving fruit and vegetable intake because they provide access to fresh produce, including fruits and vegetables. In contrast, the introduction of new retail supermarkets appeared to have a detrimental effect on fruit and vegetable intake. Also supermarkets may increase the availability of fruits and vegetables, they also increase access to less healthy foods and exposure to unhealthy food marketing, which may explain, in part, these apparently contradictory findings.The findings of the review should be considered in the context of several limitations. First, as an umbrella review, the study was restricted to the analyses reported in the included reviews, and did not re-examine or analyse primary studies. Thus, the identified gaps in the evidence base for some intervention strategies may reflect the lack of systematic reviews of these strategies rather than the absence of primary studies. Second, it is likely that there is some duplication of primary studies in the syntheses of the effects of intervention strategies reported by the included reviews, particularly among reviews reporting strategies conducted in the same setting (e.g. schools). Third, review inclusion criteria were restricted to prospective evaluations of studies reporting measures of fruit and vegetable intake (or purchasing). Some intervention strategies (e.g. those targeting modification of the food supply) may not be readily amendable to evaluation using conventional prospective designs, or their effects may be more appropriately assessed using other metrics  that can be correlated with population level intakes. Including broader study design and outcome measures in the eligibility criteria of the umbrella review may have identified other relevant reviews. Anecdotally, however, such systematic reviews were not apparent during screening for this review. The included systematic reviews also largely examined intervention strategies that were more commonly implemented in high-income countries, and most of the primary studies included in these systematic reviews were from high-income nations, reflecting the available published literature. Hence, the global applicability of the findings of some strategies may be limited, underscoring the need for both primary studies and reviews specific to intervention strategies undertaken in LMIC.Notwithstanding its limitations, the review identifies a range of options for health policy makers and practitioners interested in improving the health and wellbeing of communities through strategies to improve fruit and vegetable intake. In particular, the review provides evidence of a beneficial effect for setting-based and fiscal approaches. Many intervention strategies based on the food system  could have a profound impact on population-level fruit and vegetable consumption; however, their effects have not been reported in systematic reviews. The conduct of primary studies assessing the impact of such approaches and their inclusion in systematic reviews would better support appraisal of their benefits, which in turn would help to strengthen national and international public health nutrition efforts.Additional file 1. Search strategy (contains details of the search terms used in database searches).Additional file 2. Quality assessment of included reviews .Additional file 3. Pooled effects of intervention strategies to improve fruit and vegetable uptake.


Asthma: Novel developments from bench to bedside” a number of key topics relevant for asthma development reaching from epidemiology and lung function to the role of early immune regulation, genetics, and epigenetics as well as external factors such as viruses and the microbiome summarize recent knowledge paired with future perspectives for the next decade of asthma research and clinical translation. Insight into local airway immune responses translating from mice to men and the role of omics for asthma sum up the complex nature of this multifactorial disease. Several asthma phenotypes in combination with underlying endotypes are tackled in a number of the subsequent articles.In the current issue “Asthma epidemiology and risk factors” in this issue [Lung functional development and asthma trajectories” it is illustrated that a possible mechanism for a sustained effect of impaired lung function on asthma is the influence of early life risk factors on early life lung functional growth and development, representing the most susceptible phase of lung growth and plasticity. Hereditary and environmental peri- and postnatal factors on lung functional development are summarized including air pollution, tobacco exposure, nutrition, intrauterine growth retardation, prematurity, early life infections, microbiome, and allergies and their effect on lung functional trajectories [Asthma indeed represents a clinical syndrome affecting all age groups . Asthma is issue . In the ectories . While fectories . Future Role of early life immune regulation in asthma development,” and it’s importance and potential intervention for early prevention and treatment strategies are delineated.In parallel with lung development, it is critical how the immune system of a child responds to the interaction of genetic, epigenetic, and environmental factors and whether effective strategies for a balanced and healthy immune maturation can be assured to prevent asthma development . SeveralRecent findings in the genetics and epigenetics of asthma and allergy,” recent developments of a few key topics in this field are summarized. Several studies have focused on overlapping or specific phenotypes within the allergy spectrum and beyond, looking for common genetic traits shared between different diseases or disease entities. Importantly, asthma and allergy genetics in populations genetically different from European ancestry have been addressed, being key as the majority of new asthma patients are not white [In addition to early life immune regulation, in “ot white . In epigot white .Role of viruses in asthma,” a better understanding of personal and environmental risk factors and inflammatory mechanisms leading to asthma is discussed central for developing new strategies for the prevention and treatment of asthma.While genetics and epigenetics are relevant for asthma development without doubt, respiratory viral infections are known as key triggers of asthma exacerbations. The common cold virus rhinovirus (RV) is the most prevalent pathogen circulating in the community with high diversity with approximately 170 genotypes, an effective replication in T helper 2 cell biased, inflammatory milieu, and specific risk genes. Decreased interferon responses, disrupted airway epithelial barrier, environmental exposures, and nutritional deficiencies increase the risk to RV and other virus infections . The debDysbiosis of the gut and lung microbiome has a role in asthma,” the authors describe how the development of asthma is influenced by environmental and exogenous factors synergizing with genetic predisposition, shaping the lung microbiome in particular during peri- and postnatal phases. A healthy lung microbiome is characterized by bacteria belonging to the phyla Bacteroidetes, Actinobacteria, and Firmicutes [Haemophilus and Moraxella in young children and adult asthmatics. This dysbiosis supports induction of inflammatory pathways contributing to bronchoconstriction and bronchial hyper responsiveness. Exogenous factors can influence the natural lung microbiota composition in a positive manner such as in farming environments or negatively such as allergens or air pollutants do. Gut microbiota dysbiosis also influences asthma pathogenesis. Antibiotics, antiulcer medications, and other drugs severely impair gut and lung microbiota. Resulting dysbiosis and reduced microbial diversity dysregulate the bidirectional crosstalk across the gut-lung axis, resulting in hypersensitivity and hyper reactivity to respiratory and food allergens. Efforts are undertaken to reconstitute the microbiota and immune balance by probiotics and engineered bacteria, but results from human studies do not yet support their efficacy in asthma prevention or treatment [In the timely topic “rmicutes . As one reatment . In summModulating local airway immune responses to treat allergic asthma: lessons from experimental models and human studies,” the current understanding of the contribution of local innate immune elements in the development and maintenance of inflammatory airway responses in mice and men is comprehensively summarized, and available leads for successful targeting of those pathways for future therapeutics are envisioned. Allergic asthma with Th2-type immunity represents 90% of child and 50% of adult asthma cases. Research on animal models of allergic disease has led to the generation of biologicals, a novel class of drugs, targeting components of Th2-type inflammation [In the article “ammation . Althougammation .Omics for the future in asthma” focuses on refining of asthma phenotypes and understanding their underlying biological structure in order to facilitate precision medicine approaches. The use of a number of omics methods such as (epi)genomics, transcriptomics, proteomics, metabolomics, microbiomics, and exposomics are relevant to investigate asthma from diverse angles [Finally, “e angles . Althouge angles . The autFinally, this bouquet of further developing and novel fields of asthma research will only in concert be able to bring this complex field of this multifactorial disease forward. Thus, combined efforts across studies, country borders, and ethnicities are urgently needed. By harmonizing already available and designing novel well-defined cohorts together with clinically well-characterized phenotyping of the asthma syndrome, large, open consortia, well-prepared to integrate novel strategies of basic, clinical, and analysis methods, can offer answers to the currently unmet need, namely to understand distinct mechanisms of asthma endotypes and to treat the majority of asthma patients more individually and more efficiently. Finally, for asthma prevention, murine and human immunological studies in concert with genetic and epigenetic expertise are crucial to disentangle the key mechanisms for effective prevention strategies, early in life, but possibly also in childhood, later adolescence, and adulthood.


IJHPM editorial “Addressing NCDs: Challenges from industry market promotion and interferences,”1 further exemplify the tactics used by tobacco, alcohol and unhealthy food industry in interfering governments’ efforts to counteract the commercial determinants of non-communicable disease (NCD); in particular the best buys interventions. These interventions, in particular increase tax and retail price of tobacco and alcohol; control advertising and marketing and limit the availability of these products, clearly challenge and invite industry’s heavy fight back.2 The commentaries also raise concerns about the high level of industry interference, focusing on the emerging markets in low- and middle-income countries in Asia and Africa, in particular in the context of poor legislation and weak regulatory environment.3The four commentaries on an 4 For example, Thailand’s efforts of introducing pictorial health warning on alcohol were challenged by industries and World Trade Organization’s members including European Union as an excessive barrier to trade.5Not only four tactics identified by the editorial, the use of “trade and investment disputes” through the Technical Barrier to Trade platform of the World Trade Organization is powerful in discouraging government making bold efforts.6 Unlike other psychotropic substances, alcohol, classified by International Agency for Research on Cancer (IARC) as group 1 carcinogenic to humans, has not yet been controlled by international binding instrument. Despite these gloomy situations; the Scottish government was successful in counteracting legal threat by alcohol industry in introducing minimum unit price of alcohol to prevent promotion of consumption through lowering price.7The industry commonly uses the discourse that “alcohol related problems are in the person and not in the bottle.”“Alcoholic beverages were declared as group 1 ‘carcinogenic to humans’ by the IARC Monographs Programme , first in 1988 and then again in 2007 and in 2010.8Tumour types caused by drinking alcoholic beverages include cancers of the oral cavity, pharynx, larynx, oesophagus , liver, colorectum, and female breast. For renal cell carcinoma and non-Hodgkin lymphoma, there is ‘evidence suggesting lack of carcinogenicity’ for alcohol consumption.”910 Learning from World Health Organization (WHO) Framework Convention for Tobacco Control, the WHO Member States should negotiate the development of an international agreement on alcohol control to help foster coherent policies and regulatory measures against industry interferences and aggressive market promotion.We strongly support the proposal for a legally binding international agreement.Further, all heath conferences, meetings, events and workshops sponsored or organized by WHO, governments and academia should be alcohol free. This sets the social norm and precedence in addressing harmful use of alcohol through civic actions. We call WHO, as world health leader, leading the “alcohol-free role model.”11We strongly support that government officials shall not engage in or associate with tobacco and alcohol industry even under the so-called corporate social responsibility. The Foundation for a Smoke-Free World, launched in 2017, was vowed as an “independent” research funding body but it was fully funded by Philip Morris Inc. The Foundation can support research and development of new smokeless tobacco products.12 Strong national capacity, international collaboration and vigilance by civil society organization can synergistically respond to these emerging challenges.Capacity of government alone is inadequate to respond to market promotion and sales through internet. This fosters the needs for international instrument and collective efforts across countries. Rampant global and cross-border market promotion through internet sales via application in smart phone by tobacco industries; their website promotes sales through coupons, games, social activities/events and sweepstakes or contests.Evidence shows neither self-regulation nor collaborative initiatives are effective in achieving public health objectives to prevent NCD in particular in the context of aggressive marketing, conflicts of interest between industries and government officials and weak regulatory capacities in most low- and middle-income countries.13 There is a need for improve governance and leadership which translate into political commitment to support whole-of-government and health-in-all-policies approaches. The commitment should be translated into budget allocation for NCD prevention and control. There are good practices on the use of earmarked tax from tobacco and alcohol for active health promotion.14 There is a need to boost the implementation capacity for NCD prevention and control and the application of 16 best-buy interventions.At national level, policy coherence and effective multi-sectoral actions to safeguard health of the population are critical. Philippines have demonstrated an effective collaboration between Department of Finance and Health in introducing sugar sweetened beverage tax through legislation.15 National legal capacity can address the challenges from the use of trade and investment agreement by industry.In addition to multi-sectoral actions; there is an urgent need to mobilize the legal workforce, strengthen legal capacity and support effective use of law at the national level. Legal and regulatory actions are required to be at the centre of national NCD action plans. Strengthening legal capacity requires high-level leadership from global and national leaders, enacting evidence-based legislation and building legal capacities.Not applicable.Authors declare that they have no competing interests.All authors involved in the conceptualize the paper, design, and analysis. VT proposed the structure and main ideas. OC, WK, KM, and NP summarized key points from four commentaries. All authors read and approved the final manuscript.


Professor Chuan Qin, President of Institute of Laboratory Animal Science, Chinese Academy of Medical Science and Peking Union Medical College, President of Chinese Association for Laboratory Animal Sciences.On November 19‐20, 2020, the 2nd Longtan Science Conference and the 40th anniversary celebrations of the Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences & Comparative Medicine Center, Peking Union Medical College (hereinafter referred to as "ILAS") were held in Beijing. The conference was jointly organized by the Institute and the Chinese Association for Laboratory Animal Sciences.Laboratory animal science is a key support for and an important component of life science and health research. Since its establishment in 1980, the mission of ILAS has been to foster the development of disciplines and resources, basic research, and technical training.Following the founding of the first animal rooms 40 years ago, generations of ILAS graduates have made dedicated efforts to develop laboratory animal science research and establish the discipline of comparative medicine. Through their unremitting efforts, ILAS has set up the largest human disease animal model resource center in China, established animal models of infectious diseases in all previously targeted areas in the fight against infectious diseases, and built a national system of laboratory animal standards.Since 2003, ILAS has entered a period of rapid development. With the emergence of SARS and continuing with the emergence of COVID‐19, ILAS has been tasked with the important mission of establishing disease animal models, and has made great contributions to the prevention and control of infectious diseases worldwide.The development of ILAS over the past 40 years would not have been possible without the support of other agencies. At the opening ceremony, guests from CPPCC, the National Health Commission, the Ministry of Science and Technology, and the Chinese Academy of Medical Sciences & Peking Union Medical College offered congratulations and high praise for the efforts made by ILAS to accelerate innovation in medical sciences, promote original drug and vaccine research, and ensure public health and safety.Lifetime achievement award: Professor Lu YaozengOver 40 years, ILAS has fostered the development of dedicated and innovative scientists. The conference issued a number of awards celebrating the achievements of these leading scientists: "Epidemic research pioneer award", "40th anniversary research achievement award", "Lifetime achievement award", "Outstanding contribution award" and "Outstanding young scholar award".The celebrations of the 40th anniversary of ILAS were held jointly with the annual Longtan Science Conference. At the conference, 15 academicians and experts gave academic lectures on medical education, scientific and technological innovation, animal model research, etc., with a focus on promoting the development of research in laboratory animal science, comparing medicine and life science, and better safeguarding of human health through cutting‐edge academic exchanges. As part of its 40th anniversary events, ILAS has also organised a series of online academic lectures at home and abroad between November, 2020 and January, 2021, to enhance academic exchanges and expand academic horizons, with speakers including Professor Fuad Iraqi , Professor Grant Morahan , and Professor Erwan Bezard (University of Bordeaux).Lifetime achievement award: Professor Lu YaozengInstitute of Laboratory Animal Sciences,Chinese Academy of Medical Scienceshttp://www.cnilas.org/renshichu@cnilas.org86‐(0)10‐6777605086‐(0)10‐67776529the Website of ILAS 40th anniversaryhttp://www.cnilas.org/suoqing40/Nature for ILAS 40th anniversaryThe Website of https://www.nature.com/articles/d42473‐020‐00447‐8Nature website


Technological innovation is transforming traditional clinical practice, enabling people with multiple sclerosis (pwMS) to contribute health care outcome data remotely between clinic visits. In both relapsing and progressive forms of multiple sclerosis (MS), patients may experience variable disability accrual and symptoms throughout their disease course. The potential impact on the quality of life (QoL) in pwMS and their families and carers is profound. The introduction of treatment targets, such as NEDA (no evidence of disease activity) and NEPAD (no evidence of progression or active disease), that guide clinical decision-making, highlight the importance of utilizing sensitive instruments to measure and track disease activity and progression. However, the gold standard neurological disability tool—expanded disability severity scale (EDSS)—has universally recognized limitations. With strides made in our understanding of MS pathophysiology and DMT responsiveness, maintaining the status quo of measuring disability progression is no longer the recommended option. Outside the clinical trial setting, a comprehensive monitoring system has not been robustly established for pwMS. A 21st-century approach is required to integrate clinical, paraclinical, and patient-reported outcome (PRO) data from electronic health records, local databases, and patient registries. Patient and public involvement (PPI) is critical in the design and implementation of this workflow. To take full advantage of the potential of digital technology in the monitoring and care and QoL of pwMS will require iterative feedback between pwMS, health care professionals (HCPs), scientists, and digital experts. Multiple sclerosis (MS) is a chronic inflammatory, demyelinating, and degenerative disease of the central nervous system (CNS). MS affects more than 130,000 people in the UK and over 2.5 million worldwide , 5, partPwMS with advanced disease, for example those having an EDSS ≥ 6.5, and elderly pwMS are at particular risk of being less carefully followed up . These pHere, we provide a perspective on using a new approach of collecting data in pwMS that combines (i) clinical assessments with potential for self-monitoring and (ii) patient-reported outcomes (PROs) using a platform shared between a large data repository, the UK MS Register at Swansea University, and BartsMS in east London, UK. We describe how such point-of-care data collection may serve both research and the individual pwMS in clinic and highlight the role of patient and public involvement (PPI) in facilitating the “buy-in” of pwMS underpinned by some preliminary data on patient engagement with the UK MS Register portal and corresponding data sharing preferences.The introduction of the EDSS  as the kAs a result, the National MS Society's Clinical Outcomes Assessment Task Force started more than 25 years ago developing a new set of outcome measures. Ultimately, a set of three tests was agreed, making up what was coined the Multiple Sclerosis Functional Composite (MSFC). The MSFC consists of the Paced Auditory Serial Addition Test (PASAT), Timed 25-foot walking (T25ftWT), and the Nine Hole Peg Test (9HPT) and has been implemented in a number of clinical trials . However“BartsMS” is a clinic–academic partnership based at The Royal London Hospital  and The Blizard Institute/Queen Mary University of London providing clinical care to over 3000 pwMS. Faced with the same discrepancy between high expectations and the reality of limited resources , BartsMSThe relative simplicity of the MSFC or variations thereof, such as the 3TEST, combined with advances in technology and ever-increasing online resources and capabilities have led to the expansion and uptake of self-monitoring applications . Self-moIn addition, wearable technologies, including motion detecting devices (MTDs) and smartphone applications may facilitate minimally intrusive assessment of outcomes such as step count, walking speed, and gait  and suppResults from tests that (i) are relatively straightforward to implement in clinic and (ii) can be translated into self-monitoring tools can be combined with PRO questionnaires and fed into the patient record, which, in health care settings covering large numbers of pwMS, is usually an electronic health record (EHR). EHRs facilitate the timely recording of patient data and the simultaneous navigation by multiple HCPs from different specialities . Coding ad hoc questionnaire . This system enables extraction of coded information to populate our database of pwMS (the “BartsMS Database”) in Excel , therebyionnaire .Since 2017, BartsMS and the UKMSR have been developing a hub/spoke monitoring system . The intWe learned that patient and public involvement (PPI) is pivotal to maintain and expand data collection through the UKMSR. Valuable insights and feedback were provided through a PPI meeting held at The Royal London Hospital  on 16 February 2018. Key outcomes of this engagement day were (i) a re-designed, visually more attractive website enabling easier navigation and providing better sectioning, including a “My MS” hub page. This hub contains easily identifiable and accessible open questionnaires, including estimates of the time required for completion. This feature also provides pwMS with a snapshot of the information they have contributed and highlights any data that they should still provide; (ii) radio boxes for questionnaires, rather than drop-down menus since less mouse movement is required, making it easier to navigate for pwMS with upper limb function impairment; (iii) reduced frequency of questionnaire responses requested ; (iv) more tangible benefits for UKMSR subscribers, who were keen to receive comprehensive feedback about their collected questionnaire data—we therefore decided that the facility of viewing personal response data should be provided as an option; (v) since September 2018, participants who join the UKMSR and opt in to feedback are being offered a downloadable version of their results. By December 2019, 67% of new subscribers  had had opted into this facility. This is designed so that it can be taken along to clinic appointments. Information is displayed in easily accessible graphs, allowing pwMS to track their condition over time. Explanations in lay terms are included about what the instruments and graphs mean and their relevance to pwMS .Further insights from our PPI exercise included an understanding that pwMS wanted the UKMSR portal to enable them (i) to have better control over their health care including treatment options, (ii) access to clinical trials, and (iii) improved self-management. PwMS were also passionate about furthering research both for short-term benefit and for future generations, including their own children.To estimate the effect of our response to the PPI input received on the rate of questionnaires, we extracted the number of completed questionnaires at three time points; Winter 2018 , Spring 2019, and Winter 2019. Data were extracted from the UKMSR production databases running Microsoft SQL Server 2014.Optimizing the landscape of individualized, effective, and compassionate care with and for pwMS remains a work in progress. Whereas clinical trials provide data on a cohort level, the evidence produced can only provide a backdrop for decisions that need to be tailored to the individual pwMS. Clinical monitoring is essential to detect treatment success and failure, in order to make individual decisions. While various digital tools for disease monitoring in pwMS have been developed, their value in clinical practice is not yet established, and their adoption limited . We founOur experience trying to combine clinical and PRO data collection via the UKMSR in order to facilitate databasing for research, service audit, and individual patient care highlights the important role of PPI throughout the design and implementation process. To truly deliver patient-centered care and at the same time enable high-quality data collection, any system for pwMS needs to be developed jointly with pwMS. In our example, PPI led to a significantly increased number of completed PRO questionnaires. We are currently optimizing and streamlining mutual data exchange between BartsMS and the UKMSR to provide an integrate model of point-of- care data collection. This system may provide a model of data collection and sharing that can be adopted by other centers across the UK and beyond.All datasets generated for this study are included in the article/supplementary material.KS initiated the BartsMS Database and conceptualized the setup between the UK MS Register and BartsMS clinical interface, which the team helped establish. KA-P, RM, and KS drafted the manuscript. CA, AS, and KT-D contributed toward the subsequent revisions. RM and EB performed the data extraction and analysis. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor declared a past co-authorship with one of the authors KS.


Respiratory pathogens, such as novel influenza A viruses, Middle East respiratory syndrome coronavirus (MERS-CoV), and now, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), are of particular concern because of their high transmissibility and history of global spread  and cough, with onset within the past 10 days . In addition, DaRRE partners established a toll-free, mobile phone–based hotline in the EOC that is monitored 24 hours each day of the week and allows for expedited notification of such events. Event-based surveillance reports received through the hotline or mobile phone–based electronic reporting system were incorporated into the EOC database and dashboard in real-time. The database will also capture information on county and national public health response  to inform the government of required resources.Under the World Health Organization’s IHR, countries are required to strengthen their capacity to respond promptly and effectively to public health events of international concern  strategy, developed by CDC to enhance country capacity for identifying and controlling respiratory disease outbreaks. During April 2016–April 2020, laboratory capacity, surveillance, and emergency operations were strengthened in Kenya.DaRRE can support International Health Regulation requirements and is sufficiently flexible to accommodate country needs and available resources.


Most current care models are disease- or symptom-focused and mostly do not account for the individual needs of patients with chronic diseases. The aim of this study was to develop an innovative, evidence-based and expert-based practice model for the management of patients with type 2 diabetes mellitus.An iterative approach was used combining systematic literature search with qualitative methods, including a standardised survey of experts in chronic care (n = 92), an expert workshop of professionals (n = 22) and a multilingual online survey (n = 659). Using three consensus meetings involving researchers, policy makers and experts in chronic care, a limited number of core components and care recommendations was set up to develop a new chronic care model.The developed ‘MANAGE CARE MODEL’ includes aspects of the health and social care system, resources derived from the living environment, aspects of health promotion and prevention, as well as an expanded understanding of improved outcomes as an integral part of chronic care.The MANAGE CARE MODEL provides guidance for the development and implementation of chronic care programs, regional networks and national strategies. Future research is needed to validate the model as an instrument of regional chronic care management. A growing number of EU citizens suffers from diabetes, posing an emerging health, social and economic burden in the EU . This bu23468Integrated care is said to improve outcomes of care by linking services of providers along the continuum of care and thus overcoming issues of fragmentation . Back inHowever, recent analysis uncovered that the understanding of established models’ impact on chronic disease management is limited . This is13MANAGE CARE – Active Ageing with Type 2 Diabetes as Model in the Development and Implementation of Innovative Chronic Care Management Models in Europe. The project included 37 partner institutions like research facilities and national diabetes associations from 17 different countries in Europe.The present study makes use of published results belonging to the same EU-funded project systematic review and meta-analysis on the effectiveness of the CCM in diabetes care identified eight cluster randomised controlled trials (RCTs) . However, besides the limited evidence on the effectiveness derived from RCTs and a wide range of outcome measures, only small effects of European multifaceted diabetes care patient outcomes were identified . Records were included if they were published after the year 2000, and were written in German or English. Studies were included if they reported on the development of models and programs targeting patients with chronic diseases. Additionally, records were included if they reported on the effectiveness or quality of such models. A standardised protocol was used to summarise relevant information on the identified models. This included aims, target populations, interventions, key stakeholders, features/dimensions and outcomes, which were summarised and structured in a matrix. This matrix was used as a starting point for discussions and expert workshops within the study group  to validate and rank unmet needs from the perspective of both patients and health care professionals (HCP) [Previously published data gathered from a ls (HCP)  were agaconsensus meetings in February, April and May 2016 were set up to iteratively develop the model using feedback of the MANAGE CARE Study Group. This is in line with previous consensus meetings [22The final model was developed following the principles of Stachowiak, indicating that models are a mapping, a reduction and therefore a pragmatic tool . Three cmeetings 2223. TheThe literature review identified 24 health care models from six countries; USA (n = 11), Australia (n = 5), Canada (n = 5), Great Britain (n = 1), Germany (n = 1), and Mexico (n = 1) (annex 2). The expanded version of the chronic care model (eCCM) developed by Barr et al. argues that the CCM is inadequate to proactively cover the heterogeneity and complexities of prevention and health promotion going beyond clinical preventive services 24. Additio282931pat= 4,23; MHCP = 4.88; p < 0.01), “Health promotion and all kinds of prevention” , “Communication with the team and with the patient”  and “Availability of services related to information infrastructure”  are significantly more important to patients compared to HCPs ,Responsibilities and care pathways involving care transitions,Coordination with social care services when person has complex social needs.Care Delivery Strategies are supposed to integrate Information and Communication Technologies (ICT), which facilitate sharing information and virtually linking primary and secondary care . Joint commissioning of services should be introduced for common transversal targets between primary and secondary care in order to facilitate integrated care. For example: the rate of 30 day readmissions could be a common transversal indicator where primary and secondary care may be collaboratively accountable . ClinicaThe holistic understanding of health and social care characterises the MCM and includes aspects of participation, prevention, health promotion and public health 3839. Thi3840The integration of both the health and social care system is intended to improve the access to vulnerable and high-risk groups of T2DM. This includes social care system coverage of a population through taxes and social charges. It provides guidance for an integrated health and social care system to improve care by combining medical and social needs. The following recommendations may guide this process:link the broad community, the patient and the national health as well as social care system for an adequate population-based health planning;support collaboration between the health and social care sector as well as between HCPscreate supportive organizational, governance and leadership structures to achieve a positive and healthy public policy environmentpromote general population stratification incorporating data from hospital health records, primary care minimum data sets, long term care, health care data and social determinants of healthensure an optimal health system infrastructure with appropriate availability of health professionals, emergency rooms, hospital beds and alternative day care facilities to manage rapid response in case of crisisset up an integrative approach of care including palliative care with hospice-hospital partnerships and long-term care for patients in advanced disease stagesenhance supportive financing and commissioning of integrated care  and programs targeting uninsured populations.The MCM is based on an equal participation and collaboration of HCPs, the living environment and the individual citizen. This should be supported by transparent case management, shared-decision making and agreements to jointly develop, carry out and evaluate a productive and targeted interaction. Clinical/professional leadership at the level of counties, regions and municipalities should be supported by collaborators like health authorities to construct regional integrated care pathways. Leaders should be included in the commissioning process  to support contracts with secondary care.Chronic disease management, including self-management support for the individual patient, should be carried out by qualified health professionals with adequate experience of care. Their work should be supported by local “integrated clinical/care pathways”, representing a regional agreement of multi-professional experts, clinical leaders and services from both the acute and the primary health care sector. This should also include standards for quality monitoring. Individual care plans appropriate to age, clinical needs, cognitive function, level of frailty, physical level, basic, (psycho-) social and emotional determinants should be developed in collaboration with the patient and informal caregivers. The established phases of case and care management will be used to guide the shared-decision making .The MCM uses the full potential and resources of the individual and his living environment . The intention to closely connect the patient and the HCP with the patient environment is based on a strong need to incorporate community-based resources. Supporting local partnerships has the potential to integrate family and neighbourhood as well as communities support in the holistic care of the patient 45. This By assessing the individual needs, health risks, health literacy, and preferences, the MCM focusses on individuals at risk, patients with pre-diabetes and manifest T2DM. This individualised perspective enables to include socioeconomic factors, as well as social, psychological and cultural determinants of health and well-being.health professionals, living environment and broad community engagement and patients with diabetes (risk), is situated in the centre of the MCM. The aim is to provide a productive and targeted interaction. Stratification is applied to classify different levels of needs and priorities of complex diabetic patients. This applies to all aspects of individualised chronic disease management in T2DM patients including diabetes education, self-management support, case management as well as disease management [The dynamic relation of the three dimensions, nagement 47.triple aim of (1) Experience of Care, (2) (Population) Health Outcomes and (3) Cost-Effectiveness [Joint Commissioning of services and Shared Outcome Framework should be developed by all key stakeholders involved in patient care.The MCM summarises diversified outcomes to evaluate the productive and targeted interaction. It is important to notice that the MCM evaluates more than just medical conditions and goes beyond balancing the tiveness . Based oStarting with T2DM as a chronic care example, the MANAGE CARE Study Group developed an innovative chronic care model. This MCM addresses the specific needs of elderly populations being increasingly affected with chronic diseases as well as challenges given by the changes in the health care systems and financing structures in the European countries 10.Both, the literature review and the previously conducted systematic review  found onThe developed MCM builds on the widely implemented CCM and his expanded version (eCCM) while considering the described weaknesses. While Wagners’ CCM includes the “delivery system design” , our MCMOur MCM also makes use of important elements of the patient-centered medical home model (PCMH), like being team-based, patient-centered, coordinated, and community-oriented . HoweverThe MCM focuses on both the health and the social care system, as this was strongly suggested during the standardised survey and the expert workshop . IncreasA meta-regression on interventions designed to improve outpatient care of T2DM patients revealed that case management and team changes were associated with the largest pooled reductions in HbA1c values . As disiSelf-Management Support is the most frequent CCM intervention to be associated with statistically significant improvements, predominately for diabetes and hypertension [While the CCM is the most evaluated care model, rtension . In addirtension . Howeverrtension . Therefortension .Barriers derived from a lacking support from family, friends or the community as well as limited considerations of social determinants may impact chronic care outcomes . Therefo266141Evaluating the benefit of care models is complex and challenging. Yet, the majority of interventions are not sufficiently adapted to the CCM, which is further worsened by a low methodological quality . StudiesThe developed MCM uses the triple aim perspective as a starting point for evaluation . In 2012The developed model is in line with the working definition of “integrated care” as “the management and delivery of health services such that people receive a continuum of health protection, health promotion, disease prevention, diagnosis, treatment, long-term care, rehabilitation and palliative care services through the different levels and sites of care within the health system, and according to their needs” . One imp77375Validation studies and evidence focusing on the implementation of the model are needed to gain insights on its applicability and limitations. Both research priorities should take into account the characteristics of the health care systems as well as permutations of mixed systems . This inThis validation process may benefit from recent quality frameworks, such as the Development Model for Integrated Care (DMIC) , an imprOne strength of the present study is the iterative combination of different methodological steps, including a previously published systematic review, as well as surveys of experts and patients, and consensus meetings to develop a new model for the treatment of T2DM. That way, an evidence-based as well as expert-driven MCM using T2DM as a starting point was developed. The iterative mixed-method approach, especially the combination of systematic research with different qualitative methods, is another strength of our overall design.The model has not been validated yet. Theoretical and practical validation studies using different health systems, regions and settings as well as heterogeneous target populations are needed.Based on an evidence-based and expert-driven state-of-the-art assessment, knowledge and evidence on existing disease management models and on the needs of elderly people with T2DM was used to develop the MCM. The model has been designed to guide the development and implementation of individualised chronic care models.Future research is needed to implement and validate the model as an instrument of regional chronic care management.The additional files for this article can be found as follows:10.5334/ijic.4646.s1Annex 1.List of identified models and programs with countries.10.5334/ijic.4646.s2Annex 2.Table 3: Chronic care recommendations derived from a multi-professional expert workshop guiding the final model.10.5334/ijic.4646.s3Annex 3.Tables 4 and 5: Dimensions, sub-dimensions and examples derived from the literature review.


There is an expansive and growing body of literature that examines the mental health consequences of disasters and large-scale emergencies. There is a need, however, for more explicit incorporation of mental health research into disaster risk reduction practices. Training and education programs can serve as a bridge to connect academic mental health research and the work of disaster risk reduction practitioners. This article describes the development and evaluation of one such intervention, the CONVERGE Disaster Mental Health Training Module, which provides users from diverse academic and professional backgrounds with foundational knowledge on disaster mental health risk factors, mental health outcomes, and psychosocial well-being research. Moreover, the module helps bridge the gap between research and practice by describing methods used to study disaster mental health, showcasing examples of evidence-based programs and tools, and providing recommendations for future research. Since its initial release on 8 October 2019, 317 trainees from 12 countries have completed the Disaster Mental Health Training Module. All trainees completed a pre- and post-training questionnaire regarding their disaster mental health knowledge, skills, and attitudes. Wilcoxon Signed Rank tests demonstrated a significant increase in all three measures after completion of the training module. Students, emerging researchers or practitioners, and trainees with a high school/GED education level experienced the greatest benefit from the module, with Kruskal–Wallis results indicating significant differences in changes in knowledge and skills across the groups. This evaluation research highlights the effectiveness of the Disaster Mental Health Training Module in increasing knowledge, skills, and attitudes among trainees. This article concludes with a discussion of how this training can support workforce development and ultimately contribute to broader disaster risk reduction efforts. Disasters disrupt entire communities and cause widespread destruction, injury, and displacement. Such traumatic experiences can overwhelm regular coping capacity and available resources, contributing to adverse mental health outcomes among adults as well as children ,2,3,4,5.before a disaster occurs. In light of the differential risk experienced by people in diverse cultural and geographic contexts, global disaster policy frameworks, such as the United Nations’ Sendai Framework for Disaster Risk Reduction  and the While considerable shifts towards DRR have occurred within the disaster and emergency management fields over recent decades , comparaAs disasters have grown in frequency and magnitude, so too has the demand for the knowledge and expertise of the researchers and practitioners working in this space ,15. InveSuch education and training programs must be holistic and designed in a way that recognizes the growing disciplinary, professional, and demographic diversity of the current and future workforce ,18,19,20There is a clear and pressing need for additional training programs that bridge the divide between disaster mental health research and DRR activities. At present, however, available disaster mental health trainings often do not explicitly reference empirical evidence from past disaster studies nor include procedures and tools used for psychological screening and assessment ,26. FurtIn response to this identified knowledge gap and the need for more comprehensive training and education for current and future generations of researchers and practitioners, the CONVERGE initiative at the Natural Hazards Center at the University of Colorado Boulder partnered with the Centers for Disease Control and Prevention (CDC) to develop the CONVERGE Disaster Mental Health Training Module. This free online training module provides researchers and other professionals with an overview of mental health outcomes associated with disasters, such as post-traumatic stress disorder and depression, as well as specific risk factors that render certain populations more vulnerable to these outcomes. It describes methods used to study disaster mental health, showcases examples of evidence-based programs and tools, and provides recommendations for future research inquiries. In doing so, the module provides actionable guidance for researchers and professionals to engage in DRR practices that anticipate and reduce the mental health impacts of disasters and, ultimately, increase the resilience of individuals and communities. This article describes the creation and evaluation of the Disaster Mental Health Training Module. More specifically, we outline the unique ways that this training supports the translation of available research on disaster mental health into DRR practice. The evaluation then examines whether this novel training can effectively reach a diverse next generation of hazards and disaster workforce and increase relevant knowledge, skills, and attitudes among this population.The National Science Foundation-supported CONVERGE initiative seeks to advance ethical, coordinated, and scientifically rigorous convergence research by providing resources and connecting extreme events researchers across disciplines . One of To develop a research-based training module on disaster mental health, two members of the CONVERGE research team (Evans and Adams) identified and reviewed highly cited literature that focused on mental health outcomes associated with disasters. Our goal was to identify both theoretical and empirical literature that offered a thorough overview of risk factors that contribute to poor disaster mental health outcomes. In addition, we sought research focused on resiliency, post-traumatic growth, and evidence-based interventions. As such, we searched for studies that used a variety of theoretical lenses and methodological approaches and focused on different mental health outcomes and populations exposed to disaster.We used the search terms “mental health” AND “disaster” to find literature in both Google Scholar and Web of Science. We then downloaded the results from these searches into Google spreadsheets and organized the publications into the following categories: (1) full article citation; (2) number of citations; (3) year of publication; (4) search engine/database; and (5) abstract. Next, as part of our data cleaning, we completed a review of the abstracts to eliminate duplicates, non-English language publications, and publications that did not focus on mental health outcomes associated with disaster events. We then organized the remaining citations according to document type  and downloaded the top 25 most cited publications of each document type into separate spreadsheets, where we added additional columns to inventory the publications based on their empirical content, methodological approach, and type of disaster studied. Once the annotated bibliography spreadsheets were complete, our team reviewed the reference lists of key readings to identify additional relevant literature that did not emerge in the original searches. This helped to ensure comprehensive coverage of the disaster mental health literature. As a result of this multi-step process, we selected 96 publications to inform the development of the training module.After finalizing the literature database, the same two members of the team (Evans and Adams) read all the relevant publications and worked to draft the sections of the module. Completed drafts were regularly presented to other members of our core team from the Natural Hazards Center and the CDC for feedback, suggestions, and edits, which were then incorporated into subsequent drafts. It took approximately six months to develop a full draft of the module. Once the draft was complete, graduate students and research associates at the Natural Hazards Center reviewed the written content and provided extensive feedback using a standardized review form. After the recommended revisions were made, disaster mental health subject matter experts at the CDC reviewed the content to ensure its face validity.Next, we worked with a web developer with expertise in online learning technologies to transfer the content to an interactive online learning management system, LearnDash. LearnDash is a WordPress plugin created by leading learning industry professionals that provides practical and experience-driven guidance for individuals and organizations developing online courses. This allowed us to design the module based on best practices for e-learning and also permits our team to periodically make revisions and updates to the module, as new articles and books are published.Once the online module was completely formatted in LearnDash, we asked members from the Natural Hazards Center’s research team to test the module. Each user tested the module on different devices and using different browsers to ensure its online functionality and operability before its release via the CONVERGE website.The Disaster Mental Health Training Module summarizes decades of research on mental health in disasters while also offering practical recommendations for advancing research and practice on the topic. Specific methodological approaches and evidence-based tools are presented throughout the module to help guide the conduct and translation of rigorous disaster mental health research. The module interface features a progress bar and other navigational tools to ensure that learners know where they are in the module and can easily navigate through its various sections. To help ensure that trainees remain engaged as they move through the module, knowledge checks consisting of two true/false or multiple choice questions are included at the end of each major section. At the end of the module, trainees complete a final 10-question quiz. If they get at least 8 out of 10 questions correct on the assessment quiz, they receive a signed certificate indicating that they completed the CONVERGE module. The module takes approximately 30 to 60 min to complete and all content presented meets the accessibility standards required by the University of Colorado Boulder. The module is organized into four main lessons: (1) Background; (2) Methodological Approaches; (3) Knowledge to Action; and (4) Future Directions. Each of these lessons consists of different topics, which present interactive information that aims to achieve a specific set of learning objectives. For instance, by the end of the module it is expected that trainees are able to describe specific mental health outcomes that may emerge in the aftermath of a disaster or emergency; understand the conditions and risk factors that exist before, during, and after disaster that can influence mental health outcomes; and identify potentially vulnerable populations that may be at greater risk for poor mental health outcomes in the aftermath of a disaster. The first lesson, Background, introduces participants to the module by defining mental health within the context of various hazard types including natural hazards, technological disasters, and terrorism . It thenThe next lesson, Methodological Approaches, describes common methodological approaches used by researchers to study mental health outcomes in a disaster context, including diagnostic screening tools ,32, longThe third lesson, Knowledge to Action, bridges research and practice by highlighting advances in evidence-based action and demonstrating how disaster mental health research can inform public health, emergency management, and DRR practice and policy. Evidence-based trainings, tools, and policies are presented in call-out boxes and as illustrative examples in this particular lesson. For instance, the module describes how research on the vulnerability of children to negative disaster mental health outcomes helped to inform the development of a number of CDC resources, such as the Helping Children Cope During and After a Disaster Factsheet . It alsoThe last lesson, Future Directions, provides 10 recommendations to help researchers address enduring challenges in the field and guide the development of new disaster mental health research questions and directions. The recommendations are drawn from widely cited research articles and reviews of disaster mental health scholarship ,5,13, anIn addition to the training content, the module also contains an additional resources tab where users can access a list of resources related to disaster mental health, including links to datasets, screening and diagnostic tools, key readings, and web resources. These supplementary materials are meant to support additional learning of the many and varied mental and psychosocial consequences that children and adults may experience in disaster. https://converge.colorado.edu/resources/training-modules). Doing so allowed us to provide the module as a free resource to interested parties, though prior registration to the site is required in order to access the content. Our goal from the outset of this project was to reach members of the multi-disciplinary and rapidly growing hazards and disaster field, including students and early career researchers and practitioners. Accordingly, we worked to widely disseminate the training module. We wrote and shared an announcement through the Natural Hazards Center’s online news publication and social media accounts. We also shared brief announcements through various listservs, professional networks, and contacts across the social sciences, public health and medicine, engineering, and natural sciences disciplines. Additionally, we worked with the CDC TRAIN Learning Network to list the training module as a course on their website so that we could ensure its ongoing availability to public health practitioners. After the Disaster Mental Health Training Module was tested and finalized, it was then published online via the CONVERGE website (https://converge.colorado.edu/communications/webinar-series/) and disseminated again through various listservs and professional networks. In addition to these efforts, we continue to share the module regularly through presentations at academic and professional conferences, training sessions, and other forums. Within a month of its release, we also hosted a 30-min webinar where more than 400 researchers and practitioners signed up to view a demonstration of the module. The recorded and captioned video of the webinar was then shared on our project website . Provision of this information was voluntary, and trainees were provided with a written description informing them that no individual personal information would be shared with anyone outside of the CONVERGE research and evaluation team. Additionally, we sent a follow-up survey to all trainees to gather information on their disciplinary background and whether or not they had any previous advanced training or experience in disaster mental health. Descriptive statistics were generated for all trainee sociodemographic variables.To evaluate training effectiveness, we examined whether trainees reported an increase in knowledge, skills, and attitude (KSA) related to disaster mental health before and after completing the module. KSA is a theoretically-informed framework used to evaluate competencies gained via educational trainings and in other educational or ork settings. Grounded in psychological research, learning outcomes can be classified as cognitive, skill based, and affective . CognitiTo measure KSA, all trainees (census sample) were required to answer the following assessment questions before and after completing the module:Please rate your knowledge about disaster mental health.Please rate your methodological skill set for conducting research on disaster mental health.How important do you think building mental health knowledge and skills is to hazards and disaster research?On a scale from 1 (lowest) to 10 (highest):These questions were reviewed by subject matter experts at the CDC, as well as graduate students and research associates at the Natural Hazards Center before being disseminated. The questionnaire was integrated into the module so that all trainees were required to answer the three questions before starting the training. At the end of the module, before accessing the final quiz to receive a certificate of completion, all trainees were required to answer the same three questions as a follow-up assessment. Prior to answering these questions, trainees were informed that the responses to these questions would be used for evaluation purposes.We conducted Wilcoxon Signed Rank tests to evaluate overall changes in perceived knowledge, skills, and attitudes between pre- and post-assessments for all participants. To explore how trainees’ sociodemographic characteristics and professional background influenced changes in KSA, we conducted Kruskal–Wallis tests for each of the KSA outcomes by student status; researcher category; racial and ethnic identity; geographical location; highest degree completed; gender identity; and affiliated organization. All statistical analyses were conducted in IBM SPSS 26.From its release on 8 October 2019, through 8 September 2020, 317 trainees completed the Disaster Mental Health Training Module. Descriptive statistics for the trainee sociodemographic characteristics and professional background are shown in Users were also asked to indicate their level of involvement in the hazards or disaster field by self-identifying as either a core, periodic, situational, or emerging researcher or practitioner . The “coWilcoxon Signed Rank tests evaluating whether there were statistically significant differences in perceived knowledge, skills, and attitudes between pre- and post-assessments for all respondents are shown in p < 0.001). Similarly, there was a statistically significant and greater change in knowledge  for respondents located in the United States (mean rank = 165.16) than for those located in other countries (mean rank = 129.65). Group differences in change in knowledge across researcher/practitioner category were also highly significant , with emerging researchers/practitioners reporting the greatest change (mean rank = 175.70) and core researchers reporting the lowest change (102.17). Significant differences across education (highest degree) were also found , as respondents with high school/GED education levels reported the greatest change (mean rank = 202.08), followed by bachelor’s degree (mean rank = 169.92), associate’s degree (mean rank = 158.17), master’s degree (mean rank = 113.44), and doctoral degree (mean rank = 108.55). We also found a marginally significant difference in knowledge change across gender identity , with respondents who responded with an identity other than male or female (which includes both non-conforming/non-binary and those who preferred not to answer) reporting the greatest change between pre- and post-assessments (mean rank = 182.34). Lastly, respondents affiliated with an academic institution reported the highest mean change in knowledge (mean rank = 135.61) while those affiliated with local, state, or federal governments reported the lowest mean change (mean rank = 83.17), and the group differences were statistically significant . Significant differences in knowledge change were not found across racial and ethnic categories.Kruskal–Wallis tests were performed to examine how participant sociodemographic characteristics and professional background influenced self-reported changes in knowledge, skills, and attitudes . Overallp < 0.01). Likewise, there was a statistically significant change in skill  across researcher categories, with emerging researchers/practitioners reporting the greatest change in skill (mean rank = 168.90) and core researchers reporting the lowest change (mean rank = 121.84). Finally, group differences in change in skill across educational background were also significant , with respondents with a high school/GED education level reporting the greatest change (mean rank = 185.38) compared to the other degree categories. Group differences in skill change across affiliation, racial and ethnic group, gender, and geographical location were not significant.In terms of changes in skill, students again reported a greater change (mean rank = 166.42) compared to non-students (mean rank = 136.07), and this difference was statistically significant  to include these variables in the statistical analyses above, we found that 63.5% of those who responded did not have any advanced training or experience in disaster mental health prior to completing the module. The majority of participants came from the social sciences (51.4%), followed by public health (12.2%) and medicine/nursing (9.5%). Other disciplines represented included public administration, engineering, and the natural sciences.This article describes the development and dissemination of the CONVERGE Disaster Mental Health Training Module and evaluates changes in trainee knowledge, skills, and attitudes towards disaster mental health research after completing the module. Our evaluation of the module and its impact on the diverse user base allows us to assess progress in educating current and future members of the hazards and disaster workforce while ensuring that they are prepared to meet rising 21st-century environmental and social challenges ,15. In the eleven months since its release, 317 trainees completed the module. Our evaluation revealed that the majority of the trainees identified as female, White, students, and early career researchers/practitioners. The majority of people who completed the module were between the ages of 16 and 25 years. Most trainees live in the United States, although people from 11 additional countries also completed the module. Results from our follow-up survey also suggest that the trainees come from a range of disciplinary backgrounds, the majority of whom have no advanced training in disaster mental health. These findings suggest that we have been successful at reaching particular groups who have often been overlooked in hazards and disaster research and emergency management practice. Women, whose role has been limited in DRR  and whosWhile disaster mental health research is often conducted in the realm of the social and behavioral sciences and public health and medicine, the trainees who completed our module came from a range of additional disciplines. This is an important finding, which offers early promise in terms of bridging the gap between disciplines traditionally engaged in risk reduction activities and those in the disaster mental health field . Indeed,Overall, we found that trainees reported significant increases in knowledge, skills, and attitudes regarding disaster mental health before and after completing the module. On average, trainees experienced the greatest change in methodological skills to conduct disaster mental health research. Given the widespread lack of appropriate, empirically based guidance for mental health service professionals to engage in DRR practices ,51,52,53Considering the increasing disciplinary, professional, and demographic diversity of hazards and disaster researchers ,16,18, wAlthough the results of this evaluation are promising, there are limitations to our study that need to be addressed. First, the training module was released over a year ago and continues to be available for free online. As such, the results that we present in this article are preliminary, as more users complete the module each week. As the user base expands and diversifies, there is a chance that some of the patterns that we have shared in this article could change. Second, while analyzing the evaluation data, we realized that the initial registration form neglected to collect information on primary discipline and whether or not trainees had extensive experience or advanced training in disaster mental health. We felt this information was important for understanding our user base and thus sent a follow-up email and three additional reminders asking all trainees to provide answers to these questions. Only 74 of 317 trainees provided responses. We were therefore unable to include these variables in additional analyses, although we do infer patterns from the data we attained. We therefore acknowledge that the descriptive statistics presented for primary discipline and previous training in disaster mental health are not generalizable to our entire user base. Third, our evaluation design does not allow for assessing the longer-term career trajectories of the majority student population that we assessed for this evaluation project. We therefore have no way of knowing whether they will use the knowledge attained in their future careers or if they will apply the lessons learned toward DRR approaches. Even with these limitations in mind, we hope this module is of use to others and that it can help advance the conversation started by Gray and colleagues  regardinDespite a large body of literature examining the mental health consequences of disasters and large-scale emergencies, there is a need for more explicit incorporation of mental health and psychosocial well-being research into disaster risk reduction practices. Training and education programs, such as the CONVERGE Disaster Mental Health Training Module, can build important bridges between academic research, mental health and psychosocial service providers, and the disaster risk reduction and emergency management fields. By helping trainees build foundational knowledge of disaster mental health risk factors and outcomes, acquire the methodological skills necessary to conduct this research, and recognize the enduring challenges and questions that are central to the future of the field, our module provides actionable guidance for researchers and professionals to engage in DRR practices that aim to anticipate and reduce the mental health impacts of disasters and, ultimately, increase the resilience of people and communities.