Breastfeeding is essential for child survival but globally less than fifty percent of infants receive adequate breastfeeding. Gaps in breastfeeding knowledge and misinformation are widespread. Mass media aims to motivate mothers and families, encourage care-seeking, improve social norms, and counteract misleading advertising. However, the costs and coverage of mass media are not well documented. Our study provides a cost-accounting of four large-scale mass media interventions and coverage obtained through mass media. We retrospectively calculated annual costs and costs per beneficiary of mass media interventions based on expenditure records in four countries. The interventions were a part of multi-component breastfeeding strategies in Bangladesh, Burkina Faso, Nigeria, and Vietnam. Annual costs ranged from 566,366 USD in Nigeria to 1,210,286 USD in Vietnam. The number of mothers of children under two years and pregnant women ranged from 685,257 to 5,566,882, and all designated recipients reached during the life of programs ranged from 1,439,040 to 11,690,453 in Burkina Faso and Bangladesh, respectively. The cost per mother varied from USD 0.13 USD in Bangladesh to 0.85 USD in Burkina Faso. Evaluations showed that mass media interventions reached high coverage and frequent exposure. This analysis documents the financial costs and budgetary needs for implementing mass media components of large-scale breastfeeding programs. It provides annual costs, cost structures, and coverage achieved through mass media interventions in four low- and middle-income countries. Evidence continues to grow that recommended breastfeeding practices have large impacts on newborn, infant, and child mortality, morbidity, growth, and cognitive development; maternal health; adult chronic diseases; and the environment ,2,3. YetAlthough cost and coverage projections of mass media interventions for breastfeeding have been attempted in the past, the costs and coverage of mass media interventions based on actual in-country programs implemented at scale have not been previously reported . This stIn Bangladesh, Burkina Faso, Nigeria, and Vietnam, mass media was one component of a larger social and behavior change (SBC) program and was accompanied by individual and group counseling provided by trained health workers and community volunteers to pregnant women and mothers of children below two years, and community mobilization (8). Face-to-face communication on breastfeeding was conducted by health workers in facility contacts and during home visits for antenatal care (ANC), postnatal care (PNC), and child health services. Social mobilization events were implemented for obtaining the support of community-influential persons such as family members, peers, village/town elders, and opinion leaders through individual and group meetings and video and theater shows. The dialogue was also conducted with national and regional government officials on policies for maternity leave and restrictions on harmful marketing of infant formula.We refer to specific mass media-related actions as ‘interventions’ and the broader set of interventions as ‘programs.’ The term ‘intervention’ is used to indicate evidence-based actions designed intentionally to generate change and is based on the socio-ecological model of behavior change ,11. The In alignment with global evidence and national infant and young child feeding (IYCF) policies and strategies ,13,14,15Content and implementation strategies were adjusted during implementation if indicated by audience feedback. Most programs used data from a combination of embedded self-monitoring devices supplied routinely by media agencies and other mechanisms used by agencies to report media reach for different demographics. Special assessments were also conducted by locally hired teams. In Bangladesh, questions on media recall were added to other ongoing surveys to determine coverage and comprehension in various parts of the country. In Burkina Faso, international epidemiologists designed and analyzed the monitoring and trained the volunteer monitors who were paid a stipend. In Nigeria, a monitoring agency followed radio and TV broadcasts and trained community volunteers to document the content and frequency of airings reaching the community. Country differences in program content, structure, and management arrangements are explained by variations in program needs, local capacity in managing mass media interventions, resource constraints, and the diverse socio-cultural and media contexts of Bangladesh, Burkina Faso, Nigeria, and Vietnam. Existing breastfeeding levels and various stages of behavior change in countries played a role in shaping mass media interventions. Nigeria covered eleven states with spillover into nearby areas, while Bangladesh, Burkina Faso, and Vietnam achieved national coverage. Burkina Faso’s radio broadcasts were conducted in six languages; in Nigeria, the interventions were delivered in five languages; in Bangladesh in three; and in Vietnam, the materials were produced in two languages.To develop cost estimates for this cost-accounting study, we extracted data retrospectively from accounting records on expenditures incurred for mass media-related activities in the four countries . DetailsBelow we describe the resources used in developing and implementing mass media interventions for breastfeeding in the four countries, followed by how we calculated the costs of different operational components and costs of startup and recurring activities . We thenActivities involved in the preparation of mass media interventions include planning, research, strategy development, and creative design and testing of materials. Descriptions of each of these steps and the types of resources used in each step are shown in The sources of information on activities and resources include sub-contractor and project reports, publications on formative research, situational analysis reports, media audits, and media habits studies. Information on creative development processes for mass and social media was extracted from scopes of work and reports of firms contracted for design and development. Market rates were paid for buying media space in radio, TV, billboards, bus wraps, print, and digital poster displays. Media placement and monitoring information was extracted from contracts with media and advertising companies, and reports from firms producing monitoring results.We documented the expenditures incurred based on payments made for mass media activities. Where receipts were unavailable, resources were valued at market rates. The costing approach is a retrospective top-down expenditure analysis from a program planning perspective. The methodology is an accounting of financial expenditures rather than an economic analysis of costs . FinanciExpenditures incurred for each program component were entered into spreadsheets. Costs were allocated to the year that payments for them were recorded. Expenditures were classified as either start-up for those conducted once in the life of the program and only during the initial development of the program, or as recurring costs for activities that were repeated during the life of the program. The start-up activities include planning, situational analysis, formative research, media habits studies, and strategy development. Recurring costs include production, media placement and dissemination, monitoring, and ongoing changes in interventions based on findings from monitoring. Using the total expenditures incurred on mass media interventions, we calculated the proportion of costs attributable to four operational activities . The mass media expenditures were converted to US dollars (USD) based on the prevailing exchange rate between the host country’s local currency unit (LCU) and USD for each calendar year. These expenses were then converted into 2019 USD using the Consumer Price Index ratio of the year of expenditure to the CPI in 2019 CPI data from the World Bank .For comparative purposes, since program durations varied by country, we calculated average annual costs for each country. All start-up and recurring costs were aggregated to calculate total costs. The total costs incurred over the life of each country project were divided by the number of project years to calculate the average annual cost per year. This is important given that we need to compare annual costs with the annual number of beneficiaries reached.The number of beneficiaries consists of the number of mothers with children below two years of age and pregnant women. This was estimated from the population size of the program areas, the expected live births (birth rate per 1000 population), and less infant mortality (rate per 1000 live births) based on data from the World Bank . Since tWe divided the total cost from Sensitivity analyses were carried out to examine the effects of assumptions and parameter uncertainty on the total costs and cost per beneficiary by including three variations of management and administrative costs  and two variations of the number of beneficiaries by including pregnant women and mothers of children under two years with and without the addition of persons who influence breastfeeding practices that were targeted by mass media interventions.The total financial outlays for mass media interventions implemented to improve breastfeeding were USD 3,445,630 in Bangladesh, USD 2,171,682 in Burkina Faso, USD 2,029,370 in Nigeria, and USD 4,942,002 in Vietnam . FinanciThe total annualized costs of mass media interventions were USD 738,349 in Bangladesh, USD 579,115 in Burkina Faso, USD 566,336 in Nigeria, and USD 1,210,286 in Vietnam . ProgramThe average annual cost per mother across countries and the cost per beneficiary, including all designated beneficiaries, is shown in Varying the overhead costs for administration and management reduced the total average cost of mass media interventions across the countries by 8% if 15% was applied instead of 25%, and increased the total average cost of mass media interventions across countries by 12% if 40% was applied instead of 25%. The ranges of costs per beneficiary for pregnant women and mothers alone would vary from USD 0.24 to USD 0.29 over a range of 15–40% overheads, and from USD 0.11 to USD 0.14 when all intended beneficiaries reached are included. The cost per beneficiary was more sensitive to changes in the number of beneficiaries, and eliminating the additional beneficiary categories from the total reached by the mass media interventions increased the cost per beneficiary by 2.2 times.We documented the total costs, number of beneficiaries, and cost per beneficiary of four large-scale mass media interventions in Bangladesh, Burkina Faso, Nigeria, and Vietnam using retrospective cost-accounting of expenditures and coverage evaluations. To the best of our knowledge, this is the first detailed comparative analysis of mass media intervention designs, resource use, costs, cost structures, and reach/coverage targeted to breastfeeding promotion in diverse LMICs based on actual large-scale programs. In Bangladesh, the program was implemented over 56 months and cost a total of USD 3.4 million; in Burkina Faso, the program duration was 45 months and cost USD 2.2 million; in Nigeria, the duration was 43 months and cost USD 2.0 million; and in Vietnam, the duration was 49 months and cost USD 4.7 million. The largest proportion of expenditures was incurred for media production, dissemination, and monitoring at 72% on average; creative design and development accounted for 24% of the total, and the balance was for planning, strategy development, and monitoring. The number and types of mass media channels and duration of broadcasting and dissemination differed and accounted for variations in program delivery costs across countries. Bangladesh and Vietnam spent the largest proportion of total costs on media production and dissemination at 88% and 70%, respectively; this may reflect the predominant use of TV as well as longer program durations as compared to other countries. Administrative and management costs included in the total costs were estimated to range from 15% to 40% to reflect different scenarios where mass media is conducted as a stand-alone component (40%), rather than fully integrated with shared costs allocated across advocacy, interpersonal communication (IPC), and community mobilization interventions (15%).The number of intended recipients varied with the geographic scale of the program , and reflect the media habits of the population, in particular women with children below two years and pregnant women. These could partly explain the notable differences in costs. Since mass media is intended to reach influential persons who have proven impacts on feeding decisions and can enable women to practice breastfeeding, we included health workers, family members, and peers in the community among beneficiaries. The number of pregnant women and mothers of children below two years ranged from 685,000 in Burkina Faso to 5.5 million in Bangladesh; this number was 2.2 times greater when designated categories of influential persons were added. The cost per pregnant woman and mother (child under two years), ranged from USD 0.13 in Bangladesh to USD 0.85 in Burkina Faso. With the addition of key influential persons reached through mass media, the cost per beneficiary  was USD 0.06 to USD 0.40.Few data on the costs or coverage of mass media interventions for breastfeeding are available in the literature other than hypothetical estimates. This paper is a “cost-accounting” exercise to document the actual costs of mass media used for breastfeeding promotion in four countries. Holla-Bhar et al.  attempteComparing our costs with other breastfeeding interventions and multi-sectoral nutrition programs may provide insights into the component costs and cost structures of programs. The financial cost of two IPC programs in sub-Saharan Africa, based on the provider’s perspective suggests substantial economies of scale and lower per-beneficiary costs of mass media compared to IPC interventions. Desmond et al. costed a package of four antenatal breastfeeding counseling visits, plus fourteen breastfeeding counseling visits from birth to six months post-delivery in South Africa . The incThe analysis of costs in our study of four countries documents actual costs per beneficiary  and may p = 0.029), discussed breastfeeding with a private health provider , or received text or WhatsApp messages about breastfeeding . In Bangladesh and Vietnam, exposure to mass media improved the performance of frontline workers in service delivery by improving knowledge and motivation; this in turn positively influenced mothers’ service utilization and knowledge of infant feeding [The use of mass media for improving public health practices is not new ,51, alth feeding . The mas feeding . The intThe need to find efficient solutions to address the infant formula industry’s threats to breastfeeding is rising in priority. According to WHO/UNICEF, “Many women express the desire to breastfeed, but a sustained flow of strategic and persuasive marketing messages undermines their confidence. Women’s positive attitudes towards formula milk correlate with their marketing exposure, and the fears and doubts they express about breastfeeding often mirror the themes and messaging of marketing” . Global Limitations of the study include not considering societal or beneficiary costs. However, the main contribution of this paper is to support program budgeting for mass media, using a strategy that optimizes existing channels and media exposure that are already used and does not incur new beneficiary costs. It is possible that some variability in costs is due to programs having been developed in different periods of time and having different durations. We may have missed costs incurred during the initial stages of building collaborations, obtaining feedback, and assessments used to decide on mass media. Our archived accounting records used to collect cost data did not provide input level costs, but gross amounts spent on intervention components; for this reason, we included detailed descriptions of activities in this paper and recommend ingredients-based costing conducted prospectively in the future. Potential underestimation bias might be introduced by separating mass media only from a program where mass media was designed to be a component. Fortunately, mass media is distinct from other components and more clearly identifiable and separable from other components in measuring costs. We report different types of impact data available from the programs that were measured differently across countries, but this was not the aim of the article and is a limitation of the study. A potential limitation is the lack of shared program costs and/or administrative costs, and we did not omit them and instead allocated a proportion from actual billings submitted to donors to cover these costs (15%) and presented 25% and 40% as two alternative scenarios for administrative and management costs. To address potential limitations in estimating the number of beneficiaries, we based our projections on survey data gathered from women of reproductive age. The term ‘beneficiaries’ is used to mean recipients who were intended to receive mass media and includes both pregnant women and mothers of children under two years, plus additional influential categories. We recognize that primary beneficiaries are pregnant women for initiating breastfeeding within the first hour of pregnancy and mothers (for breastfeeding for up to two years). However, additional persons are used to illustrate the cost per person achieved through mass media as reaching the influential persons would require community mobilization intervention costs if they were not reached through mass media.Scaling up breastfeeding programs to protect infants and mothers in a country requires thoughtful consideration of mass media as a potential component due to economies of scale, and its ability to change perceptions and social norms. However, the resource needs are substantial and must be budgeted realistically. It can be a periodically intensified, ongoing core component of national breastfeeding strategies. This retrospective costing study of four mass media interventions for improving breastfeeding fills a serious gap and furthers our understanding of what resources are needed, how many beneficiaries can be reached, and provides examples of how to leverage the current and growing use of media to improve breastfeeding. Details on the content and structure of mass media interventions in different LMICs are provided as examples. We found that at USD 0.13 to USD 0.85 per beneficiary per year, the cost to governments and donors is minor compared with the cost of not achieving recommended breastfeeding practices that have been recently quantified. Selecting new mass media and social media channels that efficiently reach a high proportion of women and key influential audiences and using national expertise to design and implement programs can make mass media more affordable. Further research is needed to identify the minimum duration and frequency of media-based exposures required to achieve results and explore the synergies with interpersonal communication (counseling), community mobilization events, and legislative interventions to protect, promote, and support breastfeeding.


Investments in national immunization programs and the Global Polio Eradication Initiative (GPEI) have resulted in substantial reductions in paralytic polio worldwide. However, cases prevented because of investments in immunization programs and GPEI remain incompletely characterized.Using a global model that integrates polio transmission, immunity, and vaccine dynamics, we provide estimates of polio incidence and numbers of paralytic cases prevented. We compare the results with reported cases and estimates historically published by the World Health Organization.We estimate that the existence and use of polio vaccines prevented 5 million cases of paralytic polio for 1960–1987 and 24 million cases worldwide for 1988–2021 compared to a counterfactual world with no polio vaccines. Since the 1988 resolution to eradicate polio, our estimates suggest GPEI prevented 2.5–6 million cases of paralytic polio compared to counterfactual worlds without GPEI that assume different levels of intensity of polio vaccine use in routine immunization programs.Analysis of historical cases provides important context for understanding and communicating the benefits of investments made in polio eradication. Prospective studies will need to explore the expected benefits of future investments, the outcomes of which will depend on whether and when polio is globally eradicated. Since 1960, polio immunization has prevented nearly 30 million cases of paralysis compared to a world with no polio vaccines. We estimate that the Global Polio Eradication Initiative has decreased polio cases by 2.5–6 million since it began in 1988. Following the introduction of polio vaccines in the 1950s, many countries stopped poliovirus transmission nationally within a few decades  has coordinated efforts to stop poliovirus transmission in 105 countries that required external financial support , 4. As oPublic health authorities and health economists typically value the benefits of an intervention based on the number of bad outcomes avoided, such as lives saved, or morbidity prevented. This involves a model-based process to characterize events that did not happen. The World Health Organization (WHO) publishes annual paralytic polio cases since 1980 based on aggregation of national surveillance data including reported cases of WPVs and cVDPVs , 13. SurWhile WHO historically published estimates based on simple linear models of polio incidence and cases prevented, these stopped in 1990s. Simple calculations can provide useful but occasionally misleading assessments due to simplistic assumptions and inclusion/exclusion of benefits attributable to intervention(s). Well-calibrated global disease models can provide a basis for assessment of the simple approach and put the results in context. We have developed and maintain the only global model that integrates poliovirus transmission, immunity, vaccine dynamics, and the economics of interventions , 15. ManWe reviewed the literature to identify global reported cases of polio by year, estimates of polio cases, and estimates of polio cases prevented. The search included WHO electronic archives of publications.We applied our integrated global polio transmission and oral poliovirus vaccine (OPV) evolution model , 15 to dc) to obtain yearly global incidence, INC(yr), yr = 1980,..., 2021. For consistency with the RC, we use the same inputs for RI coverage and surviving infants (SI) for each year. We then use the formula:tr is the average take rate for OPV and PIR is the paralysis-to-infection ratio (PIR). The average tr represents a substantial simplification relative to the global transmission model, which uses subpopulation-specific and type-specific take rates for different formulations of polio vaccines [We also estimate annual polio incidence using a simple model similar to the one used historically by WHO (see discussion in ). We sumvaccines .tr = 95% or 80%), either a fixed average paralysis-to-infection ratio (aPIR) of 1/200, or serotype-specific paralysis-to-infection ratio (sPIR) of 1/200, 1/2000, and 1/1000 for poliovirus serotypes 1, 2, and 3, respectively, and consider the effect of counting or not counting the contribution of cases from countries that achieved WPV elimination (+elim or −elim). As before [As demonstrated previously , we conss before , we showTo characterize cases prevented, we compare what happens with an intervention to what happens without it, and one of these necessarily represents a counterfactual scenario . Our focus on global estimates limits the analytical framing choices to different time periods and different interventions. We demonstrate different choices for global impacts of (1) introduction of polio vaccines or (2) actions attributable to GPEI. As demonstrated in prior economic analyses of GPEI , 4, most- Flat (constant) coverage equal to the 1988 RI estimate, or- Increasing RI coverage that follows the historically reported time series of RI coverage, or- Increasing RI coverage that linearly increases between 1988 and 2021 to the mid-level between reported 1988 and 2019.The no GPEI scenarios include no planned, preventive SIAs, and we assume regular WPV importations throughout the time horizon into subpopulations that achieved local WPV elimination. Virus is imported into these subpopulations from countries or subpopulations that remain endemic . Because of importation threats, we assume that the blocks using IPV-only schedules in the RC  would usThe annual data since 1980 currently reported by WHO , 13 appetr = 95%, and vaccine coverage of zero for countries with no available data. Recognizing underreporting as a significant data quality issue, WHO used a simple linear model in the 1980s to estimate the total number of paralytic cases , 31–36. Not surprisingly, published WHO estimates (red diamond symbols) largely overlap with the simple linear models (dashed and dotted curves). These point estimates tend to overestimate the total paralytic cases compared to the RC, demonstrated by the divergence of the solid line from other lines beginning in the 1988–1990 timeframe, when polio eradication activities increasingly contributed to reducing the global burden of polio. The difference between the RC and simple models becomes so large after the mid-1990s that simple models do not reliably estimate the global burden of disease, or the number of cases prevented (see below).In Visualization of the role of vaccines in prevention of paralysis  providesFor any specific time period, we can sum the annual numbers to estimate the cumulative cases. For example, for 1960–1987, the results in Although polio represents an interdependent risk of international concern, each country collects and reports its own national data. Polio surveillance systems have varied substantially between countries and over time. Reporting of the available polio data began in the mid-20th century by some developed countries individually , and by Reported cases  provide Although we identified multiple published estimates of prevented cases , we failThe results presented here provide a powerful reminder of the positive global impact of vaccines on human health. The public perception of polio is often as a disease of the past, but the dynamics of polio control  and caseWhile simple estimations of cases and cases prevented can introduce significant errors by overly simplified input assumptions, the estimates calculated using the global model also come with limitations associated with the model structure, assumptions, and available information (see details in ). We conAnalysis of historical cases and cases prevented can provide important context for the benefits of investments made in polio eradication. By focusing on paralytic cases, our analysis undervalues prevention of substantial burdens of disability and deaths. Future studies will need to explore the expected benefits of prospective investments. Prior modeling explored both retrospective and prospective estimates of cases prevented , 4, but


Cities are recognized as an important scale for framing and implementing plans and policies for action on climate change. Within the structure of cities, it is in urban neighbourhoods that climate action becomes tangible and has the potential to engage communities. Despite its importance, scholarly literature has played limited attention to the scale of the neighbourhood as a site for locating climate action. The objective of our paper is to provide an overview of the role of neighbourhoods in leading bottom-up climate action and its implications for urban planning based on a qualitative scoping review. Our findings indicate that neighbourhoods are conceptualized as a physically bounded scale for climate action as well as a web of social networks and relationships enabling this action. Neighbourhood climate action aims to achieve neighbourhood scale sustainability and resilience by engaging with residents, municipalities, local academic institutions, neighbourhood associations and non-governmental agencies. Scholars engage with a wide range of concepts like place-based attachment and social mobilization as well as established practice-oriented tools in defining and measuring neighbourhood climate action. However, the neighbourhood scale struggles with limited resources and power in creating sustained climate action as well as in engaging with and addressing socio-economically marginalized communities. More than half of the world’s population lives in cities and directly or indirectly influences a majority of the global greenhouse gas (GHG) emissions  and Google Scholar (GS). GS was intentionally added for making the search comprehensive and to include grey literature sources. This yielded 20 results on Scopus, 26 results on web of science and 10730 results on GS as of October 2020. As GS results were substantially large in number, we constrained our search to the first 100 results, sorted in the order of relevance.We exported the first set of 146 search results to a web-based literature review manager called Covidence. We found Covidence to be a convenient platform for screening our search results as it allowed multiple researchers to review and vote on inclusion or exclusion of studies. It also automatically identified removed 28 duplicate research items. The inclusion criteria set for the research were English language articles from countries of the Global North between the years 2000 and 2020. Further, the conceptualization of neighbourhoods as a unit of human settlements in cities was used. Countries of the Global North were purposively selected for this scoping review for a similar conceptualisation of the concept of neighbourhood, neighbourhood planning and climate action. Studies published after the year 2000 were selected as Scopus and WS did not show any studies before that period.For the next stage, we conducted a title and abstract review based on the inclusion criteria. Each research article was reviewed and voted on by two researchers. Conflicts in voting, if any, were discussed based on the inclusion criteria and finally a total of 61 research articles were taken up for full text review.Each of the 61 review articles was read by at least two researchers. Through this process, we further eliminated 15 research articles but added 22 articles through the process of backward casting by identifying articles from the existing reference lists. A total of 68 research articles were thus taken up for full text review. Among them were 59 peer-reviews papers, 4 conference proceedings, 3 book chapters, 1 working paper and 1 doctoral dissertation. Figure We extracted both quantitative and qualitative data from the research articles. Quantitative data, extracted using Microsoft Excel, included a word count of keywords, countries, and regions where the study was conducted, nature of climate action (adaptation or mitigation or both), nature of the neighbourhood (existing or new) and nature of study design . Qualitative data, extracted using NViVo, included inductively coding the articles for recurring themes. These included the conceptualisation of neighbourhood and its relevance as a scale for climate action and conceptualisation of climate action. We also used the qualitative analysis to elaborate upon the theoretical and conceptual foundations of neighbourhood climate action, research methods adopted, actors involved and finally the challenges highlighted by the existing research. The following section presents the results of our analysis.A keyword analysis of 68 research articles resulted in 296 keywords. Climate change (16) and neighbourhood (8) were the two most prominent keywords. This was followed by sustainability (4) and sustainability transitions (4) and resilience (5), vulnerability 3) and adaptation (2), indicating that these are foundational concepts upon which neighbourhood climate action rests. Governance (10) and planning (16) appear in multiple iterations, e.g. climate change governance, collaborative governance, neighbourhood planning, community planning, etc. Fig.  and adapNeighbourhood is defined as the fundamental building block of the city Rohe, . NeighboThe scale of the neighbourhood is small enough to demand its own urban design and public policy, yet big enough to create an impact at the city scale (Oliver & Pearl, The challenges brought about by climate change present an opportunity to explore new models, structures and organizations at the neighbourhood scale (Rowlands, On the other hand, social capital existing in a neighbourhood presents an opportunity to build partnerships and networks and open up new ways of problem solving around climate action (Slater & Robinson, Among the 68 papers that we reviewed, 16 dealt with neighbourhood mitigation actions, 18 dealt with adaptation, 18 addressed both and 16 papers presented underlying theoretical concepts.Neighbourhood scale action in addressing climate change mitigation typically dealt with issues around energy efficiency of buildings (Fisher & Irvine, Literature focusing on neighbourhood scale adaptation typically dealt with heat stress (Guardaro et al., Neighbourhoods, particularly the new neighbourhoods, present an opportunity to be designed and modelled for a low carbon footprint (Wang et al., In this section, we elaborate upon the underlying theories and concepts that researchers engage with when exploring climate action at a neighbourhood scale. Neighbourhood climate action shares a similar concepts foundation as bottom-up climate action. Our review illustrates how these foundational concepts are applied at a neighbourhood scale and provide analytical sharpness to the concepts of bottom-up climate action.Place-based attachment often lends itself to mutualism. Mutualism is defined by Rowlands  as “collSocial capital is another dominant concept when discussing neighbourhood climate action. Social capital at a neighbourhood scale refers to the benefits individuals derive from being part of a neighbourhood network Purdue, . NeighboSocial learning as a product of collaborative problem solving is a desired outcome of climate action at a neighbourhood scale (Evers et al., Some scholars press on the need to recognise the unique position of each neighbourhood based on its history Elwood, , socio-eThis section discusses the methods adopted in research on neighbourhood climate action. Fifty-one out of 68 papers adopted a qualitative approach, 12 adopted a quantitative approach and 5 papers adopted a mixed methods approach.Qualitative research designs were dominant in the research papers addressing neighbourhood climate action. Key-informant interviews, focus groups discussions and document reviews were largely employed for data collection. Multiple researchers adopted action research designs involving neighbourhood residents, researchers, city representatives, urban planners, local NGOs and local businesses (Hendricks et al., Among quantitative papers, the focus lies on quantitative assessment of GHG emissions at a neighbourhood scale (Jones et al., A limited number of papers adopted a mixed research design. Given the physical and social dimensions of neighbourhood climate action, Passe et al.  highlighGiven the complex nature of climate action, new constellations of actors and new structures of power are emerging at the neighbourhood scale Aylett, . RecogniCity government-led project: These are the projects where residents are invited to participate in various capacities. The nature of participation varies from mere consultation to co-production Rohe, . GovernmProjects initiated by neighbourhood residents or citizen organizations: Neighbourhood organizations and homeowner associations are often successful in forming durable partnerships with residents in comparison to external agencies (Andrew et al., Researcher or NGO led projects: These are often designed around action research or experimentation. Though often short term in nature, these projects are a chance to build or strengthen valuable social infrastructure within neighbourhoods that can address climate change beyond the span of a pilot project (Klerks et al., Projects based on neighbourhood climate action can broadly be divided into three categories:With the push and pull of power and responsibilities at the neighbourhood scale, collaborative governance structures, similar to those adopted in successful neighbourhood revitalisation projects, are coming to the fore Elwood, . Cross-sSocial challenges: Wittmayer et al.  argue thData challenges: Multiple authors point towards the lack of neighbourhood scale data collection and analysis systems needed to design effective policies and programs. Localized and granular data at neighbourhood scale data can help in designing more tailor made plans and policies for mitigation and adaptation (Passe et al., Power and resource challenges: Local change agents point towards the mismatch between the expectation with regards to climate action and the limited resources or agency to do so (Smith et al., Continuity challenges: Collaborative action at a neighbourhood scale is a process that requires time to build (Guardaro et al., The scale of the neighbourhood presents exciting opportunities to address the challenges of climate change. However, literature recognises multiple challenges associated with scale, time frame, perspective and data for successful and sustained climate action at the neighbourhood scale Kellogg, . We summGiven the scale of action required to address climate change in cities, neighbourhoods emerge as the next frontier in urban climate action research. Neighbourhoods have the potential to locally respond to the global problems of climate change. Their unique scale, located at the intersection of the city and the individual/building, affords them with multiple opportunities to stir collective climate action. Proximity and tangibility of participating in climate action encourages neighbourhood residents to collectively address mitigation and adaptation challenges. Neighbourhood climate action builds upon the rich literature and practice around neighbourhood renewal Rohe,  and sustA socio-technical-ecological conceptualisation of the neighbourhood: The neighbourhood emerges as a complex entity with physical components like buildings, roads and other built infrastructure, a social network of people and ecological network of trees, plants, drains and other natural components. Quantitative research largely views neighbourhood is a physical entity whereas qualitative research addressed its social component in terms of special interest groups and residents, their networks and relationships. There is a need to develop a mix of technical, social and ecological criteria and scenarios through a mixed research designs where tangible aims like reduced GHG emissions also address intangible benefits like community building and social learning. This is also an opportunity to create neighbourhood scale data support systems that can help design locally relevant climate action projects. Given that neighbourhood governance systems have diverse participating actor, communicating climate data to multiple groups also requires further exploration.Socio-economic variables: Multiple papers in this review have indicated that neighbourhood climate action is often weakest in the most vulnerable neighbourhoods (Gilderbloom et al., Temporal continuity: The small scale and local nature of neighbourhood scale projects is often short lived. There are opportunities to ensure continuity by exploring ways of translation of city level climate goals into neighbourhood action plans (Cloutier et al., Capacity development: Locating climate action at the neighbourhood demands development of new skills and capacities of stakeholders for addressing the issue. These range from learning to work as a group to collecting and understanding locally relevant data. Similarly, an exploration into the devolution of power at the neighbourhood scale, in different political contexts, to ensure that participation goes beyond top-down consultation needs further exploration.Existing scientific literature provides multiple examples of successful neighbourhood scale projects from neighbourhood greening, infrastructure mapping to energy upgrades. However, challenges remain in terms of social cohesiveness, resources, power and continuity to scale up and magnify neighbourhood climate action. In this paper, we have provided a broad conceptualisation to the concept of neighbourhood climate action. This can serve as a basis for future empirical analysis of neighbourhood climate action efforts as well as form a basis for focused systemic reviews. Here, we present four future venues of research and action to address these challenges and gaps in knowledge:As cities prepare to re-imagine their structure in a post pandemic world as well as be equal partners in the action against climate change, the scale of the neighbourhood promises to be an exciting venue for research and practice.


Decades of techno-economic energy policymaking and research have meant evidence from the Social Sciences and Humanities (SSH)—including critical reflections on what changing a society’s relation to energy (efficiency) even means—have been underutilised. In particular, (i) the SSH have too often been sidelined and/or narrowly pigeonholed by policymakers, funders, and other decision-makers when driving research agendas, and (ii) the setting of SSH-focused research agendas has not historically embedded inclusive and deliberative processes. The aim of this paper is to address these gaps through the production of a research agenda outlining future SSH research priorities for energy efficiency. A Horizon Scanning exercise was run, which sought to identify 100 priority SSH questions for energy efficiency research. This exercise included 152 researchers with prior SSH expertise on energy efficiency, who together spanned 62 (sub-)disciplines of SSH, 23 countries, and a full range of career stages. The resultant questions were inductively clustered into seven themes as follows: (1) Citizenship, engagement and knowledge exchange in relation to energy efficiency; (2) Energy efficiency in relation to equity, justice, poverty and vulnerability; (3) Energy efficiency in relation to everyday life and practices of energy consumption and production; (4) Framing, defining and measuring energy efficiency; (5) Governance, policy and political issues around energy efficiency; (6) Roles of economic systems, supply chains and financial mechanisms in improving energy efficiency; and (7) The interactions, unintended consequences and rebound effects of energy efficiency interventions. Given the consistent centrality of energy efficiency in policy programmes, this paper highlights that well-developed SSH approaches are ready to be mobilised to contribute to the development, and/or to understand the implications, of energy efficiency measures and governance solutions. Implicitly, it also emphasises the heterogeneity of SSH policy evidence that can be produced. The agenda will be of use for both (1) those new to the energy-SSH field (including policyworkers), for learnings on the capabilities and capacities of energy-SSH, and (2) established energy-SSH researchers, for insights on the collectively held futures of energy-SSH research. Climate change mitigation represents a critically urgent normative underpinning for research and innovation  research would help drive low-carbon energy transitions. The research literature shows that involving SSH can ensure insights on, for example, the societal influences, relationships, preconditions, interventions, outcomes, impacts, etc. of energy transitions  is a poor representation of SSH and what these can offer  has been used to inform emerging research priorities in a number of sustainability-related fields, including ecology and biodiversity conservation  and SSH communities working on energy, or supporting mainstreaming of SSH into STEM. These are important issues that have been extensively covered elsewhere  that can be produced. We anticipate that our agenda  will be of use for both (1) those new to the energy-SSH field, for learnings on the capabilities and capacities of energy-SSH, and (2) established energy-SSH researchers, for insights on the collectively held futures of energy-SSH research.Energy efficiency represents an interesting focus for SSH-centred Horizon Scanning, given that it is itself a techno-economic concept that has been adopted by policymakers, and is an area in which SSH have much to offer  yet are still usually overlooked Dunlop, . Energy This paper proceeds as follows: we begin by discussing the recent evolution of SSH research on energy efficiency. We then present our Horizon Scanning approach, including the ways in which participants were involved in shaping and co-owning the final Horizon Scan agenda. The core of the paper then presents our 100 SSH priority questions, grouped into seven themes. We conclude by reflecting on: what our agenda offers and how it may be used; what it indicates about past/future directions of SSH research on energy efficiency; and, what our e.g., inductive, inclusive, and pragmatic approach has demonstrated to the field.The story of SSH research on energy efficiency has a long history. For example, in the latter half of the 1800s: William Stanley Jevons conceptualised the rebound effect Jevons, ; and PodMuch of these early commentaries involved an emphasis on how technological progress and steeply rising energy demand were widely taken for granted. This changed dramatically in the wake of the oil crises of the 1970s when first political, and then environmental, vulnerabilities of depending too much on (foreign) oil became a political priority. Fuel scarcity and high oil prices forced oil-importing governments to ration access, impacting on productivity. Therefore, after the fall of naive visions of continued progress in the ‘atomic era’ Nelson, , energy Confronted with the explosive growth of energy consumption and resulting crises, SSH research in the 1980s focused on understanding human behaviours related to energy use, and how such behaviours are grounded in specific environments. This was also the starting point of a report by the USA’s National Research Council, entitled ‘Energy use: the human dimension’  similar annual biodiversity conservation Horizon Scanning exercises. In detailing our adaptations and processes, we particularly respond to a lack of methodological specificity in most Horizon Scanning literature. An even more detailed preliminary methodological plan is presented elsewhere, in the context of the wider Horizon Scanning literature , whose responsibility it was to oversee the Horizon Scanning exercisediverse a field as possible, we have made every reasonable attempt to gain as representative a sample of participants as possible within the practical confines of a single research study.The Steering Committee and Working Group then sought input from wider research communities, with each member invited to submit their own questions and invite up to 20–25 colleagues for input. Input was gathered via an online survey (February–April 2020), which asked for 3–5 SSH research questions on energy efficiency, each with an accompanying justification. Eligibility criteria required these colleagues to have prior SSH expertise on energy efficiency and be currently based at a research organisation in an EU or Horizon 2020 Associated Country. Our intention behind our Working Group involving a cross-section of SSH disciplines, genders and European geographies, was to ensure a degree of balance to the wider pool of submitted questions. We recognise that the definition of our geographic scope, as EU and Associated Countries, is a limitation of this exercise, and that deliberative exercises encompassing wider scales would be valuable in expanding the inclusivity of SSH research agendas. As with all Horizon Scanning exercises, our dataset is thus highly contingent on the precise group of participants recruited. As noted elsewhere in the Horizon Scanning literature , and they spanned 62 (sub-)disciplines of SSH. Economics was the most represented, with 23% of respondents stating this as one or more of the SSH they aligned with; Sociology had 21%, Sciences and Technology Studies and Political Science (each had 13%), and Human Geography (11%). The respondents also spanned 23 countries and 26 nationalities, and represented a full range of career stages; a breakdown of these is available in Foulds et al.  p. 27. Tboth editors separately, with an agreement meeting to discuss the processes/outcomes and to jointly agree on final edits; and, another 5% were similarly jointly edited at the halfway point. This task led to:101 submitted questions deleted, due to lack of SSH grounding, lack of relevance to energy efficiency, or not containing question content.35 additional questions added through disaggregating multiple questions from one single submitted question, or through sourcing questions from justification texts.64 submitted questions removed due to merging, as they were overly similar.The purpose of this next stage was to produce a list of questions that were consistent in their writing style, relevance, scale and scope. The first and second authors of this paper took responsibility for this editing task, with a number of inter-editor agreement checks to ensure robustness  individually, with all questions scored on a scale of 1 (=definitely exclude) to 5 (=definitely include). Participants were asked to score each question based on how important they believed it should be for the European Commission to consider it within its Horizon Europe funding programmes. At this stage, rather than using an elaborate  set of pre-determined criteria, scorers were instructed to assign scores based on their first, strong preference, grounded in their expertise and unique disciplinary vantage points. There were no restrictions on the number of questions you could, for example, score highly.n = 1)Questions with a median of 5 were automatically selected for inclusion. (n = 49)Highest-scoring 49 questions were selectedn = 183)Questions with medians of 1–3 were automatically excluded. (n = 150)Remaining edited questions compiled as a long-list for Working Group consideration. . The rules applied were:All evaluation scores and rulings were transparently shared with the Working Group. Following this, a first virtual deliberation workshop discussed the results with Working Group members. Discussion was prompted by each member advocating for three questions from the 150-question long-list. We gathered feedback on specific questions that should be included, with agreement reached that not enough of the selected questions to date had covered, e.g., gender, the Global South, social innovation, and unintended consequences. Here too, rather than using a pre-determined set of criteria against which to judge all questions, we followed a reflective and deliberative approach, which allowed Working Group members to holistically consider each question on its own merits and against the overall goal of producing a list of 100 questions that adequately captured the breadth of SSH approaches to energy efficiency.Following this first workshop, the Committee provisionally selected 95 questions as well as inductively generated seven themes to organise said questions around. A second virtual deliberation workshop discussed the: salient gaps that the final five questions needed to fill; theme descriptions; overall mission statement; and associated narratives accompanying the final 100 questions. Both workshops involved members making direct text edit suggestions to the selected questions. The final 100 selected questions were signed off by members prior to publication.To promote SSH research that better situates energy efficiency in relation to social systems of energy demand and supply; and to constructively challenge notions of energy efficiency by opening up questions of its meanings, applications and implications across diverse contexts, actors and scales.We produced a Mission Statement, which represented the Working Group’s shared intention behind these 100 questions and seven themes. This Statement was produced after the questions had been agreed and the themes inductively generated:This section presents the 100 questions, broken down under each of our seven themes. In these seven sub-sections that follow, we discuss each theme in terms of synergies between recent calls in the literature and our own advocated lines of SSH development.While further information on how to navigate these questions is available elsewhere, including how it is out-of-scope to discuss herein how these questions should be investigated  of social innovation that may be effectively utilised  policy solutions : age, income, ethnicity, disability, family structure and religion. This certainly fits with the literature’s small, but growing, appreciation of intersectional issues in energy efficiency  that aims to support the adoption, and long-term maintenance, of energy efficient or energy sufficient ways of life.This theme centres on fundamental issues of how energy efficiency is defined, modelled, understood and measured Table . The aimMatters pertaining to frames, definitions and measurements are significant in SSH because one’s point of departure and inherent reference points will shape the findings generated and the conclusions/recommendations that can be provided  of energy efficiency policies.This theme also focuses on how policies are designed and implemented, and the politics of energy efficiency. With different policies and policy instruments at play, the literature has called for more research on how new policies can be integrated within existing policy systems, while ensuring that both sets of policies  continue to work effectively and that they can be aligned without one obstructing the other , while striving to remedy the effectiveness of the policies . Concurrently, given the differences between and across (sub-)sectors, the literature has called for more analyses that examine and/or compare different sectors , in an effort to provide a more holistic overview of the effectiveness and/or implementation of energy efficiency policies across sites and scales. This theme also delves into global issues of consumption, production and their intersections, responding to calls from the literature for analyses that move beyond ‘simplistic’ understandings of how energy efficiency relates to consumption and production  specifically dealing with the Global South; this reflects the fact that, despite our focus on the Global North, this theme deals with economic systems that are fundamentally global. As such, the questions consider issues around supply chains that link the Global North and Global South, and how emerging economies might avoid the lock-ins experienced by more energy-intensive nations. We note that within existing SSH literatures there is a major gap in knowledge on energy efficiency in Global South contexts, resulting in a narrower understanding of the effectiveness of the energy efficiency policies in different settings Aliu, . While wThe aim of this theme is to investigate how economic systems, supply chains and financial mechanisms can be mobilised and/or reorganised in order to contribute to energy efficiency and sufficiency goals. In particular, this theme raises a range of important questions that have not yet been adequately addressed through the already extensive work on energy efficiency within Economics, Marketing, Business Management and related disciplines. The questions will provide important insights to any research relating to the economics of energy efficiency, and the roles of business and industry. This theme shows how critical-SSH can open up radically new perspectives on socio-economic innovations and transitions, including transformations towards energy sufficiency.This theme concerns the ways in which energy efficiency interventions overlap and intersect with other areas of policy and practice Table . As suchSome questions in this theme draw on the idea of ‘rebound effects’ , which has been developed within techno-economic approaches to efficiency. However, this theme goes beyond these conventional perspectives to ask novel questions about how such effects are situated within social, cultural, organisational and policy contexts . A partBy exploring these various linkages, which are rarely recognised by researchers or policymakers, this theme aims to improve the evidence that informs energy efficiency policy, thus helping to avoid unintended consequences and to also optimise potential win-win scenarios or double-dividends. These questions thus have direct value to any research that aims to fully understand and effectively manage both the direct and indirect outcomes of energy efficiency policies and interventions, including work grounded in STEM disciplines.The aim of this paper was to produce a research agenda outlining future SSH research priorities for energy efficiency in Global North contexts. We undertook a Horizon Scanning exercise that involved input from 152 energy-SSH researchers, who spanned 23 EU and Associated countries, 26 nationalities, 62 SSH (sub-)disciplines, both academic and industry organisations, and a range of career stages. A Working Group of 27 members—all of whom held SSH expertise in energy efficiency—used this wider input to select and edit 100 SSH priority questions, across seven inductively produced themes: (1) Citizenship, engagement and knowledge exchange in relation to energy efficiency; (2) Energy efficiency in relation to equity, justice, poverty and vulnerability; (3) Energy efficiency in relation to everyday life and practices of energy consumption and production; (4) Framing, defining and measuring energy efficiency; (5) Governance, policy and political issues around energy efficiency; (6) Roles of economic systems, supply chains and financial mechanisms in improving energy efficiency; and (7) The interactions, unintended consequences and rebound effects of energy efficiency interventions.Taken together, these questions and themes (our ‘agenda’) represent beyond state-of-the-art research opportunities at the frontiers of SSH thinking on energy efficiency, illustrating how interdisciplinary synergies can be forged across SSH. The agenda highlights strategic opportunities for both researchers and decision-makers, especially given the fact that SSH receives significantly less energy/climate research funding than the Technical/Natural Sciences. We prioritised different perspectives, intentionally opening up the Horizon Scanning exercise as much and as early as possible. This fundamentally enabled a more inclusive approach and the creation of a truly interdisciplinary agenda, based on cross-disciplinary deliberative negotiations. Implicit to our agenda is the demonstration that interdisciplinarity need not be limited to bridging the Technical/Natural Sciences and the SSH; there is considerable interdisciplinary potential within the SSH, which is usually overlooked by policy and funding actors. Indeed, our research agenda showcases the possibilities afforded by embracing SSH problem definitions and lines of enquiry. It also, in the most basic sense, provides a list of ready-made research questions, which we hope may be especially helpful for early-career researchers and/or those newer to the energy-SSH field. Colleagues are welcome to use these questions to kick-start their own project proposals, studies and papers.We understand that these questions are not representative of every SSH discipline/community and all its various members. We also appreciate that our agenda only represents views and preferences during that particular period in time. For example, should the exercise be conducted in 2022, we may expect more questions on the geo-politics and international governance challenges of energy efficiency, given the emerging effects of Russia’s invasion of Ukraine. However, it was never our intention to provide a definitive, long-lasting and representative agenda. Instead, our hope is that our agenda will spark debate and discussion, as indeed any good Horizon Scanning exercise should aim to do. We especially welcome responses from those who would advocate for different sets of research questions, based on different ontologies and epistemic points of departure.We begin here by reflecting on what we believe these 100 questions, together, are working against. We argue that the questions selected are a product of the SSH research communities’ representatives fighting back (consciously or not) against a mainstream paradigm that has long-dominated research and policy approaches to energy efficiency (and low-carbon energy transitions more broadly). In this way, what we now immediately discuss is actually represented in the agenda by its absence in the most part.Mainstream energy efficiency research and policy approaches are often based on principles of (1) substitution of technological and energy inputs and of (2) modification of individual behaviours. These approaches are mostly dichotomous, as they split energy demand and supply. They either assume that technological and energy inputs  can be changed without altering outputs , or that individual behaviours  can be modified without altering the material and social contexts that shape supply and demand. This dichotomy reflects a wider imagined separation between subject and object that societies have inherited from modernity and that still mostly informs the organisation of human activities in all sectors. This dichotomy is at the core of the separation that has been created between, for example, ‘hard’ and ‘soft’ sciences, or between producers and consumers. This dichotomy also explains how mainstream energy efficiency approaches can still be mostly linear and top-down, and do not consider how, for example, demand and supply actually co-evolve, or how technologies shape societies and vice-versa, etc. Such a point of departure is broadly absent from our questions.In contrast, against this mainstream backdrop, our 100 questions regularly emphasise the importance of interconnectedness and complexity, as shown by “systems” being so commonly referred to, for instance. Similarly, the questions move far beyond out-dated overly linear, individualistic ontologies, with regular reference made instead to “communities” and “institutions”, for example. In addition, by so overtly distancing itself from technological determinism, this agenda also sought to recast and reframe notions of ‘innovation’ as a purely technological endeavour, to a societally driven and enabled endeavour . Such a shift is essential if—again, as this agenda makes firmly clear—it is important to appreciate how changes induced in social practices by energy efficiency improvements always arrive in unexpected ways; and thus, that a key part of SSH’s remit should be to understand the lived experiences of energy efficiency, so that expectations can be better managed and detrimental impacts effectively minimised.Our agenda, and its underlying Horizon Scanning exercise, emphasise the need for a pragmatic stance and coalition that enables the space to challenge, but still contains numerous normative touch points with, current policy pathways. This is well demonstrated by us producing a SSH Horizon Scan on energy efficiency, which is in itself a concept traditionally re-produced and enabled by technological determinism  remember how energy policymaking cannot (and should not) be easily disentangled from energy efficiency  policymaking, and (2) better acknowledge the usually overlooked interconnections between energy (efficiency) policy and, for example, government finance, geo-politics and other policy areas. Energy efficiency research and innovation systems would indeed benefit by broadening its scope to include interactions and investigations of wider public policy programmes, as our final Theme 7 particularly emphasises. This agenda both highlights the complexities and the parameters involved in following such a pathway, as well as provides possible solutions by building on decades-long SSH-knowledge.This paper has also demonstrated the utility of using Horizon Scanning methods to construct research agendas within/across SSH disciplines. We have applied methods traditionally used in the interdisciplinary Environmental Sciences, to SSH perspectives on energy efficiency, adapting them to better account for diversity within the field and with a view to greater methodological transparency than is typical of other published examples in the field. We assert such methods have considerable unfulfilled potential in the energy-SSH and welcome responses to these outcomes from colleagues.


Epidemiological data from Europe and North America suggest that 1–1.5% of the adult population has heart failure with reduced left ventricular ejection fraction (HFrEF). Development of edema (pulmonary or systemic) is a major hallmark of heart failure (HF) and a key driver of symptoms, such as exertional dyspnea and fatigue, reduced quality of life, morbidity and mortality  and evaluate tools – biomarkers, imaging modalities, and algorithms that might facilitate diagnosis and monitoring of edema or, in other words, the management of HF.Abassi et al. and Aronson comprehensively overviewed mechanisms underlying HF-associated edema formation and discussed novel strategies that might facilitate effective decongestion. The potential clinical relevance of novel biomarkers that reflect the activation of different pathways leading to edema and driving progression of HFrEF has been reviewed and discussed by Chiorescu et al..The pathophysiology of edema formation during the advanced stages of HF is multifactorial and can be influenced by concurrent comorbidities, in particular renal failure. In patients with HFrEF, edema is attributed to the pathological extracellular fluid accumulation in the interstitial space resulting from renal salt and water retention and impaired extra fluid removal mechanisms (including the lymphatic system) from the interstitial to intravascular space. Persistent overactivation of the renin-angiotensin-aldosterone system, impairment of natriuretic peptide system and dysregulation of other hormonal axes concur to cause salt and water retention and worsen edema further . EffectiKobayashi et al. assessed the clinical value of combining a chest x-ray congestion score and plasma volume estimated from hemoglobin and hematocrit at admission in a cohort of 252 patients presenting to an emergency department with acute dyspnea, who were subsequently diagnosed with acute HF. They found that patients with both evidence of pulmonary and intravascular edema had a greater risk of dying in hospital compared to those who had either of the two features, or none.Routinely collected, readily available diagnostic information can improve risk stratification for patients with dyspnea presenting to an emergency department. In another manuscripts published in this issue, Palazzuoli et al. proposed incorporating a bedside echocardiographic examination into the Stevenson classification. The comparative analysis of Stevenson classification data and echocardiographic findings reported by this research team supports the benefits of echocardiographic evaluation for improving characterization of the HF patient's clinical profile and diagnosis.To extend the clinical algorithm that characterizes the hemodynamic status and type of congestion in patients with acute HF, Mesin et al. outline current development in this field and highlight the clinical potential of these novel, non-invasive, diagnostic methods.Intravascular volume status can be estimated using ultrasound by measuring the inferior vena cava (IVC) or internal jugular vein (iJV) diameter and their responses to simple respiratory maneuvers . A dilatImplementation of modern treatments, for instance sacubitril/valsartan and sodium-glucose co-transporter-2 inhibitors , 6, in cAll authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


A significant proportion of the global burden of disease can be attributed to mental illness. Despite important advances in identifying risk factors for mental health conditions, the biological processing underlying causal pathways to disease onset remain poorly understood. This represents a limitation to implement effective prevention and the development of novel pharmacological treatments. Epigenetic mechanisms have emerged as mediators of environmental and genetic risk factors which might play a role in disease onset, including childhood adversity (CA) and cannabis use (CU). Particularly, human research exploring DNA methylation has provided new and promising insights into the role of biological pathways implicated in the aetio-pathogenesis of psychiatric conditions, including: monoaminergic (Serotonin and Dopamine), GABAergic, glutamatergic, neurogenesis, inflammatory and immune response and oxidative stress. While these epigenetic changes have been often studied as disease-specific, similarly to the investigation of environmental risk factors, they are often transdiagnostic. Therefore, we aim to review the existing literature on DNA methylation from human studies of psychiatric diseases (i) to identify epigenetic modifications mapping onto biological pathways either transdiagnostically or specifically related to psychiatric diseases such as Eating Disorders, Post-traumatic Stress Disorder, Bipolar and Psychotic Disorder, Depression, Autism Spectrum Disorder and Anxiety Disorder, and (ii) to investigate a convergence between some of these epigenetic modifications and the exposure to known risk factors for psychiatric disorders such as CA and CU, as well as to other epigenetic confounders in psychiatry research. Both genetic and environmental factors are implicated in the aetiology of psychiatric disorders, however, the key causal mechanisms for guiding effective prevention and treatment remain poorly understood  . While bDifferent biological pathways have been implicated in the aetio-pathogenesis across multiple mental disorders. Some of these are pathways related to neurotransmission such as serotonin , Synaptic plasticity and Neurogenesis; the Immune system, Inflammation and Oxidative stress and the major mental conditions (focusing on Eating Disorders (ED): anorexia nervosa (AN) and bulimia nervosa (BN), Autism Spectrum Disorder (ASD), BD and Psychotic Disorder, Depression, Post Traumatic Stress Disorder (PTSD) and Anxiety Disorders). Summary of findings is illustrated in SLC6A4) with candidate genes studies suggesting an increased in methylation in depression  system dysfunction in a broad range of psychiatric diseases  has been reported to be hypermethylated  gene  and GABAergic  neurotransmission, supporting previous candidate genes results. Findings related to GRIA family genes have been replicated in latter EWAS studies   activity  is essential for neurogenesis and extensively studied as a biomarker in psychiatry ; other EWAS have also reported an enrichment in the immune system pathway by differently methylated genes  , and in NR3C1 there is consistent evidence on a positive correlation between CA and DNAm in Borderline PD and MDD and some clinical outcomes  summarises the main findings on studies examining the link between DNAm and genes involved in the HPA-axis, and key findings are summarised in enes see . The SKASLC6A is associated with resilience to PTSD , BDNF, GAD and the GRIND family,  are also associated to CA. This suggests that some of the DNAm changes attributed to these disorders may be partially related to the consequence of CA exposure, as illustrated in As a whole, DNAm changes in some of the genes that have been previously linked to major psychiatric conditions  and pathways involved in DNA repair (B-cell)  from a sample of adolescents with CU disorder pointed at many methylation sites relevant to brain function and to neurodevelopment  and CA in PTSD subjects , which are genes involved in myelinisation and neurogenesis (Online Supplementary Table S1 (SM) – EWAS section).Candidate genes studies have linked CA with DNAm changes in GGT6 gene that were associated with exposure to CA in a sample of Borderline PD patients; GGT6 is key for glutathione homoeostasis  replicated across studies.A number of publications have identified robust associations between tobacco smoking and DNAm , inflammation (HERC5) and in GABA receptors (a receptor delta and B receptor subunit 1); all of which are pathways previously associated with different mental disorders, as shown in There is some initial evidence to suggest that alcohol use is associated with DNAm changes . Specifically, collaborative efforts between geneticists, epigeneticists and epidemiologists will lead to increased understanding of how the DNAm changes mapping to specific pathways, might mediate the biological link between environmental exposures and increased liability to specific or transdiagnostic psychiatric morbidity.